Palliative Care: Goals and
Nonpain Symptom
Management
Leigh Vaughan, MD
Medical University of South Carolina
March 6, 2012
Outline
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Definition of PC
Goals of PC
Who should be considered for PC
Symptoms identified in PC
Management and treatment options
Learning Objectives
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Define palliative care.
Determine effective management strategies for palliative
care patients.
Process strategies for prevention and treatment of
complications from palliative care interventions.
Assess the impact of interventions on patient comfort
and prognosis.
Recognize and address the psychosocial effects of life
threatening illness in hospitalized patients.
Assess and respond to patient's symptoms, including
pain, dyspnea, nausea, constipation, fatigue, anorexia,
anxiety, depression and delirium.
Key Messages
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Palliative care is a multi-disciplinary approach to
treating the "total pain" of a patient (including
physical, psychosocial, and spiritual needs of the
patient and family).
Palliative care is appropriate at any stage of
disease and can be given simultaneous to all
other medical therapies, including those with
curative intent.
There are multiple symptoms to target at the
end-of-life and Palliative care teams specialize in
management of refractory symptoms.
Palliative Care Definition
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Collaborative, comprehensive, interdisciplinary approach
to treating “total pain” (includes physical, psychosocial,
and spiritual needs of patients and families)
Appropriate at any stage of illness and
simultaneously with all other medical treatments
Goals of PC
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Improve the quality of life of patients living with
debilitating, chronic or terminal illness
Prevention and relief of suffering by early identification,
assessment, and treatment of distressing symptoms
Accomplished by combined efforts of an interdisciplinary
team
Components of IDT
(Interdisciplinary Team)
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Patient*
Family, loved ones*
MD primary team
MD consultants
Nursing
Psychologist, psych liaison
Social support- SW, case management
Physical or occupational therapy, respiratory therapy
Nutrition services
Spiritual support
Nursing home, hospice, home health services
Pharmacists
Volunteers
Complimentary and Alternative therapy
Patients to consider for PC
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Yes to "surprise question“ : You would not be surprised if the patient died
within 12 months?
Patients with frequent admissions
Patients whose admissions are prompted by difficult-to-control physical or
psychological symptoms
Patients with complex care requirements (eg, functional dependency;
complex home support for ventilator/antibiotics/feedings)
Patients with decline in function, feeding intolerance, or unintended decline
in weight (eg, failure to thrive)
Admissions from long-term care facility or medical foster home
Elderly patients, cognitively impaired, with acute hip fracture
Patients with metastatic or locally advanced incurable cancer
Patients with chronic home oxygen use
Patients who have an out-of-hospital cardiac arrest
Current or past hospice program enrollee
Patients with limited social support (eg, family stress, chronic mental
illness)
No history of completing an advance care planning discussion/document
Symptoms Management
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Under curative model, symptoms are clues to a diagnosis
Under Palliative care model, symptoms are entities in of
themselves
Goal is to identify, evaluate underlying cause, and treat
If treatment is pharmacologic, consider alternative
routes when and if p.o. administration fails
Alternative routes of delivery
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Enteral if feeding tubes
Transmucosal –widely used in palliatve care, immediate
delivery
Rectal
Transdermal -takes 24 hours to work
Parenteral
Intraspinal
Frequent symptoms in PC
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Dyspnea
Fatigue, poor function status, sedation
Nausea, vomiting, constipation
Mouth discomfort
Weight loss, dysphagia, anorexia
Depression, psychological pain
Delirium
Pain
Terminal secretions
Dyspnea
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Only reliable measure is patient self-report
RR, pO2, blood gas DO NOT correlate with the feeling of
breathlessness
Treatment options
 Opioids- best
 Anxiolytics- only if an anxiety component, not as
effective alone without opioids
 O2- no benefit over Room air if not hypoxic
 Non-pharmacologic management
Dyspnea with specific treatment
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Pulmonary edema
- Furosemide
Bronchospasm
- Albuterol, steroids, ipratropium bromide, inhaled
racemic epinephrine
Thick secretions
- Scopolamine, glycopyrrolate
Pleural effusion
 Drainage, pleurodesis
Fatigue
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Underlying causes: anemia, dehydration, meds, hypoxia,
insomnia, pain, infection, deconditioning
Possible treatments: Transfusions, O2, diuresis or
hydration, sleep aids and sleep hygiene, PT, exercise,
methylphenidate
Relaxation, meditation
Nausea/vomiting
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Causes:
-Bowel obstruction
-Drugs (ex: opioids)
-Malignancy related gastroparesis
-Metabolic derangements
-Increased ICP –especially brain mets
Treat underlying cause : treat with haldol/dexameth for
bowel obstruction, opioid rotation, treat constipation,
correct metabolic abnormalities
Treatment options- Nausea
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Dopamine antagonists (Haloperidol, Metoclopramide,
Prochlorperazine)
Prokinetic agents (metoclopromide)
Antacids/PPIs
Cytoprotective agents
Antihistamines (Diphenhydramine, Meclizine, Hydroxyzine)
Steroids
THC
benzodiazepines
Anticholinergics (scopolamine)
Serotonin antagonists (odansetron)
Neurokinin antagonists (aprepitant)
Constipation
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Begin dual therapy: stool softner (docusate=colace) +
stimulator (senna or bisacodyl = dulcolax)
Step up therapy: added to prior
 osmotics (Lactulose, MoM, mag citrate,)
 lubricants (glycerin, castor oil)
 large volume enema (500 cc of water,
phosphate, oil retention)
Mouth Discomfort
Symptoms
Causes
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Mucositis
Dry mouth
Mouth pain
Change in taste
Difficulty swallowing
Difficulty with speaking
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Mouth breathers
Medications (anticholingergics)
Advanced age
Cancer patients
History of radiation to the
head and neck
Sjögren's syndrome
Diabetes mellitus
Anxiety states
Dehydration (but rehydration
often does not improve this
symptom)
herpes simplex infection
Mouth Care
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Address underlying issue
Cleaning, denture care
Maintain hydration
Rehydrating gel
Suspension options:
 “Difflam” benzydamine hydrochloride 0.15% (oral
rinse) 15ml, 2-3 hourly for especially for radiation
 Consider sucralfate suspension (part of Magic Mouth)
 Chlorhexidine gluconate (Perisol)- Analgesia
 Saliva substitute (Pilocarpine or Salagen)
Weight loss, anorexia
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Treatment options:
 Megace, steroids
 THC
 Small frequent meals
Establish goals
Educate family, avoidance of coercion
Terminal Secretions
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Also called “death rattle”
From impaired swallowing of saliva, or congestion from
impaired cough ability
Treatment:
 Avoid suctioning
 Avoid xs hydration
 Medications: Scopolamine transdermal (but slow
onset) or Glycopyrrolate: 0.4 to 1.2 mg/day by
continuous IV or 0.2 mg SC every 4 to 6 hours
Pharmacologic Treatment
Options
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Psychostimulants
 Methylphenidate (Ritalin)
 Modafinil (Provigil)
 rapid onset of action and well tolerated.
SSRI’s
Tricyclic antidepressants (benefit of treating concurrent
neuropathic pain)
Insomnia- consider short course treatment
Anxiety- consider benzodiazpines
Delirium
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Identify underlying cause
Treat and diagnose within the context of agreed upon
level of care
Pain is a potent precipitant of delirium and its’
management is associated with significantly reduced
risks
Bone pain- Treatment
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Opioids, NSAIDS
Radiation- if cancer related
Bisphosphonates
Steroids
Consider Complimentary and Alternative Therapy (CAM)
CAM
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Acupuncture, hypnosis, Reiki, reflexology, biofeedback,
specialty diets, music, art therapy
Balance potential underutilized benefit with potential
toxicity
Often patients latch onto any therapy
More successful if institution supports resources
References
Identifying patients in need of a palliative care assessment in the hospital setting: a
consensus report from the center to advance palliative care. Weissman, David, J
Palliat Med. 2011;14(1):17.
Nonpain Symptom Management in the Dying Patient. Rousseau P. Hospital Physician.
2002 Hospital Physician;38(2):51 - 6.
Physiological changes and clinical correlations of dyspnea in cancer outpatients. Dudgeon
DJ J Pain Symptom Manage. 2001;21(5):373.
Treatment of metastatic prostatic cancer with low-dose prednisone: evaluation of pain
and quality of life as pragmatic indices of response Tannock , J Clin Oncol.
1989;7(5):590.
The mouth and palliative care. Sweeney MP Am J Hosp Palliat Care. 2000;17(2):118.
Recommendations for the Use of Antiemetics: Evidence-Based, Clinical Practice
Guidelines Gralla R, et al. J Clin Oncol, 1999.
Hospice and Palliative Care Training for Physicians: UNIPAC Series, Third Edition, 2008