End of Life Symptom Management Dec 3, 2014 Mudit Dabral Rosene Pirrello

Understand concept of death Identify & manage common symptoms Objectives

Everyone will die <10% suddenly >90% prolonged illness Time course unpredictable Need to review the plan regularly Last Hours of Living

Affirms life Regards dying as a normal process Neither hastens nor postpones death Relieves symptoms Palliative Care

Integrates medical, psychological & spiritual aspects of care Is often a support system to patients & family Palliative Care

Anorexia (loss of appetite) Cachexia (Weight loss) Gradual Symptoms

Medications Depression Nausea Dysphagia Odynophagia Any advance disease Anorexia & Cachexia

Reversible causes – Medications side effects Pain Nausea Constipation Depression Anorexia & Cachexia

Lift dietary restrictions Environmental pleasantries Socialization Small portions Oral hygiene Anorexia - Cachexia

Metoclopramide Magesterol acetate Anorexia - Cachexia

? Given up ? Not fighting Fatigue

Little is known about Pathophysiology & treatment Fatigue

Reversible Causes: Medications Dehydration Anemia Electrolyte imbalance Suboptimal sleep Fatigue

Give patient permission to rest Clarify the role of underlying disease Fatigue

Steroids Dexamethasone (2-20mg/d) Psychostimulants (methylphenadate mg q AM & noon) Fatigue

Medications Decreased motility Impaction Mechanical obstruction Dehydration Metabolic (Hypercalcemia, Hypokalemia) Constipation

Treat the cause Laxatives - Stimulants, Osmotic Prokinetics Constipation

Nausea, vomiting Pain

Hospitalized patients: 14%-56% Dying patients 80%-90% Terminal Delirium

End of Life

Can contribute to complicated & prolonged grief disorder Diminishes opportunity for closure of relationships Terminal Delirium

Reversible 50% Pain Constipation Urinary retention Hypercalcemia, Hepatic failure, Hypoxia Infection Dehydration Medications Delirium

Major organ failure Hypoxic encephalopathy Terminal Delirium

Create a familiar environment Reassure family Give permission to die Touch Treatment - Terminal Delirium

Benzodiazepines - Lorazepam, Midazolam Neuroleptics - Haloperidol, Chlorpromazine Treat seizures Treatment - Terminal Delirium

Dyspnea Altered breathing patterns Low tidal volume, Cheyne-Stroke respirations Accessory muscle use Last few reflex respiratory efforts “Death rattle” Respiratory Changes

Fears – Suffocation Support family Oxygen may prolong dying process Purpose of treatment is relief of unpleasant sensation. Respiratory Changes

Opioids (MS mg) Steroids (prednisone 10-20mg 3x a day, Dexamethasone 8 mg per day) Anxiolytics (Lorazepam 0.5-2mg q 6 hrs) Diuretics Bronchodilators Anticholinergics (scopolamine patch, Glycopyrrulate 1 mg-2mg q 6-8hrs ) Dyspnea - Treatment

Care in the last hours is as important as at any other time in life Overall Message

QUESTIONS?