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Module #5 END-OF-LIFE CARE: Module 5 Non-Pain Symptom Management.

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Presentation on theme: "Module #5 END-OF-LIFE CARE: Module 5 Non-Pain Symptom Management."— Presentation transcript:

1 Module #5 END-OF-LIFE CARE: Module 5 Non-Pain Symptom Management

2 Module #5 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.

3 Module #5 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

4 Module #5 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

5 Module #5 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

6 Module #5 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?

7 Module #5 From the Patient’s Perspective A symptom is what is bothersome

8 Module #5 Symptom Analysis Checklist Physiological Factors Local Central Mental Factors Cognitive Affective Spiritual

9 Module #5 Skills Practice: Patient with pain symptoms due to metastatic bone cancer Physiological factors Local: Central: Mental Factors Cognitive: Affective: Spiritual:

10 Module #5 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

11 Module #5 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?

12 Module #5 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

13 Module #5 A Central Final Pathway for Nausea CTZ Vestibular Apparatus CNS GI Tract VOMIT CENTER (Acetylcholine, Histamine) (???)(Dopamine, Serotonin) (Acetylcholine, Histamine) (Acetylcholine, Histamine, Serotonin + mechanoreceptors)

14 Module #5 Receptor Affinity Common Antiemetics DrugReceptors DopamineMusc. Chol.Histamine Scopalomine >10,000.08>10,000 Promethazine Prochlorperazine Chlorpromazine Metoclopramide270>10,0001,000 Haloperidol4.2>10,0001,600 Potency: K1 (nanomolar) The lower the number, the stronger this agent is at blocking this receptor Adapted from Peroutka and Snyder, 1982

15 Module #5 Causes of Nausea & Vomiting Vestibular Obstruction Mind Dysmotility Infection (irritation) Toxins (taste and other senses)

16 Module #5 Vestibular Apparatus Nausea with head movement Medicated by acetylcholine and histamine receptors Most anticholinergic, antihistamine drugs will help

17 Module #5 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

18 Module #5 Mind Memory, meaning, and emotions can be very powerful Manipulate taste and other senses

19 Module #5 Dysmotility Multiple causes –Upper intestinal dysmotility is very common Prokinetics : –Metoclopramide (upper only) –Senna (lower only)

20 Module #5 Infection/Irritation Mediated through chemoreceptors Gut and adjacent organ inflammation can trigger Anticholinergic/antihistaminic medications can help

21 Module #5 Toxins Most important source: medications Various mechanisms of inducing nausea Treatment depends on mechanism of action

22 Module #5 Opioid-Related Nausea Incidence of dysmotility caused by opioids may be underestimated Haloperidol recommended for nausea related to chemoreceptor trigger zone (CTZ)

23 Module #5 5HT3 Antagonists May have a variety of uses Minimally tested outside of their use in chemotherapy-related nausea Expensive

24 Module #5 Symptom Analysis Checklist Physiological Factors –Local –Central Mental –Cognitive –Affective –Spiritual

25 Module #5 Exercise 1: The Runner Are you dyspneic? Short of breath? What is your O 2 saturation level? What is happening locally in you chest? What do you think about your run? Any spiritual importance? Are you suffering?

26 Module #5 Exercise 2: Being Held Under Water Are you dyspneic? Short of breath? What is your O 2 saturation level? What is happening locally in you chest? What do you think about your run? Any spiritual importance? Are you suffering?

27 Module #5 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 O 2 Sat There is a low-pitched beeping sound, which you know is not good The nurse looks distressed and rushes from the room

28 Module #5 Treating Dyspnea Physiological Factors Local: Fan, cool breeze Central: WOB may be particularly responsive to low dose opioids Mental factors Cognitive: Education, reframing Affective: Emotional support, benzodiazepines for panic sensation

29 Module #5 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

30 Module #5 ‘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

31 Module #5 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

32 Module #5 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.

33 Module #5 Definitions Cachexia = physical wasting Anorexia = lack of appetite Asthenia = weakness, fatigue

34 Module #5 Physiological Mechanisms Complex physiology Best studied in cancer Key finding: Not the same as starvation –Significant physiological differences Often not reversed by artificial feeding

35 Module #5 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

36 Module #5 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

37 Module #5 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

38 Module #5 Artificial Hydration at the End of Life is Controversial

39 Module #5 Brainstorm What are some arguments on both sides of the EOL artificial hydration controversy?

40 Module #5 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

41 Module #5 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

42 Module #5 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


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