symptom management in the palliative care patient Flashcards
What are the needs of a
patient with a life-limiting
illness?
Management of physical symptoms.
Management of psychological symptoms.
Need for social support.
Culturally specific needs related to information.
Need for information about treatment, prognosis.
Spiritual concerns about loss of hope, loss of
meaning.
Financial concerns.
Legal concerns.
Principles of symptom
management
Evaluation Explanation Discussion Individualised treatment Attention to detail Monitoring progress. Rapid dose escalation as symptoms progress
The 7 most common physical
symptoms experienced by
palliative care patients
Pain Appetite problems Fatigue Bowel problems Nausea Difficulty sleeping Breathing problems
Pain
The majority of pain in palliative care can be
managed with available drugs and evidence
based practice.
Managing this type of pain is proactive: a long
acting opioid in the background with break
through analgesia when necessary.
Regular assessment of pain and side effects of
the medications.
Use of validated pain assessment tool should
be used
Other pain assessment tools
PAINAID
ABBEY pain scale
Pain assessment tool in advanced dementia
Measures breathing, negative vocalisation, facial
expression, body language and consolability
Gives each section a number.
Results rate 0-10.
Measures vocalisation, facial expression, change in
body language, behavioural change, physiological
changes, physical changes.
Syringe Drivers
For intractable pain, patients need to have
continuous infusion of opioid analgesia and may
need a syringe driver with morphine and/ or
sedation and /or anti-emetics.
Adjuvant therapy
Adjuvant refers to a substance’s ability to enhance
the action of another substance.
In palliative care, this refers to drugs or therapy that
may not be specific pain therapy but when used
with analgesia assists in treating the pain.
Examples of adjuvant drug therapy are antidepressants (amitriptiyline), anti-convulsants
(pregabalin, gabapentin), local anaesthetics (which
may be infused as an epidural, for example) , antiinflammatories (dexamethasone) and ketamine.
Biphosphonates
act on the bones by destroying
osteoclasts (which break down bone), thereby
slowing down bone loss
Appetite problems
Loss of weight (cachexia) and loss of appetite (anorexia)
are important concerns for the palliative patient and may
affect prognosis and mortality.
Patients who lose weight , but then achieve weight
stabilisation have longer survival and improved quality of
life when compared to those who continue to lose weight.
It is important to treat potentially reversible causes of these
problems: mouth ulcers, nausea, pain, dysphagia,
inappropriate presentation of food, etc.
Therapy to treat appetite
problems
Drug therapy: Dexamethasone, prednisolone and
methylprednisolone have all been shown to improve
appetite, and some studies have also shown increases in
quality of life and wellbeing.
Stimulating appetite often does not reverse cachexia.
Artificial nutrition may include dietary supplements or more
invasive routes.
Invasive routes would be intravenous feeding, Total Parenteral
Nutrition (TPN) or tube feeding : Naso-gastric or Percutaneous
Endoscipic Gastrostomy feeding.
Invasive treatment really depends on the condition
Ethical issues around artificial nutrition
TPN is never a long term solution : needs central venous
access with associated risk of sepsis (EXCEPTIONS).
Some patients with neurological conditions have PEG
feeds for decades, if they are unable to swallow.
Motor neurone disease, multiple sclerosis are examples.
Providing artificial nutrition to patients with end stage
illness does not prolong life, and needs careful
consideration about quality of life, life expectancy and
functional capability.
Patients who are dying need minimal food and drink to
satisfy hunger and thirst
Fatigue
is defined as a persistent feeling of tiredness that is not relieved by sleep or rest. It is an extremely common problem in palliative patients and causes significant distress and affects quality of life.
Treatable causes of Fatigue need
to be managed
Anaemia Nutritional deficiencies. Metabolic disorders Physical deterioration and deconditioning. Pain Depression Insomnia Chemotherapy and radiation. Side-effects of medications Easier said than done
Further treatment of fatigue
A multidisciplinary approach involving
nutritional counselling, exercise or activity
enhancement, psychosocial support,
distraction and family activities.
BUT, fatigue may be a protection factor
towards the end of life and encouraging
activity may be inappropriate.
constipation
An assessment of constipation in the palliative context needs
to address opioid induced bowel dysfunction. Other possible
contributing factors include:
Medications – 5-HT3 antagonists (ondonsetron),
anticholinergics, iron, some antihypertensives
Decreased oral intake, dehydration, alterations in diet
Metabolic abnormalities (eg. hypercalcaemia, uraemia,
hypothyroidism, hypokalaemia, diabetes)
Decreased mobility, weakness, difficulty accessing toilet
facilities
