To prevent and relieve To prevent and relieve suffering, and promote suffering, and promote

quality of life quality of life at every stage of lifeat every stage of life

To prevent and relieve To prevent and relieve suffering, and promote suffering, and promote

quality of life quality of life at every stage of lifeat every stage of life

Common SymptomsCommon Symptoms

Frank D. Ferris, Frank D. Ferris, MDMDMedical Director, Palliative Care Standards Medical Director, Palliative Care Standards

CCENTERENTER F FOR OR PPALLIATIVEALLIATIVE S STUDIESTUDIESSan Diego Hospice and Palliative CareSan Diego Hospice and Palliative Care

““Education and Research in the Art and Science of Palliative Care”Education and Research in the Art and Science of Palliative Care”

Department of Family and Preventative Medicine, Department of Family and Preventative Medicine, UCSD School of MedicineUCSD School of Medicine

Department of Family and Community Medicine, Department of Family and Community Medicine, andand

Joint Center for Bioethics, University of TorontoJoint Center for Bioethics, University of Toronto

Frank D. Ferris, Frank D. Ferris, MDMDMedical Director, Palliative Care Standards Medical Director, Palliative Care Standards

CCENTERENTER F FOR OR PPALLIATIVEALLIATIVE S STUDIESTUDIESSan Diego Hospice and Palliative CareSan Diego Hospice and Palliative Care

““Education and Research in the Art and Science of Palliative Care”Education and Research in the Art and Science of Palliative Care”

Department of Family and Preventative Medicine, Department of Family and Preventative Medicine, UCSD School of MedicineUCSD School of Medicine

Department of Family and Community Medicine, Department of Family and Community Medicine, andand

Joint Center for Bioethics, University of TorontoJoint Center for Bioethics, University of Toronto

ObjectivesObjectives

Know general guidelines for managing non-pain symptoms

Know how to assess and manage common symptoms

www.CPSOnline.info

Publications / presentations

Know general guidelines for managing non-pain symptoms

Know how to assess and manage common symptoms

www.CPSOnline.info

Publications / presentations

General guidelines . . .General guidelines . . . History, physical examination

Conceptualize likely causes

Discuss treatment options

Assist with decision making

History, physical examination

Conceptualize likely causes

Discuss treatment options

Assist with decision making

. . . General guidelines. . . General guidelines Provide education, support

Involve entire interdisciplinary team

Reassess frequently

Provide education, support

Involve entire interdisciplinary team

Reassess frequently

HIV WastingHIV Wasting

HIV WastingHIV Wasting

Loss of weight > 10% of baseline with fever, weakness, diarrhea > 30 days

inadequate nutrient intake

excessive nutrient loss

metabolic dysregulation

Loss of weight > 10% of baseline with fever, weakness, diarrhea > 30 days

inadequate nutrient intake

excessive nutrient loss

metabolic dysregulation

Managementof anorexia / cachexia . . .

Managementof anorexia / cachexia . . . Assess, manage comorbid

conditions

Educate, support

Favorite foods / nutritional supplements

Assess, manage comorbid conditions

Educate, support

Favorite foods / nutritional supplements

. . . Managementof anorexia / cachexia. . . Managementof anorexia / cachexia Alcohol

Megestrol acetate

Dexamethasone

Dronabinol

Androgens, eg, testosterone

Alcohol

Megestrol acetate

Dexamethasone

Dronabinol

Androgens, eg, testosterone

Fatigue /WeaknessFatigue /

Weakness

Managementof fatigue / weakness . . .

Managementof fatigue / weakness . . . Promote energy conservation Evaluate medications Optimize fluid, electrolyte intake Permission to rest Clarify role of underlying illness Educate, support patient, family Include other disciplines

Promote energy conservation Evaluate medications Optimize fluid, electrolyte intake Permission to rest Clarify role of underlying illness Educate, support patient, family Include other disciplines

. . . Managementof fatigue / weakness. . . Managementof fatigue / weakness Dexamethasone

feeling of well-being, increased energy

effect may wane after 4-6 weeks

continue until death

Methylphenidate

Dexamethasone feeling of well-being, increased energy

effect may wane after 4-6 weeks

continue until death

Methylphenidate

Fever /SweatsFever /Sweats

Management of fever / sweatsManagement of fever / sweats Paracetamol (acetaminophen)

NSAIDs, eg, ibuprofen

Corticosteroids, eg, dexamethasone

Anticholinergics, eg, scopolamine

Rehydration

Bathing, drying

Paracetamol (acetaminophen)

NSAIDs, eg, ibuprofen

Corticosteroids, eg, dexamethasone

Anticholinergics, eg, scopolamine

Rehydration

Bathing, drying

Nausea /VomitingNausea /Vomiting

Nausea / vomitingNausea / vomiting

Nausea subjective sensation

stimulation • gastrointestinal lining, CTZ, vestibular

apparatus, cerebral cortex

Vomiting neuromuscular reflex

Nausea subjective sensation

stimulation • gastrointestinal lining, CTZ, vestibular

apparatus, cerebral cortex

Vomiting neuromuscular reflex

Causesof nausea / vomitingCausesof nausea / vomiting Metastases

Meningeal irritation

Movement

Mental anxiety

Medications

Mucosal irritation

Metastases

Meningeal irritation

Movement

Mental anxiety

Medications

Mucosal irritation

Mechanical obstruction

Motility

Metabolic

Microbes

Myocardial

Mechanical obstruction

Motility

Metabolic

Microbes

Myocardial

Pathophysiologyof nausea / vomitingPathophysiologyof nausea / vomiting

CortexCortexCortexCortex

Vestibular Vestibular apparatusapparatusVestibular Vestibular apparatusapparatus

GI tractGI tractGI tractGI tract

ChemoreceptorChemoreceptorTrigger Zone (CTZ)Trigger Zone (CTZ)

ChemoreceptorChemoreceptorTrigger Zone (CTZ)Trigger Zone (CTZ)

NeurotransmittersNeurotransmitters AcetylcholineAcetylcholine DopamineDopamine HistamineHistamine SerotoninSerotonin

NeurotransmittersNeurotransmitters AcetylcholineAcetylcholine DopamineDopamine HistamineHistamine SerotoninSerotonin

Vomiting centerVomiting centerVomiting centerVomiting center

Managementof nausea / vomitingManagementof nausea / vomiting Dopamine

antagonists

Antihistamines

Anticholinergics

Serotonin antagonists

Dopamine antagonists

Antihistamines

Anticholinergics

Serotonin antagonists

Prokinetic agents

Antacids

Cytoprotective agents

Other medications

Prokinetic agents

Antacids

Cytoprotective agents

Other medications

Acetylcholine antagonists(anticholinergics)

Acetylcholine antagonists(anticholinergics)

Scopolamine

Atropine

Scopolamine

Atropine

Dopamine antagonistsDopamine antagonists Haloperidol

Prochlorperazine

Metoclopramide (also prokinetic)

Haloperidol

Prochlorperazine

Metoclopramide (also prokinetic)

Histamine antagonists (antihistamines)

Histamine antagonists (antihistamines) Diphenhydramine

Meclizine

Hydroxyzine

Diphenhydramine

Meclizine

Hydroxyzine

Serotonin antagonistsSerotonin antagonists Ondansetron

Granisetron

Ondansetron

Granisetron

AntacidsAntacids Antacids

H2 receptor antagonists cimetidine ranitidine

Proton pump inhibitors omeprazole

Antacids

H2 receptor antagonists cimetidine ranitidine

Proton pump inhibitors omeprazole

Cytoprotective agentsCytoprotective agents Misoprostol

Proton pump inhibitors omeprazole

Misoprostol

Proton pump inhibitors omeprazole

Other medicationsOther medications

Dexamethasone

Tetrahydrocannabinol

Lorazepam

Octreotide

Dexamethasone

Tetrahydrocannabinol

Lorazepam

Octreotide

ConstipationConstipation

ConstipationConstipation Medications

opioids calcium-channel

blockers anticholinergic

Decreased motility

Ileus

Mechanical obstruction

Medications opioids calcium-channel

blockers anticholinergic

Decreased motility

Ileus

Mechanical obstruction

Metabolic abnormalities

Spinal cord compression

Dehydration

Autonomic dysfunction

Malignancy

Metabolic abnormalities

Spinal cord compression

Dehydration

Autonomic dysfunction

Malignancy

Managementof constipationManagementof constipation General measures

establish “normal” bowel pattern

regular toileting

gastrocolic reflex

General measures establish

“normal” bowel pattern

regular toileting

gastrocolic reflex

Specific measures stimulants

osmotics

detergents

lubricants

large volume enemas

Specific measures stimulants

osmotics

detergents

lubricants

large volume enemas

Stimulant laxativesStimulant laxatives

Prune juice

Senna

Casanthranol

Bisacodyl

Prune juice

Senna

Casanthranol

Bisacodyl

Osmotic laxativesOsmotic laxatives

Milk of magnesia (other Mg salts)

Lactulose

Polyethylene glycol

Sorbitol

Magnesium citrate

Milk of magnesia (other Mg salts)

Lactulose

Polyethylene glycol

Sorbitol

Magnesium citrate

Surfactant laxatives(stool softeners)Surfactant laxatives(stool softeners)

Sodium docusate

Calcium docusate

Phosphosoda enema prn

Sodium docusate

Calcium docusate

Phosphosoda enema prn

Prokinetic agentsProkinetic agents

Metoclopramide Metoclopramide

Lubricant stimulantsLubricant stimulants

Glycerin suppositories

Oils mineral

peanut

Glycerin suppositories

Oils mineral

peanut

Large-volume enemasLarge-volume enemas

Warm water

Soap suds

Warm water

Soap suds

Constipationfrom opioids . . .Constipationfrom opioids . . . Occurs with all opioids

Pharmacologic tolerance developed slowly, or not at all

Dietary interventions alone usually not sufficient

Avoid bulk-forming agents in debilitated patients

Occurs with all opioids

Pharmacologic tolerance developed slowly, or not at all

Dietary interventions alone usually not sufficient

Avoid bulk-forming agents in debilitated patients

. . . Constipationfrom opioids. . . Constipationfrom opioids Combination stimulant / softeners

are useful first-line medications casanthranol + docusate sodium

senna + docusate sodium

Prokinetic agents

Combination stimulant / softeners are useful first-line medications

casanthranol + docusate sodium

senna + docusate sodium

Prokinetic agents

DiarrheaDiarrhea

Causes of diarrheaCauses of diarrhea Infections GI bleeding Malabsorption, eg, lactose intolerance Medications, eg, HAART Obstruction, eg, cancer Overflow incontinence Stress

Infections GI bleeding Malabsorption, eg, lactose intolerance Medications, eg, HAART Obstruction, eg, cancer Overflow incontinence Stress

Management of diarrheaManagement of diarrhea Establish “normal” bowel pattern

Treat underlying cause

Avoid gas-forming foods Increase bulk, i.e., fiber

Transient, mild diarrhea bismuth salts

Establish “normal” bowel pattern

Treat underlying cause

Avoid gas-forming foods Increase bulk, i.e., fiber

Transient, mild diarrhea bismuth salts

Managementof persistent diarrheaManagementof persistent diarrhea Rehydration

Oral salt containing fluids Parenteral

Loperamide Diphenoxylate / atropine Tincture of opium Octreotide

Rehydration Oral salt containing fluids Parenteral

Loperamide Diphenoxylate / atropine Tincture of opium Octreotide

Shortnessof Breath(Dyspnea)

Shortnessof Breath(Dyspnea)

Breathlessness (dyspnea) . . .Breathlessness (dyspnea) . . . Described as

shortness of breath

a smothering feeling

inability to get enough air

suffocation

Described as shortness of breath

a smothering feeling

inability to get enough air

suffocation

. . . Breathlessness (dyspnea). . . Breathlessness (dyspnea) Only reliable measure is patient self-

report

Respiratory rate, pO2, blood gas determinations DO NOT correlate with the feeling of breathlessness

Prevalence 12 – 74%

Only reliable measure is patient self-report

Respiratory rate, pO2, blood gas determinations DO NOT correlate with the feeling of breathlessness

Prevalence 12 – 74%

Causes of breathlessnessCauses of breathlessness Anemia

Anxiety

Airway obstruction

Bronchospasm

Hypoxemia

Infections

Metabolic

Anemia

Anxiety

Airway obstruction

Bronchospasm

Hypoxemia

Infections

Metabolic

Pleural effusion

Pulmonary edema

Pulmonary embolism

Thick secretions

Family / financial / legal / spiritual / practical issues

Pleural effusion

Pulmonary edema

Pulmonary embolism

Thick secretions

Family / financial / legal / spiritual / practical issues

Managementof breathlessness . . . Managementof breathlessness . . . Treat the underlying cause

antibiotics

avoid fluid overload

dry secretions

Mechanical ventilation

Treat the underlying cause antibiotics

avoid fluid overload

dry secretions

Mechanical ventilation

. . . Managementof breathlessness. . . Managementof breathlessness Symptomatic management

oxygen

opioids

anxiolytics

nonpharmacologic interventions

Symptomatic management oxygen

opioids

anxiolytics

nonpharmacologic interventions

OxygenOxygen

Pulse oximetry not helpful

Potent symbol of medical care

Expensive

Fan may do just as well

Pulse oximetry not helpful

Potent symbol of medical care

Expensive

Fan may do just as well

OpioidsOpioids

Small doses

Central and peripheral action

Relief not related to respiratory rate

No ethical or professional barriers

Do not shorten life

Small doses

Central and peripheral action

Relief not related to respiratory rate

No ethical or professional barriers

Do not shorten life

AnxiolyticsAnxiolytics

Safe in combination with opioids lorazepam• 0.5-2 mg po q 1 h prn until settled

• then dose routinely q 4–6 h to keep settled

Safe in combination with opioids lorazepam• 0.5-2 mg po q 1 h prn until settled

• then dose routinely q 4–6 h to keep settled

Nonpharmacologic interventions . . .Nonpharmacologic interventions . . . Reassure, work to manage anxiety

Behavioral approaches, eg, relaxation, distraction, hypnosis

Limit the number of people in the room

Open window

Reassure, work to manage anxiety

Behavioral approaches, eg, relaxation, distraction, hypnosis

Limit the number of people in the room

Open window

Nonpharmacologic interventions . . .Nonpharmacologic interventions . . . Eliminate environmental irritants

Keep line of sight clear to outside

Reduce the room temperature

Avoid chilling the patient

Eliminate environmental irritants

Keep line of sight clear to outside

Reduce the room temperature

Avoid chilling the patient

. . . Nonpharmacologic interventions

. . . Nonpharmacologic interventions Introduce humidity

Reposition elevate the head of the bed

move patient to one side or other

Educate, support the family

Introduce humidity

Reposition elevate the head of the bed

move patient to one side or other

Educate, support the family

Common Symptoms

Summary

Common Symptoms

Summary