Palliative Care: Goals and Palliative Care: Goals and Nonpain Symptom Nonpain Symptom

ManagementManagement

Leigh Vaughan, MDLeigh Vaughan, MDMedical University of South Medical University of South

CarolinaCarolinaMarch 6, 2012March 6, 2012

OutlineOutline Definition of PCDefinition of PC Goals of PCGoals of PC Who should be considered for PCWho should be considered for PC Symptoms identified in PCSymptoms identified in PC Management and treatment optionsManagement and treatment options

Learning ObjectivesLearning Objectives Define palliative care.Define palliative care. Determine effective management strategies for Determine effective management strategies for

palliative care patients.palliative care patients. Process strategies for prevention and treatment of Process strategies for prevention and treatment of

complications from palliative care interventions.complications from palliative care interventions. Assess the impact of interventions on patient comfort Assess the impact of interventions on patient comfort

and prognosis.and prognosis. Recognize and address the psychosocial effects of life Recognize and address the psychosocial effects of life

threatening illness in hospitalized patients.threatening illness in hospitalized patients. Assess and respond to patient's symptoms, including Assess and respond to patient's symptoms, including

pain, dyspnea, nausea, constipation, fatigue, anorexia, pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.anxiety, depression and delirium.

Key MessagesKey Messages Palliative care is a multi-disciplinary approach Palliative care is a multi-disciplinary approach

to treating the "total pain" of a patient to treating the "total pain" of a patient (including physical, psychosocial, and spiritual (including physical, psychosocial, and spiritual needs of the patient and family).needs of the patient and family).

Palliative care is appropriate at any stage of Palliative care is appropriate at any stage of disease and can be given simultaneous to all disease and can be given simultaneous to all other medical therapies, including those with other medical therapies, including those with curative intent.curative intent.

There are multiple symptoms to target at the There are multiple symptoms to target at the end-of-life and Palliative care teams specialize end-of-life and Palliative care teams specialize in management of refractory symptoms.in management of refractory symptoms.

Palliative Care DefinitionPalliative Care Definition

Collaborative, comprehensive, interdisciplinary Collaborative, comprehensive, interdisciplinary approach to treating “total pain” (includes approach to treating “total pain” (includes physical, psychosocial, and spiritual needs of physical, psychosocial, and spiritual needs of patients patients andand families) families)

Appropriate at Appropriate at any stageany stage of illness and of illness and simultaneouslysimultaneously with all other medical with all other medical treatmentstreatments

Goals of PCGoals of PC Improve the quality of life of patients living with Improve the quality of life of patients living with

debilitating, chronic or terminal illnessdebilitating, chronic or terminal illness

Prevention and relief of suffering by early Prevention and relief of suffering by early identification, assessment, and treatment of identification, assessment, and treatment of distressing symptomsdistressing symptoms

Accomplished by combined efforts of an Accomplished by combined efforts of an interdisciplinary teaminterdisciplinary team

Components of IDT Components of IDT (Interdisciplinary Team)(Interdisciplinary Team)

Patient*Patient* Family, loved ones*Family, loved ones* MD primary teamMD primary team MD consultantsMD consultants NursingNursing Psychologist, psych liaisonPsychologist, psych liaison Social support- SW, case managementSocial support- SW, case management Physical or occupational therapy, respiratory therapyPhysical or occupational therapy, respiratory therapy Nutrition servicesNutrition services Spiritual supportSpiritual support Nursing home, hospice, home health servicesNursing home, hospice, home health services PharmacistsPharmacists VolunteersVolunteers Complimentary and Alternative therapyComplimentary and Alternative therapy

Patients to consider for PCPatients to consider for PC Yes to "surprise question“ : Yes to "surprise question“ : You would not be surprised if the patient You would not be surprised if the patient

died within 12 months?died within 12 months? Patients with frequent admissionsPatients with frequent admissions Patients whose admissions are prompted by difficult-to-control physical Patients whose admissions are prompted by difficult-to-control physical

or psychological symptomsor psychological symptoms Patients with complex care requirements (eg, functional dependency; Patients with complex care requirements (eg, functional dependency;

complex home support for ventilator/antibiotics/feedings)complex home support for ventilator/antibiotics/feedings) Patients with decline in function, feeding intolerance, or unintended Patients with decline in function, feeding intolerance, or unintended

decline in weight (eg, failure to thrive)decline in weight (eg, failure to thrive) Admissions from long-term care facility or medical foster homeAdmissions from long-term care facility or medical foster home Elderly patients, cognitively impaired, with acute hip fractureElderly patients, cognitively impaired, with acute hip fracture Patients with metastatic or locally advanced incurable cancerPatients with metastatic or locally advanced incurable cancer Patients with chronic home oxygen usePatients with chronic home oxygen use Patients who have an out-of-hospital cardiac arrestPatients who have an out-of-hospital cardiac arrest Current or past hospice program enrolleeCurrent or past hospice program enrollee Patients with limited social support (eg, family stress, chronic mental Patients with limited social support (eg, family stress, chronic mental

illness)illness) No history of completing an advance care planning discussion/documentNo history of completing an advance care planning discussion/document

Symptoms ManagementSymptoms Management Under curative model, symptoms are clues to a Under curative model, symptoms are clues to a

diagnosisdiagnosis Under Palliative care model, symptoms are Under Palliative care model, symptoms are

entities in of themselvesentities in of themselves Goal is to identify, evaluate underlying cause, and Goal is to identify, evaluate underlying cause, and

treattreat If treatment is pharmacologic, consider If treatment is pharmacologic, consider

alternative routes when and if p.o. administration alternative routes when and if p.o. administration failsfails

Alternative routes of deliveryAlternative routes of delivery Enteral if feeding tubesEnteral if feeding tubes Transmucosal –widely used in palliatve care, Transmucosal –widely used in palliatve care,

immediate deliveryimmediate delivery RectalRectal Transdermal -takes 24 hours to workTransdermal -takes 24 hours to work ParenteralParenteral IntraspinalIntraspinal

Frequent symptoms in PCFrequent symptoms in PC DyspneaDyspnea Fatigue, poor function status, sedationFatigue, poor function status, sedation Nausea, vomiting, constipationNausea, vomiting, constipation Mouth discomfortMouth discomfort Weight loss, dysphagia, anorexiaWeight loss, dysphagia, anorexia Depression, psychological painDepression, psychological pain DeliriumDelirium PainPain Terminal secretionsTerminal secretions

DyspneaDyspnea Only reliable measure is patient self-reportOnly reliable measure is patient self-report RR, pORR, pO22, blood gas DO NOT correlate with the , blood gas DO NOT correlate with the

feeling of breathlessnessfeeling of breathlessness Treatment optionsTreatment options

Opioids- bestOpioids- best Anxiolytics- only if an anxiety component, not Anxiolytics- only if an anxiety component, not

as effective alone without opioidsas effective alone without opioids O2- no benefit over Room air if not hypoxicO2- no benefit over Room air if not hypoxic Non-pharmacologic managementNon-pharmacologic management

Pulmonary edemaPulmonary edema- Furosemide- Furosemide

BronchospasmBronchospasm- Albuterol, steroids, ipratropium bromide, inhaled - Albuterol, steroids, ipratropium bromide, inhaled racemic epinephrine racemic epinephrine

Thick secretionsThick secretions- Scopolamine, glycopyrrolate - Scopolamine, glycopyrrolate

Pleural effusion Pleural effusion Drainage, pleurodesisDrainage, pleurodesis

Dyspnea with specific treatmentDyspnea with specific treatment

FatigueFatigue Underlying causes: anemia, dehydration, meds, Underlying causes: anemia, dehydration, meds,

hypoxia, insomnia, pain, infection, deconditioning hypoxia, insomnia, pain, infection, deconditioning Possible treatments: Transfusions, O2, diuresis or Possible treatments: Transfusions, O2, diuresis or

hydration, sleep aids and sleep hygiene, PT, hydration, sleep aids and sleep hygiene, PT, exercise, methylphenidate exercise, methylphenidate

Relaxation, meditationRelaxation, meditation

Nausea/vomitingNausea/vomiting Causes: Causes:

-Bowel obstruction-Bowel obstruction-Drugs (ex: opioids)-Drugs (ex: opioids)-Malignancy related gastroparesis-Malignancy related gastroparesis-Metabolic derangements-Metabolic derangements-Increased ICP –especially brain mets-Increased ICP –especially brain mets

Treat underlying cause : treat with Treat underlying cause : treat with haldol/dexameth for bowel obstruction, opioid haldol/dexameth for bowel obstruction, opioid rotation, treat constipation, correct metabolic rotation, treat constipation, correct metabolic abnormalitiesabnormalities

Treatment options- NauseaTreatment options- Nausea Dopamine antagonists (Haloperidol, Metoclopramide, Dopamine antagonists (Haloperidol, Metoclopramide,

Prochlorperazine)Prochlorperazine) Prokinetic agents (metoclopromide)Prokinetic agents (metoclopromide) Antacids/PPIsAntacids/PPIs Cytoprotective agentsCytoprotective agents Antihistamines (Diphenhydramine, Meclizine, Hydroxyzine)Antihistamines (Diphenhydramine, Meclizine, Hydroxyzine) SteroidsSteroids THCTHC benzodiazepinesbenzodiazepines Anticholinergics (scopolamine)Anticholinergics (scopolamine) Serotonin antagonists (odansetron)Serotonin antagonists (odansetron) Neurokinin antagonists (aprepitant)Neurokinin antagonists (aprepitant)

ConstipationConstipation Begin dual therapy: stool softner Begin dual therapy: stool softner

(docusate=colace) + stimulator (senna or (docusate=colace) + stimulator (senna or bisacodyl = dulcolax)bisacodyl = dulcolax)

Step up therapy: added to prior Step up therapy: added to prior osmotics (Lactulose, MoM, mag citrate,)osmotics (Lactulose, MoM, mag citrate,)

lubricants (glycerin, castor oil) lubricants (glycerin, castor oil) large volume enema (500 cc of water, large volume enema (500 cc of water,

phosphate, oil retention)phosphate, oil retention)

Mouth DiscomfortMouth DiscomfortSymptomsSymptoms MucositisMucositis Dry mouthDry mouth Mouth painMouth pain Change in taste Change in taste Difficulty swallowingDifficulty swallowing Difficulty with speakingDifficulty with speaking

CausesCauses Mouth breathersMouth breathers Medications Medications

(anticholingergics)(anticholingergics) Advanced ageAdvanced age Cancer patientsCancer patients History of radiation to the History of radiation to the

head and neckhead and neck Sjögren's syndromeSjögren's syndrome Diabetes mellitusDiabetes mellitus Anxiety states Anxiety states Dehydration (but Dehydration (but

rehydration often does not rehydration often does not improve this symptom)improve this symptom)

herpes simplex infectionherpes simplex infection

Mouth CareMouth Care Address underlying issueAddress underlying issue Cleaning, denture careCleaning, denture care Maintain hydrationMaintain hydration Rehydrating gelRehydrating gel

Suspension options:Suspension options: ““Difflam” benzydamine hydrochloride 0.15% Difflam” benzydamine hydrochloride 0.15%

(oral rinse) 15ml, 2-3 hourly for especially for (oral rinse) 15ml, 2-3 hourly for especially for radiationradiation

Consider sucralfate suspension (part of Magic Consider sucralfate suspension (part of Magic Mouth)Mouth)

Chlorhexidine gluconate (Perisol)- AnalgesiaChlorhexidine gluconate (Perisol)- Analgesia Saliva substitute (Pilocarpine or Salagen)Saliva substitute (Pilocarpine or Salagen)

Weight loss, anorexiaWeight loss, anorexia Treatment options:Treatment options:

Megace, steroidsMegace, steroids THCTHC Small frequent mealsSmall frequent meals

Establish goalsEstablish goals Educate family, avoidance of coercionEducate family, avoidance of coercion

Terminal SecretionsTerminal Secretions

Also called “death rattle”Also called “death rattle” From impaired swallowing of saliva, or congestion From impaired swallowing of saliva, or congestion

from impaired cough abilityfrom impaired cough ability Treatment: Treatment:

Avoid suctioningAvoid suctioning Avoid xs hydrationAvoid xs hydration Medications: Scopolamine transdermal (but slow Medications: Scopolamine transdermal (but slow

onset) or Glycopyrrolate: 0.4 to 1.2 mg/day by onset) or Glycopyrrolate: 0.4 to 1.2 mg/day by continuous IV or 0.2 mg SC every 4 to 6 hourscontinuous IV or 0.2 mg SC every 4 to 6 hours

Pharmacologic Treatment Pharmacologic Treatment OptionsOptions

PsychostimulantsPsychostimulants 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 Tricyclic antidepressants (benefit of treating

concurrent neuropathic pain)concurrent neuropathic pain) Insomnia- consider short course treatmentInsomnia- consider short course treatment Anxiety- consider benzodiazpinesAnxiety- consider benzodiazpines

DeliriumDelirium Identify underlying causeIdentify underlying cause Treat and diagnose within the context of agreed Treat and diagnose within the context of agreed

upon level of careupon level of care Pain is a potent precipitant of delirium and its’ Pain is a potent precipitant of delirium and its’

management is associated with significantly management is associated with significantly reduced risksreduced risks

Bone pain- TreatmentBone pain- Treatment Opioids, NSAIDSOpioids, NSAIDS Radiation- if cancer relatedRadiation- if cancer related BisphosphonatesBisphosphonates Steroids Steroids Consider Complimentary and Alternative Therapy Consider Complimentary and Alternative Therapy

(CAM)(CAM)

CAMCAM Acupuncture, hypnosis, Reiki, reflexology, Acupuncture, hypnosis, Reiki, reflexology,

biofeedback, specialty diets, music, art therapybiofeedback, specialty diets, music, art therapy Balance potential underutilized benefit with Balance potential underutilized benefit with

potential toxicitypotential toxicity Often patients latch onto any therapyOften patients latch onto any therapy More successful if institution supports resourcesMore successful if institution supports resources

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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.Dudgeon DJ J Pain Symptom Manage. 2001;21(5):373.

Treatment of metastatic prostatic cancer with low-dose prednisone: evaluation of pain Treatment of metastatic prostatic cancer with low-dose prednisone: evaluation of pain and quality of life as pragmatic indices of response Tannock , J Clin Oncol. and quality of life as pragmatic indices of response Tannock , J Clin Oncol. 1989;7(5):590.1989;7(5):590.

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Recommendations for the Use of Antiemetics: Evidence-Based, Clinical Practice Recommendations for the Use of Antiemetics: Evidence-Based, Clinical Practice Guidelines Gralla R, et al. J Clin Oncol, 1999.Guidelines Gralla R, et al. J Clin Oncol, 1999.

Hospice and Palliative Care Training for Physicians: UNIPAC Series, Third Edition, 2008Hospice and Palliative Care Training for Physicians: UNIPAC Series, Third Edition, 2008