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E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium Session3: Nonpain Symptoms at the End of Life Fairfield University Quinnipiac University School of Nursing ELDER Project E L N E C Geriatric Curriculum Objectives: 1. Identify common symptoms associated with end of life. 2. Discuss the need for continual assessment. 3. Describe the role of various members of the palliative care team to assess and manage symptoms E L N E C Geriatric Curriculum Symptom Management Requires• Ongoing assessment and evaluation • Requires interdisciplinary teamwork E L N E C Geriatric Curriculum Common EOL Symptoms • Respiratory – Dyspnea – Cough • GI – – – – – E L • General/Systemic – Fatigue – Weakness • Psychological Anorexia Constipation Diarrhea Nausea Vomiting N E C Geriatric Curriculum – – – – – Depression Anxiety Delirium Agitation Confusion Case Study #6 Mr. C: Dyspnea/Fatigue • Mr. C. is a 75-year-old African American man with end-stage cardiac disease and long standing congestive heart failure including pulmonary edema. He experienced his first myocardial infarction at 45 years of age, had a quadruple bypass procedure at 58, and repair of an abdominal aortic aneurysm at 62. He has been retired for 15 years after working as an engineer. He lives at home with his wife, who is a cancer survivor. • He has led a very active life, even after retirement, but in the past few months has experienced severe fatigue that leaves him unable to participate in or enjoy previous activities. He often says, “I feel as if I have no ambition,” and “I can’t do anything anymore. I am worthless.” In the past few weeks, Mr. C. has been experiencing shortness of breath, initially relieved with oxygen. Unfortunately, the dyspnea has progressed during the past week and he has developed a dry cough. He has no advance directive. E L N E C Geriatric Curriculum Dyspnea • Distressing shortness of breath • Difficulty breathing • Associated with anxiety, depression, and decreased quality of life E L N E C Geriatric Curriculum Assessment of Dyspnea • Clinical assessment- it is what the patient says it is. Derby et al., 2010; Dudgeon, 2010 E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Treatment of Dyspnea • Oxygen therapy • Pharmacologic treatments – – – – opioids bronchodilators diuretics corticosteroids Clemens & Klaschik, 2007; Derby et al., 2010; Dudgeon, 2010; Jacobs, 2003 E L N E C Geriatric Curriculum Treatment of Dyspnea • Non-pharmacologic – Be calm and provide reassurance – Counseling – Pursed lip breathing – Energy conservation – Fans, elevation, positioning – Distraction, relaxation exercise Dudgeon, 2010 E L N E C Geriatric Curriculum Question? • What have you done to provide nonpharmacologic treatment of dyspnea? • How do you think Mr. C. would assess his QOL? E L N E C Geriatric Curriculum Fatigue • Subjective • Commonly associated with many diseases • Impacts all dimensions of QOL How is fatigue affecting Mr. C’s QOL? E L N E C Geriatric Curriculum Causes of Fatigue • Psychological Stress Anxiety Depression Family • Disease and Treatment related • Why is Mr. C. so fatigued? E L N E C Geriatric Curriculum Treatment of Fatigue • Non-drug strategies: Frequent rest periods Energy conservation Prioritize goals PT/OT Maintain nutrition & hydration • Medical therapies: Blood transfusions Corticosteroids Antidepressants E L N E C Geriatric Curriculum Anorexia and Cachexia • Anorexia - loss of appetite, usually with decreased intake • Cachexia - lack of nutrition and wasting • Anorexia and cachexia often follow fatigue! Wholihan, 2010 E L N E C Geriatric Curriculum A client in advanced stages of AIDS is reporting fatigue. Which of the following assessment findings is commonly associated with the symptom of fatigue? a. anorexia /cachexia b. reduced serum calcium c. hyperthyroidism d. increased hemoglobin/hematocrit E L N E C Geriatric Curriculum Causes of Anorexia and Cachexia • Disease related • Psychological • Treatment related • What cultural consideration might need to be addressed with Mr. C.? Wholihan, 2010 E L N E C Geriatric Curriculum Assessment of Anorexia and Cachexia • • • • • Physical findings Impact on function and QOL Calorie counts/daily weights Lab tests Skin breakdown Wholihan, 2010 E L N E C Geriatric Curriculum Treatment of Anorexia and Cachexia • • • • Treat the cause Dietary consultation Appetite stimulants Parenteral / enteral nutrition • What long term planning needs to be addressed with Mr. C.? E L N E C Geriatric Curriculum Case Study #7 “Mr. T.” Diarrhea/Constipation • • Mr. T. is an 85-year-old Korean widower who has been in a nursing home for two years with progressive dementia. He is unable to communicate with his two adult sons, their wives, his grandchildren, or with the staff. In fact, the family visits infrequently and is obviously distressed when they observe Mr. T. He has been unable to ambulate, requiring full assistance with transferring to or from a chair. • He had several episodes of aspiration one year ago, when a feeding tube was placed. He had significant diarrhea when tube feedings were first started. However, in the past few months, he has been constipated, requiring disimpaction several times each month. During the past week, he has had frequent episodes of liquid diarrhea. E L N E C Geriatric Curriculum Constipation • Infrequent passage of stool • Stool that is hard & difficult to pass • Frequent symptom in palliative care • Prevention is key Economou, 2010; Sykes, 2004 • What family teaching is essential? E L N E C Geriatric Curriculum Causes of Constipation • • • • Decreased fluid and food intake Decreased physical activity Medications Chronic illness • What cultural considerations need to be addressed for Mr. T.? E L N E C Geriatric Curriculum Assessment of Constipation • Bowel history • Physical symptoms Rubbing abdomen Restlessness Change in behavior Crying; resisting care • Abdominal assessment • Rectal assessment • Medication review E L N E C Geriatric Curriculum Economou, 2010 Treatment of Constipation • Medications Senokot Peri-Colace Dulcolax Others • Dietary/fluids • Comfort measures, privacy • Key-anticipate & prevent • What long term planning should be considered for Mr. T.? E L N E C Geriatric Curriculum Berger et al., 2007; Economou, 2010 A client with terminal cancer has been prescribed fentanyl and dilaudid for pain. Which of the following goals would be essential to include in the client's plan of care? a. Client will remain continent of urine and stool. b. Client will have usual bowel pattern. c. Client will not report dyspnea. d. Client will not report fatigue. E L N E C Geriatric Curriculum Which of the following clients is at the highest risk for developing constipation? a. A 48-year-old with metastatic cancer of the spine on high doses of opioids who has dehydration. b. A 76-year-old with cancer of the bowel who has begun treatment for Clostridium difficile. c. An 85-year old with hepatic encephalopathy who is receiving prescribed neomycin (Mycifradin) and lactulose. d. A 90-year-old with uterine cancer and laboratory evidence of hypocalcemia and hyperkalemia. E L N E C Geriatric Curriculum The home health worker is caring for a client at the end of life who has a recent history of constipation. Which of the following may mean that there is fecal impaction? a. b. c. d. E L foul smelling diarrhea sudden onset of liquid stool fatty looking stools blood and mucous strands in stool N E C Geriatric Curriculum Case Study #2 "Mr. Hayes“ Nausea/depression • Mr. Hayes is a 73-year-old with metastatic colon cancer, which has spread throughout his abdomen. He has been a resident in your NH for about 6 months and recently developed intractable nausea and is experiencing rapid weight loss. He is barely capable of managing any activities of self care. He is very embarrassed and distressed by this. E • Mr. Hayes has been found to have a non-resectable partial small bowel obstruction. He asks, "How much longer do I have?" and "Can we speed this up?" “I don’t want my daughter to see me suffer.” “I don’t want to be in pain.” The patient admits to feeling down but denies any suicidal ideation. He is clearly concerned about becoming a burden to his family. He is a devout Catholic and mentions to the NA that he is certain his symptoms and suffering are a punishment for his having a divorce ten years ago. L N E C Geriatric Curriculum Depression • • • • Ranges from sadness to suicidal Often unrecognized and undertreated Occurs in 25-77% of terminally ill Estimated to occur in 22% of nursing home residents AGS, 2002; Coyle, 2010; Dahlin, 2009 E L N E C Geriatric Curriculum Causes of Depression • Physical: pain, illnesses, medications, sensory deficits • Psychological: loss, grief, memory problems • Social: isolation, conflicted relationships • Biological: family history, genetics • Medications – Why is Mr. Hayes depressed? E L N E C Geriatric Curriculum Depression • Depression is the most frequently observed symptom in the terminally ill – Observed in 77% of persons with far-advanced cancer • Suggested questions to assess depression: – – – – “Can you describe your mood for me?” “How long have you felt this way?” “What is the feeling of depression like for you?” “Have you noticed changes in your level of interest in normal activities?” – “How would you rate your feeling of depression on a 1-to-10 scale?” • E L ©2001 D.J. Wilkie & TNEEL Investigators N E C Geriatric Curriculum (Isaacs, 1998) MOOD SCALE (short form) Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO Answers in bold indicate depression. Although differing sensitivities and specificities have been obtained across studies, for clinical purposes a score > 5 points is suggestive of depression and should warrent a follow-up interview. Scores > 10 are almost always depression. http://www.stanford.edu/~yesavage/GDS.english.short.score.html E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum PHQ-9 • Scoring: add up all checked boxes on PHQ-9 – For every Not at all = 0; Several days = 1; – More than half the days = 2; Nearly every day = 3 • Interpretation of Total Score - Total Score Depression Severity – – – – – • • • E L 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a trademark of Pfizer Inc. A2662B 10-04-2005 N E C Geriatric Curriculum Pharmacological Interventions for Depression • Antidepressants • Stimulants • Nonbenzodiazepines • Steroids E • Do you think Mr. Hayes would benefit from medication? L N E C Geriatric Curriculum Nondrug Interventions for Depression • • • • • • Empathetic listening Assurance and support Concrete information Symptom management Relaxation/imagery Counseling • What nondrug therapy might work best for Mr. Hayes? E L N E C Geriatric Curriculum Mr. Hayes • When would be a good time to talk to Mr. Hayes about palliative care and an advance directive? • Is an additional suicide assessment indicated? • How might various members of the team contribute to Mr. Hayes’ care? E L N E C Geriatric Curriculum Suicide Assessment • Do you think life isn’t worth living? • Have you thought about how you would kill yourself? E L N E C Geriatric Curriculum Key Palliative Care Team Roles E • • • • • • Patient advocacy Assessment, Assessment, Assessment Pharmacologic treatments Non-pharmacologic treatments Patient/family teaching Presence L N E C Geriatric Curriculum Conclusion • Multiple symptoms are common • Coordination of care with physicians and other team members • Use drug and nondrug treatment • Patient/family teaching and support E L N E C Geriatric Curriculum Last question… • What one practice improvement can you begin as a result of attending this session? E L N E C Geriatric Curriculum References City of Hope & the American Association of Colleges of Nursing, 2007; Revised, 2010. The End-of-Life Nursing Education Consortium (ELNEC)- Geriatric Training Program and Curriculum is a project of the City of Hope (Betty R. Ferrell, PhD, FAAN, Principal Investigator) in collaboration with the American Association of Colleges of Nursing (Pam Malloy, RN, MN, OCN, Co-Investigator). Supported by DHHS/HRSA/BHPR/Division of Nursing Grant # D62HP06858 E L N E C Geriatric Curriculum