Symptom Relief in End of Life Care

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Symptom Relief inEnd of Life Care
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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

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Dying Common Family Concerns

• Is my loved one in pain how would we know?
• Arent 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?

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Dying Timing

• Well nourished, hydrated, uninfected patients
  live longer

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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

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Communication

• Open, honest rapport
• Diversity
• Spirituality

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Dying Early

• Bed Bound
• Loss of interest and/or ability to drink/eat
• Cognitive changes
• Increased sleep
• Delirium

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Dying Mid

• Progressive decline in mental status
• Obtundation
• Terminal Delirium
• Death rattle

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Dying Late

• Coma
• Fever
• Aspiration Pneumonia
• Dehydration
• Altered respiratory pattern
• Apnea
• Hypopnea
• Hyperpnea
• Irregularity
• Cheyne-Stokes
• Mottled extremities
• Livido Mortis vs Livido Reticularis

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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

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Pain

• Narcotics are safe and effective
• Multiple products and routes
• Bowel regimens
• Adjunctive therapies

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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

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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, Cr0.5 over baseline or
  Cr1.0 in CRI
• Reduced dose CrCl infusion

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Pain Neuropathic

• Gabapentin
• Tricyclics
• Narcotics

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Dypnea

• Anxiolytics
• Moving Air
• Open doors and windows
• Mouth Care

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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.

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Secretions Non-pharmacologic Rx

• Postural 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

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Secretions Pharmacologic Rx
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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

• Medications
• opioids,
• anticonvulsants
• tricyclics
• SSRI's
• contrast dye
• anesthetics
• penicillins
• cephalosporins
• imipenem
• quinolones
• cannabinoids
• ifosfamide

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Seizures

• Usual Care
• May require large doses of medication

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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.

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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

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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

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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

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Anxiety

• Address underlying causes
• Treat dyspnea
• Treat sleep deprivation
• Narcotic euphoria overlaps anxiolysis
• Address spiritual issues
• Benzodiazepines
• Other Drug Treatment

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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

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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-psychoticsdrug of
  choice
• Underused
• Benzodiazepines
• Second choice
• Paradoxical worsening of delirium
• Overused

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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

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Spirituality

• Chaplain
• Diverse pastoral care
• Music therapy
• Communication

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Ethical Issues

• Truth-Telling
• Family
• Euthanasia
• Hospice Resource Allocation

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Diversity and Ethnic Issues

• Cultural Competency in questioning
• Awareness of beliefs
• Ritual
• Communication
• Staff education

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Hospice

• Use liberally

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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

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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 [phone] Email
  info_at_epec.net
• The EPEC Project was supported from 1996-2003
  with funding from The Robert Wood Johnson
  Foundation.Last modified 12/09/2005.

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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

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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

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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

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