Symptom Management in Palliative Care

1
Symptom Management in Palliative Care

• Delirium, Dyspnea, Oncologic Emergencies

2
Delirium
Cognitive Failure, Confusion

• Pathophysiological disorder which manifests
  itself in impaired cognitive functioning and
  perceptual, emotional, and behavioral alterations
• Transient global disorder of cognition and
  attention
• Incidence - from 25 -85
• Higher in elderly, hospitalized

3
Delirium
Cognitive failure, confusion

• May interfere with recognition and control of
  other physical or psychological symptoms
• Often a pre-terminal event

4
Possible causes

• Drug Toxicity
• Accumulated opioid metabolites
• Undesired effects of drugs acting on CNS
• Infection, sepsis
• May be earliest indication

5
Possible causes (contd)

• Metabolic - electrolyte imbalance
• Hypercalcemia, hyponatremia, hypokalemia, uremia,
  liver failure
• Dehydration
• Hypoxia

6
Causes of Delirium
usually multifactorial ( research n94)

• Primary cause Secondary
  cause
  Metabolic
  44 89
• Medication 29
  44
• CNS metastasis 32
  ---
• Infection - fever and symptoms in 50, but only
  4 had positive blood cultures

7
Clinical subtypes

• Hyperactive
• Hallucinations, delusions, agitation
• Hypoactive
• Hypoarousal, hypoalert, lethargic -may be taken
  for depression
• Mixed
• Alternates between features of hyper and
  hypoactive

8
Delirium vs Dementia

• Feature Delirium Dementia
• Onset Acute Slow
• Duration Brief
  Chronic
• Consciousness Fluctuates Static
• Attention Always impaired May be intact

9
Delirium vs Dementia (contd)

• Feature Delirium
  Dementia
• Perception Disturbed, vivid Less florid
• Thinking Disorganized Impaired
  Rich
  Empty
• Sleep Always disturbed Usually
  
  normal
• EEG Abnormal

10
Diagnosis of Delirium

• MiniMental Status Exam - determines cognitive
  function
• Delirium Rating Scales

11
Groups of 3

• Is the MMSE an adequate measure for diagnosing
  delirium?
• Explain your thinking.

12
Factors that may exacerbate confusion

• Disruption to usual routine
• Strange environment
• Lack of control
• Sensory deprivation
• Pain
• Forced immobility

13
Management of Delirium

• Treat the cause
• Family information and support
• Pharmacological
• Haldol drug of choice
• Consider changing narcotics to deal with
  accumulated metabolites

14
Management of Delirium (contd)

• Provide calm, nonstimulating environment
• Adequate lighting
• Eyeglasses, hearing aids
• Frequent reminders of time and place
• Bring in familiar possessions

15
Management of Delirium (contd)

• Request family to stay with pt
• Organize care to allow for uninterrupted sleep
  periods
• Avoid physical restraints
• Reminder - grasp reflex returns in delirium
  (avoid labelling behav as combative)

16
Delirium
The destructive triangle

• Pt agitated confused
• 
  
• Family distress Caregiver
  distress

17
Sedation for intractable distress in the dying
-Terminal sedation

• Definition- deliberately inducing and maintaining
  deep sleep, but not deliberately causing death

18
Sedation for intractable distress in the dying
-Terminal sedation
Circumstances

• For relief of one or more intractable symptoms
  when all other interventions have failed
• Patient must be perceived to be near death
• For relief of profound anguish not amenable to
  spiritual, psychological, or other intervention

19
Sedation for intractable distress in the dying
-Terminal sedation
Survey of 61 practitioners, Chater et al., 1998

• Sometimes necessary 89
• Used in past year 77
• Successful 90
• Would use again 98

20
Sedation for intractable distress in the dying
-Terminal sedation

• Reasons for using
• Pain
• Anguish
• Agitation
• Dyspnea
• Restlessness
• Unendurable emotional distress
• Panic, terror

21
Take 5 minutes to write your thoughts on the
practice of terminal sedation

• Possible themes
• - benefits, risks
• - effect on family
• - would you want your mother to be sedated in
  this circumstance?
• - would you want to be?

22
Dyspnea

• An uncomfortable awareness of breathing or the
  urge to breathe
• Subjective - indiv with comparable degrees of
  lung impairment experience varying degrees of
  dyspnea
• Objective signs often dont match with pts
  perception or with degree of functional
  impairment

23
Dyspnea

• Occurs in at least 70 of terminally ill pts in
  last 6 weeks
• Research shows often not adequately addressed
• Possible causes- tumor, infection, CHF, SVCS,
  pleural effusion, pulmonary embolus, airway
  obstruction, anemia

24
Dyspnea
Causes in palliative care

• Direct tumor effects
• Indirect tumor effects
• Treatment-related
• Unrelated to cancer

25
Dyspnea Pathophysiology

• 3 components of control
• 1. Brain
• A) medulla - respiratory centre (autonomic)
• Integrates peripheral and central input
  and generates efferent activity such as resp
  rhythm
• B) cerebral cortex -controls voluntary
  respiration

26
Dyspnea
Pathophysiology (contd)

• 2. Respiratory receptors
• A) chemical -aorta and carotid body
  -send input to medulla
• B) mechanical -bronchial, Jreceptors
  -lungs
• 3. Respiratory muscles - diaphragm, intercostal
  muscles, sternomastoid muscle

27
Opioids for dyspneaMain pharmacological
intervention

• Reduces awareness of muscle exertion
• Suppresses ventilatory drive (lowers demand on
  resp muscles)
• Eases vascular resistance
• Eases anxiety

28
Titration of Opioids for dyspnea

• All strong Opioids appropriate
• Use short-acting preparations
• If already on Opioids for pain, increase dose by
  25 -100
• Dyspnea crisis aggressive response, give double
  current dose s/c or s/l q 30 min until settled
• Duration of effect in dyspnea will be less than
  in pain

29
Treatment Approaches

• Sedatives and tranquilizers -promethazine,
  chlorpromazine
• Oxygen
• Breathing techniques - pursed lip breathing,
  diaphragmatic breathing
• Positioning

30
Treatment Approaches

• Air circulation - fans, open windows
• Anxiety reduction techniques -meditation,
  imagery, music, etc
• Reassurance that wont be abandoned
• Family support

31
How do you know that the aggressive use of
Opioids doesnt actually bring about or speed up
the patients death?
32
Symptoms of excessive opioid dosing

• Gradual slowing of respiratory rate
• Breathing deep and regular
• Pinpoint pupils

33
Oncologic EmergenciesSuperior Vena Cava Syndrome

• Caused by tumor pressing on superior vena cava in
  mediastinum
• Most commonly associated with lung cancer (75
  SVC - 3 of lung ca pts)
• Lymphoma (15)
• Other solid tumors eg. Breast (10)

34
SVCS

• Early signs
• Facial, trunk, and upper extremity edema
• Pronounced venous pattern on trunk
• Neck vein distention
• Cough

35
SVCS

• Late signs
• Hoarseness, stridor
• Engorged conjunctiva, visual disturbances
• Headache, dizziness
• Change in mental status
• Respiratory distress

36
SVCS

• Treatment possibilities
• Radiation
• Diuretics
• Steroids
• Comfort measures

37
Spinal Cord Compression

• Caused by tumor encroachment upon spinal cord or
  cauda equina
• Most common in cancers that involve bone mets
• Eg. Lung, breast, prostate

38
Spinal Cord Compression

• Early signs
• Back pain, radicular or localized
• Motor weakness
• Sensory loss
• May occur gradually or suddenly

39
Spinal Cord Compression

• Late signs
• Motor loss
• Urinary retention, overflow, incontinence
• Difficulty expelling stool, constipation,
  incontinence
• Poor sphincter control

40
Spinal Cord Compression

• Diagnosis
• Myelogram
• CT scan
• MRI

41
Spinal Cord Compression

• Treatment
• Radiation
• Steroids
• Surgery
• Comfort measures

42
Hypercalcemia

• Occurs in 10 all cancer pts
• Myeloma most common
• Also breast, lung, and renal cancers (bone mets,
  lytic lesions)

43
Hypercalcemia

• Factors in Production
• Increased osteoclast activity
• Increased bone resorption
• Decreased renal clearance of calcium
• Tumor secretion of peptides

44
Hypercalcemia

• Symptoms
• Lethargy, Confusion
• Muscular weakness, Incoordination
• Polyuria, Thirst
• Nausea, Vomiting, Constipation
• Cardiac toxicity- arrhythmia

45
Hypercalcemia

• TREATMENT
• IV rehydration
• Diuretics
• Bisphosphonates