symptom management in the palliative care patient 2 Flashcards
Nausea
Investigate the causes of nausea before you can
implement treatment:
Metabolic problems e.g. electrolyte imbalances,
liver failure
Sepsis
Conditions affecting gastrointestinal motility like
constipation, previous surgery, gastroparesis or
autonomic failure.
Reflux or peptic ulcer disease
Medication and treatment side effects, including
opioids and other drugs, chemotherapy, and
radiotherapy
Anxiety and depression, anticipatory nausea
Inappropriate presentation of food.
Treatment of nausea
Treat the cause, if possible. Anti-emetics that can be used are a dopamine antagonist: metoclopramide (Maxolon); holoperidol and 5HT3 antagonists Ondonsetron (Zofran) In palliative care, we avoid ondonsetron because of its constipating effects.
Difficulty sleeping
Insomnia and poor sleeping affect quality of life
for palliative patients and their caregivers.
Difficulty getting to sleep, fragmented sleep
and waking too early are all part of it.
Many chronic illnesses may cause insomnia:
cancer associated insomnia syndrome; hepatic
encephalopathy (in liver disease) may reverse
night and day; orthopnoea in end respiratory
illness.
Potentially treatable causes of
sleeping problems
Depression, anxiety, pain
Delirium
Obstructive sleep apnoea, dyspnoea, cough,
pleural effusion
Nausea, vomiting
Movement disorders eg, restless legs, akathisia
Night sweats
Pruritis (itch)
Environmental disruption, especially for in-patients
Reduced bed mobility, and physical problems that
limit comfortable sleeping position
Medications eg, steroids
Incontinence or nocturia
Medical treatment of sleeping
problems
Benzodiazepines are effective in the short term but can cause day time sleepiness and worsening cognition, without long term effectiveness. Treating the cause (in previous slide) may be more effective than sedation in the long term.
Breathing problems
Breathing problems may include dyspnoea,
cough, haemoptysis, obstruction and
respiratory secretions.
These can also affect the quality of life for
patients and their carers.
End of life breathing problems can be
especially difficult for family members.
Potentially treatable causes should be
identified and managed. These include:
nausea
Pulmonary embolus Pleural effusion Ascites or intra-abdominal pressure. Pericardial tamponade. Anaemia. Radiation damage to lungs. Anxiety/ panic. Assistance with mobility aids in the home.
Medical management of
breathing problems
In cardiac and respiratory disease, treating the
underlying cause benefits breathing problems:
i.e. diuretics, anti-hypertensives, steroids, vasodilators, etc.
Opiates are effective in managing respiratory
distress, e.g. codeine phosphate to stop
coughing, morphine to relieve dyspnoea.
Despite their popular use, there is no evidence
that using anti-cholinergics to dry up secretions
is any better than placebo.
Managing terminal secretions
at the end of life
Recent evidence states that the use of anticholinergics INCREASES patient’s suffering.
Side effects of glycopyrrolate and hysoscine:
Dry mouth.
Agitation.
Delirium.
Urinary retention.
Recommendations are: position the patient,
educate the family that the person is not suffering,
play soft music.
Symptom management in the
patient with end stage congestive
heart failure
Continuation of medications until death approaches.
These medications manage symptoms and enhance quality
of life.
These include diuretics, angiotension converting
enzyme(ACE) inhibitors (anti-hypertensives), digoxin, beta
blockers,
Chest pain and other pains related to poor tissue perfusion,
can be treated with GTN in oral, spray or patch form.
Oxygen may improve quality of life.
Symptom management in the
patient with end stage respiratory
disease.
Continue medications until death approaches to maintain
quality of life.
This may include vasodiIators, nebullisers, puffers, steroids.
Dyspnoea may be relieved by sitting upright or sleeping in a
recliner chair.
Decrease in activities and exercise as the disease progresses.
Carers should space activities like eating, dressing, washing, so
that the person is not tired out.
Oxygen, morphine to help with breathing, codeine to depress
cough reflex, anxiolytics to help with anxiety.
Symptom management in the
patient with end stage respiratory
disease.
Continue medications until death approaches to maintain
quality of life.
This may include vasodiIators, nebullisers, puffers, steroids.
Dyspnoea may be relieved by sitting upright or sleeping in a
recliner chair.
Decrease in activities and exercise as the disease progresses.
Carers should space activities like eating, dressing, washing, so
that the person is not tired out.
Oxygen, morphine to help with breathing, codeine to depress
cough reflex, anxiolytics to help with anxiety.
Symptom management in the
patient with end stage
neurological disease
Neurological symptoms may be acute or progressive, depending on the illness. Acute: Diagnosis of a brain tumour A stroke A traumatic brain injury. Progessive: Parkinsons Multiple sclerosis Dementia
Symptom management in the
patient with end stage
neurological disease
In some sad cases, the carer or loved one actually loses their
loved one before death, e.g. with dementia or a traumatic
brain injury.
The living body may serve as reminder of the loss and not allow
families to grieve properly.
Waiting is the most difficult task: families deal with it differently.
Symptoms of end stage neurological conditions may be similar:
personality changes, decline in cognition, decline in physical
functioning, seizures.
The principles of symptom control.
How do we know if we are
delivering good palliative
care?
Palliative Care Outcomes Collaborative (PCOC).
A national initiative measuring patient outcomes.
Benchmark questions are:
1. Time from referral to first contact : measures
responsiveness of the service. Benchmark is
2. Time patient spends in an unstable phase. An
urgent phase is when a patient experiences a new
or unexpected symptom and an urgent plan is
needed to treat the patient. Benchmark is:
3. Change in pain. Pain is the “core business of
palliative acre”
