1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 3a Symptoms – General Introduction Module 3a Symptoms – General Introduction EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

3. Objectives... l Discuss general assessment and management guidelines l Describe the possible causes and underlying pathophysiology l Conduct a careful assessment l Initiate management including rapid and breakthrough dosing l Discuss general assessment and management guidelines l Describe the possible causes and underlying pathophysiology l Conduct a careful assessment l Initiate management including rapid and breakthrough dosing

4. ... Objectives l Describe principles of multi- symptom management l Understand principles of double effect l Describe principles of multi- symptom management l Understand principles of double effect

5. Video

6. Introduction l Most cancer patients have fatigue, pain, other symptoms l Poor symptom control undermines completion of anti-neoplastic treatment l Symptom control necessary for patient goals l Most cancer patients have fatigue, pain, other symptoms l Poor symptom control undermines completion of anti-neoplastic treatment l Symptom control necessary for patient goals

7. Symptom management l Best medicine - treat cause & experience PharmacologySurgeryRadiationChemotherapy Clinical trials Other l Best medicine - treat cause & experience PharmacologySurgeryRadiationChemotherapy Clinical trials Other

8. Assessment and plan l Comprehensive assessment l Conceptualize likely causes l Discuss treatment options l Negotiate goals of care, treatment priorities l Comprehensive assessment l Conceptualize likely causes l Discuss treatment options l Negotiate goals of care, treatment priorities

9. Information gathering l Common symptoms l Collect chart information: Onset, location, quality, timing, severity, effect of medication, adverse effects l Use scales to assess, chart severity l Common symptoms l Collect chart information: Onset, location, quality, timing, severity, effect of medication, adverse effects l Use scales to assess, chart severity

10. Manage quickly l Treat the cause of the symptom l Manage the experience l Continuous dosing l Breakthrough / intermittent dosing l Treat the cause of the symptom l Manage the experience l Continuous dosing l Breakthrough / intermittent dosing

11. Rationalize management l Multiple symptoms l Optimize non-invasive, non- pharmacological approaches l Avoid polypharmacy Use 1 agent for 2 symptoms if you can Consider adverse effects Preempt interactions Use renal and hepatic dosing as needed l Multiple symptoms l Optimize non-invasive, non- pharmacological approaches l Avoid polypharmacy Use 1 agent for 2 symptoms if you can Consider adverse effects Preempt interactions Use renal and hepatic dosing as needed

12. Coordinate care l Educate the patient, family, caregivers l Include the interdisciplinary team l Use palliative care consultants l Reassess often l Educate the patient, family, caregivers l Include the interdisciplinary team l Use palliative care consultants l Reassess often

13. Intended vs. unintended consequences l Primary intent dictates ethical medical practice l Double effect Definition Minimal application in palliative care l Terminal sedation Involve palliative care specialists l Primary intent dictates ethical medical practice l Double effect Definition Minimal application in palliative care l Terminal sedation Involve palliative care specialists

14. Summary l Principles of symptom management Understand the pathophysiology Manage quickly; continuous & breakthrough dosing Rationalize multisymptom management l Coordination of care Patient, family education Interdisciplinary team l Intended versus unintended effects Terminal sedation requires consultation l Principles of symptom management Understand the pathophysiology Manage quickly; continuous & breakthrough dosing Rationalize multisymptom management l Coordination of care Patient, family education Interdisciplinary team l Intended versus unintended effects Terminal sedation requires consultation