Download Treat Causes

Symptom Relief in
End of Life Care
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

Dying: Common Family Concerns
Is my loved one in pain; how would we
know?
 Aren’t 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?

Dying: Timing
< 1 day to 14 days
 Well nourished, hydrated, uninfected
patients live longer

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

Communication
Open, honest rapport
 Diversity
 Spirituality

Dying: Early
Bed Bound
 Loss of interest and/or ability to drink/eat
 Cognitive changes



Increased sleep
Delirium
Dying: Mid

Progressive decline in mental status



Obtundation
Terminal Delirium
Death rattle
Dying: Late


Coma
Fever



Altered respiratory pattern






Aspiration Pneumonia
Dehydration
Apnea
Hypopnea
Hyperpnea
Irregularity
Cheyne-Stokes
Mottled extremities

Livido Mortis vs Livido Reticularis
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
Pain
Narcotics are safe and effective
 Multiple products and routes
 Bowel regimens
 Adjunctive therapies

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
Bone Pain

Bisphosphonates







Prophylaxis


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
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, Cr>0.5 over baseline or Cr>1.0 in CRI
Reduced dose CrCl <73.0 mg/dl, and slower infusion
Pain: Neuropathic
Gabapentin
 Tricyclics
 Narcotics

Dypnea
Anxiolytics
 Moving Air
 Open doors and windows
 Mouth Care

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.
Secretions: Non-pharmacologic Rx
Postural drainage


Position patient lateral or semi-prone
A minute or two of Trendelenburg


Gentle oropharyngeal suctioning



aspiration risk is increased.
often ineffective
Frequent suctioning disturbs patient and
visitors
Reduce fluid intake
Secretions: Pharmacologic Rx
Drug
Route Dose
Onset Cross Notes
BBB?
hyoscyamine hydro.
(Scopolamine Patch)
Patch
1 or more
patches
(about
1mg/3d)
12 hr
Yes
hyoscyamine sulph.
(Levsin)
PO
0.125 po
Q2-6 hr
30 min
No
Glycopyrrolate
(Robinul)
PO
1 mg/2-12 hr
30 min
No
SC, IV
.2 mg
1 min
Most potent
Erratic
absorption
PO, SL
1-10 gtt 1%
Q2-6 hr
1 mg
30 min
Yes
Cheap
Flexible
Most delirium
Atropine
IM, IV
1 min
Need short
term interim
meds 1st 12 hr
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
Dantrolene 50mg to 100mg daily

Medications












opioids,
anticonvulsants
tricyclics
SSRI's
contrast dye
anesthetics
penicillins
cephalosporins
imipenem
quinolones
cannabinoids
ifosfamide
Seizures

Usual Care

May require large doses of medication
Hiccups (Singultus) Pharmacologic


Pharmacological
Anti-Psychotics:

Chlorpromazine - the only FDA approved drug for hiccups.



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



25-50 mg po tid qid. IV 25-50 mg in 500-1000cc of NS over several hours
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.
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
Pruritis: Non-Pharmacologic

Treat Causes








Moisturizer


Dermatologic
Metabolic
Hem/Onc
Drugs
Infection
Allergy
Psychogenic.
Xerosis
Cooling agents


Calamine
Menthol in aqueous cream 0.5%-2%
Pruritis: Pharmacologic


EMLA Cream
Antihistamines



Steroids





Inflammatory itching
Topical
Systemic for refractory cases
Aveeno
Cholestyramine


Histamine mediated itching
Doxepin may work in selected cases
Cholestatic
Other



Ondansetron,
Paroxetine
Naloxone
Anxiety
Address underlying causes
 Treat dyspnea
 Treat sleep deprivation
 Narcotic euphoria overlaps anxiolysis
 Address spiritual issues
 Benzodiazepines
 Other Drug Treatment

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

Delirium and Terminal Delirium

Waxing and waning level of consciousness



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



Hyperactive
Hypoactive
High-potency short-acting anti-psychotics=drug of choice
Underused
Benzodiazepines



Second choice
“Paradoxical” worsening of delirium
Overused
Delirium and Terminal Delirium

Other neuroleptics



Chlorpromazine


Probably comparable to haloperidol
Olanzapine is up and coming
Sedation is desired
Newer atypical antipsychotic



May help
EMB scant
Perhaps with underlying dystonia or Parkinsons
Spirituality
Chaplain
 Diverse pastoral care
 Music therapy
 Communication

Ethical Issues
“Truth-Telling”
 Family
 Euthanasia
 Hospice Resource Allocation

Diversity and Ethnic Issues
Cultural Competency in questioning
 Awareness of beliefs
 Ritual
 Communication
 Staff education

Hospice

Use liberally
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

EPEC



http://www.epec.net/EPEC/webpages/index.cfm
The EPEC Project, Northwestern University's
Feinberg School of Medicine
750 N Lake Shore Drive, Suite 601 Chicago, IL
60611
Tel. 312/503-3732, FAX: 312/503-5868 Email:
[email protected]
The EPEC Project was supported from 1996-2003
with funding from The Robert Wood Johnson
Foundation.
Last modified 12/09/2005.
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

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
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