palliative care: goals and nonpain symptom management leigh vaughan, md medical university of south...
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Palliative Care: Goals and Palliative Care: Goals and Nonpain Symptom Nonpain Symptom
ManagementManagement
Leigh Vaughan, MDLeigh Vaughan, MD
Medical University of South Medical University of South CarolinaCarolina
March 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, pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.anorexia, 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 Patients whose admissions are prompted by difficult-to-control
physical or psychological symptomsphysical or 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 No history of completing an advance care planning
discussion/documentdiscussion/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 Discomfort
SymptomsSymptoms 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 Medications: Scopolamine transdermal (but
slow onset) or Glycopyrrolate: 0.4 to 1.2 slow onset) or Glycopyrrolate: 0.4 to 1.2 mg/day by continuous IV or 0.2 mg SC every 4 mg/day by continuous IV or 0.2 mg SC every 4 to 6 hoursto 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 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. pain 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, Hospice and Palliative Care Training for Physicians: UNIPAC Series, Third Edition, 20082008