5th Year Palliative Care
Common symptom
management
Dr Sarah Hanrott
Specialty doctor, Sobell House
March 2019
Common symptoms at the end of life
1. Dyspnoea
2. Delirium, anxiety, agitation, acute
confusion
3. Nausea and vomiting
4. Constipation
5. Pain
Principles of symptom management
Comprehensive & holistic
Are there any reversible causes?
Non pharmacological methods
Adjust one thing at a time
Balance symptom benefit with adverse effects/burden of drugs
1. Dyspnoea
Dyspnoea
Fan therapy,
Physio: breathing techniques
Reassurance … (Oxygen)
Then….
Opioids
Benzodiazepines
Secretions
Fan Therapy (Simon and Bausewein, 2009)
Hand held fan
Standing fan
Open window
Flow of air to the face, nasal mucosa, pharynx may alter ventilation
Exact mechanism unclear
Postulated that cold receptors in the nose arising from the trigeminal nerve give sensory input to effect respiration and decrease breathlessness
Significant benefit has been evidenced in COPD patients
Techniques
Breathing – Thinking – Functioning
Techniques that patients can initiate themselves increase self efficacy and can have a positive impact on QoL in chronic illness
Much evidence and techniques are extrapolated from COPD
Breathing Techniques
Positions of ease
Pacing/prioritisation/planning (the 3 P’s)
“Blow as you go”
Energy conservation
Visualisation
Acupressure
Acupuncture
Anxiety management/relaxation
Breathing Techniques
Breathing control
With hand positioning
Pursed lip breathing
Rectangular breathing
Things to consider
Large meals may be difficult due to coordinating eating and breathing
Small energy dense meals throughout the day may help (simon and Bausewein,
2009)
Encouraging expiration
Decreasing CO2 so as to activate the brains respiratory centre more effectively
Pharmacological treatments for breathlessness?
Opiates: low dose morphine 2.5-5mg as needed – if more than 2 doses in 24 hours, convert to slow release morphine. ( NB lower doses in COPD – 1mg bd)
Evidence: 50% improved with 10mg od SR morphine, 90% improved with 20mg od (Currow et al 2011)
No evidence low doses suppress respiration
Benzodiazepines – only use if anxiety exacerbating breathlessness: e.g. Lorazepam 0.5mg SL or PO bd PRN.
Or at the end of life if distressed – e.g Midazolam 2.5 -5mg SC hourly as needed.
Secretions
If patient unconscious, not distressed, then reassurance to loved ones necessary, not always necessary to treat.
Hyoscine butylbromide 20mg SC qds – use PRN, if helps, then use in syringe driver.
Use midazolam if distressed.
2. Anxiety, agitation, delirium, confusion
Anxiety/ Agitation
OR
Delirium/ confusion
Anxiety/ agitation :
Diazepam 2 – 5 mg tds PO prn
Lorazepam 0.5- 1 mg PO bd prn
Midazolam 2.5-5mg SC hourly prn
Non pharmacological: explore fears etc, environment.
Delirium:
REVERSIBLE??: drugs, (?toxicity), pain, metabolic, infection, RETENTION, CONSTIPATION.
Haloperidol 0.5 – 5mg SC or PO tds.
2nd line: Levomepromazine 2.5 – 5mg SC qds – can titrate up (sedating antiemetic).
3. Nausea & vomiting
Causes in Advanced Disease?
Causes in Advanced Disease? • Disease related - Site of tumour
• GI, gynae, peritoneal, pelvic with Intestinal obstruction – lower and upper Constipation Ascites Gastric stasis Gastric dysmotility
• Respiratory Cough
• Brain
Brain metastases Raised intracranial pressure
Causes in Advanced Disease?
• Metabolic Hypercalcaemia Renal failure Hyperglycaemia Hypoglycaemia
• Drugs/treatments Opioids SSRIs Iron supplements Digoxin toxicity Antibiotics Steroids Chemotherapy and radiotherapy
• Psychological Sense of smell Fear and anxiety
Pain
Nausea and Vomiting
• Treat reversible aetiology:
• CONSTIPATION
• Hypercalcaemia … other metabolic
• Drugs: can any be discontinued?
• SC route (same dose as PO)
Receptor affinities of antiemetics
Agonist/Antagonist AChM
Ant H1
Ant 5HT2
Ant D2 Ant
5HT3 Ant
5HT4 Ag
Metoclopramide (PO/IV/SC)
++ (+) ++
Domperidone (PO) ++
Haloperidol (PO/SC) +++(*)
Cyclizine (PO/IV/SC) ++ +++
Ondansetron (PO/IV) expensive, constipating
+++
Levomepromazine (PO/SC) (Nozinan)
+ + ++ +(*) * Prokinetic effect of metoclopramide and domperidone is partly attributed to D2 antagonism –
however there is no evidence that haloperidol or other neuroleptics have prokinetic activity.
Antiemetic choices
Metoclopramide: prokinetic + central effect
Indication: gastric stasis and toxic causes.
Dose 10mg tds po/sc (can go to 20mg qds).
Alt: Domperidone 10mg tds (if risk of EPSE with metoclopramide)
Haloperidol Indication: toxic/chemical causes.
Dose 0.5-1.5mg nocte po/sc up to tds.
Alt levomepromazine 6.25-12.5 mg starting.
Both sedating – esp if also delirious.
Cyclizine: slows gut and central effect
Indication: bowel obstruction/ raised ICP/motion sickness.
Dose: 50mg tds po/sc (SC – painful/erythema)
Other - Dexamethasone, Midazolam, Ondansetron
Routes of Administration
Give regularly, ensuring a PRN dose is available
Orally (tablets/ solution)
Regular sub-cut via a butterfly needle
24 hour syringe-driver
IV
Oral, IV and sc
doses are the same
N&V: obstruction
• How do you manage malignant bowel obstruction?
Causes of bowel obstruction
Cancer related
Intrinsic – bowel Ca
Extrinsic – often gynae with peritoneal, omentum spread, nodal disease.
Lymphoma
Treatment-related (adhesions/radiation)
Impaction (see causes of constipation)
Benign (hernia)
Surgical Management
Is it technically feasible?
Is the patient fit enough?
Is the patient likely to benefit?
It is appropriate?
Medical management of bowel obstruction
Incomplete obstruction
Aim get bowel moving
1. Metoclopramide
50-100 mg/24h in CSCI, starting at
30-60 mg and increase.
Stop if causes colic
2. Bowel care as indicated
3. +/- dexamethasone (poor evidence)
4. +/-levomepromazine
Complete obstruction:
Aim reduce gut motility & secretions
1. Stop metoclopramide
2. Use cyclizine or haloperidol or
levomepromazine
3. If large volume vomit: add hyoscine
butylbromide or octreotide
4. +/- NGT (Ryles tube)
5. Bowel care as indicated
6. +/- dexamethasone
4. Constipation
Constipation
Defined as difficulty in defaecation
Incidence in palliative care = 50%
of which 63% are not taking opioids
Laxatives needed in 87% of pts using opioids
Causes of constipation
Causes
Disease-related
Hypercalcaemia
Site of malignancy
immobility
poor nutrition (decreased intake)
poor fluid intake
dehydration (vomiting, polyuria, fever)
weakness
Drugs:
Opioids
Anticholinergics (cyclizine, tricyclics)
5HT3 antagonists
ondanestron
Diuretics
How does morphine make you constipated?
Acts on m2 receptors to :- reduce peristalsis increase sphincter tone impair rectal sensitivity blockade water secretion increase water absorption
Constipation results in …
Pain
Abdominal distension
Nausea and vomiting
Distress and lack of dignity
Overflow diarrhoea
Agitation
Urinary retention
Management of constipation
Examination and investigation
Ward level observations
Think about contributing causes.
Treatment of constipation
Faecal softeners: Docusate 100 mg bd->200mg tds
Osmotic agents: Lactulose, Macrogol (Laxido/ Movicol)
Stimulants: Senna (large bowel only), danthron (mainly large bowel)
Rectal measures: suppositories and enemas
Glycerol suppository 4 g
Bisacodyl supp 10 mg
Phosphate enema
Arachis oil enema
Other measures – eg urinary catheter, new drugs coming
5. Pain
Types of pain
• Somatic (soft tissues, muscle, bone)
• Visceral (smooth muscle)
• Neuropathic
• Phantom
Pain management: non-opioids
Paracetamol
1g qds (<50 kg use 500 mg qds)
Oral (incl liquid) or IV
Side effects are rare
NSAIDS
Ibuprofen 400 – 800 mg tds oral
Naproxen 250 – 500 mg bd oral
Co-prescribe: PPI or ranitidine if regular use
SE:
renal
bleeding (care with LWMH, aspirin, steroids)
cardiac
Opioids
Weak opioids
Codeine (15 – 60 mg qds) oral*
Tramadol (50 – 100 mg qds) oral*
Strong
Morphine (oral, SC, IV)*
Oxycodone (oral, SC, IV)*
* Seek specialist help in renal impairment:
Moderate renal impairment: use lower doses at reduced frequency
Severe may need to switch to fentanyl/alfentanil:
Fentanyl (patches [s/l, sc]) and alfentanil (SC)
Seek senior / specialist advice before prescribing.
Morphine
Morphine sulphate immediate release (i/r)
Oramorph Liquid 10 mg/5 mL
Onset: ½ hour,
lasts: 4 hours
(Sevredol tablets: 10 mg, 20 mg and 50 mg)
Morphine sulphate modified release e.g. Zomorph
Onset: 2-6 hours,
lasts: 12 hours (regular twice daily dosing)
Capsules and tablets (5 mg, 10mg, 30mg, 60mg, 100mg, 200mg)
Morphine
Start with lowest effective dose
Titrate up opioid naïve: morphine (I/R) 2.5 -5 mg every 1 – 4 hours.
Convert to bd modified release Eg patient using average of 6 PRNs/day each of 5 mg = 30 mg total/day
=15 mg morphine MR (MST) bd
Common side effects of morphine
Constipation
Nausea
Sedation
Myoclonus (toxic)
Hallucinations, delirium … (toxic)
Itch
Respiratory depression (rare with careful prescribing)
Non-addictive
Opioid Conversions
Co-prescribing
Laxatives
Antiemetics
Reassurance
Syringe drivers
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