Non-Pain 1

Question 1

When managing non-pain symptoms, should choose treatment strategies that support the patient’s goals of care

Answer 1

• Age
• Functional Status
• Overall Needs
• Rate of change of the disease
• Life expectancy

Question 2

Don’t treat the symptoms, treat the _____ of the disease whenever possible

Answer 2

CAUSE

Question 3

Goal setting with Geriatrics

Answer 3

• Are the goals achievable?
• Are the goals beneficial?
• —extend life or improve comfort?
• How will the results be measured… timeframe to reassess and decide whether to continue or stop the intervention.

Question 4

Most common non-pain symptoms in palliative care

Answer 4

• Constipation
• Nausea and vomiting
• Diarrhea
• Bowel Obstruction
• Anorexia and Cachexia
• Delirium
• Depression
• Dyspnea

Question 5

Dyspnea is common is which diseases?

Answer 5

• Cancer
• COPD
• HIV/AIDS
• CHF
• ALS
• Dementia
• Tends to worsen as death approaches

Question 6

Assessing Dyspmea

Answer 6

• Dyspnea is SUBJECTIVE
• Self-report the gold standard
• RR, signs of increased WOB, oxygen saturation, and other tests DON’T correlate with patient reporting dyspnea
• Rx is dependent upon prognosis, goals of care, risks and benefits of tests/interventions

Question 7

Causes of Dyspnea

Answer 7

BREATH AIR mneumonic

• Bronchospasm
• Rales
• Effusion
• Airway obstruction
• Thick Secretions
• Hemoglobin is low
• Anxiety
• Interpersonal issues
• Religious concerns

Question 8

Treatment for Dyspnea

Answer 8

• Oxygen
• Opioids (first line)
• Anxiolytics (treat anxiety, not dyspnea)
• General Measures
• Alternative, Complimentary- things like acupressure, acupuncture, meditation, massage
• Non-invasive ventilator support (CPAP)

Question 9

General, non “medical” interventions for treating dyspnea

Answer 9

• Reduce exertion/energy expenditure
• Reposition the patient- upright or the compromised lung down
• Provide skin care for the buttocks
• Improve air circulation
• Address anxiety and provide reassurance
• Discuss any patient, family, or staff concerns about using opioids to relieve dyspnea

Question 10

General things to assess with Dysphagia

Answer 10

• “difficulty swallowing”
• Discern whether it is neurologic or non-neurologic—- things like solids progressing to liquids (obstruction) and simultaneous solids and liquids (neurologic)
• Conservative management can ameliorate dysphagia for the majority of patients
• — emphasize good oral hygiene

Question 11

Reversible causes of anorexia

Answer 11

• Aches and Pains
• Nausea and GI dysfunction
• Oral Candidiasis
• Reactive (or organic) depression
• Evacuation problems (constipation, retention)
• Xerostomia (dry mouth)
• Iatrogenic (radiation, chemo, drugs)
• Acid-related problems (gastritis, peptic ulcers)

Question 12

Anorexia Treatment

Answer 12

Appetite stimulants- 
-- megestrol Acetate
-- Corticosteroids
-- Eicosapentaenoic acid
-- Thalidomide
-- Cannabinoids
Artificial Nutrition and Hydration
-- Enteral feedings (tube)
-- Parenteral feeding
-- The benefits of artificial nutrition for palliative care patients are difficult to identify

Question 13

Reframing Requests for artificial Hydration and Nutrition

Answer 13

• Validate their concern
• Suggest other alternative interpretation
• share more info and give alternative explanation and suggestions

Question 14

Nausea and Vomiting- General

Answer 14

• In seriously and terminally ill patients, these two symptoms are extremely common.
• Nausea and vomiting can cause significant distress
• Can usually be controlled in over 90% of patients

Question 15

Treatment strategies for Nausea and vomiting

Answer 15

• Select an antiemetic agent based on the likely cause, pathway mediating the symptoms, and neurotransmitters involved
• Other general measures, like small and frequent meals, frequent small sips of fluids, avoiding strong odors or unpleasant tastes, and address nonphysical symptoms like psychological, social, and spiritual

Question 16

Malignant Bowel Obstruction

Answer 16

• 1/2 of ovarian and GI cancer patients have this
• Patients diagnosed with this have a median survival of 3 months
• High symptom burden

Question 17

Treating Malignant Bowel Obstruction

Answer 17

• Management dependent upon functional status, goals of care, expected survival
• Surgical- limited evidence of the benefit and QoL
• Endoscopic techniques- stents (if single point of obstruction)
• Medical management- the mainstay of Rx

Question 18

Delirium signs/symptoms

Answer 18

• Acute Onset
• Fluctuating
• Altering levels of consciousness- hyperactive, hypoactive, or mixed
• Cognitive impairments
• • Altered orientation
• • Altered organization of thought
• • Altered perceptions
• • memory impairment

Question 19

What causes Delirium in elderly patients

Answer 19

THE HUGE ONE- MEDS!!!!!

- other are infection, constipation, urinary retention, and uncontrolled pain

Question 20

Assessing Delirium

Answer 20

• Identify potentially reversible causes
• Treat underlying cause
• Use low dose non-sedating antipsychotics
• AVOID benzodiazepines- and NEVER use without an antipsychotic

Question 21

Issues with delirium

Answer 21

• High incidence
• VERY distressing to patients and family members
• Cause of discord between family members and health care professionals
• aggressive preventative measures

Question 22

Preventative Measures for Delirium

Answer 22

• Prevent dehydration
• Remove unnecessary catheters/IVs, restraints
• Reduced light and sound at night with minimal interventions
• Decrease environmental stimuli
• Sleep, music, massage

Question 23

Key points from this lecture!!

Answer 23

• Most patients receiving palliative care have multiple symptoms
• Screening assessment is key to identifying the symptom constellation
• Detailed history and comprehensive PE are needed to determine most probably cause
• Treatment strategies should be determined by the patient’s goals of care and directed at treating the underlying cause whenever possible!