Palliative Care: Goals and Nonpain Symptom Management

1. Palliative Care: Goals and Nonpain Symptom Management Leigh Vaughan, MD Medical University of South Carolina March 6, 2012

2. Outline • Definition of PC • Goals of PC • Who should be considered for PC • Symptoms identified in PC • Management and treatment options

3. Learning Objectives • Define palliative care. • Determine effective management strategies for palliative care patients. • Process strategies for prevention and treatment of complications from palliative care interventions. • Assess the impact of interventions on patient comfort and prognosis. • Recognize and address the psychosocial effects of life threatening illness in hospitalized patients. • Assess and respond to patient's symptoms, including pain, dyspnea, nausea, constipation, fatigue, anorexia, anxiety, depression and delirium.

4. Key Messages • Palliative care is a multi-disciplinary approach to treating the "total pain" of a patient (including physical, psychosocial, and spiritual needs of the patient and family). • Palliative care is appropriate at any stage of disease and can be given simultaneous to all other medical therapies, including those with curative intent. • There are multiple symptoms to target at the end-of-life and Palliative care teams specialize in management of refractory symptoms.

5. Palliative Care Definition • Collaborative, comprehensive, interdisciplinary approach to treating “total pain” (includes physical, psychosocial, and spiritual needs of patients and families) • Appropriate at any stage of illness and simultaneously with all other medical treatments

6. Goals of PC • Improve the quality of life of patients living with debilitating, chronic or terminal illness • Prevention and relief of suffering by early identification, assessment, and treatment of distressing symptoms • Accomplished by combined efforts of an interdisciplinary team

7. Components of IDT (Interdisciplinary Team) • Patient* • Family, loved ones* • MD primary team • MD consultants • Nursing • Psychologist, psych liaison • Social support- SW, case management • Physical or occupational therapy, respiratory therapy • Nutrition services • Spiritual support • Nursing home, hospice, home health services • Pharmacists • Volunteers • Complimentary and Alternative therapy

8. Patients to consider for PC • Yes to "surprise question“ : You would not be surprised if the patient died within 12 months? • Patients with frequent admissions • Patients whose admissions are prompted by difficult-to-control physical or psychological symptoms • Patients with complex care requirements (eg, functional dependency; complex home support for ventilator/antibiotics/feedings) • Patients with decline in function, feeding intolerance, or unintended decline in weight (eg, failure to thrive) • Admissions from long-term care facility or medical foster home • Elderly patients, cognitively impaired, with acute hip fracture • Patients with metastatic or locally advanced incurable cancer • Patients with chronic home oxygen use • Patients who have an out-of-hospital cardiac arrest • Current or past hospice program enrollee • Patients with limited social support (eg, family stress, chronic mental illness) • No history of completing an advance care planning discussion/document

9. Symptoms Management • Under curative model, symptoms are clues to a diagnosis • Under Palliative care model, symptoms are entities in of themselves • Goal is to identify, evaluate underlying cause, and treat • If treatment is pharmacologic, consider alternative routes when and if p.o. administration fails

10. Alternative routes of delivery • Enteral if feeding tubes • Transmucosal –widely used in palliatve care, immediate delivery • Rectal • Transdermal -takes 24 hours to work • Parenteral • Intraspinal

11. Frequent symptoms in PC • Dyspnea • Fatigue, poor function status, sedation • Nausea, vomiting, constipation • Mouth discomfort • Weight loss, dysphagia, anorexia • Depression, psychological pain • Delirium • Pain • Terminal secretions

12. Dyspnea • Only reliable measure is patient self-report • RR, pO2, blood gas DO NOT correlate with the feeling of breathlessness • Treatment options • Opioids- best • Anxiolytics- only if an anxiety component, not as effective alone without opioids • O2- no benefit over Room air if not hypoxic • Non-pharmacologic management

13. Dyspnea with specific treatment • Pulmonary edema - Furosemide • Bronchospasm - Albuterol, steroids, ipratropium bromide, inhaled racemic epinephrine • Thick secretions - Scopolamine, glycopyrrolate • Pleural effusion • Drainage, pleurodesis

14. Fatigue • Underlying causes: anemia, dehydration, meds, hypoxia, insomnia, pain, infection, deconditioning • Possible treatments: Transfusions, O2, diuresis or hydration, sleep aids and sleep hygiene, PT, exercise, methylphenidate • Relaxation, meditation

15. Nausea/vomiting • Causes: -Bowel obstruction -Drugs (ex: opioids) -Malignancy related gastroparesis -Metabolic derangements -Increased ICP –especially brain mets • Treat underlying cause : treat with haldol/dexameth for bowel obstruction, opioid rotation, treat constipation, correct metabolic abnormalities

16. Treatment options- Nausea • Dopamine antagonists (Haloperidol, Metoclopramide, Prochlorperazine) • Prokinetic agents (metoclopromide) • Antacids/PPIs • Cytoprotective agents • Antihistamines (Diphenhydramine, Meclizine, Hydroxyzine) • Steroids • THC • benzodiazepines • Anticholinergics (scopolamine) • Serotonin antagonists (odansetron) • Neurokinin antagonists (aprepitant)

17. Constipation • Begin dual therapy: stool softner (docusate=colace) + stimulator (senna or bisacodyl = dulcolax) • Step up therapy: added to prior • osmotics (Lactulose, MoM, mag citrate,) • lubricants (glycerin, castor oil) • large volume enema (500 cc of water, phosphate, oil retention)

18. Symptoms Mucositis Dry mouth Mouth pain Change in taste Difficulty swallowing Difficulty with speaking Causes Mouth breathers Medications (anticholingergics) Advanced age Cancer patients History of radiation to the head and neck Sjögren's syndrome Diabetes mellitus Anxiety states Dehydration (but rehydration often does not improve this symptom) herpes simplex infection Mouth Discomfort

19. Mouth Care • Address underlying issue • Cleaning, denture care • Maintain hydration • Rehydrating gel • Suspension options: • “Difflam” benzydamine hydrochloride 0.15% (oral rinse) 15ml, 2-3 hourly for especially for radiation • Consider sucralfate suspension (part of Magic Mouth) • Chlorhexidine gluconate (Perisol)- Analgesia • Saliva substitute (Pilocarpine or Salagen)

20. Weight loss, anorexia • Treatment options: • Megace, steroids • THC • Small frequent meals • Establish goals • Educate family, avoidance of coercion

21. Terminal Secretions • Also called “death rattle” • From impaired swallowing of saliva, or congestion from impaired cough ability • Treatment: • Avoid suctioning • Avoid xs hydration • Medications: Scopolamine transdermal (but slow onset) or Glycopyrrolate: 0.4 to 1.2 mg/day by continuous IV or 0.2 mg SC every 4 to 6 hours

22. Pharmacologic Treatment Options • Psychostimulants • Methylphenidate (Ritalin) • Modafinil (Provigil) • rapid onset of action and well tolerated. • SSRI’s • Tricyclic antidepressants (benefit of treating concurrent neuropathic pain) • Insomnia- consider short course treatment • Anxiety- consider benzodiazpines

24. Delirium • Identify underlying cause • Treat and diagnose within the context of agreed upon level of care • Pain is a potent precipitant of delirium and its’ management is associated with significantly reduced risks

25. Bone pain- Treatment • Opioids, NSAIDS • Radiation- if cancer related • Bisphosphonates • Steroids • Consider Complimentary and Alternative Therapy (CAM)

26. CAM • Acupuncture, hypnosis, Reiki, reflexology, biofeedback, specialty diets, music, art therapy • Balance potential underutilized benefit with potential toxicity • Often patients latch onto any therapy • More successful if institution supports resources

27. References Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the center to advance palliative care. Weissman, David, J Palliat Med. 2011;14(1):17. Nonpain Symptom Management in the Dying Patient. Rousseau P. Hospital Physician. 2002 Hospital Physician;38(2):51 - 6. Physiological changes and clinical correlations of dyspnea in cancer outpatients. Dudgeon DJ J Pain Symptom Manage. 2001;21(5):373. 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. 1989;7(5):590. The mouth and palliative care. Sweeney MP Am J Hosp Palliat Care. 2000;17(2):118. Recommendations for the Use of Antiemetics: Evidence-Based, Clinical Practice Guidelines Gralla R, et al. J Clin Oncol, 1999. Hospice and Palliative Care Training for Physicians: UNIPAC Series, Third Edition, 2008