1. Palliative Management Of:
Nausea And Vomiting
Dyspnea
Secretions
Delirium
Mike Harlos MD, CCFP, FCFP
Medical Director, WRHA Palliative Care
Professor, University of Manitoba Faculty of Medicine

2. MECHANISM OF NAUSEA AND VOMITING
vomiting centre in reticular formation of medulla
activated by stimuli from:
Chemoreceptor Trigger Zone (CTZ)
area postrema, floor of the fourth ventricle
outside blood-brain barrier (fenestrated venules)
Upper GI tract & pharynx
Vestibular apparatus
Higher cortical centres

3. Cortex
CTZ GI
VOMITING
CENTRE
Vestibular

4. Chemoreceptor Trigger Zone
Stimuli Of Vomiting Pathways
Chemoreceptor Trigger Zone
Vestibular
Cortical
Peripheral
drugs
opioids
chemoTx
etc...
biochemical
­ Ca++
renal failure
liver failure
sepsis
radiotherapy
tumor
anxiety
association
­ ICP
chemotherapy
GI irritation
inflammation
obstruction
paresis
compression

5. PRINCIPLES OF TREATING NAUSEA & VOMITING
Treat the cause, if possible and appropriate
Environmental measures
Antiemetic use:
anticipate need if possible
use adequate, regular doses
aim at presumed receptor involved
combinations if necessary
anticipate need for alternate routes

6. Chemoreceptor trigger zone
Stimulus
Area
Receptors
Drugs,
Metabolic
Chemoreceptor trigger zone
Motion,
Position
Vestibular
Visceral
Organs
? Non-specific
CNS
↑ ICP
Cerebral cortex D 2
5HT M
5HT H1 M H1
VOMITING
CENTRE D 2
5HT
CB1 H1
Effector
Organs D 2
5HT H1 M
CB1
Dopamine
Serotonin
Histamine
Muscarinic
Cannabinoid

7. E S Antonarakis and R D W Hain
From:
Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice
Arch. Dis. Child. 2004;89;
E S Antonarakis and R D W Hain

8. Dyspnea In Palliative Care

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 Prevalence
Reuben 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-oriented
Disease-specific

13. Simple Non-Specific Measures In Managing Dyspnea
calm reassurance
patient sitting up / semi-reclined
open window
fan

14. Non-Specific Pharmacologic Interventions In Dyspnea
Oxygen - hypoxic and ? non-hypoxic
Opioids - complex variety of central effects
Chlorpromazine or Methotrimeprazine - some evidence in adult literature; caution in children due to potential for dystonic reactions
Benzodiazepines - literature inconsistent but clinical experience extensive and supportive

15. TREAT THE CAUSE OF DYSPNEA - IF POSSIBLE AND APPROPRIATE
Anti-tumor: chemo/radTx, hormone, laser
Infection
Anemia
CHF
SVCO
Pleural effusion
Pulmonary embolism
Airway obstruction

16. DISEASE-SPECIFIC MEDICATIONS
FOR DYSPNEA
Corticosteroids
obstruction: SVCO, airway
lymphangitic carcinomatosis
radiation pneumonitis
Furosemide
CHF
Antibiotics
Anticoagulation – pulm. embolus
Bronchodilators
Transfusion

17. Opioids in Dyspnea Uncertain mechanism
Comfort achieved before resp compromise; rate often unchanged
Often patient already on opioids for analgesia; if dyspnea develops it will usually be the symptom that leads the need for titration
Dosage should be titrated empirically; may easily reach doses commonly seen in adults
May 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 pupils
gradual slowing of the respiratory rate
breathing is deep (though may be shallow) and regular

21. COMMON BREATHING PATTERNS IN THE FINAL HOURS
Cheyne-Stokes
Rapid, shallow
“Agonal” / Ataxic

22. Palliative Management of Secretions

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 respiratory
Level of alertness and expectations thereof
Proximity of expected death
“Death Rattle” – up to 50% in final hours of life
At times the issue is more one of creating an environment less upsetting to visiting family/friends
Suctioning: “If you can see it, you can suction it”
Suctioning
Increased
Secretions
Mucosal
Trauma

25. CONGESTION IN THE FINAL HOURS
“Death Rattle”
Positioning
ANTISECRETORY: Scopolamine, glycopyrrolate
Consider suctioning if secretions are:
distressing, proximal, accessible
not responding to antisecretory agents

26. Atropine Eye Drops For Palliative Management Of Secretions
Atropine 1% ophthalmic preparation
Local oral effect for excessive salivation/drooling
Dose is usually 1 – 2 drops SL or buccal q6h prn
There may be systemic absorption… watch for tachycardia, flushing

27. Delirium in Palliative Care

28. Definition
Etiologically 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 Criteria
Change in consciousness with reduced ability to focus, sustain or shift attention
Change in cognition (e.g., memory, disorientation, change in language, perceptual disturbance) that is not dementia
Abrupt onset (hours to days) with fluctuation
Evidence 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. mixed
Changes in sleeping patterns
Incoherent, rambling speech
Fluctuating emotions
Activity that is disorganized and without purpose

31. Delirium Types confusion, somnolence,  alertness
Hypoactive
confusion, somnolence,  alertness
Hyperactive
agitation, hallucinations, aggression
Mixed (>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 unit
68% - 90% prior to death
Lawlor et al (J Pall Care 1998)
n = 103 pts
50% of episodes reversible
Terminal delirium in 88%
Hyperactive (5%) vs. hypoactive (47%)
Mixed (48%) most common

33. Delirium versus Dementia
Delirium Dementia
Abrupt onset Insidious onset
Decreased/Fluctuating LOC LOC intact, alert
Erratic behaviour Consistent behaviour
Sleep/wake cycle change Minimal changes
Reversible (theoretically) Irreversible

34. Causes Of Delirium In Palliative Care
Tumour
Primary, metastatic, leptomeningeal, paraneoplastic syndrome
Metabolic / physiologic
hypercalcemia
Hyponatremia (hypernatremia less commonly)
↑ or ↓ glucose
anemia, hypoxia
CO2
Renal or liver failure
Infection – UTI, pneumonia, biliary tract, wounds
Medication administration – opioids, antiemetics (esp. anticholinergic), sedatives, antisecretory
Medication / Drug withdrawal
Etc…..

35. Management Of Delirium In Palliative Care
Environmental
Quite, private setting: single room if possible
Low lighting, calendar, clock, familiar objects
Minimal room changes with unnecessary distractions
Fix the Fixable – if possible and appropriate
Help family navigate complex choices and non-choices, dictated by how the patient would guide care if that were possible
Effective sedation – with frank discussion of anticipated course
If delirium irreversible, goal of care is sedation
Sedation does not hasten the dying process
Will facilitate meaningful visiting
Encourage communication, even though patient not interactive