Module 1: Managing the Major Symptoms

1. Module 1: Managing the Major Symptoms Instructor Joy Jones, RN Heyman HospiceCare at Floyd Unit 6: Symptom Management

2. Objectives • Understand how to assess pain and recommend the most appropriate therapies • Understand how to assess other major symptoms and recommend the most appropriate therapies • Understand the integration of the different aspects of care when treating pain and other major symptoms Unit 6: Symptom Management

3. Introduction For the purpose of this program, we will be looking at the management of pain and other major symptoms from a palliative care perspective Unit 6: Symptom Management

4. RESPONDING TO PATIENT NEEDS • Palliative care is indicated throughout all phases of life, whenever there are significant health from illness or trauma

5. Palliative Care Movement in the United States Characteristics • Patient and family are unit of care • Rely on interdisciplinary assessment, treatment and evaluation • Energetically respond to the consequences of illness facing the patient and family • Managing symptoms • Practical guidance and support of care at home • Offering anticipatory counseling/crisis prevention/critical decision support • Recognizing the need for health promotion, even in the face of physical decline

6. Palliative Care Trajectory Palliative Care

7. CLINICAL PRACTICE GUIDELINES FOR PALLIATIVE CARE 8 DOMAINS • Structure and Process of Care • Physical Aspects of Care • Psychological and Psychiatric Aspects of Care • Social Aspects of Care • Spiritual, Religious and Existential Aspects of Care • Cultural Aspects of Care • Care of the Imminently Dying Patient • Ethical and Legal Aspects of Care

8. PAIN Palliative Care addresses the four components of pain • P – PHYSICAL problems, often multiple, must be specifically diagnoses and treated. • A – ANXIETY, anger and depression are critical components of real pain that must be addressed by the whole team • I – INTERPERSONAL problems – social problems, financial stress, and family tensions are always interwoven in the fabric of the patient’s symptoms • N – NON-ACCEPTANCE or spiritual distress can cause severe suffering that opiods won’t help

9. History and Physical Exam • Patients see that you are really concerned and confident that something can be done to improve things • Can learn: • How much of pain is physical, and how much is psychosocial or spiritual • How many different sources of pain are there

10. History and Physical Exam • Can learn (cont’d): • Which of these pains are: • Unrelated to the disease or therapy • Caused indirectly by the disease or therapy • Caused directly by the disease or therapy • How the patient has responded to previous therapy

11. Treatment of Pain • Specific remedies – analgesics, laxatives, antifungals, radiation therapy • Helpful equipment – hospital bed, APP • Actions – regular turning, massage, insertion of urinary catheter • Involve other disciplines – address psychosocial, spiritual, social, and financial components

12. Treatment of Pain

13. Treatment of MILD Pain • Non Opiod • +/- Adjuvant

14. Treatment of MILD Pain • Acetaminophen (APAP) • Notable side effects • Hypothermia • Rash • Hepatotoxicity (rare with doses < 4 g/day) • Nephrotoxicity

15. Treatment of MILD Pain • Acetaminophen (APAP) • Notable side effects • Hypothermia • Rash • Hepatotoxicity (rare with doses < 4 g/day) • Nephrotoxicity

16. Treatment of MILD Pain • Acetaminophen (APAP) • Important considerations • Avoid use or use cautiously in patients with hepatic disease or chronic alcohol abuse. • Maximum dose is 2g/day in patients with hepatic disease, those who chronically consume alcohol, and patients using APAP >10 days continuously

17. Treatment of MILD Pain • Acetaminophen (APAP) • Monitor medication regime for other potentially hepatotoxic medications (list not all inclusive)

18. Treatment of MILD Pain • NSAIDS • Important considerations • Traditional NSAIDs inhibit platelet aggregation and prolong bleeding time • Evaluate risk factors for upper GI adverse events • Age > 65 years • History of peptic ulcer disease • History of GI bleeding • Concomitant use of oral corticosteroids • Concomitant use of anticoagulants

19. Treatment of MILD Pain • NSAIDS • Important considerations • Evaluate risk factors for [reversible] renal toxicity • Age > 65 years • History of peptic ulcer disease • History of GI bleeding • Concomitant use of ACEI • Concomitant use of angiotensin II receptor blockers (ARB) • Concomitant use of diuretics • Use NSAIDS with caution in patients with hypertension, CHF, or mild to moderate renal insufficiency • Avoid use in patients with severe renal impairment

20. Treatment of MODERATE Pain • Opiod for moderate pain • +/- Non-opiod • +/- Adjuvant

21. Treatment of MODERATE Pain • Opiods • Notable Side effects • Nausea • Vomiting • Constipation • Sedation • Confusion

22. Treatment of MODERATE Pain • Opiods • Important Considerations • Every patient prescribed opiod therapy should have a bowel regime in place to prevent constipation • Propoxyphene is NOT recommended for pain management because it lacks efficacy and has the potential for adverse effects. Elderly patients may be especially at risk. • Meperidine is NOT recommended for pain management because of the potential for accumulation of [toxic] metabolites and adverse effects.

23. Treatment of MODERATE Pain • Common opiod preparations for moderate pain • Hydrocodone /APAP (various strengths) 1 – 2 tab po q4-6h ATC or PRN • Codeine /APAP (various strengths) 1 – 2 tab po q4-6h ATC or PRN • Oxycodone /APAP 5/325 mg 1 – 2 tab po q4-6h ATC or PRN • Oxycodone /APAP 5/500 mg 1 – 2 tab po q4-6h ATC or PRN • Morphine IR 5 – 10 mg po q3-4h ATC or PRN • Oxycodone 5 – 10 mg po q3-4h ATC or PRN

24. Treatment of MODERATE Pain • Opiods for moderate pain • Important Considerations • Be aware of the amount of acetaminophen used as the non-opiod in the combination products. • If the number of tablets required to alleviate pain exceeds the maximum dose of acetaminophen, use each product separately • Acetaminophen tablets plus hydrocodone tablets/liquid • Allows further titration of the opiod without exceeding the daily limits of the non-opiod

25. Treatment of SEVERE Pain • Opiod for severe pain • +/- Non-opiod • +/- Adjuvant

26. Treatment of SEVERE Pain • Opiods for severe pain • Morphine LA po q12h if allergic: • Oxycodone LA po q12h (only if patient has previously tolerated oxycodone) • Methadone po q8h if unable to swallow: • Transdermalfentanyl – start with 12.5 mcgm/hr if opiod naive

27. Treatment of SEVERE Pain • Opiods for severe pain • Continue to use short-acting opiod for breakthrough pain • Titrate up long-acting opiod based on usage of short-acting opiod • Reevaluate in 24 – 48 hours

28. Treatment of Pain

29. B R E A T H A I R DYSPNEA Specific Causes and Treatments

30. Specific Causes and Treatments for Dyspnea • B – BRONCHOSPASM – if present, consider nebulized Albuterol and/or oral steroids; if not present, consider lowering doses of theophyline and adrenrgic agents to reduce any tremor and anxiety that often exacerbate dyspnea. • R – RALES – If volume overload is present, reduce artificial feedings or stop IV fluids. Diuretics are occasionally needed. If pneumonia seems likely, decide whether an antibiotic will rehabilitate the patient or just prolong the dying process. Patient and family participation in this decision is essential.

31. Specific Causes and Treatments for Dyspnea • E – EFFUSIONS – Thoracentesis can be effective, but if the effusion recurs and the patient is ambulatory, consider chest tube pleurodesis to prevent recurrent lung collapse. If the patient is close to death, palliate the dyspnea with opiods and loving kindness. • A – AIRWAY OBSTRUCTION – Make sure tracheostomy appliances are cleaned regularly. If aspiration of food is likely, puree solids and thicken liquids with cornstarch or “Thick-it,” and instruct the family in positioning the patient during feeding and suctioning if necessary.

32. Specific Causes and Treatments for Dyspnea • T – THICK SECRETIONS – If the cough reflex is still strong, loosen secretions with nebulized saline. If the cough is weak, dry secretions with Hyoscyamine (Levsin) 0.125 mg PO or SL q8h or TransdermScop 1-3 patches every 3 days, or Atropine eye drops, 2 drops SL q4h. • H – HEMOGLOBIN LOW – A blood transfusion may add energy and reduce dyspnea for a few weeks. More often, hemorrhage or marrow failure are part of the dying process and are best palliated with opiods and loving kindness.

33. Specific Causes and Treatments for Dyspnea A – ANXIETY • Sitting upright, using a bedside fan, listening to calming music, and practicing relaxation techniques can be extremely effective, as can skillful counseling and the presence of a calming physician. • Dyspnea exacerbates normal fears and anxiety, so treat it with opiods first, then try a benzodiazepine if needed. If the opiod dose is limited by drowsiness, reduce the benzodiazepine and increase the opiod.

34. Specific Causes and Treatments for Dyspnea I – INTERPERSONAL ISSUES • Social and financial problems can contribute to dyspnea. Counseling and interaction with social workers and other members of the interdisciplinary team may bring relief. • When family relationships exacerbate the problem, a few days spent in a peaceful, homelike hospice inpatient unit may help relieve the patient’s symptoms.

35. Specific Causes and Treatments for Dyspnea R – RELIGIOUS CONCERNS • Faith or experience of the transcendent can bring profound comfort. • Some religious beliefs can precipitate dyspnea and/or exacerbate its symptoms. • “God is punishing me.” • “God would heal me if I had enough faith.” • Take time to listen with full attention and presence. • Help patient to explore ways to reconnect with God, the cosmos, or the deepest parts of the self. • Coordinate treatment with the family’s spiritual adviser, chaplain, counselor, other healthcare professionals, and family members

36. Treatment of Dyspnea • Like pain – complex of physical sensations, psychosocial reactions and spiritual concerns. • HX, and physical exam can reveal many aspects amenable to treatment • Interdisciplinary team approach is essential.

37. Treatment of Dyspnea with Opiod Drugs • If no treatable etiology is found, the first-choice agents for dyspnea are the opiod analgesics. • Safe and very effective for the treatment of dyspnea in cancer and COPD when used in individually adjusted doses. • In COPD – shown to increase exercise tolerance with decreased ventilation. • If dose titrated to the degree of dyspnea the patient is having, respiratory depression can usually be avoided. • If patient is alert and conversant, you can safely increase the opiod dose.

38. Treatment of Dyspnea with Opiod Drugs • If a terminally ill patient has been on a stable dose of opiods for several days and then becomes very weak and less alert, develops cool extremities and decreased or erratic respirations, he is probably dying. • The appropriate action is to talk to the family and let them know you care. • Narcan should be reserved for cases of accidental overdose. • To completely reverse the effects of opiods in a dying cancer patient can be extremely traumatic.

39. Treatment of Nausea and Vomiting • Careful hx. and physical – may reveal several types of physical and psychosocial problems that are contributing to the N & V. • Frequently can treat the problem specifically. • If cause cannot be eliminated, approach can be tailored to be most helpful. • Increased ICP may respond to dexamethasone. • Motion sickness - meclizine

40. Treatment of Nausea and Vomiting • Most common causes – mediated via the CTZ • Mild – Antiemetic tablet • Promethazine 25 mg (Phenergan) • Scopolamine patch (Transderm Scop) • More severe • Occasional suppository use – Compazine 25 mg • Regular schedule of more potent CTZ antiemetic • Haloperidol (Haldol) 1-5 mg tid • Metoclopramide (Reglan) 10 – 20 mg q4h.

41. Treatment of Nausea and Vomiting • Reevaluate patient if medications not effective • Bowel obstruction or “squashed-stomach syndrome? • Renal failure or theophylline toxicity? – blood test? • Brain metastases? – Trial of steroids

42. Treatment of Nausea and Vomiting • If persistent or no treatable causes can be found, a combination of antiemetics may be required. • Begin with a potent agent like haloperidol – push the dose to 10 or even 15 mg per day. • Add an antihistamine (like hydroxyzine or cyclizine 50 –150 mg per day. • Addition of dexamethasone can be helpful. • Ondansetron (Zofran) sometimes very effective – expensive.

43. Treatment of Nausea and Vomiting • Nausea and vomiting of terminal illness can be controlled in 90% of patients • Even nausea of a complete bowel obstruction can often be palliated successfully without an IV or NG tube. • Don’t forget to reassess for changes in the patient’s condition and to use the interdisciplinary team to help with the critically important social, psychosocial, and spiritual aspects of the symptoms.

44. CONSTIPATION • Prevent and treat early • Prevalent in palliative medicine • Low intake of fluid and fiber • Impaired mobility • Require opiod analgesics and other drugs that impair gut motility • Complicating medical conditions – bowel obstructions and hemorrhoids.

45. CONSTIPATION PREVENTION • Patients started on opiod analgesic should also receive a regular laxative dose. • Avoid bulk-forming agents • Stool softeners helpful • Severe constipation may require a saline laxative – cramping and bloating. • Suppositories, enemas occasionally needed

46. QUESTIONS