http:// module #5 end-of-life care: module 5 non-pain symptom management

Module #5http://www.growthhouse.org/stanford

END-OF-LIFE CARE:Module 5

Non-Pain Symptom Management

Module #5http://www.growthhouse.org/stanford

Case

Imagine you have advanced pancreatic cancer. You’ve lost 30 pounds over the past few months. There is no evidence of GI obstruction and you are not nauseated. You are very weak, and are now bedridden, with no appetite. Your mouth is dry. Your spouse keeps trying to get you to eat and you try, but you just can’t do it. You keep wondering why this is happening, and your spouse is very upset. You are admitted to the hospital and lab tests reveal that you are dehydrated. The intern comes to insert an IV.

Module #5http://www.growthhouse.org/stanford

Learning Objectives

• Increase understanding of how physical and mental factors affect symptomatology

• Be able to use this understanding in the treatment of patients suffering from nausea and vomiting, dyspnea, and cachexia/anorexia/asthenia

• Incorporate this content into your clinical teaching

Module #5http://www.growthhouse.org/stanford

Outline of Module

• Non-pain symptoms at EOL• Symptom analysis checklist• Nausea and vomiting

Break• Dyspnea• ‘Terminal Syndrome Characterized by Retained

Secretions’• Cachexia/anorexia/asthenia

Module #5http://www.growthhouse.org/stanford

Symptoms as Clues

A physical or mental phenomenon, circumstance or change of condition arising from and accompanying a disorder and constituting evidence for it… specifically a subjective indicator perceptible to the patient and as opposed to an objective one (compare with sign).

The New Shorter Oxford English Dictionary

Module #5http://www.growthhouse.org/stanford

Disease as a Clue to the Symptom

Questions to ask:

• How does the disease give rise to the symptom?

• What cognitive, affective, and spiritual components are involved?

Module #5http://www.growthhouse.org/stanford

From the Patient’s Perspective

A symptom is what is bothersome

Module #5http://www.growthhouse.org/stanford

Symptom Analysis Checklist

Physiological Factors

• Local

• Central

Mental Factors

• Cognitive

• Affective

• Spiritual

Module #5http://www.growthhouse.org/stanford

Skills Practice: Patient with pain symptoms due to metastatic bone cancer

Physiological factors

Local:

Central:

Mental Factors

Cognitive:

Affective:

Spiritual:

Module #5http://www.growthhouse.org/stanford

Non-Pain Symptoms at the EOL

Akathesia Anhedonia Anorexia Anxiety Colic Confusion Constipation Cough Crying Death rattle/secretions Diarrhea Dizziness Drooling Dry skin Dysarthria Dysgeusia Dyspepsia Dysphagia Dysphoria Dyspnea Dysuria Failure to thrive Fatigue Fear Fecal incontinence Fever Flatulence Halitosis Hallucinations Hearing loss Hiccups Impotence Irritability Memory loss Mucositis Muscle spasms Nausea Odor Panic attacks Peripheral edema Photosensitivity Polydipsia Polyuria Pruritus Restlessness Sexual dysfunction Sleep disorders Stomatitis Taste alterations Urinary frequency Urinary incontinence Visual problems Vomiting Xerostomia

Index, Oxford Textbook of Palliative Medicine, 1998

Module #5http://www.growthhouse.org/stanford

Nausea & Vomiting

When you were a resident (or if you are a resident now: when you were in medical school), what were you taught about antiemetics?

Module #5http://www.growthhouse.org/stanford

Nausea & Vomiting As Protective Mechanisms

Serial barriers:

1. Sight, smell, taste

2. Chemoreceptors and mechanoreceptors

3. Brain receptors

4. Message to vomit residual gut contents

Module #5http://www.growthhouse.org/stanford

A Central Final Pathway for Nausea

CTZ

VestibularApparatus

CNS

GI Tract

VOMIT CENTER(Acetylcholine,

Histamine)

(???)(Dopamine, Serotonin)

(Acetylcholine, Histamine)

(Acetylcholine, Histamine, Serotonin + mechanoreceptors)

Module #5http://www.growthhouse.org/stanford

Receptor Affinity Common Antiemetics

Drug ReceptorsDopamine Musc. Chol. Histamine

Scopalomine >10,000 .08 >10,000Promethazine 240 21 2.9Prochlorperazine 15 2100 100Chlorpromazine 25 130 28Metoclopramide 270 >10,000 1,000Haloperidol 4.2 >10,000 1,600

Potency: K1 (nanomolar)

The lower the number, the stronger this agent is at blocking this receptor

Adapted from Peroutka and Snyder, 1982

Module #5http://www.growthhouse.org/stanford

Causes of Nausea & Vomiting

• Vestibular

• Obstruction

• Mind

• Dysmotility

• Infection (irritation)

• Toxins (taste and other senses)

Module #5http://www.growthhouse.org/stanford

Vestibular Apparatus

• Nausea with head movement

• Medicated by acetylcholine and histamine receptors

• Most anticholinergic, antihistamine drugs will help

Module #5http://www.growthhouse.org/stanford

Obstruction/Opioids

• Constipation = most common cause

• External or internal obstruction

• Mediated by mechanoreceptors and/or chemoreceptors

• Controversy as to best medication for true bowel obstruction

• Anti-constipation meds for constipation

Module #5http://www.growthhouse.org/stanford

Mind

• Memory, meaning, and emotions can be very powerful

• Manipulate taste and other senses

Module #5http://www.growthhouse.org/stanford

Dysmotility

• Multiple causes

– Upper intestinal dysmotility is very common

• Prokinetics:

– Metoclopramide (upper only)

– Senna (lower only)

Module #5http://www.growthhouse.org/stanford

Infection/Irritation

• Mediated through chemoreceptors

• Gut and adjacent organ inflammation can trigger

• Anticholinergic/antihistaminic medications can help

Module #5http://www.growthhouse.org/stanford

Toxins

• Most important source: medications

• Various mechanisms of inducing nausea

• Treatment depends on mechanism of action

Module #5http://www.growthhouse.org/stanford

Opioid-Related Nausea

• Incidence of dysmotility caused by opioids may be underestimated

• Haloperidol recommended for nausea related to chemoreceptor trigger zone (CTZ)

Module #5http://www.growthhouse.org/stanford

5HT3 Antagonists

• May have a variety of uses

• Minimally tested outside of their use in chemotherapy-related nausea

• Expensive

Module #5http://www.growthhouse.org/stanford

Symptom Analysis Checklist

• Physiological Factors

– Local

– Central

• Mental

– Cognitive

– Affective

– Spiritual

Module #5http://www.growthhouse.org/stanford

Exercise 1: The Runner

• Are you dyspneic? Short of breath?

• What is your O2 saturation level?

• What is happening locally in you chest?

• What do you think about your run?

• Any spiritual importance?

• Are you suffering?

Module #5http://www.growthhouse.org/stanford

Exercise 2: Being Held Under Water

• Are you dyspneic? Short of breath?

• What is your O2 saturation level?

• What is happening locally in you chest?

• What do you think about your run?

• Any spiritual importance?

• Are you suffering?

Module #5http://www.growthhouse.org/stanford

Exercise 3: Lung Cancer

• Imagine that you have lung cancer, on top of pre-existing COPD

• You are getting winded with the least possible exercise.• Coming back from the bathroom to the bed you are now

very dyspneic• You wish there was a window you could open

• The nurse measures your O2 Sat

• There is a low-pitched beeping sound, which you know is not good

• The nurse looks distressed and rushes from the room

Module #5http://www.growthhouse.org/stanford

Treating Dyspnea

Physiological FactorsLocal: Fan, cool breeze

Central: WOB may be particularly responsive to low dose opioids

Mental factorsCognitive: Education, reframing

Affective: Emotional support, benzodiazepines for panic sensation

Module #5http://www.growthhouse.org/stanford

Dyspnea in the Dying

• Common

- 70% of patients in last 6 weeks of life

Reuben & Mor, 1986• Care has traditionally focused more on lung

physiology than central processes

• Not always correlated with oxygen level

Module #5http://www.growthhouse.org/stanford

‘Terminal Syndrome Characterized by Retained Secretions’

• Relative lack of cough

• Not always associated with dyspnea

• Deep suctioning ineffective

• Hydration may flood lungs

– Because patient is unable to cough

• Use of antibiotics, IV fluids controversial

Module #5http://www.growthhouse.org/stanford

Treatment of this Terminal Syndrome

• Peaceful environment• For dyspnea

– Opioid-naïve: 2-4 mg SC morphine or equivalent q1-2 hours

– On opioid: increase dose by 25%– Lorazepam or chlorpromazine for agitation

• For secretions• Oxygen, fan

Module #5http://www.growthhouse.org/stanford

Case Exercise

Imagine you have advanced pancreatic cancer. You’ve lost 30 pounds over the past few months. There is no evidence of GI obstruction and you are not nauseated. You are very weak, and are now bedridden, with no appetite. Your mouth is dry. Your spouse keeps trying to get you to eat and you try, but you just can’t do it. You keep wondering why this is happening, and your spouse is very upset. You are admitted to the hospital and lab tests reveal that you are dehydrated. The intern comes to insert an IV.

Module #5http://www.growthhouse.org/stanford

Definitions

• Cachexia = physical wasting

• Anorexia = lack of appetite

• Asthenia = weakness, fatigue

Module #5http://www.growthhouse.org/stanford

Physiological Mechanisms

• Complex physiology

• Best studied in cancer

• Key finding: Not the same as starvation

– Significant physiological differences

• Often not reversed by artificial feeding

Module #5http://www.growthhouse.org/stanford

Cachexia/Anorexia/Asthenia

• Strongly correlated with decreased functional status

• Associated with multiple losses- Appetite and pleasure in eating

- Energy level

- Independence

- Activities of daily living

Module #5http://www.growthhouse.org/stanford

Medical Interventions

• Treat underlying nausea, pain, depression

• Artificial feeding may or may not be appropriate

• To increase appetite– Megestrol acetate

– Steroids

– Cannabinoids

• Transfusion for anemia– May or may not improve asthenia

Module #5http://www.growthhouse.org/stanford

Psychological Interventions

Treat underlying depression

Address loss in patient and family– Reflect back losses of nurturing, functional status and

independence

– Help patient/family redefine these losses

Coach in new ways to nurture

Consider therapies to compensate for functional loss

Module #5http://www.growthhouse.org/stanford

Artificial Hydration at the End of Life is Controversial

Module #5http://www.growthhouse.org/stanford

Brainstorm

• What are some arguments on both sides of the EOL artificial hydration controversy?

Module #5http://www.growthhouse.org/stanford

Some Arguments...

In Favor:• Minimum standard of care• ? Greater comfort• ? Less confusion,

restlessness

Against:• Not clear that it prolongs

life• Increases urine output, GI

secretions/nausea, & pulmonary secretions with pneumonia

• Not clear that it alleviates thirst

• Decreasing fluids acts as natural anesthesia

Module #5http://www.growthhouse.org/stanford

Medical Issues Aside…

• Some prefer a more ‘natural death’ without artificial hydration

• Others may see hydration as minimal, humane (if technical) support

• Important to take patient goals and situation into account

Module #5http://www.growthhouse.org/stanford

Learning Objectives

• Increase understanding of how physical and mental factors affect symptomatology

• Be able to use this understanding in the treatment of patients suffering from nausea and vomiting, dyspnea, and cachexia/anorexia/asthenia

• Incorporate this content into your clinical teaching