e l n e c objectives · 2020. 12. 16. · 3/19/2019 1 e l n e c end-of-life nursing education...

3/19/2019

1

CENLEEnd-of-Life Nursing Education Consortium

SuperCore Curriculum

Symptom Management, Part 1

Judy Fihn, RN, OCN, CHPNPalliative Care Nurse

Seattle Cancer Care Alliance

[email protected] N E CL SuperCore Curriculum

Objectives

Identify common symptoms associated with end of life processes

Describe the role of the nurse in managing symptoms that commonly occur at end of life

E N E CL SuperCore Curriculum

Common Symptoms at End of Life

Constipation

Diarrhea

Lymphedema

Edema

Ascites

Fever

Seizures

Fatigue

Depression

Dyspnea

Cough

Anxiety

Delirium/Agitation & Confusion

Anorexia & Cachexia

Nausea & Vomiting

Wounds


“Life is pleasant.

Death is peaceful.

It’s the transition that is troublesome.”

Isaac Asimov (1920-1992)


Approach to Symptom Management

Ongoing assessment required

Symptoms create suffering and distress

Interdisciplinary teamwork needed

Psychosocial approaches must complement the pharmacological therapies

Patient and family support!

Symptoms are very distressing, especially at EOL

Reimbursement concerns

Research needed

EOL = end of lifeE N E CL SuperCore Curriculum

“We have to concern ourselves with the quality of life as well as its length.”

Dame Cicely SaundersFounder of the modern hospice movement

3/19/2019

2


Constipation - Definition

Infrequent passage of stool

Frequent symptom in palliative care 10% of general population

50-80% of “ill adults”

Patient may be too embarrassed to discuss

Vigilance and prevention the KEY!!

ELNEC Super-Core

Quill TE, et al. Primer of Palliative Care, 5th ed. 2010. p. 65.


Goal for Bowel Passages

Stool that is

Soft

Formed

Easy to pass without straining

Every day or every other day


Causes of Constipation at EOL

• Obstruction: GI, ovarian, bulky tumors (sarcoma)• Lifestyle: Inactivity, decreased food & fluid intake• Hypercalcemia, hypokalemia• Surgical adhesions• Neurological: Spinal cord compression• Other conditions: Diabetes, gastroparesis• Drugs

• Opioids• Some antidepressants• Other drugs: ondansetron!• Certain chemotherapies

• vinka alkaloids, cisplatin, thalidomide


Assessment of Constipation

• Bowel history• Abdominal assessment

• Bowel sounds, tenderness, distention, tympany

• Rectal exam• Avoid in neutropenia/thrombocytopenia

• Medication review• Rule out bowel obstruction before starting

treatment• Diarrhea: consider “overflow diarrhea” as cause

• and ask if taking Lomotil!


Bowel Exam

Stool in vault -> disimpactionPremedicate with a benzodiazepine

Avoid if neutropenic or thrombocytopenic

Hard stool impaction -> soften with oil retention enema

Soft stool impaction -> dulcolax suppository or large volume saline enema

Aggressive prevention is needed to avoid impaction

Quill. Primer of Palliative Care, p. 65


Treatment of Constipation

• Medications

• Dietary changes• Generally avoid fiber in advanced disease

• Adequate fluid intake (if able)

• Exercise (if tolerated)

• Other approaches• Abdominal Massage

• Avoid if abdominal tumors

3/19/2019

3


Constipation Medications

Osmotic laxative Polyethylene glycol (MiraLax) Lactulose, sorbitol

Stimulant/Irritant Senna, Bisacodyl

Magnesium salts (“saline”) Magnesium hydroxide (MOM), Magnesium citrate

Prokinetic Agents Metoclopramine (Reglan)

Lubricant mineral oil

(Note: Fiber bulking agents such as psyllium (Metamucil®) or Citrucel® are typically not used in advanced disease)

“Push”

“Gush”


Methylnaltrexone (Relistor®)Movantik (Naloxogel)

Opioid Antagonist Indicated for opioid-induced constipation in advanced

disease Dosed based on weight

38-61 kg (84-135 lb): 8 mg (0.4 cc)

62-114 kg (136-251 lb): 12 mg (0.6 cc)

Relistor: Subcutaneous injection q48 hrs May repeat in 24 hrs if no results Also available as a tablet

Movantik: Oral Tablet 48% have BM within 4 hrs of 1st injection (15% placebo) ADE: abd cramping, nausea, flatulence Contraindicated if bowel obstruction suspected


Constipation: Home RemedyMilk and Molasses Enema

8 oz warm water

3 oz powdered milk

4.5 oz molasses

Put water and milk into plastic jar with lid. Cover and shake until mixed. Add molasses and shake until well mixed and uniform color

Pour in enema bag. Administer “high” enema, gently pass 12” into rectum. Do not push beyond resistance. Repeat every 6 hours until good results are achieved.

Textbook of Palliative Nursing. 2006. p. 226


Patient Education

Opioids must be linked to a bowel program!

“Mush, Push, and Gush”

Use regularly, cannot use “prn”

Need a “maintenance” bowel program and a “treatment” program

Care team should be proactive in asking about the bowels, especially if patient is on opioids


Malignant Bowel Obstruction

Occlusion of lumen or absence of normal propulsion

Becomes a self-perpetuating phenomenon

Distension causes increased secretions, which causes bacterial overgrowth, leading to more distension

Signs/symptoms

pain, colic, nausea/vomiting, absent or hyperactive bowel tones, borborygmi, abdominal distension

flat/upright abdominal films

Treatment: consider goals of care Bowel rest, IVF, NG tube; surgery-colostomy; gastric or colonic stent.

Textbook of Palliative Nursing. 2006. p. 222-4

3/19/2019

4


Diarrhea: Definition

• Increase in stool volume and liquidity resulting in 3 or more BM per day

• Significant effect on Quality of Life

• fatigue, dehydration, skin breakdown• caregiver burden

• fear of leaving home


Causes of Diarrhea

• Disease related• HIV, GVHD post-transplant, GI tract infection (C diff)

• Malabsorption• Short bowel syndrome post operative Whipple

• Concurrent diseases• Lactose intolerance, irritable bowel syndrome

• Psychological

• Treatment related• Radiation, biologicals, overuse of bowel program

• Constipation• “overflow diarrhea”


DiarrheaMore than you ever wanted to know

Osmotic: enteral feeding soln, enterocolic fistula, hemorrhage into bowel (blood is osmotic laxative)

Secretory: mechanical damage to GI cells from chemotherapy and radiation. Carcinoid, other tumors Most difficult type to control

Hypermotile: partial bowel obstruction can cause reflex hypermotility. Biliary/pancreatic obstruction, chemotherapy

Exudative: Inflammation from radiation, releases prostaglandins



Assessment of Diarrhea

• Bowel history• What does “diarrhea” mean to the patient? • Is this actually constipation?

• Medication review• Dietary changes

• High fat, high sugar, high spice• Street vendor, buffets

• Infectious processes• Clostridium difficile most common • Giardia


Treatment of Diarrhea

Treat the underlying cause

Dietary modifications Clear liquids, toast, bland diet

Hydration

Pharmacological agents• Opioids: Tincture of opium .6 cc q4-6 hr, loperamide

(Imodium), Lomotil• Absorbents: pectin, aluminum hydroxide• Octreotide (Sandostatin) for secretory diarrhea from

endocrine tumors, GVHD, post bowel resection

• Avoid overtreating→ constipation


Homemade Electrolyte Replacement Solution

1 tsp salt

1 tsp baking soda

1 tsp corn syrup

6 oz frozen Orange Juice concentrate

6 cups water


3/19/2019

5


Edema

Causes: Bulky tumor compression of lymphatic and venous return

Hypoalbuminemia

cardiac/hepatic/renal disease

Medication (steroids)

Consider thrombosis, infection

Workup as appropriate for goals of care

Treatment:

elevation, compression, diuretics, sodium restriction


Lymphedema

Chronic, progressive swelling due to failure of lymph drainage

Risk of infection and cellulitis

Lymphedema is different than edema Primary lymphedema is usually

asymmetrical

Change in skin texture

Fibrosis

Rule out DVT, CHF, medications


“Secondary” Lymphedema

Breast cancer treatment is the most common cause

Highest risk: axillarynode dissection

Sentinel node biopsy has reduced risk

Other cancers

Lymphoma, head/neck

Radiation

Lower extremity

Cervical, endometrial, ovarian, prostate, gastrointestinal cancers

Inguinal node dissection


Treatment of Lymphedema

Early Diagnosis

Compression garments

Bandaging

Manual lymphatic drainage (MLD)

Sequential compression devices

Elevation

Education Avoid prolonged arm constriction (shopping bags)

Discuss exercise plan/weight lifting with PT or MD

Check skin integrity daily

Expect worsening in hot weather, plane flights, hot tubs

Very difficult to treat in advanced and progressive cancer


Ascites

Symptoms

Abdominal bloating & fullness

Pain

◼ Not very responsive to opioids

Nausea/vomiting

Increased water weight

Heartburn

Dyspnea

Orthopnea

Scrotal/labial edema

Significant impact on quality of life


Treatment of Ascites

Diuretics In proportion: Furosemide 20 mg to Spirinolactone 50 mg

Diet Free water restriction Low sodium diet

Interventional Paracentesis Peritoneal catheter for daily draining

Cirrhotic and cardiac ascites are more responsive to diuretics and dietary measures

Malignant ascites is less responsive to these treatments

3/19/2019

6


Seizures: Causes

Tumors

Primary and Secondary (metastatic)

Infections

Trauma

HIV

Medications

Metabolic imbalances


Tumor Types Likely to Spread to the Brain

Lung 48%

Breast 15%

Genitourinary 11%

Osteosarcoma 10%

Melanoma 9%

Head and Neck 6%

GI: Colorectal/pancreatic 3%


Assessment for Seizures

Manifestations Absence seizure

Partial-complex ◼ Most common in Palliative/EOL setting

Generalized (tonic-clonic, grand mal) ◼ Loss of consciousness

◼ May have loss of bladder and bowel control

Mental status changes

Sensory changes

Physical and neurological exam

Labs: CBC, Metabolic panel, alcohol/drug screen


Treatment for Seizures

Limit trauma

Anticonvulsant treatments

Phenytoin

Phenobarbital

Lorazepam, diazepam

Steroids

Patient and caregiver education

Assess impact on caregiver

Observing a seizure is traumatic


Fevers

Definition: > 100 F

Causes

Infection

◼ Pneumonia, UTI, abscess, HIV

Tissue injury

Altered thermoregulation

◼ Very common in the last days of life


Assessment/Treatment of Fevers

Clinical Flushing

Malaise/fatigue

Rigors/shaking

Treatment Antibiotics

◼ If congruent with goals of care

Antipyretics

Avoid aggressive cooling measures-may cause shivering and worsen fever

No treatment is needed if EOL and patient is comfortable

3/19/2019

7


Fatigue

Disease related

Psychological

Depression/anxiety

Sleep disorder

Treatment related

Chemo/rad/surgery

Anemia

Medication induced

◼Opioids, benzodiazepines


Treatment of Fatigue

Realistic goals for activity level

“Pacing” of activities

Sleep Hygiene

Medications

Stimulants: Caffeine, methylphenidate (Ritalin®), modafinil (Provigil®)

Antidepressants

Sleeper


Depression

• Ranges from sadness to suicidal• Often unrecognized & undertreated• Occurs in 25-77% of terminally ill• Distinguish normal vs. abnormal

• Persistent feelings of helplessness, hopelessness, inadequacy, depression and suicidal ideation are not normal at the end of life

• Should not be dismissedWilson et al., 2000


Causes of Depression

• Disease related• Pain, metabolic

• Psychological• Existential factors

related to impending death

• Changes in body image• Pre-existing conditions• Social/ Financial issues

• Medication related• Chemo, steroids, HTN

• Treatment related• Brain radiation


Risk Factors for Depression

• Male, over 45

• Living alone

• Social isolation

• Uncontrolled pain

• Presence of multiple deficits• Bed bound

• Loss of bowel/bladder control

• Inability to eat


Depression Assessment

“Vegetative” symptoms of depression are unreliable at end-of-life Weight loss, anorexia, excessive sleeping, low energy Standard depression scales not reliable

More reliable symptoms Depressed appearance Fearfulness, withdrawal◼ (However, these may be present as EOL approaches)

Sense of guilt, self-pity, or sense of punishment Mood that cannot be improved with good news or

happy occasions◼ Such as the grandchildren coming to visit

3/19/2019

8


Depression Screening Questions

• Do you think you are depressed?

• How have your spirits been lately?

• Are you able to find pleasure in life?

• What do you see in your future?

• What is the biggest problem you are facing?


Depression: Pharmacological

• Antidepressants• SSRI, SNRI, TCA

• Take 2-6 weeks to have an effect on mood

• Stimulants• Methylphenidate (Ritalin®)

• Steroids• Dexamethasone (Decadron®)


Nursing Role in Depression

• Promote autonomy

• Draw on patient’s strengths

• Cognitive strategies• Relaxation, imagery, self-hypnosis, mindfulness,

breathing exercises

• Grief counseling

• Patient/family teaching• Destigmatize diagnosis and treatment


Increased Suicide Risk

Cancer Type Oral, pharyngeal, lung cancer

The strongest predictors of suicide risk is Past history of suicide attempt Current psychiatric disorder Current depression Alcohol abuse

Psychosocial Male Socially isolated Perceived poor health Chronic progressive illness Recently received bad news (new diagnosis or disease

progression) Recent loss of relationship


Suicide Assessment

• Do you think life isn’t worth living?• Have you thought about harming

yourself?• How would you harm/kill yourself?• Arrange for immediate assessment if:

• Clear intent to harm self• Clear plan to harm self• Access to complete the plan

• e.g. have access to a gun


Conclusion

Multiple symptoms are common in advanced disease and at end-of-life

Multidisciplinary approach is best

Both pharmacological and non-pharmacological treatments are helpful

The nursing role is essential in providing patient/family teaching and support

e l n e c objectives · 2020. 12. 16. · 3/19/2019 1 e l n e c end-of-life nursing education...

Documents