1. Common Physical Symptoms at the End of Life: Pulmonary and GI Symptoms Mike Marschke, MD

2. Mr. M - Chronic Smoker Mr. M, 78 YO, is a lifetime smoker. Dyspnea began 5 years ago. intubated twice in the past year. Since last admission 2 mos ago always needs 2-3 l/min nasal cannula oxygen, even at rest. He has lost 15 lbs, has a persistent cough, with gray phlegm He is on steroids and nebulizers

3. What is Dyspnea? Subjective sense that you need to breath, that you ‘hunger air.’ Mechanism Respiratory Center of Medulla Chemo receptors sensing low O2, hi CO2 Mechano receptors (J receptors) in lung, respiratory muscles, and diaphragm Vascular congestion-CHF Cerebral Cortex

4. Measurements? pO2, pCO2, O2 sats Peak flows Pulmonary function tests measuring lung volumes and flow Prognosis < 6 mos. :  Class IV respiratory failure (= dyspnea at rest)  Frequent ER/hospital stays, recurring pulmonary infections, intubations  pO2 50

5. Dr. arrives Mr. K is sitting in a reclining chair. Feels “breathless” with minimal exertion. Breathing is “heavy and suffocating”. No apparent precipitating infection etc.

6. Evaluation Physical exam- distant breath sounds, coarse crackles at bases bilaterally, RR = 32 at rest, takes breathes in mid- sentence. tachycardic at 100/min Recent Weight loss of 15lbs. in 6 months. 2+ edema bilateral lower extremities

7. The Bargainer Has no wish to be “brutalized”. He knows his emphysema will kill him someday. He has executed a DNR He wants to feel better but does not want to go back into the hospital. What about CXR, labs?

9. Assess cause Complete assessment – may lead to treatable condition. Pleural effusion Pneumothorax Anemia PE CHF Pneumonia

10. CXR Findings Mass occluding R bronchus Post obstruction atelectasis Treatment options Bronchoscopy Radiation Supportive Weigh risk/benefits and patient wishes

11. Oxygen Pulse oximetry not helpful – go on symptoms Potent symbol of medical care Expensive, noisy, hot, uncomfortable for some Fan may do just as well

12. Opioids Relief not related to respiratory rate No ethical or professional barriers Small doses Central and peripheral action Inhaled morphine works peripherally but may induce bronchospasm

13. Anxiolytics Safe in combination with opioids lorazepam 0.5-2 mg po q 1 h prn until settled then dose routinely q 4–6 h to keep settled

14. Nonpharmacologic interventions... Reassure, work to manage anxiety Behavioral approaches, eg, relaxation, distraction, hypnosis Other CAM – aromatherapies (Eucalyptus, Bergomot), massage, healing touch Limit the number of people in the room Open window

15. Nonpharmacologic interventions... Eliminate environmental irritants Keep line of sight clear to outside Reduce the room temperature Avoid excessive temperatures

16. ... Nonpharmacologic interventions Introduce humidity Reposition elevate the head of the bed move patient to one side or other Educate, support the family

17. 4 Weeks Later in Hospice More dyspneic and semi-comatose Lots of upper airway noise with wheezes more prevalent Gets agitated at times, cyanotic Difficult swallowing pills At times when sleeping family feels he is choking to death

18. Final hours of care Educate the family- no surprises Double effect? Oral secretions can be lessened by keeping patient dry, scopalamine patch, levsin (anti-cholenergics) Use opioids/benzodiazepams as needed Suctioning difficult for patient and likely not to be able to get deep enough

19. Gastrointestinal Sx: EOL Anorexia 60-80% Xerostomia 55-70% Nausea 15-30% Vomiting 15-25% Constipation 50% Diarrhea <10%

20. Anorexia Corticosteroids Megestrol acetate Dronabinol Other causes – gastritis/PUD – PPIs, early satiety/reflux – Reglan, oral thrush – anti-fungals. Realize patient usually VERY comfortable with this!

21. Dry Mouth Hyposalivation Mouth care and gum/candy, popsicles Artificial saliva Oral swabs/wash cloth Pilocarpine 5mg tid Mucositis Diphenhydramine, dexamethasone, lidocaine, and nystatin swish and swallow

22. Nausea/vomiting Anxiety, fear, anticipatory, psychologic factors, increased intra-cranial pressure Dopaminergic (narcotic – induced and many others) Serotinergic (chemo induced) Histamine (labrynthitis, meds) Vagally mediated (ulcers, masses, irritations…) Reflux, gastritis, regurgitation, masses, ulcers, gastric outlet obstruction Small bowel obstruction, impaction Renal (pyelonephritis, stones), liver (hepatitis, cirrhosis), gall bladder, uterine…

23. A Mechanistic Approach Central – Increased pressures (tumor, swelling, hydrocephalus) – steroids, RT, surgery Anxiety, fear, anticipatory – benzodiazipines, psychotherapy Chemo-trigger Receptor Zone (narcotics, other meds, many GI causes) Anti-dopaminergics – prochlorperazine (compazine), haloperidol, droperidol, trimethobenzamide (Tigan), metoclopramide (Reglan), promethazine (phenergan) Can be given PO, suppository, some IM/IV, some even in a paste form

24. A Mechanistic Approach Nausea Center (chemotherapy induced) – Anti-serotinergics – ondansetron (Zofran), granisetron (Kytril), dolasetron, palonosetron IV, PO, and expensive Vestibular-ocular reflex (with vertigo) – Anti-histamines – Benedryl, Antivert, Atarax Anti-cholinergics - Scopolamine Oro-pharyngeal vagal – lidocaine swish and swallow, treat the lesion

25. A Mechanistic Approach Gastro-esophageal – Reflux/regurg – prokinetic agents like metoclopramide (reglan), H2 blockers/Proton pump inhibitors Gastritis/ulcers – H2 blockers/PPIs Delayed gastric emptying (narcotics, DM) – metoclopramide Gastric outlet obstruction – NG suction, surgery

26. A Mechanistic Approach Intestinal Obstruction – NG suction, surgery, NPO with Octreotide (Sandostatin) Impaction – remember to check rectal exam – may need manual dis-impaction, enemas Other organs – try to treat underlying cause if possible, may also respond to meds effecting CRZ

27. Other agents for nausea CAM – aromas (peppermint, ginger), herbs (ginger, cola), mind-focusing (meditation), acupuncture Dronabinol (marijuana) Combination suppositories/gels BDR (Benadryl, Decadron, Reglan) Can add ativan, Tigan, compazine and others

28. Constipation Defined: hard, infrequent stools, needing to strain for 10 minutes Uncomfortable feeling Incidence- US nutrition- Male 8% Fem. 21% Hospice 80% Hospice on narcotics 90% Hospital 66%; Home 22%

29. Physiology Meal passes out of stomach into small intestine, with the addition of gastric, pancreatic, and biliary secretions Transit time is 1-2 hrs thru the small intestine, where digestion and absorption takes place Large bowel transit time is 1-3 days, where bulk of water is removed and stool is formed Final BM – when rectal ampula fills, increase abdomenal pressure, relax anal sphincter and “the brown river flows”

30. Constipation – causes: Medications opioids calcium-channel blockers anticholinergic Decreased motility Ileus Mechanical obstruction Diet (lo fiber, hi meat and starch) Metabolic abnormalities (hi Ca) Spinal cord compression Dehydration Autonomic dysfunction (DM) Malignancy

31. Opioids do Two things: Block Bowel (opioid receptors in mesenteric plexus and bowel wall) Decrease propulsion Increase sphincter tone Increase bowel tone Block pain/discomfort with packed bowel

32. Management of constipation General measures establish what is “normal” regular toileting gastrocolic reflex Check impaction – 98% in rectal vault – hard packed in stool to large to evacuate Diet – hi fiber (greens, fruits, bran…), fluids, additive fibers (avoid with opioids at EOL) Specific measures stimulants osmotics detergents lubricants large volume enemas

33. Stimulant laxatives Prune juice Senna (Senokot) Casanthranol (Pericolace) Bisacodyl (Dulcolax) * Good preventatives with opioid use

34. Osmotic laxatives Lactulose or sorbitol Milk of magnesia (other Mg salts) Magnesium citrate Polyethylene Glycol (Miralax) * Good add-ons if stimulants not enough with opioid induced constipation

35. Detergent laxatives (stool softeners) Sodium docusate Calcium docusate Phosphosoda enema prn

36. Prokinetic agents Metoclopramide Cisapride

37. Lubricant stimulants Glycerin suppositories Oils mineral peanut

38. Large-volume enemas Warm water Soap suds

39. Mr. L – 62 yo with Colon cancer Mr. L has end-stage metastatic colon cancer, diagnosed 6 months ago, with liver mets, ascites, carcinomatosis. He failed chemo, now in hospice for 2 wks. Over 2 days he has had persistent vomiting, unrelieved with compazine, steroids, ativan, with reglan making it worse. Over this time his abdomen has become very distended, he has crampy peri- umbilical pain, and he has not had a BM in 7 days. Lately, his vomit smells slightly fecal-like and is brown. He is miserable and wants to die now!

40. Mr. L – exam, tests? PE – In distress - Abdomen distended and tense, tympanitic - Bowel sounds hyper - Abdomen diffusely tender - No stool in vault on rectal, hemoccult negative Tests – KUB and upright abd x-ray shows dilated loops of bowel and multiple air-fluid levels

41. Obstruction Vomiting 90+%, Pain 75% Hyperparastalsis Absent bowel sounds – complications, perforation X-ray - dilated loops, air-fluid levels on upright Contrast only if surgical candidate Consider Surgery

42. Conservative Management Antiemetics Haloperidol, phenothiazines Scopalamine Octreotide - somatostatin Dexamethasone Ativan

43. …Conservative management Anticholinergics Analgesics: Opioids, SQ/IV Consider NG suction (though very uncomfortable) Keep PO intake limited (what goes in must come up!)

44. Hospice emergencies Acute arterial bleed – either GI or pulmonary source (though also could be peripheral artery/aorta) From above – throwing up bright red blood, from below – bright red blood per rectum, from abd aorta – get acute rapid distention of abdomen (left side first), then cold pulseless feet Usually the end catastrophic event but LOTS of anxiety, hard for family to watch, may have acute pain, then passes out Morphine/ativan right away Red towels to hide the blood May need emergent hospitalization for family sake