Presentation on theme: "Palliative Management Of:"— Presentation transcript:
1 Palliative Management Of: Nausea And VomitingDyspneaSecretionsDeliriumMike Harlos MD, CCFP, FCFPMedical Director, WRHA Palliative CareProfessor, University of Manitoba Faculty of Medicine
2 MECHANISM OF NAUSEA AND VOMITING vomiting centre in reticular formation of medullaactivated by stimuli from:Chemoreceptor Trigger Zone (CTZ)area postrema, floor of the fourth ventricleoutside blood-brain barrier (fenestrated venules)Upper GI tract & pharynxVestibular apparatusHigher cortical centres
4 Chemoreceptor Trigger Zone Stimuli Of Vomiting PathwaysChemoreceptor Trigger ZoneVestibularCorticalPeripheraldrugsopioidschemoTxetc...biochemical Ca++renal failureliver failuresepsisradiotherapytumoranxietyassociation ICPchemotherapyGI irritationinflammationobstructionparesiscompression
5 PRINCIPLES OF TREATING NAUSEA & VOMITING Treat the cause, if possible and appropriateEnvironmental measuresAntiemetic use:anticipate need if possibleuse adequate, regular dosesaim at presumed receptor involvedcombinations if necessaryanticipate need for alternate routes
6 Chemoreceptor trigger zone StimulusAreaReceptorsDrugs,MetabolicChemoreceptor trigger zoneMotion,PositionVestibularVisceralOrgans? Non-specificCNS↑ ICPCerebral cortexD25HTM5HTH1MH1VOMITINGCENTRED25HTCB1H1EffectorOrgansD25HTH1MCB1DopamineSerotoninHistamineMuscarinicCannabinoid
7 E S Antonarakis and R D W Hain From:Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practiceArch. Dis. Child. 2004;89;E S Antonarakis and R D W Hain
9 An uncomfortable awareness of breathing DYSPNEA:An uncomfortable awareness of breathing
10 “...the most common severe symptom in the last days of life” DYSPNEA:“...the most common severe symptom in the last days of life”Davis C.L. The therapeutics of dyspnoea Cancer Surveys 1994 Vol.21 p
11 National Hospice Study Dyspnea PrevalenceReuben DB, Mor V. Dyspnea in terminally ill cancer patients.Chest 1986;89(2):234-6.
12 Approach To The Dyspneic Palliative Patient Two basic intervention types:Non-specific, symptom-orientedDisease-specific
13 Simple Non-Specific Measures In Managing Dyspnea calm reassurancepatient sitting up / semi-reclinedopen windowfan
14 Non-Specific Pharmacologic Interventions In Dyspnea Oxygen - hypoxic and ? non-hypoxicOpioids - complex variety of central effectsChlorpromazine or Methotrimeprazine - some evidence in adult literature; caution in children due to potential for dystonic reactionsBenzodiazepines - literature inconsistent but clinical experience extensive and supportive
15 TREAT THE CAUSE OF DYSPNEA - IF POSSIBLE AND APPROPRIATE Anti-tumor: chemo/radTx, hormone, laserInfectionAnemiaCHFSVCOPleural effusionPulmonary embolismAirway obstruction
17 Opioids in Dyspnea Uncertain mechanism Comfort achieved before resp compromise; rate often unchangedOften patient already on opioids for analgesia; if dyspnea develops it will usually be the symptom that leads the need for titrationDosage should be titrated empirically; may easily reach doses commonly seen in adultsMay need rapid dose escalation in order to keep up with rapidly progressing distress
18 A COMMON CONCERN ABOUT AGGRESSIVE USE OF OPIOIDS IN THE FINAL HOURS How do you know that the aggressive use of opioids for pain or dyspnea doesn't actually bring about or speed up the patient's death?
19 SUBCUTANEOUS MORPHINE IN TERMINAL CANCER Bruera et al. J Pain Symptom Manage ; 5:
20 Typically, with excessive opioid dosing one would see: pinpoint pupilsgradual slowing of the respiratory ratebreathing is deep (though may be shallow) and regular
21 COMMON BREATHING PATTERNS IN THE FINAL HOURS Cheyne-StokesRapid, shallow“Agonal” / Ataxic
23 Secretions - Prevalence At Study Entry And In Last Month Of Life UK Children’s Cancer Study Group/Paediatric Oncology Nurses Forum Survey Goldman A et al; Pediatrics 2006; 117;
24 Managing Secretions in Palliative Patients Factors influencing approach management:Oral secretions vs.. lower respiratoryLevel of alertness and expectations thereofProximity of expected death“Death Rattle” – up to 50% in final hours of lifeAt times the issue is more one of creating an environment less upsetting to visiting family/friendsSuctioning: “If you can see it, you can suction it”SuctioningIncreasedSecretionsMucosalTrauma
25 CONGESTION IN THE FINAL HOURS “Death Rattle”PositioningANTISECRETORY: Scopolamine, glycopyrrolateConsider suctioning if secretions are:distressing, proximal, accessiblenot responding to antisecretory agents
26 Atropine Eye Drops For Palliative Management Of Secretions Atropine 1% ophthalmic preparationLocal oral effect for excessive salivation/droolingDose is usually 1 – 2 drops SL or buccal q6h prnThere may be systemic absorption… watch for tachycardia, flushing
28 DefinitionEtiologically non-specific global cerebral dysfunction associated with changes in LOC, attention, thinking, perception, memory, psychomotor behavior, emotion and the sleep/wake cycle
29 DSM-IV CriteriaChange in consciousness with reduced ability to focus, sustain or shift attentionChange in cognition (e.g., memory, disorientation, change in language, perceptual disturbance) that is not dementiaAbrupt onset (hours to days) with fluctuationEvidence of medical condition judged to be etiologically related to disturbance
30 Characteristics Abrupt onset Disorientation, fluctuation of symptoms Hypoactive vs.. hyperactive (restlessness, agitation, aggression) vs. mixedChanges in sleeping patternsIncoherent, rambling speechFluctuating emotionsActivity that is disorganized and without purpose
31 Delirium Types confusion, somnolence, alertness Hypoactiveconfusion, somnolence, alertnessHyperactiveagitation, hallucinations, aggressionMixed (>60%)features of both
32 Prevalence of Delirium 20% - 44% on admission to a palliative care unit (common reason for admission)28% - 45% of patients developed delirium while on the palliative care unit68% - 90% prior to deathLawlor et al (J Pall Care 1998)n = 103 pts50% of episodes reversibleTerminal delirium in 88%Hyperactive (5%) vs. hypoactive (47%)Mixed (48%) most common
33 Delirium versus Dementia Delirium DementiaAbrupt onset Insidious onsetDecreased/Fluctuating LOC LOC intact, alertErratic behaviour Consistent behaviourSleep/wake cycle change Minimal changesReversible (theoretically) Irreversible
34 Causes Of Delirium In Palliative Care TumourPrimary, metastatic, leptomeningeal, paraneoplastic syndromeMetabolic / physiologichypercalcemiaHyponatremia (hypernatremia less commonly)↑ or ↓ glucoseanemia, hypoxiaCO2Renal or liver failureInfection – UTI, pneumonia, biliary tract, woundsMedication administration – opioids, antiemetics (esp. anticholinergic), sedatives, antisecretoryMedication / Drug withdrawalEtc…..
35 Management Of Delirium In Palliative Care EnvironmentalQuite, private setting: single room if possibleLow lighting, calendar, clock, familiar objectsMinimal room changes with unnecessary distractionsFix the Fixable – if possible and appropriateHelp family navigate complex choices and non-choices, dictated by how the patient would guide care if that were possibleEffective sedation – with frank discussion of anticipated courseIf delirium irreversible, goal of care is sedationSedation does not hasten the dying processWill facilitate meaningful visitingEncourage communication, even though patient not interactive
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