symptom relief in end of life care. goals, objectives, standards apply a full set of skills in end...

Symptom Relief inEnd of Life Care

Goals, Objectives, Standards Apply a full set of skills in end of life care Bookmark websites with end of life care

information for future ongoing use Discuss feeling regarding death and dying

Dying: Common Family Concerns Is my loved one in pain; how would we

know? Aren’t we just starving my loved one to

death? What should we expect? How will we know that time is short? Should I/we stay by the bedside? Can my loved one hear what we are

saying? What do we do after death?

Dying: Timing < 1 day to 14 days Well nourished, hydrated, uninfected

patients live longer

Goal Setting and Communication Confirm treatment goals

Stop Rx unrelated to comfort Progress notes

“Patient is dying", not “Prognosis is poor". Treat symptoms/signs as they arise Provide daily counseling and support to

family

Communication Open, honest rapport Diversity Spirituality

Dying: Early Bed Bound Loss of interest and/or ability to drink/eat Cognitive changes

Increased sleep Delirium

Dying: Mid Progressive decline in mental status

Obtundation Terminal Delirium

Death rattle

Dying: Late Coma Fever

Aspiration Pneumonia Dehydration

Altered respiratory pattern Apnea Hypopnea Hyperpnea Irregularity Cheyne-Stokes

Mottled extremities Livido Mortis vs Livido Reticularis

Symptom Relief Pain

Somatic Bone Neuropathic

Dyspnea Secretions Myoclonus Seizures Singultus Pruritis Anxiety Insomnia Delirium and Terminal Delirium Spiritual Crisis and Distress Goal Setting and Communication

Pain Narcotics are safe and effective Multiple products and routes Bowel regimens Adjunctive therapies

Pain: Somatic WHO protocol Mild: Non-pharmacologic, Acetaminophen Moderate: NSAID, ASA Severe: Narcotics

Fixed twice daily dosing Break-through medication Oral 3x parenteral Equivalency charts

Treat anxiety, depression, psychiatric illness

Bone Pain Bisphosphonates

Breast cancer and multiple myeloma most responsive Lung, GI and prostate carcinomas less responsive 50-70% of patients get 30% pain reduction by a week for 12 wk Repeat in a week for lack of response Zoledronic acid 4mg IV over 15 minutes, cheaper, faster Pamidronate 90mg IV administered over 2 hours, expensive, slower

Prophylaxis Decreases skeletal-related events by 30% if known bone involvement

Toxicity Pamidronate and zoledronic acid identical. Injection site reaction, Flu-like syndrome Hypocalcemia, Scleritis less common Renal dysfunction in long-term, or high dose use Contraindicated CRF, Cr>0.5 over baseline or Cr>1.0 in CRI Reduced dose CrCl <73.0 mg/dl, and slower infusion

Pain: Neuropathic Gabapentin Tricyclics Narcotics

Dypnea Anxiolytics Moving Air Open doors and windows Mouth Care

Secretions: Overview Death Rattle

Turbulent air over pooled Median time from onset to death 16 hr Two sub-types of Death Rattle proposed

significance regarding treatment not established

Type 1 = predominantly salivary secretions Type 2 = predominantly bronchial secretions.

Secretions: Non-pharmacologic RxPostural drainage

Position patient lateral or semi-prone A minute or two of Trendelenburg

aspiration risk is increased.

Gentle oropharyngeal suctioning often ineffective Frequent suctioning disturbs patient and

visitors Reduce fluid intake

Secretions: Pharmacologic Rx

Drug Route Dose Onset Cross BBB?

Notes

hyoscyamine hydro. (Scopolamine Patch)

Patch 1 or more patches (about 1mg/3d)

12 hr Yes Need short term interim meds 1st 12 hr

hyoscyamine sulph. (Levsin)

PO 0.125 poQ2-6 hr

30 min No

Glycopyrrolate(Robinul)

PO

SC, IV

1 mg/2-12 hr

.2 mg

30 min

1 min

No Most potentErratic absorption

Atropine PO, SL

IM, IV

1-10 gtt 1%Q2-6 hr1 mg

30 min

1 min

Yes CheapFlexibleMost delirium

Myoclonus Focal or generalized

sudden, brief, shock-like, involuntary

Disrupts sleep, aggravates families DDX

Metabolic abnormalities Medication Induced Opioid-induced

usually generalized, may be provoked by a stimulus or voluntary movement.

Dystonia Focal CNS Seizure disorders. Nocturnal Myoclonus Sleep related

Treatment Underlying cause Opioid induced: change opioid Benodiazepine Midazolam infusion Dantrolene 50mg to 100mg daily

Medications opioids, anticonvulsants tricyclics SSRI's contrast dye anesthetics penicillins cephalosporins imipenem quinolones cannabinoids ifosfamide

Seizures Usual Care

May require large doses of medication

Hiccups (Singultus) Pharmacologic Pharmacological Anti-Psychotics:

Chlorpromazine - the only FDA approved drug for hiccups. 25-50 mg po tid qid. IV 25-50 mg in 500-1000cc of NS over several hours

Haloperidol – 2.0-5.0 mg (IM/PO) loading then 1-4 mg po tid Anti-Convulsants:

Phenytoin - reportedly effective in patients with a CNS etiology 200 mg slow IV push followed by 300 mg po qd.

Valproic Acid and Carbamazepine :maybe Miscellaneous:

Baclofen - The only drug studied in a double blind randomized controlled study for treatment of hiccups;

5 mg po q8H did not eliminate hiccups but provided symptomatic relief in some patients.

Metoclopramide - 10 mg po qid maybe for stomach distension Nifedipine - 10 mg bid with gradual increase up to 20 mg tid maybe Last ditch: amitriptyline, inhaled lidocaine, ketamine, edrophonium,

amantidine.

Hiccups (Singultus) Non-Pharmacologic Irritant

Gargling with water Biting a lemon Swallowing sugar

Vagal Produce a fright response Vagal stimulation Carotid massage Valsalva maneuver Interruption of phrenic

nerve transmission by rubbing over the 5th cervical vertebrae

Respiratory Sneezing Coughing Breath holding Hyperventilation Breath into a paper bag

Other Acupuncture Diaphragmatic pacing Surgical ablation of reflex

arc

Pruritis: Non-Pharmacologic Treat Causes

Dermatologic Metabolic Hem/Onc Drugs Infection Allergy Psychogenic.

Moisturizer Xerosis

Cooling agents Calamine Menthol in aqueous cream 0.5%-2%

Pruritis: Pharmacologic EMLA Cream Antihistamines

Histamine mediated itching Doxepin may work in selected cases

Steroids Inflammatory itching Topical Systemic for refractory cases

Aveeno Cholestyramine

Cholestatic Other

Ondansetron, Paroxetine Naloxone

Anxiety Address underlying causes Treat dyspnea Treat sleep deprivation Narcotic euphoria overlaps anxiolysis Address spiritual issues Benzodiazepines Other Drug Treatment

Insomnia Symptom Relief Treat Undiagnosed Sleep Disorders Sleep Hygiene Relaxation Techniques Sleep Restriction Cognitive Behavioral Therapy Stimulus Control Therapy There is no EBM on nightmares The usual drug therapies

Delirium and Terminal Delirium Waxing and waning level of consciousness

Hyperactive Hypoactive

Non-pharmacologic Rx Reduce or increase sensory stimulation Relatives and friends stay with patient Frequent reorientation Familiar objects

Haloperidol 0.5 to 2 mg po IV q 1 hour: EBM High-potency short-acting anti-psychotics=drug of choice Underused

Benzodiazepines Second choice “Paradoxical” worsening of delirium Overused

Delirium and Terminal Delirium Other neuroleptics

Probably comparable to haloperidol Olanzapine is up and coming

Chlorpromazine Sedation is desired

Newer atypical antipsychotic May help EMB scant Perhaps with underlying dystonia or Parkinsons

Spirituality Chaplain Diverse pastoral care Music therapy Communication

Ethical Issues “Truth-Telling” Family Euthanasia Hospice Resource Allocation

Diversity and Ethnic Issues Cultural Competency in questioning Awareness of beliefs Ritual Communication Staff education

Hospice Use liberally

EPERC Medical College of Wisconsin http://www.eperc.mcw.edu/ Fast Facts are available for downloading

onto your PDA. Information and download available at www.infingo.com/mninfo.htm

EPEC http://www.epec.net/EPEC/webpages/index.cfm The EPEC Project, Northwestern University's

Feinberg School of Medicine750 N Lake Shore Drive, Suite 601 Chicago, IL 60611Tel. 312/503-3732, FAX: 312/503-5868 Email: info@epec.net

The EPEC Project was supported from 1996-2003 with funding from The Robert Wood Johnson Foundation.Last modified 12/09/2005.

Summary EMB for symptomatic relief at the end of

life is accumulating Many distressing symptoms can be

remitted Web-based resources for information are

readily available

Bibliography Fast Facts and Concepts #109. Death rattle and oral secretions. Bickel K and Arnold R.

March 2004. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

DeMonaco D and Arnold R. Fast Facts and Concepts #114. Myoclonus. May 2004. End-

of-Life Physician Education Resource Center www.eperc.mcw.edu. Fast Facts and Concepts #104. Miller M and Arnold R. Insomnia: Non Pharmacological

Treatments. January 2004. End-of-Life Physician Education Resource Center www.eperc.mcw.edu

Malhotra, S and Arnold R. MD Fast Facts and Concepts #88 . Nightmares. April 2003.

End-of-Life Physician Education Resource Center www.eperc.mcw.edu

Fast Facts and Concepts #81 Hiccups. Farmer, C. January 2003. End-of-Life Physician

Education Resource Center www.eperc.mcw.edu Fast Facts and Concepts #37 Gunten CF, Ferris F. Pruritis. August, 2005. 2nd edition.

End-of-Life Palliative Education Resource Center www.eperc.mcw.edu

Bibliography Diagnosis and Management of terminal delirium. Fast Fact and Concept #1; 2nd

Edition, July 2005. End-of-Life Palliative Education Resource Center www.eperc.mcw.edu

Syndrome of Imminent Death. Fast Fact and Concept #3; 2nd Edition, July 2005. End-

of-Life Palliative Education Resource Center www.eperc.mcw.edu Fast Facts and Concepts #60 Pharmacologic Management of Delirium; update on

newer agents. Earl Quijada, M.D. and J. Andrew Billings, M.D.. January, 2002. End-of-

Life Physician Education Resource Center www.eperc.mcw.edu

Weinstein E and Arnold A. Fast Facts and Concepts #113. Bisphosphonates for bone pain. April 2004. End-of-Life Physician Education Resource Center www.eperc.mcw.edu