Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Symptom Management in Palliative Care: Part 2 Scott Akin MD [email protected] Outline • Pain control: That was part #1 of this talk…e-mail me for a copy • Depression • Dyspnea • Nausea and vomiting • Anorexia Depression in Palliative Care • Common: numbers hover around 30% • Misunderstood – Myth that all dying patients “should” be depressed, and it is a “normal” part of dying • Underdiagnosed – Clinicians fearful of upsetting patients • Undertreated: only 10% in one study Depression • Sadness, grief, depressed mood, and feeling of loss are all appropriate responses to dying…but • Feelings of hopelessness, worthlessness, helplessness, guilt, no desire for pleasure…are NOT • Bottom line: – Depression is NOT a normal part of dying – Depression is an illness, with symptoms that need to be recognized and treated How Do You Diagnose Depression? • DSM-IV….But not really set up for the medically ill. Many depressive symptoms in medically ill patients may be a result of their medical illness or treatment. • Careful interview. • Consider simple 1-2 word screening tools: – Are you depressed? – Have you been depressed for most of the time for the past 2 weeks? – One of the above + loss of interest of usual activities. Treatment of Depression • First, relieve uncontrolled symptoms (pain, nausea, dyspnea, etc.) • Psychosocial interventions – Psychotherapy – CBT • Pharmacologic interventions Treatment of Depression: Drugs • Not much data in palliative care setting • As when treating depression in other settings, use side effect profile -Poor appetite/insomnia: Mirtazapine (Remeron) -neuropathic/other pain: TCAs, duloxetine (cymbalta), venlafaxine (effexor) -Fatigue/psychomotor slowing: activating SSRI (fluoxitine, venlafazine) or psychostimulants • The “default” is probably an SSRI…unless Depression in Last Weeks of Life • SSRIs need 4-6 weeks to work, so why start one if your patient is in last weeks of life? • Instead, use pychostimulants such as methylphenidate (Ritalin) or modafinil (Provigil) – Very rapid onset of action (hours) – Start low (2.5 of methlyphenidate daily) and titrate upwards slowly – You should see effect after 1-2 doses Dyspnea • • • • “discomfort in breathing” “breathlessness” “Shortness of breath” “uncomfortable awareness of breathing” -------------------------------------------Dyspnea is a SUBJECTIVE sensation, for which the standard of assessment is the patient’s self-report (different from tachypnea which is an OBJECTIVE, measured number) Dyspnea • Common in cancer patients (21-78%) • Common in non cancer patients – – – – – – 70% Dementia patients 68% terminal HIV/AIDS patients 65% CHF patients 56% COPD patients 50% ALS patients 36% CVA patients Dyspnea Treatment * Goal in terminally ill: Improve subjective sensation expressed by patient * In order to do that you must think about cause… – Sometimes interventions may be consistent with patient’s goals of care… – Other times they may not be… Causes of Dyspnea “BREATH AIR” • • • • • Bronchospasm: Nebs and steroids? Rales: Stop IVF, diuretics, antibiotics? Effusions: Tap? Airway obstruction: Change diet? Suction? Thick secretions: Thin with: -Atropine drops – Nebulized saline (3%) – Nebulized NAC (mucomyst) Hemolgobin low: Transfusion? -Glycopyrrolate -scopolamine (patch) Causes of Dyspnea “BREATHE AIR” • Anxiety: *Sit upright, bedside fan, music -Benzos if primary anxiety (if anxious because sobopiates) -antidepressants • Interpersonal issues: emotional support • Religious concerns: emotional support, coordinate connection with chaplain/spiritual advisor Treatment of Dyspnea • General Measures – Proper positioning: vertical (if comfortable)…or compromised lung down if horizontal – Modify activity level (bathroom aids, wheelchair) – Instruct on pursed lip breathing – Fan (?stim V2, decreasing dyspnea perception) – Open windows – Avoid strong odors – Keep room cool…humidifier – Family/friends at bedside Treatment of dyspnea • Opioids: FIRST LINE – Decrease receptor response to elevated CO2 – Vasodilitation/preload reduction – Anxiolytic -Nebulized opoids? Not yet… • Which one to use? Probably doesn’t matter – – – – Morphine 2.5-5 mg PO q 4 hours Hydrocodone 2.5-5mg PO q 4 hrs Oxycodone 5mg PO q 4 hours Hydromorphone 1-2mg PO q 4 hours titrate up 25-50% q 12 hrs Treatment of Dyspnea • Oxygen: Interestingly, there is no clear evidence that O2 works to relieve dyspnea any better than air…even in hypoxemic patients (studies poor). • Anxiolytics: Anxiety usually response to dyspnea. – 4 of 5 RCTs found no benefit of benzos in dyspnea. – Benzos more for refractory dyspnea worsened by anxiety symptoms…(although some try when one cannot titrate the opioid up further due to side effects). – Lorazepam is probably 1st choice (fast onset of action, and lasts 4-6 hours). Next topic: Nausea and Vomiting • What is the cause? – – – – – – – – Opioids Other drugs Constipation PUD Autonomic insufficiency Metabolic abnormalities Bowel obstruction Increased ICP CORRECT THE UNDERLYING CAUSE Nausea and Vomiting • Opioid induced n/v (stimulation of CTZ) – Mild nausea tends to be self-limited with time – If not, or severe symptoms, change to other opioid – Consider long acting opioids to lessen the potential fluctuation of levels which can stimulate the CTZ Nausea and Vomiting • Opioid induced n/v – Best drugs to treat: • • • • • Haloperidol* (Haldol: THE most potent anti-dopinergic) Prochlorperazine* (compazine: Potent anti-dopa, weak antihis) Promethazine* (phenergan: Antihistamine, weak anti-dopa) Scopolamine (especially if vestibular symptoms) Diphenhydramine (benadryl….Careful in elderly) • Metabolic induced n/v: – Correct the metabolic derangement – Best drugs to treat: Dopamine antagonists* as above Nausea and Vomiting • Constipation induced n/v – First step: prevention • Everyone on opioids gets DSS + cathartic (senna, ducolax) • Hydration, physical activity – If develops despite prophylaxis • 1st r/o obstruction (rectal examdisimpaction helped by mineral oil, glycerine supp, saline enemas) • then treat with osmotic laxative (lactulose, PEG, Mag citrate) Nausea and Vomiting • Constipation induced n/v – If patient too nauseated to take pos • Sodium Phos (fleet) enema • Bisocodyl suppository – Refractory constipation induced n/v: • Neostigmine • opioid antagonists – oral naloxone (?systemic absorption) – SQ methylnaltrexone (selective peripheral antagonist) Nausea/vomiting • Dysmotilityabdominal distension (gastric stasis) – Common in pts on opioids/anticholinergics – Pts c/o early satietynausea (not fasting n/v) • Metoclopramide (5-10mg PO qHS and qAC…or higher): don’t use in renal failure, Parkinson’s • DON’T USE Promethazine (phenergan)…which is an anticholinergic • Anorexia or increased ICP – Dexamethasone (2-4mg PO bid-QID) Nausea/vomiting • Anticipatory nausea: – Benzos: Lorezepam (0.5-2mg q 6 hrs)…avoid as single agent (very weak antiemetic). • Vestibular nausea: – Scopolamine. – Promethazine (Phenergan). • Chemotherapy induced nausea/vomiting: – 5HT3 antagonists (Ondansetron 4-8mg q 6 hours). • Also in postoperative setting, or sometimes after other agents have failed. Can cause mild headache, constipation. Anorexia-Cachexia • ACS (Anorexia Cachexia Syndrome) – Loss of body weight (muscle mass and fat) in the setting of cancer…predicts 3-6 month survival ------vs------ • General anorexia/cachexia at the end of life – Reflects end result of metabolic, neuroendocrine cascade (ketones, uremia, etc)…part of disease process – Probably universal in the dying process Anorexia-Cachexia – Frequent cause of considerable concern for families. – Goals of treatment: • Symptomatic not nutritional. • Establish therapeutic relationship with patient/family. • Emphasis on social aspects of eating (pleasure, nurturing, bonding experience). • Education, Education, Education. Anorexia/Cachexia • Reversible causes? – – – – Pain Nausea Constipation Depression -Dry Mouth -Candidiasis -Gastritis -Iatrogenic (XRT, chemo) Anorexia/Cachexia • Appetite stimulants. – Rare to use…mostly when underlying cause cannot be addressed, and in setting of being consistent with patient’s goals of care. – Consider time limited “therapeutic trial” in selected patients after discussing goals of care (goal might be to gain strength/independence which can be reevaluated weekly for a few weeks). Appetite Stimulants • Megesterol acetate (megace) – Initially for AIDS associated wasting – No change in muscle mass – “Increases” weight (of >5% in only 15-20% of patients) by increasing water retention and fat deposition…over 6-8 weeks – No survival benefit…risk of thrombosis – If decide to use it, use elixir (cheaper, easier), start at 400mg daily800mg daily Appetite Stimulants • Coricosteroids (dexamethasone, prednisone). – Have temporary effect (up to a few weeks) on appetite without increase in body mass…used mostly if prognosis measured in weeks and if other target symptoms might respond to steroids also (nausea, bronchospasm, bone pain). – May increase energy for brief period. – Side effects! (mood swings, elevated BP, inc glucose). – Stop if no benefit within a week or so. Appetite Stimulants • Others: Data mixed and routine use not recommended. – – – – – Eicosapentaenoic acid (omega 3 fish oil). Thalidomide (in HIV/AIDS). Melatonin. NSAIDs. Cannabinoids…(i.e. dronabinol). Hydration at end of life *Arguments for: – Dehydrationelectrolyte problemsconfusion. – Dying patients more comfortable if hydrated (?) – Withholding fluid might set precedent for withholding other therapies which might be appropriate (patients labeled “comfort care”). Hydration at end of life *Arguments against: -No evidence fluids significantly prolong life. -Interferes with acceptance of death. -Less UOPless need for bed pain, urinal, foley. -Less GI fluidless vomiting. -Less pulm secretions/cough/congestion/edema -Electrolyte disturbances/uremia may lead to decreased level of consciousnessless suffering. What to avoid • “The tube feeding death spiral” – Patient admited for massive stroke/urosepsis with advanced underlying dementia – Can’t swallow/aspirating/losing weight tube feeds – Patient agitated with NGTremoves – NGT replacedrestraints placed – Aspiration PNA develops moved to ICU/pulse ox – Repeat PNA 3-4 more times – Family meeting – Death Summary • Depression: recognize and treat at end of life – Don’t forget about psychostimilants • Dyspnea = subjective sensation. Goal of therapy is patient telling you they are better – Treat underlying cause (if appropriate) – Opiates are first line Summary • Nausea/vomiting: – Consider cause before treating – Most common cause is medication related which is most effectively treated with Dopamine antagonists: – Haldol >Compazine > Phenergan • Anorexia/cachexia – Educate families – Medications not that helpful