managing non-pain symptoms

Question 1

Non pain symptom management

Answer 1

• choose treatment strategies that support the patients goals of care (age, function status, overall needs, rate of change of disease, life expectancy)
• identify the cause whenever possible and treat the CAUSE of the symptom

Question 2

goals of clinical symptom assessment

Answer 2

• elicit the most distressing symptoms for the patient and family
• determine underlying pathophysiology, cause, and contributing factors for each symptom
• screen for common distressing symptoms
• review current and past treatments, their effectiveness and side effects
• document assessment and plan
• reassess at regular intervals

Question 3

Dyspnea

Answer 3

• Discomfort in breathing
• aka: breathlessness, shortness of breath, work of breathing
• subjective sensation (physical, psychological, social and spiritual)
• occurs in broad range of diseases (cancer, COPD, AIDS, CHF, ALS, dementia)
• tends to worsen as death approaches

Question 4

Dyspnea assessment

Answer 4

• self-report is GOLD standard
• RR, sings of increased WOB, oxygen saturation and other tests DO NOT CORRELATE with patient report of dyspnea
• hx/PE - clarify causes of dyspnea
• Rx dependent upon prognosis, goals of care risks and benefits of tests/interventions

Question 5

Causes of dyspnea

Answer 5

• BREATH AIR
• B = bronchospams
• R = Rales
• E = Effusion
• A = airway obstruction
• T = Thick secretions
• H = hemoglobin low
• A = anxiety
• I = interpersonal issues
• R = religious concerns

Question 6

tx for dyspnea

Answer 6

• oxygen (may be no more beneficial than air; caution if CO2 retention)
• Opioids (first line, small doses)
• anxiolytics (treat anxiety, not dyspnea)
• general measures
• alternative, complimentary (acupressure, acupuncture, meditation, massage)
• Non-invasive ventilator support

Question 7

describe general measures to tx dyspnea

Answer 7

• reduce exertion/energy expenditure
• reposition the patient (upright or compromised lung down)
• provide skin care for the buttocks
• improve air circulation (draft/fan, adjust humidity, avoid strong odors, fumes etc)
• address anxiety and provide reassurance
• consider rehabilitative strategies (breathing retraining - prolong experiation)
• discuss any patient, family, or staff concerns about using opioids to relieve dyspnea

Question 8

Dysphagia

Answer 8

• difficulty swallowing
• discern whether neurologic or non-neurologic (solids progressing to liquids is obstruction; simultaneous solids and liquid is neurological)
• Conservative management can ameliorate dysphagia for a majority of patients (emphasize good oral hygiene, etc)

Question 9

what are some conditions that result in dysphagia

Answer 9

• dentures fit poorly
• poor dental hygiene
• taste disorder
• weakness or neuromuscular problems
• stress and tension

Question 10

Anorexia-cachexia

Answer 10

• multi-faceted cascade of events leading to loss of appetite for food, usually resulting in cachexia
• often superimposed on the anorexia of the aging process
• Hx and PE (seek to identify reversible causes)

Question 11

what are reversibel causes of anorexia

Answer 11

• ANOREXIA
• A = aches and pains
• N = nausea and gastrointestinal dysfunction
• O = oral candidiasis
• R = reactive depression
• E = evacuation problems (constipation, retention)
• X = xerstomia (dry mouth)
• I = Iatrogenic (radiation, chemo, drugs)
• A = Acid related problems (gastritis, peptic ulcers)

Question 12

Tx for anorexia

Answer 12

• appetite stimulants
• artificial nutrition and hydration
• -> enteral feeding (tube); parenteral feeding (TPN)

Question 13

artificial nutrition and hydration (anorexia)

Answer 13

• ANH does not improve healing of decubitus ulcers
• ANH often shortens, not lengthens survival
• perioperative mortality/PEG placement 6-24%
• infection, thrombosis, aspiration

Question 14

Nausea and vomiting

Answer 14

• in seriously and terminally in patients, N/V are common symptoms in
• N/V cause significant distress
• can usually be controlled in 90% of patients

Question 15

describe the various origins of nausea and vomiting

Answer 15

• intracrnail pressure, anxiety and memories (CEREBRAL CORTEX)
• Motion sickness, vestivular disease (VESTIBULAR APPARATUS)
• uremia, hypercalcemia, drugs (CHEMORECEPTOR TRIGGER ZONE)
• Gastric irritation, intestinal distension, gag reflex (GI TRACT)

Question 16

Neasua and vomiting tx

Answer 16

• Select antiemetic agent on the basis of: likely cause, pathway mediating the symptoms, NT involved
• General measures
• -> small and frequent meals
• -> frequent small sips of fluid
• -> avoid strong odors or unpleasant tastes
• -> address nonphysical factors

Question 17

malignant bowel obstruction

Answer 17

• up to 50% of patients with ovarian and GI cancers have malignant bowel obstruction
• patients diagnosed with malignant bowel obstruction have median survival of 3 months
• HIGH SYMPTOM BURDEN (N/V, colic and abdominal pain)

Question 18

Tx of maligant bowel obstruction

Answer 18

• management dependent upon functional status, goals of care, expected survival
• tx options
• -> surgical-limited evidence of benefit QoL and EoL
• -> endoscopic techniques: stents
• -> medical management: mainstay of Rx

Question 19

Delirium

Answer 19

• ACUTE ONSET
• Fluctuating course
• altered level of consciousness (hyperactive or hypoactive or both)
• cognitive impairments
• -> altered orientation
• -> altered organization of thoughts
• -> altered perceptions (delusions, hallucinations)
• -> emotional labiality
• -> reversal of sleep wake cycle
• -> memory impairment

Question 20

delirium assessment and treatment

Answer 20

• Hx and PE - identify potential reversible causes
• treat underlying cause
• use low dose non-sedating antipsychotic
• actively dying, non-ambulatory patients may benefit from sedating antipsychotic
• AVOID BENZODIAZEPINES (NEVER use without an antipsychotic)

Question 21

describe preventative measures of delirium

Answer 21

• prevent dehydration
• remove unnecessary catheters/IVs, restraints
• decrease environmental stimuli
• reduced light and sound at night; minimal interventions
• hearing and visual assessment
• reorientation and cognitive stimulation
• inducement of sleep with music or massage

Question 22

KEY POINTS

Answer 22

• most patients receiving palliative care have multiple symptoms
• screening assessment is key to identifying the symptom constellations
• detailed History and comprehensive PE are needed to determine most probably cause
• tx strategies should be determined by patients goals of care and directed at treating the underlying cause whenever possible