GSAPNALecture at the BeachSeptember 19, 2015

M. Jane Griffith, RN, MSN, GNP-BC, ACHPN

(Caroline Duquette, DNP, APRN, CHPN, contributing author)

• Define common palliative care symptoms in a variety of disease conditions/illnesses.

• Define components of symptom assessment.

• Develop symptom management plan of care including pharmacologic and non-pharmacologic interventions.

AD is a 65 year old white male presenting tothe acute care facility with SOB, generalizedweakness and rapid atrial fibrillation.

Treated with TEE-guided cardioversion to normal sinus rhythm. Started on amiodarone 200mg 3 times a day.

“I just feel tired”.

• Coronary Artery Disease: s/p CABG, s/p PTCA• Ischemic Cardiomyopathy; EF 20%, congestive heart failure,

mitral regurgitation• End-stage renal disease with hemodialysis, left upper

extremity fistula• Hypertension• Hyperlipidemia• Lupus anticoagulant• Antiphospholipid antibody syndrome with DVT• Gastroparesis, constipation• Renal osteodystrophy

• Obstructive sleep apnea• Tobacco dependence• Weight loss• Hypothyroidism• Depression• Sacral pressure ulcer• Cholecystitis• Pneumonia• Pleural effusions• DJD of lumbar spine, chronic pain, opioid dependence• Peripheral neuropathy

Pertinent Positives: •Chronic low back pain•Insomnia/depression/anxiety•Muscular jerks/myoclonus•Confusion•Nausea/Constipation/Anorexia/Abdominal Pain•Dyspnea/Shortness of Breath/cough/pleuritic chest pain•Fatigue/Activity Intolerance•Weakness/Falls

• Pain is often not assessed• Atypical presentation: confusion or agitation.• May be described as aching or discomfort

• Incidence: 25-45% elders living in community; 45-85% elders in long term care (American Geriatrics Society 2009).

• Fear of addiction, side effects (e.g. constipation), or loss of control.

• Etiology: osteoarthritis, cancer, diabetic neuropathy, herpes zoster, and osteoporosis.

• “Start low and go slow” (American Geriatrics Society, 2009).

• Achieving good pain management: complicated by co-morbid disease and increased risk of adverse drug reaction

• Pain is whatever the patient says it is whenever they experience it (McCaffery).

• Pain is an unpleasant sensory and emotional experience, associated with actual or potential tissue damage (IASP).

Nociceptive pain syndromes : stimulation of the primary afferent nociceptive neurons; indicates tissue damage. •Somatic pain – Cutaneous, bone, musculoskeletal tissues. Well localized.

• Examples: Bone pain, postsurgical incisional pain, pain from inflammation, obstruction or stretching of organs .

Visceral pain – Activation of pain or autoimmune fibers, infiltration, compression, distention, or stretching of thoracic or abdominal viscera. Poorly localized.

• Example: cirrhotic pain.

Neuropathic pain syndromes : Dysfunction of the nervous system. Burning, shooting, electrical, or vise like pain.

Examples: diabetic peripheral neuropathy, post herpetic neuralgia, post- surgical pain syndromes (e.g. mastectomy, thoracotomy, etc.) and sciatic pain.

• Acute: sudden, recent onset pain.– Examples: abdominal pain from cholecystitis, kidney stone, back pain

due to a very recent injury.• Chronic: present longer than 3 months.

– Examples: rib/chest pain from lung cancer, bone pain from cancer, back pain and shoulder pain from past injuries

• Acute on Chronic pain: acute pain process overlayed on a chronic pain– Examples: chronic pain due to bone mets, develops pathologic fracture;

chronic arthritis pain, develops acute pain from herpes zoster. .

• Self-report is the gold standard and is best way to elicit pain report.

• Family can corroborate pain and medication use.

•For patients who are unable to give self-report• Assume pain is present if you suspect there is reason for

pain.• Observe behavioral characteristics. • Discuss with proxy and seek input for professional care

givers. • Use appropriate scales consistently by each team member.• Cultural consideration

• Location(s): indicate site(s) of pain.• Intensity: numerical scale 0-10 scale, color scale light colors

to red, descriptive scale “no pain” to “worst pain imaginable.”• Quality: Description: dull, sharp, achy, pounding, pressure,

electrical, shooting, pulsating.• Pattern: Intermittent pain versus constant or both. • Aggravating/alleviating factors - What makes the pain

better? What makes it worse? Provides information regarding the etiology of the pain, as well as potential treatments. Example: if massage makes the pain better, it is probably of musculoskeletal origin, rather than neuropathic.

• Emotional state/suffering/ total pain: Evaluating the emotion behind the pain. Sign of the reality of the disease? Is the patient depressed and/or anxious?

• Meaning of the pain: can profoundly affect pain perception at

the end of life: ie, punishment. Reframing may help, resulting in improved comfort.

• Functional assessment: ability to perform self-care: getting up and down to toilet; dress; groom and bathe self.

• Psychosocial: effect on social, emotional, spiritual and psychological domains.

Observation/Inspection :•Ability to ambulate into exam area, ability to sit and stand•Non-verbal cues: withdrawal, fatigue, grimaces, moans, and irritability. •Inspect and examine sites of pain: trauma, skin breakdown, changes in bony structures, etc.Palpation: Palpate for tenderness. Range of motion. Is there allodynia? Does the pain follow a dermatone?Auscultation•Abnormal breath sounds : crackles, rhonchi, decreased breath sounds (pneumonia)•Bowel sounds: hyperactive bowel sounds (bowel obstruction).Percussion: fluid accumulation or gas (obstruction, ascites).Neurological exam : evaluate sensory and/or motor loss, as well as changes in reflexes, coordination.

• How will the course of therapy change by the findings of this test? Is this the best use of the patient’s resources ?

• Labs- hypercalcemia as a cause of delirium.• Radiology - X-ray or CT scan may differentiate between pain due to

ascites (potentially relieved with a paracentesis) or pain due to obstruction (relieved by venting gastrostomy tube, or avoiding enteral intake of fluid and food).

• Advanced studies- bone scan, PET scan, EMG (may be useful if suspecting nerve entrapment or systemic neurological disease), MRI, swallowing studies, testosterone and progesterone levels (chronic opioid use).

• The Three Step Approach:– Give The Right Drug– Give The Right Dose– Give At Right Time

– This approach is 80-90% effective and the most inexpensive.

• Acetaminophen– Mechanism of Action – Analgesic, Antipyretic– Adverse effects- Possible liver dysfunction in routine

doses > 2000 mg/day in patients with normal liver; > 3000 mg/day acutely.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) Examples: Aspirin, ibuprofen, naproxen, selective cyclooxygenase-2 inhibitors (celecoxib) – Blocks cyclooxygenase which inhibit prostaglandins;

periostium of the bone and in the uterus. – Anti-inflammatory, analgesic and antipyretic.

• Ceiling effect. Increasing the dose beyond a certain point will not increase analgesia; will only increase the risk of adverse effects.

• Gastric toxicity through local and systemic effects. • Platelet aggregation is inhibited; risk of bleeding. • Renal dysfunction, especially in dehydration.• Risks of adverse effect increase with concurrent use of

NSAIDs and corticosteroids.• NSAIDs now linked to increase in deaths due to cardiac and

cerebrovascular effects.

• Codeine; morphine; hydrocodone; hydromorphone; fentanyl; methadone; oxycodone; oxymorphone. – Mechanism of action: opioid agonist. Block the

release of neurotransmitters that are involved in the processing of pain.

– Adverse effects of opioids: Respiratory depression, sedation, constipation, nausea, sweating, pruritus, urinary retention, hormonal changes.

– Opioid rotation/equianalgesic tables.

Medication PO IV

Morphine 30 mg 10 mg

Oxycodone 20 mg X

Hydromorphone 7.5 mg 1.5 mg

Oral 24-hour morphine equivalent(mg/day)

Fentanyl transdermal(mcg/hr)

60 -134 25

135-224 50

225-314 75

315-404 100

405-494 125

495-584 150

585-674 175

675-764 200

765-854 225

855-944 250

945-1034 275

1035-1124 300

• History of sleep apnea or sleep disorder diagnosis• Morbid obesity• Snoring• Patients over the age of 65• Patients who are opioid naïve• Postoperative patients, especially if surgery included the upper abdomen

or thorax• Lengthy anesthesia requirements during surgery• Patients on benzodiazepines or other sedating drugs• Patients who are active smokers• Pre-existing pulmonary or cardiac diseases or major organ failure• Patients requiring significantly high doses of opiates

Methadone:•appears to act as an antagonist in the N-methyl-D-aspartate (NMDA) receptor, in addition to opioid receptor binding•useful in neuropathic pain syndromes, inexpensive. •Long half life (8-59 hours): can be an advantage but also a disadvantage , ie difficulty to titrate. •QTc effects - increases the corrected QT (QTc)•numerous drug interactions: increased methadone levels in varying degrees via P450 3A4 inhibition. •Methadone should be utilized by clinicians with adequate knowledge and experience due to increased potential risks. Tramadol: Binds to mu opioid receptors and weakly inhibits norepinephrine/serotonin reuptake producing analgesia.Tapentadol: Binds to mu opioid receptors and inhibits norepinephrine

reuptake.

Tricyclic Antidepressants: nortriptyline, desipramine, imipramine, amitriptyline

•Action - appears to be related to inhibition of norepinephrine and serotonin reuptake (neuropathic pain).•Adverse effects: Dry mouth, constipation, dizziness, blurred vision, drowsiness; QT prolongation•Relative contraindications: cardiac arrhythmias, conduction abnormalities, narrow-angle glaucoma, and clinically significant prostatic hyperplasia.

Atypical antidepressants: Venlafaxine and duloxetine for chronic neuropathic pain; Milnacipran for fibromylagia.

•Action - Blocks serotonin and norepinephrine reuptake.•Adverse effects – Fatigue, constipation, dry mouth, dizziness, risk of suicide

Anticonvulsants: Gabapentin and pregabalin.Action –blocks calcium channels, modulates excitatory neurotransmitter release.

• Pregabalin has 90% bioavailability regardless of dose • Gabapentin bioavailability diminishes to 35% when

administering higher doses.– Adverse effects – sedation, confusion, edema (rare)– The analgesic doses of gabapentin ranges from 900-3600

mg/day. Older adults 100 mg a day and see how they tolerate it.

Anticonvulsants:•Carbamazepine: Older anticonvulsant for neuropathic pain.

–Action - blocks sodium channels blocking conduction of pain through sensory neurons

–Significant adverse effects: liver dysfunction and aplastic anemia; monitor blood chemistries (specifically liver function tests) and hematology profiles

•Newer anticonvulsant agents: lamotrigine, levetiracetam , oxcarbazepine. Unique adverse effect profiles to be considered when prescribing.

• Cannabinoids: THC (tetrahydrocannabinal), an active derivative of marijuana, ex: Dronabinol.

• Corticosteroids -neuropathic pain, bone pain, headache secondary to raised intracranial pressure, pain secondary to organ capsule distension, pain due to obstruction of a hollow viscus, and pain secondary to lymphedema. – Glucocorticoids reduce pain by inhibiting prostaglandin synthesis, which

leads to inflammation.– Dexamethasone commonly used- less mineralocorticoid effects and long

half-life. • Lidoderm: local anesthetic affect• Capsacian: desensitizes cutaneous nociceptive neurons.• Muscle relaxers: cyclobenzaprine, tizanadine, baclofen, carisoprodol

Interventions/Procedures: Blocks, Epidural, Intrathecal

• IDT: – Social work: support of pain issues and assistance with coverage of

medications/treatments– Chaplaincy – spiritual distress of pain and assessing suffering– PT/OT: to improve function, obtain needed equipment and safety. – Psychological support/counseling: improving coping strategies.

• Cognitive Behavior Therapy (CBT) • Relaxation• Guided imagery• Distraction• Cognitive reframing• Support groups

• Rehabilitation therapies – physical medicine and rehab evaluation; occupational therapy/physical therapy

• Physical measures: producing relaxation and relieving pain: heat/cold; Massage

• Meditation practices• Pastoral counseling/prayer • Complementary therapies

– Little data regarding the efficacy of complementary therapies (e.g., herbals, magnets, others) in relieving pain. Some culturally based.

– Encourage patients to report the use of any complementary therapies to avoid interactions with other pharmacologic agents

• Cutaneous electrostimulation

• Distressing shortness of breath; frequently called breathlessness. Frightening experience.

• Occurrence: 50% of the general outpatient cancer population and as many as 70% of advanced cancer patients

• Respiratory rate and oxygenation status do not always correlate with the symptom of breathlessness.

• The amount of dyspnea present may not be related to the extent of the disease.

• Often overlooked and not assessed

• Pulmonary: Tumor infiltration; aspiration; pleural &/or cardiac effusion; SVC syndrome; pneumonia; PE; COPD; thick secretions due to infection or dehydration; bronchospasm.

• Cardiac: CHF; pulmonary edema; pulmonary hypertension; severe anemia; CAD; fluid overload.

• Neurological: CVD; ALS; MS; muscular dystrophy; myasthenia gravis; dementia; trauma.

• End-stage renal disease • Metastatic cancer • Metabolic disorder e.g. alkalosis • Obesity• Anxiety• Spiritual issues e.g. feelings of guilt and issues of trust

Subjective report of the patient is the only reliable indicator. •Dyspnea Rating Scale: 0 = no breathlessness; 10 = the worst

0 1 2 3 4 5 6 7 8 9 10

Physical Exam:•Observation – Presentation/Appearance: Wheelchair, with oxygen, ability to talk in complete sentences, pain with inspiration, use of accessory muscles.•Auscultation - Breath sounds for respiratory rate and depth, crackles, wheezes, rhonchi.•Percussion – Dullness in lungs, evidence of mass or fluid.•Palpation - Elevated jugular pressure, bilateral crackles, pain with respiratory movement, diaphragmatic excursion.

Consider goals of care, the benefits and burdens of the test itself, and whether the results or outcome would change the care plan or overall care.•Laboratory studies: CBC, H&H, CMP, electrolytes, BNP, ABG•Oxygen saturation•PFTs•CXR: Infection, effusion, atelectasis•CT/MRI: Lung disease, cardiac issues, rule out pulmonary embolism

Oxygen therapy: Consider trial of oxygen therapy. Saturation < 88% unless on hospice. May have limited benefit if not hypoxemic.Severe COPD & chronic hypoxia: use of long-term O2, >15 hours/day, improves quality of life and increases survival (goal SaO2 >90%).•High Flow Oxygen•BiPAP (Bi-level positive air pressure) •CPAP (continuous positive airway pressure)•Ventilator as a time limited trial: goals of care.•Consider sleep study

• Opioids: Start low and go slow• Steroids: prednisone, dexamethasone• Bronchodilators/anticholinergics: Duo-Nebs • Role of benzodiazepines controversial. Should not be

considered as a first line treatment. • Diuretics: to reduce fluid overload• Pressors: dopamine, dobutamine, and milrinone • Epoprostenol: primary pulmonary hypertension and

hypertension associated with scleroderma

• Antibiotics• Influenza/pneumonia vaccines• Blood transfusions may be of benefit if goal of transfusion

outweighs burden. Erythropoietin. • Thoracentesis/paracentesis/PleurX catheter• Stent tube placement to open an occluded airway• Endobronchial laser therapy• Radiation therapy to shrink tumor • Hemodialysis or CVVH • Left Ventricular Access Device (LVAD) as bridge to

transplant or destination therapy.

• Counseling: cognitive-behavioral therapy, interpersonal and complementary strategies for both patient and family.

• Pursed lip breathing: slows respiratory rate and decreases small airway collapse.

• Energy conservation techniques: save energy, reduce fatigue, allow the patient to maintain control of lifestyle changes.

• Fans, open windows and air conditioners: circulate air. Compressed air via nasal cannula may be useful

• Elevation of the head of the bed, high fowlers position: reduce choking sensations and promotes expansion of the lungs.

• Placing the patient’s arms on pillows: promote air exchange.• Education of patient/family: reduces anxiety. • Music: relaxation and distraction, reduces dyspnea.• Calm room environment.• Cold air directed against the cheek may reduce the

perception of breathlessness • Prayer: promote comfort and relaxation.• Acupuncture may help although the studies

inconconclusive.

• A subjective perception and/or experience of extreme tiredness/exhaustion related to disease, emotional state and/or treatment.

• Multidimensional• Not easily relieved by rest• Profound impact on quality of life including physical,

psychological, social and spiritual well-being. • Cultural influences• Reduced capacity to carry out expected or required

daily activities.

Cancer related fatigue is reported in as many as 60% to 90% of patients.•Anemia•Cytokine production: anorexia-cachexia syndrome as well as fatigue•Metabolic/Endocrine: hypothyroidism, DM (Hyper/Hypoglycemia) or electrolyte imbalances (low Na, low K, low Mg, hypercalcemia)•Malnutrition •Infection •Fever •Pain•Organ failure (heart/lungs/kidneys/liver)•Adverse environment (heat or cold extremes)•CNS injury: disruption of the electrical pathway within the nervous system•Hypoxia

• Psychological: Depression.• Deconditioning: Immobility resulting from disease process,

medical intervention, or psychological response: decrease ADLs.

• Treatment related: Inadequate rest, unrelieved symptoms, medications, psychological and spiritual distress.

• Treatment effects: drug therapy, radiation, and surgery.• Med effect: anti-emetics, hypnotics, anxiolytics,

antihistamines, analgesics (trial of 25% dose reduction)• Unrelieved symptoms: diarrhea, constipation, vomiting and

pain.

• Subjective • Impact on ADLs and IADLs• Medication review• Sleep pattern• Associated symptoms, ie

depression/anxiety/ability to concentrate• Fatigue Rating Scale: 0 = no fatigue; 10= no energy

at all: 0 1 2 3 4 5 6 7 8 9 10

• Observation• Vital signs• Physical Assessment including cardiac,

respiratory, GI and neurological exam• Diagnostics:

– Labs: CBC, H&H, electrolytes, albumin/prealbumin, LFTs, TSH

– Pulse oximetry– Electrocardiogram

Pharmacologic •Stimulants: methylphenidate, modafinil•Steroids: dexamethasone•Antidepressants

Interventions•Based on Goals of Care•Consider transfusions if indicated•Consider feeding tube (ie, ALS, H/N cancer)

• Energy conservation: frequent rest periods and use of energy conservation techniques and tools.

• 1-2 priority activities a day; family assistance

• Home health devices: BSC, wheelchair, and/or walker.

• Personal care to assist with ADLs and IADLs.

• Physical and occupational therapy

• Conditioning from exercise program may decrease the severity of fatigue.

• Nausea: subjective sensation• Vomiting: neuromuscular reflex, stimulation

of vomiting center.• Anticipatory, acute, delayed• Common in advanced disease (nausea up to

70% of terminally ill, vomiting up to 30%), particularly in cancer, renal and hepatic disease.

GI: Stimulation of vagal and sympathetic pathways (visceral response)•gastric irritation & stasis•constipation•intestinal obstruction •pancreatitis •ascites •liver failure•intractable cough•effects of radiation.

Metabolic causes: Stimulation of chemoreceptor trigger zone•Hypercalcemia•Uremia•Infection •DrugsCNS causes: •Raised ICP•Pain•InfectionVestibular disturbances: •Motion sickness•Toxic action of certain drugs (ASA, opiates)

• Frequency, duration, triggers, contributing factors (constipation, uncontrolled pain, infection, anxiety), relationship to food intake

• Medication review• Volume and content of emesis, presence of

blood• Past history of N/V and effectiveness of

treatment

Physical Exam•Vital signs, weight.•Auscultation of bowel sounds•Possible rectal exam (impaction)•Ear exam: infection•Oral exam: thrush

Diagnostics•Renal and liver function tests•Electrolytes, calcium, serum drug levels•Radiologic: Abdominal radiograph &/or head CT or MRI

Directed by presumed cause

•Anticholinergics: hyoscyamine, scopolamine: motion sickness, intractable N&V, SBO•Antihistamines: cyclizine, meclizine: intestinal obstruction, raised ICP, peritoneal irritation, vestibular causes•Steroids: dexamethasone- cytotoxic induced N&V•Prokinetic agents: metaclopramide-gastric stasis or ileus•Benzodiazepines: lorazepam- anxiety related N&V•5 HT3 receptor antagonists: ondansetron-post op N&V and chemo related emesis (QTc prolongation)

• Octeotride: bowel obstruction: inhibits peristalsis and intestinal secretions

• Neurokinin-1 receptor antagonists: aprepitant- inhibit post op and post chemo N&V

• Butyrophenones: haloperidol and droperidol-opioid induced nausea, chemical and mechanical nausea

• Phenothiazines: prochlorperazine, dopamine antagonist.

• Cannabinoids: dronabinol, medical marijuana

Hypercalcemia: bisphosphonates, diuretics, calcitonin, and hydrationOpioid induced N&V

• Opioid naïve: schedule anti-emetic for 1st 72 hrs• Alter dose, schedule or consider opioid rotation

•NG tube or PEG for venting•Hydration•TPN: limited role in pall care; benefit/burden•Surgical options (ie SBO)

Based on Goals of Care

• Anticipatory nausea: distraction/relaxation techniques, acupuncture, acupressure, music therapy and hypnosis

• Dietary – Small, frequent meals; keep prepared snacks nearby– Use of family/friends to cook; avoid smells and stress of food preparation.– Serve meals at room temperature with clear fluids; avoid strong smells. – Restrict fluids with meals.– Bland, cold or room-temperature food.– Eat slowly, avoiding large, high bulk meals. – Avoid sweet, salty, fatty, and spicy foods. – Ginger, chamomile tea                                                          

• Positioning – Positioned to avoid aspiration. – Do not lie flat for 2 h after eating.

• Personal Care– Oral care after each episode of emesis– Wear loose-fitting clothes.

• Topical – Application of a cool damp cloth to the forehead, neck, and wrists– Use of wrist pressure bands (Sea Bands®) to minimize nausea and vomiting.– Acupuncture

• Environment – Decrease noxious stimuli like odors and pain.– Have fresh air with a fan or open window.– Limit sounds, sights, and smells that precipitate nausea and vomiting.

•

Definition: less than 3 stools per week or altered characteristics such as hard, painful, stools accompanied by abdominal distention, nausea, vomiting, loss of appetite, and other symptoms. •10% of the general population, •May be as high as 50 to 78% in the ill adult.

• Intestinal obstruction, partial or complete, tumor in or compressing bowel. Mesothelioma, ovarian, and gastrointestinal cancers.

• Electrolyte imbalances: hypercalcemia and hypokalemia• Spinal cord injuries (i.e. compression or transection) slow transmission of

food via the intestines.• Endocrine conditions: diabetes, hypothyroidism• Other: colitis, diverticulitis, or chronic neurological states• Surgical adhesions: scarring.• Dehydration: stool consistency; dry, hard stools.• Inactivity, weakness, loss of privacy: effect daily bowel habits.• Pain• Depression • Decreased abdominal muscle tone

Medication profile review: many medications can contribute to severe constipation, especially when patients are on combination therapies.•Vitamins and minerals – Calcium supplement, iron•Chemotherapeutic agents - Taxanes, vinca alkaloids.•Antidepressants – Tricyclics, SNRIs•Pain and adjuvant pain medications – Opioids, NSAIDS, Anticonvulsants •Antiemetics - 5HT3 antagonists, phenothiazines•Anti-diarrheal agents•Cardiac medications - Diuretics, antihypertensives

• Stool: Frequency, consistency, volume, usual bowel pattern, date of last BM

• Associated symptoms: pain, bloating, flatulence, bleeding, N&V

• Recent oral intake and level of activity• Medications: prescription, OTC, dietary supplements• Past history of constipation and effective treatment strategies

(laxatives, suppositories, enemas) • Functional status: ability to toilet, environmental issues

related to toileting• Psychosocial or cognitive factors: depression, anxiety, general

mood disturbances

Physical Exam•Inspection: bloating, distention•Auscultation: bowel sounds (hyperactive, hypoactive or absent)•Palpation: assesses for distention, firmness and tenderness•Percussion: fluid, mass•Rectal assessment: hemorrhoids, ulceration or rectal fissure; pain infection, fecal leakage and/or impaired rectal tone. Caution in neutrapenic patient.Diagnostics: consider goals of care

– Abdominal x-ray to rule out bowel obstruction– Electrolytes BUN, calcium and potassium– Thyroid function tests

Maintenance often requires a prophylactic stool softener and stimulant. A minimum goal for a bowel movement is at least every 72 hours, regardless of intake.

•Bulk forming –fiber medications•Osmotics – sorbitol, lactulose, polyethylene glycol 3350•Stimulants – senna•Surfactants – docusate•Opioid-Receptor Antagonist (methylnaltrexone, lubiprostone)•Lubricant-mineral oil•Suppositories, enemas

• Dietary and fluid interventions • Gentle activity• Massage • Dietary• OTC products and herbal medicines: mulberry,

flax, and rhubarb have laxative properties

• Mood disorder with psychological symptoms: – Low mood, inability to think or make decisions– Somatic symptoms: altered sleep, fatigue, slowed

movements, decreased energy – Altered mood, affect, and personality– Includes situational depression caused by a serious life

threatening illness (American Psychiatric Association, 2013)

• Symptoms last 2 weeks or longer and associated with loss of interest or pleasure in nearly all activities

• Depression occurs in about 22% to 77% of the terminally ill population

• Depression in palliative care is related to many diseases and causes:– Uncontrolled pain and/or other symptoms (i.e.

constipation, anorexia, and sleep disturbances) may exacerbate depression

– Neurological – Hyper or hypothyroidism– Infectious diseases – HIV/AIDS– Cancer – pancreatic, head and neck, and lung– Cardiopulmonary disease– Trauma – head injuries

• Antibacterial and antifungals• Antihypertensive and cardiac medications• Anticancer medications (interferon, bleomycin,

and vincristine are common culprits)• Antiretroviral medications• Anticonvulsants• Benzodiazepines• Steroids• Hormonal therapies

• Current diagnosis and prognosis – – Chronic deteriorating medical illness with perceived

poor health– recent diagnosis of a life-threatening illness– recent conflict or a loss of significant relationship.

• Current status of symptom management.• Previous psychiatric history/treatment including

previous depression, family history with depression, substance abuse, past suicide attempts.

• Social support.

• Suicide - A history of depression, suicide attempts, or substance abuse.

• Cancer patients at highest risk for suicide include those with diagnoses of oral, pharyngeal, or lung cancers.

• Other predictors include male gender, over the age of 45, living alone, lacking a support system.

• Other risk factors: Uncontrolled pain, presence of multiple deficits, including inability to walk, loss of bowel and bladder control, amputation, inability to eat or swallow, sensory loss, and exhaustion.

• Are you depressed? Have you felt down or blue in the last month?

• How have your spirits been lately? • How would you describe your mood today?• How are you sleeping lately?• What is your energy level?• What do you see in your future?• What is the biggest problem you're facing?• Can you concentrate as well as you usually could?

Questions for suicide risk•Do you ever think that life is not worth living?•Do you find yourself wishing you would die more quickly?•Have you thought about killing yourself?•Have you discussed this with anyone?•Are you thinking of that now?•How have you thought you would do this? Do you have a plan?

• Physical Examination– Observation – overall appearance – Inspection– Lung, cardiac and neuro examination

• Diagnostics: Laboratory studies to rule out etiologies: – CBC: anemia or infection– Electrolyte imbalances– TSH for thyroid abnormalities– LFTs for liver impairment

• Electroencephalography (EEG)• Radiology, including CT scan of brain

Antidepressants•SSRIs: fluoxetine, paroxetine, sertraline, citalopram. •SNRIs: venlafaxine, mirtazapine, duloxetine. Duloxetine: good for pain and depression. Mirtazapine: insomnia, anorexia, and depression.•Bupropion: inhibits neuronal uptake of norepinephrine and dopamine.•Tricyclics: amitriptyline, nortriptyline; treat nerve pain, depression, and sleep issues.

• Psychostimulants: methylphenidate or dextroamphetamine; rapid onset and short duration of side effects.

• Steroids: dexamethasone and prednisone may offer euphoria for a short term benefit; improved overall sense of well-being.

• Ketamine: rapid anti-depressant response and may offer a benefit to certain patients.

• Interdisciplinary collaboration between social work, chaplaincy, and mental health professionals.

• Psychotherapy, along with medications• Electroconvulsive therapy may be considered for

patients with suicidal or psychotic features.• Grief counseling: assist patients and families to deal

with past, present, and future losses. • Psychiatric counseling: for those experiencing

significant inability to cope with the experience of their medical illness.

• Cognitive behavioral techniques: assist the patient to re-frame negative thoughts into positive thoughts

• Cultural affects: symptom presentation and responses to depression. • Latino and Mediterranean cultures: may complain of

"nerves" and headaches• Chinese or other Asian cultures: "imbalance"

• Promote and facilitate autonomy and control; participate in own care; reduce feelings of helplessness.

• Reminiscence and life review: life accomplishments; closure and resolution of life events for the patient and family.

• Maximize symptom management.• Assist the patient to draw on previous sources of strength,

such as faith and other belief systems.

Feelings of distress and/or tension with or without a known stimulus:•An acute, severe wave of intense anxiety with cognitive, physiologic, and behavioral components.•A low-grade persistent distress consisting of restlessness or being on edge, difficulty in concentrating, irritability, muscle tension, and altered sleep that interferes with psychosocial functioning. •Anxiety Disorder due to Another Medical Condition: Related to the pathophysiologic consequences of a medical condition; not explained by a mental disorder; affects the social, occupational and general functioning of the patient.•Generalized Anxiety Disorder, phobia, Panic Disorder

• Poorly managed pain and symptoms• Cancer related conditions – Hormone producing tumors• Cardiovascular – Angina, CHF, past history of MIs • Endocrine disorders – Diabetes, thyroid dysfunction, Cushing Syndrome,

Carcinoid • Immune disorders - AIDS, infections• Pulmonary – Asthma, COPD, PNA pulmonary edema, dyspnea, PE• Metabolic - Anemia, hyperkalemia, hyponatremia• Neurological - Encephalopathy, brain lesion• Psychosocial:

– Coping with uncertain future and prognosis and mortality– Lack of control - Multiple changes: health, lifestyle, employment, finances– Dealing with difficult/exhausting treatment regimens/side-effects – Dependency on others; Confronting family conflicts

• Stimulants • Corticosteroids• Analgesics• Thyroid replacement hormones • Neuroleptics• Digitalis• Antihypertensives • Antihistamines • Antiparkisonian medications• Anticholinergics• Abrupt cessation/withdrawal of medications such as alcohol,

analgesics, benzodiazepines, antipsychotics, and nicotine• Paradoxical reactions from medications

• Assessment of chronic apprehension, worry, inability to relax, difficulty concentrating, difficulty falling and staying asleep.

• Physical symptoms: sweating, tachycardia, restlessness, agitation, trembling, chest pain, hyperventilation, tension.

• Cognitive symptoms: sadness, fear, anger, difficulty concentrating, confusion, and loss of control.

• Recurrent and persistent thoughts, ideas, or impulses, the fear of "going crazy", and the fear of dying. Treatment depends on the etiology and severity of symptoms.

Questions for anxiety assessment • Have you experienced any anxiety symptoms

since your diagnosis or treatment? When do they occur and how long do they last?

• Do you feel nervous, shaky, or jittery?• Have you had a sudden onset of feeling you

might be going crazy, losing control, or dying?• Do you worry about when your pain will return

and how bad it will get? Do you worry if you'll be able to get your next dose of medication on schedule?

Physical examination•Observation – VS, tachycardia, shortness of breath, sighing, diaphoresis, rapid speech, tense posture•Inspection – Dilated pupils, tremors•Palpation - Gastrointestinal distress•Cardiac, respiratory, neuro assessmentDiagnostics: To rule out other conditions:•CBC•Electrolytes•Thyroid function test•Pulmonary function test if indicated•CT Scan-for suspected PE

Benzodiazepines are the first-line drugs •Lorazepam, midazolam and alprazolam have short half-lives Diazepam and clonazepam have longer half-lives. •Cautious use in older adults: may cause cognitive dysfunction and ataxia. Antidepressant: used for primary anxiety disorders

– May take 2-6 weeks to take full effect and relieve anxiety.– Sertraline, citalopram, and escitalopram have fewer drug-to-drug

interactions.– Mirtazapine: use with related insomnia, anorexia, and weight loss;

beneficial side effects of sedation and increased appetite.– Consider tricyclic antidepressants (amitriptyline, nortriptyline, and

desipramine) with patients who have anxiety, chronic pain, and diarrhea. Caution in patients with conduction abnormalities.

Antipsychotics: anxiety associated with delirium• Haloperidol:

• Most frequently used in the medical setting• Inexpensive and accessible• Monitor for side effects: restlessness, increased anxiety, EPS

• Olanzapine:• More expensive• Monitor QTc changes, particularly if on methadone.• Risperidone/quetiapine

•Hypnotics for sleep: zolpidem and antihistamines.

• Psychiatric counseling: Stress management programs, exercise programs, music, art and expressive therapies for patient and family

• Cognitive behavioral therapy (CBT) for reframing• Behavioral techniques: guided imagery techniques • Psychotherapy: promote coping clarifying of fears and

identifying and building on existing coping strategies.• Spiritual counseling• Integrative therapies: acupuncture, massage, Reiki,

aromatherapy, therapeutic touch are helpful.• Encourage these interventions for families as well to avoid

the spread of anxiety from patient to family.

• Acknowledge patient’s fears

• Written materials to promote education. Be consistent in answering repetitive questions

• Provide concrete information to eliminate fear of the unknown

• Provide warning and counseling for stressful events

• Write prescriptions for anxiety reducing measures: medication, distraction, &/or exercise

• Promote dietary modifications: decreasing caffeine and alcohol intake, food diary

• For older adults: environmental manipulation, may enable confidence in living situations. Consider PT/OT.

• Difficulty falling asleep or maintaining sleep; interrupted sleep• Ineffective or inconsistent sleep contributing to poor cognition,

mood, and overall functioning with potential for accidents

• Causes/contributing factors: – Cardiac disease– Respiratory failure– Obesity– Pulmonary conditions– Acute/chronic pain– Psychiatric disorders: dysthymia, depression, anxiety, psychiatric Dx– Medications: stimulants, steroids, albuterol– OTC substances: alcohol, nicotine and caffeine– Delirium– Uncontrolled symptoms

History: onset, pattern and duration of sleep; transient, intermittent or persistent. •How often do you have trouble sleeping, how long has the problem persisted?•How often do you take naps? •When do you go to bed and get up during the week and weekends? •How long does it take you to fall asleep, how often do you wake up at night, and how long does it take to fall back asleep? •Do you snore loudly and frequently, or wake up gasping or feeling out of breath?•How refreshed do you feel when you wake up, and how tired do you feel during the day? •How often do you doze off or have trouble staying awake during routine tasks especially driving?•How is this affecting your family?

Physical examination•Observation – Age, vital signs•Inspection – Any sites of pain•Cardiac, Respiratory, Neurological examDiagnostics•Usually not necessary unless ruling out another issue(s)•EEG •Sleep clinic, if appropriate

Pharmacologic:•Pain medication adjustment for optimal pain management•Sleep medications: non-benzodiazepines, trazodone, zolpidem•AntidepressantsNon-Pharmacologic•Sleep evaluation; Adjust sleep hygiene•Cognitive behavioral therapy (CBT)•Relaxation therapy (i.e. guided meditation, yoga)•Psychotherapy to discuss worries and concerns with mental health specialist, and/or chaplain•Environmental setting; calm setting at bed time•Use of rituals, such as a warm bath or shower•Massage; Aromatherapy; Acupuncture

Chronic low back pain/peripheral neuropathy Muscular jerks/Myoclonus/Confusion Nausea/Constipation/Anorexia/Abdominal Pain Dyspnea/Shortness of Breath/cough/pleuritic chest pain Depression/anxiety/Insomnia Fatigue/Activity Intolerance Weakness/Falls

Nociceptive and Neuropathic componentsIs morphine ER a good choice?

– Toxicity due to impaired renal function: myoclonus/confusion.– M3G metabolite: neuroexcitatory/lacks analgesic properties– M6G metabolite: adverse effects/toxicity– Other options: Fentanyl and methadone, limited doses of short

acting hydromorphone.Neuropathic : methadone (NMDA antagonist), adjuvants: gabapentin, pregabalin; venlafaxine, duloxetine.TCA: not a good choice due to arrhythmia and fatigue.Non-pharmacologic:

– Nociceptive: heat/cold compresses (skin integrity), repositioning, distraction(music, relaxation)

– Neuropathic: Soothing lotions (Sarna), optimize blood sugars.

Nausea/Constipation/Anorexia/Abdominal Pain

Multifactorial: CHF, CKD, med effect, hypothyroidism, constipation, cholecystitis, depression

• Gastroparesis: trial metaclopramide, d/c promethazine• Constipation: Senna or polyethylene glycol or lactulose• Discontinue megestrol (high risk for thrombosis)• Small, frequent meals.• Antibiotics for choleycistitis• Consider haloperidol

Dyspnea/Shortness of Breath/cough/pleuritic chest pain

CHF: Diuretic, beta blocker, opioid (no ace-I due to renal failure), O2, fanObstructive Sleep Apnea: CPAPAnemia: erythropoeitin, blood transfusions if indicatedCKD: dialysis dependentTobacco Use Disorder: encourage smoking cessation, con’t nicotine patchThyroid Disorder: check TSH (amiodorone effect)Amiodarone : risk for Pulmonary Fibrosis: CT scanPleural Effusion: diuretics, thoracentesis, PleurX catheter, pleurodesisPneumonia: CAP v. HAP v. Asp PNA: O2, AntibioticHypoalbuminemia: treat GI symptoms.PE: Supratherapeutic INR: Vitamin K, hold Coumadin, medication/food interactions

Depression/Anxiety/InsomniaMultifactorial: multiple co-morbidities/med effect/psychosocial

•Venlafaxine ER: titrate to 150mg daily dose: improve mood and effective dose for pain management; duloxetine•Or consider changing to mirtazepine: + effect on mood, insomnia, nausea and appetite.•Consider low dose benzo: lorazepam 0.25 to 0.5mg BID to TID prn (caution with hx sleep apnea).•Above may improve insomnia or consider low dose zolpidem.•Non-pharmacologic: counseling/psychosocial support, sleep hygiene.

Fatigue/Activity Intolerance/Weakness/FallsMultifactorial: disease burden/med effect

• PT/OT • Regular exercise routine if able• Adequate nutritional intake• Methylphenidate/modafinil not recommended due to his history of PSVT and rapid a fib, and may also worsen anxiety.

Goals of Care

• Importance of Goals of Care discussion• Benefits/Burdens of interventions• Advanced Care planning: Living Will, MPOA, code status.• Palliative care or hospice referral

Visual Analogue Scale: Can be used for any symptom

ORT: Opioid Risk Assessment Tool: http://www.opioidrisk.com/node/1203

Edmonton Symptom Assessment Scale

http://www.palliative.org/newpc/professionals/tools/esas.html

The St . George’s Respiratory Questionnaire: http://www.fda.gov/ohrms/dockets/ac/03/briefing/3976B1_01_L-Glaxo-Appendices.pdf

Baseline and Transition Dyspnea Index:http://ekstern.infonet.regionsyddanmark.dk/files/Formularer/Upload/2013/06/BDI.pdf

Geriatric Depression Scalehttp://consultgerirn.org/uploads/File/trythis/try_this_4.pdf

PHQ 9: Patient Health Questionnairehttp://www.integration.samhsa.gov/images/res/PHQ%20-

%20Questions.pdf

Generalized Anxiety Disorder Scale http://carybehavioralhealth.com/wp-content/uploads/2011/06/Generalized-Anxiety-Scale.pdf

• Insomnia Severity Index: https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_pageLabel=healthyLiving&contentPage=healthy_living/sleep_insomnia_index.htm