1. Palliative Care: Goals and Nonpain Symptom Management Leigh Vaughan, MD Medical University of South Carolina March 6, 2012

2. Outline Definition of PC Definition of PC Goals of PC Goals of PC Who should be considered for PC Who should be considered for PC Symptoms identified in PC Symptoms identified in PC Management and treatment options Management and treatment options

3. Learning Objectives Define palliative care. Define palliative care. Determine effective management strategies for palliative care patients. Determine effective management strategies for palliative care patients. Process strategies for prevention and treatment of complications from palliative care interventions. Process strategies for prevention and treatment of complications from palliative care interventions. Assess the impact of interventions on patient comfort and prognosis. Assess the impact of interventions on patient comfort and prognosis. Recognize and address the psychosocial effects of life threatening illness in hospitalized patients. Recognize and address the psychosocial effects of life threatening illness in hospitalized patients. Assess and respond to patient's symptoms, including pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium. Assess and respond to patient's symptoms, including pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

4. Key Messages Palliative care is a multi-disciplinary approach to treating the "total pain" of a patient (including physical, psychosocial, and spiritual needs of the patient and family). Palliative care is a multi-disciplinary approach to treating the "total pain" of a patient (including physical, psychosocial, and spiritual needs of the patient and family). Palliative care is appropriate at any stage of disease and can be given simultaneous to all other medical therapies, including those with curative intent. Palliative care is appropriate at any stage of disease and can be given simultaneous to all other medical therapies, including those with curative intent. There are multiple symptoms to target at the end-of-life and Palliative care teams specialize in management of refractory symptoms. There are multiple symptoms to target at the end-of-life and Palliative care teams specialize in management of refractory symptoms.

5. Palliative Care Definition Collaborative, comprehensive, interdisciplinary approach to treating “total pain” (includes physical, psychosocial, and spiritual needs of patients and families) Collaborative, comprehensive, interdisciplinary approach to treating “total pain” (includes physical, psychosocial, and spiritual needs of patients and families) Appropriate at any stage of illness and simultaneously with all other medical treatments Appropriate at any stage of illness and simultaneously with all other medical treatments

6. Goals of PC Improve the quality of life of patients living with debilitating, chronic or terminal illness Improve the quality of life of patients living with debilitating, chronic or terminal illness Prevention and relief of suffering by early identification, assessment, and treatment of distressing symptoms Prevention and relief of suffering by early identification, assessment, and treatment of distressing symptoms Accomplished by combined efforts of an interdisciplinary team Accomplished by combined efforts of an interdisciplinary team

7. Components of IDT (Interdisciplinary Team) Patient* Patient* Family, loved ones* Family, loved ones* MD primary team MD primary team MD consultants MD consultants Nursing Nursing Psychologist, psych liaison Psychologist, psych liaison Social support- SW, case management Social support- SW, case management Physical or occupational therapy, respiratory therapy Physical or occupational therapy, respiratory therapy Nutrition services Nutrition services Spiritual support Spiritual support Nursing home, hospice, home health services Nursing home, hospice, home health services Pharmacists Pharmacists Volunteers Volunteers Complimentary and Alternative therapy Complimentary and Alternative therapy

8. Patients to consider for PC Yes to "surprise question“ : You would not be surprised if the patient died within 12 months? Yes to "surprise question“ : You would not be surprised if the patient died within 12 months? Patients with frequent admissions Patients with frequent admissions Patients whose admissions are prompted by difficult-to-control physical or psychological symptoms Patients whose admissions are prompted by difficult-to-control physical or psychological symptoms Patients with complex care requirements (eg, functional dependency; complex home support for ventilator/antibiotics/feedings) Patients with complex care requirements (eg, functional dependency; complex home support for ventilator/antibiotics/feedings) Patients with decline in function, feeding intolerance, or unintended decline in weight (eg, failure to thrive) Patients with decline in function, feeding intolerance, or unintended decline in weight (eg, failure to thrive) Admissions from long-term care facility or medical foster home Admissions from long-term care facility or medical foster home Elderly patients, cognitively impaired, with acute hip fracture Elderly patients, cognitively impaired, with acute hip fracture Patients with metastatic or locally advanced incurable cancer Patients with metastatic or locally advanced incurable cancer Patients with chronic home oxygen use Patients with chronic home oxygen use Patients who have an out-of-hospital cardiac arrest Patients who have an out-of-hospital cardiac arrest Current or past hospice program enrollee Current or past hospice program enrollee Patients with limited social support (eg, family stress, chronic mental illness) Patients with limited social support (eg, family stress, chronic mental illness) No history of completing an advance care planning discussion/document No history of completing an advance care planning discussion/document

9. Symptoms Management Under curative model, symptoms are clues to a diagnosis Under curative model, symptoms are clues to a diagnosis Under Palliative care model, symptoms are entities in of themselves Under Palliative care model, symptoms are entities in of themselves Goal is to identify, evaluate underlying cause, and treat Goal is to identify, evaluate underlying cause, and treat If treatment is pharmacologic, consider alternative routes when and if p.o. administration fails If treatment is pharmacologic, consider alternative routes when and if p.o. administration fails

10. Alternative routes of delivery Enteral if feeding tubes Enteral if feeding tubes Transmucosal –widely used in palliatve care, immediate delivery Transmucosal –widely used in palliatve care, immediate delivery Rectal Rectal Transdermal -takes 24 hours to work Transdermal -takes 24 hours to work Parenteral Parenteral Intraspinal Intraspinal

11. Frequent symptoms in PC Dyspnea Dyspnea Fatigue, poor function status, sedation Fatigue, poor function status, sedation Nausea, vomiting, constipation Nausea, vomiting, constipation Mouth discomfort Mouth discomfort Weight loss, dysphagia, anorexia Weight loss, dysphagia, anorexia Depression, psychological pain Depression, psychological pain Delirium Delirium Pain Pain Terminal secretions Terminal secretions

12. Dyspnea Only reliable measure is patient self-report Only reliable measure is patient self-report RR, pO 2, blood gas DO NOT correlate with the feeling of breathlessness RR, pO 2, blood gas DO NOT correlate with the feeling of breathlessness Treatment options Treatment options Opioids- best Opioids- best Anxiolytics- only if an anxiety component, not as effective alone without opioids Anxiolytics- only if an anxiety component, not as effective alone without opioids O2- no benefit over Room air if not hypoxic O2- no benefit over Room air if not hypoxic Non-pharmacologic management Non-pharmacologic management

13. Pulmonary edema Pulmonary edema - Furosemide Bronchospasm Bronchospasm - Albuterol, steroids, ipratropium bromide, inhaled racemic epinephrine Thick secretions Thick secretions - Scopolamine, glycopyrrolate Pleural effusion Pleural effusion Drainage, pleurodesis Drainage, pleurodesis Dyspnea with specific treatment

14. Fatigue Underlying causes: anemia, dehydration, meds, hypoxia, insomnia, pain, infection, deconditioning Underlying causes: anemia, dehydration, meds, hypoxia, insomnia, pain, infection, deconditioning Possible treatments: Transfusions, O2, diuresis or hydration, sleep aids and sleep hygiene, PT, exercise, methylphenidate Possible treatments: Transfusions, O2, diuresis or hydration, sleep aids and sleep hygiene, PT, exercise, methylphenidate Relaxation, meditation Relaxation, meditation

15. Nausea/vomiting Causes: Causes: -Bowel obstruction -Drugs (ex: opioids) -Malignancy related gastroparesis -Metabolic derangements -Increased ICP –especially brain mets Treat underlying cause : treat with haldol/dexameth for bowel obstruction, opioid rotation, treat constipation, correct metabolic abnormalities Treat underlying cause : treat with haldol/dexameth for bowel obstruction, opioid rotation, treat constipation, correct metabolic abnormalities

16. Treatment options- Nausea Dopamine antagonists (Haloperidol, Metoclopramide, Prochlorperazine) Dopamine antagonists (Haloperidol, Metoclopramide, Prochlorperazine) Prokinetic agents (metoclopromide) Prokinetic agents (metoclopromide) Antacids/PPIs Antacids/PPIs Cytoprotective agents Cytoprotective agents Antihistamines (Diphenhydramine, Meclizine, Hydroxyzine) Antihistamines (Diphenhydramine, Meclizine, Hydroxyzine) Steroids Steroids THC THC benzodiazepines benzodiazepines Anticholinergics (scopolamine) Anticholinergics (scopolamine) Serotonin antagonists (odansetron) Serotonin antagonists (odansetron) Neurokinin antagonists (aprepitant) Neurokinin antagonists (aprepitant)

17. Constipation Begin dual therapy: stool softner (docusate=colace) + stimulator (senna or bisacodyl = dulcolax) Begin dual therapy: stool softner (docusate=colace) + stimulator (senna or bisacodyl = dulcolax) Step up therapy: added to prior Step up therapy: added to prior  osmotics (Lactulose, MoM, mag citrate,)  lubricants (glycerin, castor oil)  large volume enema (500 cc of water, phosphate, oil retention)

18. Mouth Discomfort Symptoms Mucositis Mucositis Dry mouth Dry mouth Mouth pain Mouth pain Change in taste Change in taste Difficulty swallowing Difficulty swallowing Difficulty with speaking Difficulty with speaking Causes Mouth breathers Medications (anticholingergics) Advanced age Cancer patients History of radiation to the head and neck Sjögren's syndrome Diabetes mellitus Anxiety states Dehydration (but rehydration often does not improve this symptom) herpes simplex infection

19. Mouth Care Address underlying issue Address underlying issue Cleaning, denture care Cleaning, denture care Maintain hydration Maintain hydration Rehydrating gel Rehydrating gel Suspension options: Suspension options: “Difflam” benzydamine hydrochloride 0.15% (oral rinse) 15ml, 2-3 hourly for especially for radiation “Difflam” benzydamine hydrochloride 0.15% (oral rinse) 15ml, 2-3 hourly for especially for radiation Consider sucralfate suspension (part of Magic Mouth) Consider sucralfate suspension (part of Magic Mouth) Chlorhexidine gluconate (Perisol)- Analgesia Chlorhexidine gluconate (Perisol)- Analgesia Saliva substitute (Pilocarpine or Salagen) Saliva substitute (Pilocarpine or Salagen)

20. Weight loss, anorexia Treatment options: Treatment options: Megace, steroids Megace, steroids THC THC Small frequent meals Small frequent meals Establish goals Establish goals Educate family, avoidance of coercion Educate family, avoidance of coercion

21. Terminal Secretions Also called “death rattle” Also called “death rattle” From impaired swallowing of saliva, or congestion from impaired cough ability From impaired swallowing of saliva, or congestion from impaired cough ability Treatment: Treatment: Avoid suctioning Avoid suctioning Avoid xs hydration Avoid xs hydration Medications: Scopolamine transdermal (but slow onset) or Glycopyrrolate: 0.4 to 1.2 mg/day by continuous IV or 0.2 mg SC every 4 to 6 hours Medications: Scopolamine transdermal (but slow onset) or Glycopyrrolate: 0.4 to 1.2 mg/day by continuous IV or 0.2 mg SC every 4 to 6 hours

22. Psychological symptoms Depression vs grief- not interchangeable Depression vs grief- not interchangeable Depression -needs aggressive and prompt treatment Depression -needs aggressive and prompt treatment Grief - part of diagnosis for many, doesn’t require therapy Grief - part of diagnosis for many, doesn’t require therapy Anxiety Anxiety Insomnia Insomnia Spiritual Pain Spiritual Pain

23. Pharmacologic Treatment Options Psychostimulants Psychostimulants Methylphenidate (Ritalin) Methylphenidate (Ritalin) Modafinil (Provigil) Modafinil (Provigil) rapid onset of action and well tolerated. rapid onset of action and well tolerated. SSRI’s SSRI’s Tricyclic antidepressants (benefit of treating concurrent neuropathic pain) Tricyclic antidepressants (benefit of treating concurrent neuropathic pain) Insomnia- consider short course treatment Insomnia- consider short course treatment Anxiety- consider benzodiazpines Anxiety- consider benzodiazpines

25. Delirium Identify underlying cause Identify underlying cause Treat and diagnose within the context of agreed upon level of care Treat and diagnose within the context of agreed upon level of care Pain is a potent precipitant of delirium and its’ management is associated with significantly reduced risks Pain is a potent precipitant of delirium and its’ management is associated with significantly reduced risks

26. Bone pain- Treatment Opioids, NSAIDS Opioids, NSAIDS Radiation- if cancer related Radiation- if cancer related Bisphosphonates Bisphosphonates Steroids Steroids Consider Complimentary and Alternative Therapy (CAM) Consider Complimentary and Alternative Therapy (CAM)

27. CAM Acupuncture, hypnosis, Reiki, reflexology, biofeedback, specialty diets, music, art therapy Acupuncture, hypnosis, Reiki, reflexology, biofeedback, specialty diets, music, art therapy Balance potential underutilized benefit with potential toxicity Balance potential underutilized benefit with potential toxicity Often patients latch onto any therapy Often patients latch onto any therapy More successful if institution supports resources More successful if institution supports resources

28. References Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the center to advance palliative care. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the center to advance palliative care. Weissman, David, J Palliat Med. 2011;14(1):17. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the center to advance palliative care. Nonpain Symptom Management in the Dying Patient. Rousseau P. Hospital Physician. 2002 Hospital Physician;38(2):51 - 6. Physiological changes and clinical correlations of dyspnea in cancer outpatients. Physiological changes and clinical correlations of dyspnea in cancer outpatients. Dudgeon DJ J Pain Symptom Manage. 2001;21(5):373. Physiological changes and clinical correlations of dyspnea in cancer outpatients. Treatment of metastatic prostatic cancer with low-dose prednisone: evaluation of pain and quality of life as pragmatic indices of responseTreatment of metastatic prostatic cancer with low-dose prednisone: evaluation of pain and quality of life as pragmatic indices of response Tannock, J Clin Oncol. 1989;7(5):590. Treatment of metastatic prostatic cancer with low-dose prednisone: evaluation of pain and quality of life as pragmatic indices of response The mouth and palliative care. The mouth and palliative care. Sweeney MP Am J Hosp Palliat Care. 2000;17(2):118. The mouth and palliative care. Recommendations for the Use of Antiemetics: Evidence-Based, Clinical Practice GuidelinesRecommendations for the Use of Antiemetics: Evidence-Based, Clinical Practice Guidelines Gralla R, et al. J Clin Oncol, 1999. Recommendations for the Use of Antiemetics: Evidence-Based, Clinical Practice Guidelines Hospice and Palliative Care Training for Physicians: UNIPAC Series, Third Edition, 2008