1. health and fitness
2. disease

Non-pain Symptomatic
Management in Palliative Care
OLIVER A. CERQUEIRA, D.O.
ASSISTANT PROFESSOR OF INTERNAL
MEDICINE
CLERKSHIP DIRECTOR, INTERNAL
MEDICINE
OU-TULSA SCHOOL OF COMMUNITY
MEDICINE
Objectives
 Apply generalized principles of symptom
management to "real world" clinical scenarios
 Choose appropriate management for a variety of
non-pain symptoms that are addressed by palliative
care
Palliative Care
So, what S/Sx are out there to be addressed?













Nausea & Vomiting**
Dyspnea**
Constipation
Diarrhea
Ascites/Pleural Effusions
Bowel Obstruction
Fatigue
Singultus
Depression
Lymphedema/Edema
Anuria
Insomnia
Hot Flashes
Anxiety
Delirium/Confusion**
Secretions
Pruritus
Fever
Cough
Anorexia/Cachexia
Xerostomia
Mucositis/Stomatitis
Pressure Ulcers/Wound
Care/Wound Odor
 Bladder Spasms
 Candidiasis










Generally, what are two ways to manage S/Sx?
 Non-pharmacologic/Mechanical
 Pharmacologic
 Routes of Administration
PO
 IV
 IM
 Sub-Q
 Buccal & SL
 TD
 PR
 Intranasal/Inhalation

Principles of Symptom Control
 Four domains of the
human suffering
experience:




Physical
Emotional
Social
Spiritual
Principles of Symptom Control
 Do NOT overlook symptomatic management
while focusing on disease-oriented care

e.g. Pleuritic CP & PNA
 When possible, identify the underlying pathophysiology
&/or mechanism
 Symptoms are the patient’s experience of the
illness
 The clinician is obligated to relieve those
symptoms
 Unrelieved suffering is demoralizing & demeaning

Suffering patients may lose the will to live, become depressed &
withdrawn, & decline more rapidly
Principles of Symptom Control
 Treatment considerations:

Anticipate predictable complications of disease states


Anticipate associated complications of palliative treatments


e.g. poor home support & complex treatment regimens; low income &
medication affordability
Ultimately, patient’s goals of care drive symptomatic management
decisions


e.g. opioids & N/V, constipation, sedation, delirium
Evaluate for psychosocial difficulties


e.g. colorectal cancer patients & bowel obstruction; head & neck
cancer patients & sudden exsanguination
e.g. clarity of mind vs. suffering pain
Frequent re-evaluation
Nausea & Vomiting
 Occurs 60-70% of patients with advanced cancer
 Prevention is key: Regular dosing of antiemetics




can often prevent recurrent nausea
Associated with autonomic s/sx, including pallor, cold
sweats, decreased respiratory rate, & sometimes diarrhea
Hypersalivation
Cardiac rhythm disturbances may occur
Gastric emptying is reduced in the presence of
nausea – don’t assume PO medications will
work, even if there is no vomiting!
Nausea & Vomiting – 4 Inputs
Nausea & Vomiting
Nausea & Vomiting – Pharmacologic Treatment
 V.O.M.I.T. acronym

Vestibular
Cholinergic, Histaminic
 Scopolamine, Promethazine


Obstruction of bowel by constipation (NOT mechanical obstruction)
Cholinergic, histaminic, likely 5HT3
 Stimulate myenteric plexus – Senna


DysMotility of the upper gut
Cholinergic, histaminic, 5HT3, 5HT4
 Metoclopramide


Infection, Inflammation


Cholinergic, histaminic, 5HT3, NK1
Toxins stimulating CTZ
Dopamine 2, 5HT3
 Haloperidol, Odansetron, Prochlorperazine

Nausea & Vomiting – Pharmacologic Treatment
Nausea & Vomiting – Non-pharmacologic
 Ginger Root

5HT3 antagonism in animal models
 Measures to enhance gastric emptying and decrease
gastric distention



Liquid diet
Frequent small meals
Foods low in fats & fiber, high in protein
 Measures to minimize other noxious or associated stimuli


Cool foods
Foods with a pleasant appearance & w/o odors
 Acupuncture


At the P6 or pericardium 6 point
Produces vagal modulation & enhances 5HT3RA efficacy
 Cognitive—Behavioral Therapy

Induces muscle relaxation & reverses autonomic arousal that accompanies ALL
nausea
Delirium - Definition
Delirium – Subtype Manifestations
 Three subtypes based on arousal levels &
psychomotor behavior

Hyperactive delirium


Hallucinations, agitation, delusions, & disorientation
Hypoactive delirium
Decreased consciousness, somnolence
 In PC, is more common – up to 80%


Mixed-form with alternating features
Delirium - Pathophysiology
Delirium – Risk Factors & Causes
Delirium – Risk Factors & Causes
 Medications are the most common identifiable
causes of delirium in the hospital setting!



Anti-cholinergics
Sedative-hypnotics
Opioids
 Other common causes:
 Metabolic derangements
 Infections
 CNS pathology
 Drug/alcohol withdrawal
Delirium – Risk Factors & Causes
Delirium – Pharmacologic Treatment
 Benzodiazepines may
cause paradoxical
worsening of symptoms
(possibly by a serotonergic
mechanism) & should not be
used first line
 Use lowest doses possible,
especially with haloperidol as
EPS side effects are dosedependant!
 IV haloperidol may cause
less EPS than PO
 When reaching maximum
dosages of haloperidol, one
option is to add or switch to a
more sedative neuroleptic
Delirium – Non-pharmacologic
Dyspnea
 Experienced by up to 70% of terminally ill cancer




patients at some point during the course of their disease
Diminishes functional status, social activities, QOL, & the
will to live
In one multi-center study from 2000, terminal
sedation was prompted by dyspnea 3X more
commonly than by pain
The typical pattern is one of chronic dyspnea, punctuated
by unpredictable, but expected, acute episodes
SUBJECTIVE!!


e.g. patients may be hypoxic & “look dyspneic,” but when
well-palliated, they report no sense of dyspnea
Patient self-report is the only accurate measure of dyspnea
Dyspnea – Multidimensional
Dyspnea – Physiology & Pathophysiology
 The sensory cortex receives
copies of respiratory motor
commands arising from the
medulla or motor cortex &
sensory information from
peripheral chemoreceptors
& mechanoreceptors
 Dyspnea occurs if the
degree of motor output
required is perceived to be
unsustainable or
disproportionate to the
sensory information
received
Dyspnea – Generalized Treatment Measures
 Address the underlying etiology or etiologies, if at all






possible
Reduce the need for exertion
Repositioning, usually to a more upright position
Keep the compromised lung down in unilateral
pulmonary disease
Improve air circulation – open doors & windows,
use a fan
Avoid strong odors, fumes, & smoke
Identify & avoid any triggers that precipitate or worsen
dyspnea
Dyspnea – Opioids
 First-line therapy
 Can be used alone or aside reversible etiologies
 Most beneficial for dyspnea at rest
 Evidence has repeatedly shown that opioids can be
safe & effective at controlling dyspnea in several
clinical populations, including COPD, CHF,
pulmonary fibrosis, & cancer
 Respiratory depression is uncommon when
titration is appropriate & is almost always
preceded by drowsiness/sedation

Hold Parameters
Dyspnea – Opioids
 Reversal agents (i.e., naloxone) should only be used
in the setting of life-threatening opioid toxicity
 Most published trials studied morphine, but trials of
other opioids such as fentanyl, M6G, &
hydromorphone suggest a class effect
 Most common adverse effects experienced in
this population: Constipation, nausea,
sedation
Dyspnea – Opioids
 Mechanisms by Which Opioids May Reduce
Dyspnea:







Decreased metabolic rate and ventilatory requirements
Reduced medullary sensitivity & response to hypercarbia or
hypoxia
Alteration of neurotransmission within medullary respiratory
center
Cortical sedation (i.e., suppression of respiratory awareness)
Analgesia reduction of pain-induced respiratory drive
Vasodilation (i.e., improved cardiac function)
Anxiolytic effects
Dyspnea – Opioids
 Opiate-naïve older age or
patients with CKD


Consider reducing
starting dose by ½
Avoid morphine in renal
disease if possible
 DOE or dyspnea with
movement

Give 30 minutes prior to
activity
 If on stable IR dosage,
consider trial of LA as
baseline with IR PRN in
between doses
Dyspnea – Other Treatment
 Benzodiazepines
Addresses concomitant anxiety
 No evidence that there is a direct benefit

 Oxygen
Often patients report improved dyspnea, even when not
hypoxemic or when they remain hypoxemic
 ? Placebo effect due to inherent medical symbolism
 Some studies have demonstrated dampening of dyspnea due to
stimulation of the trigeminal nerve, V2 branch
 Depending on patient preference, generally avoid face masks

Dyspnea – Pursed Lip Breathing
The End!!
References
Bruera, Eduardo et al. Textbook of Palliative Medicine. 1st ed. Houston, TX: CRC Press; 2009.
Adamis, D. et al. Delirium Scales: A review of current Evidence. Aging & Mental Health. 2010; Vol 14, No.5;543-555.
Walsh, Declan et al. Palliative Medicine. 1st ed. Philadelphia, PA: Saunders; 2008.
Karnani, NG. Management of Selected Non-Pain Symptoms at the End of Life. Northeast Florida Medicine. 2010; Vol 61,
No.4:18-21.
Rousseau, Paul. Nonpain Symptom Management in the Dying Patient. Hospital Physician. 2002; Feb:51-56.
Montagnini, Marcos et al. Non-Pain Symptom Management in Palliative Care. Clinics in Family Practice. 2004;Vol 6, No.2:395422.
Quill, Timothy E. et al. Primer of Palliative Care. 5th ed. Glenview, IL: American Academy of Hospice and Palliative Medicine;
2010.
Weissman, DE. Dyspnea at End-of-Life, 2nd ed. Fast Facts and Concepts. July 2005;27.
http://www.eperc.mcw.edu/fastfact/ff_027.htm. Accessed Feb 10, 2013.
Weissman, DE. Diagnosis and Management of Terminal Delirium, 2nd ed. Fast Facts and Concepts. July 2005;1.
http://www.eperc.mcw.edu/fastfact/ff_001.htm. Accessed Feb 10, 2013.
Quijada, E, Billings JA. Pharmacologic Management of Delirium; Update on Newer Agents, 2nd Ed. Fast Facts and Concepts.
July 2006;60. http://www.eperc.mcw.edu/fastfact/ff_060.htm. Accessed Feb 10, 2013.
Hallenbeck J. The Causes of Nause and Vomiting (V.O.M.I.T.), 2nd Ed. Fast Facts and Concepts. July 2005; 5.
http://www.eperc.mcw.edu/fastfact/ff_005.htm. Accessed Feb 10, 2013.
Shirk, Mary B. et al. Unlabeled Uses of Nebulized Medications. Am J Health-Syst Pharm. Sept 15, 2006; Vol 63: 1704-1716.
Kallet, Richard H. The Role of Inhaled Opiods and Furosemide for the Treatment of Dyspnea. Respiratory Care. Jul 2007; Vol
52, No.7:900-910.
Casarett, DJ, and Inouye, SK. Diagnosis and Management of Delirium near the End of Life. Ann Intern Med. 3 July
2001;135(1):32-40.
Manepalli, Jothika N. et al. Differential Diagnosis of the Older Patient With Psychotic Symptoms. Primary Psychiatry.
2007;14(8):55-62.
Mergenhagen, KA and Arif, S. Delirium in the Elderly: Medications, Causes, and Treatment.
http://www.uspharmacist.com/continuing_education/ceviewtest/lessonid/105762/ . Updated June 1, 2008. Accessed Feb 10,
2013.
Walker HK, et al. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Chapter 83: Nausea and
Vomiting by William F. Maule. Boston: Butterworths; 1990.
Leonard R Johnson; John H Byrne; et al. Essential medical physiology, 3rd ed. 491-493. Amsterdam : Elsevier Academic Press,
©2003.
Fallon, M. and Hanks, G. ABC of Palliative Medicine, 2nd Ed. Malden, MA: Blackwell Publishing Ltd; 2006.