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Palliative Management Of: Nausea And Vomiting Dyspnea Secretions Delirium Mike Harlos MD, CCFP, FCFP Medical Director, WRHA Palliative Care Professor,

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Presentation on theme: "Palliative Management Of: Nausea And Vomiting Dyspnea Secretions Delirium Mike Harlos MD, CCFP, FCFP Medical Director, WRHA Palliative Care Professor,"— Presentation transcript:

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 Vestibular GI VOMITING CENTRE

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

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 StimulusAreaReceptors Drugs, Metabolic Chemoreceptor trigger zone Motion, Position Vestibular VisceralOrgans ? Non- specific CNS ICP Cerebral cortex D 2 5HT M H1H1H1H1 VOMITING CENTRE Effector Organs Dopamine SerotoninHistamine Muscarinic CB 1 Cannabinoid CB 1 D 2 D 2 5HT H1H1H1H1 H1H1H1H1 H1H1H1H1 M M

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

8 Dyspnea In Palliative Care

9 DYSPNEA: An uncomfortable awareness of breathing

10 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: 1.Non-specific, symptom-oriented 2.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 Anti-tumor: chemo/radTx, hormone, laser Infection Anemia CHF SVCO Pleural effusion Pulmonary embolism Airway obstruction TREAT THE CAUSE OF DYSPNEA - IF POSSIBLE AND APPROPRIATE

16 DISEASE-SPECIFIC MEDICATIONS FOR DYSPNEA Corticosteroids – obstruction: SVCO, airway – lymphangitic carcinomatosis – radiation pneumonitis Furosemide – CHF – lymphangitic carcinomatosis 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. 1990; 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 Childrens 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 A.Change in consciousness with reduced ability to focus, sustain or shift attention B.Change in cognition (e.g., memory, disorientation, change in language, perceptual disturbance) that is not dementia C.Abrupt onset (hours to days) with fluctuation D.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 Hypoactive –confusion, somnolence, alertness Hyperactive –agitation, hallucinations, aggression Mixed (>60%) –features of both

32 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 Prevalence of Delirium

33 Delirium versus Dementia DeliriumDementia 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 1.Tumour Primary, metastatic, leptomeningeal, paraneoplastic syndrome 2.Metabolic / physiologic hypercalcemia Hyponatremia (hypernatremia less commonly) or glucose anemia, hypoxia CO 2 Renal or liver failure 3.Infection – UTI, pneumonia, biliary tract, wounds 4.Medication administration – opioids, antiemetics (esp. anticholinergic), sedatives, antisecretory 5.Medication / Drug withdrawal 6.Etc…..

35 Management Of Delirium In Palliative Care 1.Environmental Quite, private setting: single room if possible Low lighting, calendar, clock, familiar objects Minimal room changes with unnecessary distractions 2.Fix the Fixable – if possible and appropriate 3.Help family navigate complex choices and non-choices, dictated by how the patient would guide care if that were possible 4.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

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