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: [email protected]
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
