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Common Physical Symptoms at the End of Life: Pulmonary and GI Symptoms
Mike Marschke, MD
Mr. M - Chronic Smoker Mr. M, 78 YO, is a lifetime
smoker. Dyspnea began 5 years ago.
intubated twice in the past year.
Since last admission 2 mos ago always needs 2-3 l/min nasal cannula oxygen, even at rest.
He has lost 15 lbs, has a persistent cough, with gray phlegm
He is on steroids and nebulizers
What is Dyspnea? Subjective sense that you need to
breath, that you ‘hunger air.’ Mechanism
Respiratory Center of Medulla Chemo receptors sensing low O2, hi CO2 Mechano receptors (J receptors) in lung,
respiratory muscles, and diaphragm Vascular congestion-CHF
Cerebral Cortex
Measurements? pO2, pCO2, O2 sats Peak flows Pulmonary function tests measuring lung
volumes and flowPrognosis < 6 mos. : Class IV respiratory failure (= dyspnea at
rest) Frequent ER/hospital stays, recurring
pulmonary infections, intubations pO2 < 56mmHg, O2 sat < 89%, pCOs
>50
Dr. arrives Mr. K is sitting in a reclining chair. Feels “breathless” with minimal
exertion. Breathing is “heavy and suffocating”. No apparent precipitating infection etc.
Evaluation Physical exam- distant breath
sounds, coarse crackles at bases bilaterally, RR = 32 at rest, takes breathes in mid-sentence.
tachycardic at 100/min Recent Weight loss of 15lbs. in 6
months. 2+ edema bilateral lower
extremities
The Bargainer Has no wish to be “brutalized”. He
knows his emphysema will kill him someday.
He has executed a DNR He wants to feel better but does not
want to go back into the hospital.
What about CXR, labs?
Assess cause Complete assessment – may lead
to treatable condition. Pleural effusion Pneumothorax Anemia PE CHF Pneumonia
CXR Findings Mass occluding R bronchus Post obstruction atelectasis Treatment options
Bronchoscopy Radiation Supportive
Weigh risk/benefits and patient wishes
Oxygen Pulse oximetry not helpful – go on
symptoms Potent symbol of medical care Expensive, noisy, hot,
uncomfortable for some Fan may do just as well
Opioids Relief not related to respiratory rate No ethical or professional barriers Small doses Central and peripheral action Inhaled morphine works peripherally
but may induce bronchospasm
Anxiolytics Safe in combination with opioids
lorazepam 0.5-2 mg po q 1 h prn until settled then dose routinely q 4–6 h to keep
settled
Nonpharmacologic interventions . . . Reassure, work to manage anxiety Behavioral approaches, eg,
relaxation, distraction, hypnosis Other CAM – aromatherapies
(Eucalyptus, Bergomot), massage, healing touch
Limit the number of people in the room
Open window
Nonpharmacologic interventions . . . Eliminate environmental irritants Keep line of sight clear to outside Reduce the room temperature Avoid excessive temperatures
. . . Nonpharmacologic interventions Introduce humidity Reposition
elevate the head of the bed move patient to one side or other
Educate, support the family
4 Weeks Later in Hospice More dyspneic and semi-comatose Lots of upper airway noise with
wheezes more prevalent Gets agitated at times, cyanotic Difficult swallowing pills At times when sleeping family feels
he is choking to death
Final hours of care Educate the family- no surprises
Double effect? Oral secretions can be lessened by
keeping patient dry, scopalamine patch, levsin (anti-cholenergics)
Use opioids/benzodiazepams as needed Suctioning difficult for patient and likely
not to be able to get deep enough
Gastrointestinal Sx: EOL Anorexia 60-80% Xerostomia 55-70% Nausea 15-30% Vomiting 15-25% Constipation 50% Diarrhea <10%
Anorexia Corticosteroids Megestrol acetate Dronabinol Other causes – gastritis/PUD – PPIs,
early satiety/reflux – Reglan, oral thrush – anti-fungals.
Realize patient usually VERY comfortable with this!
Dry Mouth Hyposalivation
Mouth care and gum/candy, popsicles Artificial saliva Oral swabs/wash cloth
Pilocarpine 5mg tid Mucositis
Diphenhydramine, dexamethasone, lidocaine, and nystatin swish and swallow
Nausea/vomitingAnxiety, fear, anticipatory, psychologic factors,
increased intra-cranial pressureDopaminergic (narcotic – induced and many
others)
Serotinergic (chemo induced)
Histamine (labrynthitis, meds)
Vagally mediated (ulcers, masses, irritations…)
Reflux, gastritis, regurgitation, masses, ulcers, gastric outlet obstruction
Small bowel obstruction, impaction
Renal (pyelonephritis, stones), liver (hepatitis, cirrhosis), gall bladder, uterine…
A Mechanistic Approach Central –
Increased pressures (tumor, swelling, hydrocephalus) – steroids, RT, surgery
Anxiety, fear, anticipatory – benzodiazipines, psychotherapy
Chemo-trigger Receptor Zone (narcotics, other meds, many GI causes)
Anti-dopaminergics – prochlorperazine (compazine), haloperidol, droperidol, trimethobenzamide (Tigan), metoclopramide (Reglan), promethazine (phenergan)
Can be given PO, suppository, some IM/IV, some even in a paste form
A Mechanistic Approach Nausea Center (chemotherapy induced)
– Anti-serotinergics – ondansetron (Zofran),
granisetron (Kytril), dolasetron, palonosetron IV, PO, and expensive
Vestibular-ocular reflex (with vertigo) – Anti-histamines – Benedryl, Antivert, Atarax Anti-cholinergics - Scopolamine
Oro-pharyngeal vagal – lidocaine swish and swallow, treat the lesion
A Mechanistic Approach Gastro-esophageal –
Reflux/regurg – prokinetic agents like metoclopramide (reglan), H2 blockers/Proton pump inhibitors
Gastritis/ulcers – H2 blockers/PPIs Delayed gastric emptying (narcotics, DM)
– metoclopramide Gastric outlet obstruction – NG suction,
surgery
A Mechanistic Approach Intestinal
Obstruction – NG suction, surgery, NPO with Octreotide (Sandostatin)
Impaction – remember to check rectal exam – may need manual dis-impaction, enemas
Other organs – try to treat underlying cause if possible, may also respond to meds effecting CRZ
Other agents for nausea CAM – aromas (peppermint, ginger),
herbs (ginger, cola), mind-focusing (meditation), acupuncture
Dronabinol (marijuana) Combination suppositories/gels
BDR (Benadryl, Decadron, Reglan) Can add ativan, Tigan, compazine and
others
Constipation Defined:
hard, infrequent stools, needing to strain for 10 minutes
Uncomfortable feeling Incidence-
US nutrition- Male 8% Fem. 21% Hospice 80% Hospice on narcotics 90% Hospital 66%; Home 22%
Physiology Meal passes out of stomach into small
intestine, with the addition of gastric, pancreatic, and biliary secretions
Transit time is 1-2 hrs thru the small intestine, where digestion and absorption takes place
Large bowel transit time is 1-3 days, where bulk of water is removed and stool is formed
Final BM – when rectal ampula fills, increase abdomenal pressure, relax anal sphincter and “the brown river flows”
Constipation – causes: Medications
opioids calcium-channel
blockers anticholinergic
Decreased motility
Ileus Mechanical
obstruction Diet (lo fiber, hi
meat and starch)
Metabolic abnormalities (hi Ca)
Spinal cord compression
Dehydration Autonomic
dysfunction (DM) Malignancy
Opioids do Two things: Block Bowel (opioid receptors in
mesenteric plexus and bowel wall) Decrease propulsion Increase sphincter tone Increase bowel tone
Block pain/discomfort with packed bowel
Managementof constipation General measures
establish what is “normal”
regular toileting gastrocolic reflex
Check impaction – 98% in rectal vault – hard packed in stool to large to evacuate
Diet – hi fiber (greens, fruits, bran…), fluids, additive fibers (avoid with opioids at EOL)
Specific measures stimulants osmotics detergents lubricants large volume enemas
Stimulant laxatives Prune juice Senna (Senokot) Casanthranol (Pericolace) Bisacodyl (Dulcolax)
* Good preventatives with opioid use
Osmotic laxatives Lactulose or sorbitol Milk of magnesia (other Mg salts) Magnesium citrate Polyethylene Glycol (Miralax)
* Good add-ons if stimulants not enough with opioid induced constipation
Detergent laxatives(stool softeners)
Sodium docusate Calcium docusate Phosphosoda enema prn
Prokinetic agents Metoclopramide Cisapride
Lubricant stimulants Glycerin suppositories Oils
mineral peanut
Large-volume enemas Warm water Soap suds
Mr. L – 62 yo with Colon cancerMr. L has end-stage metastatic colon cancer,
diagnosed 6 months ago, with liver mets, ascites, carcinomatosis. He failed chemo, now in hospice for 2 wks. Over 2 days he has had persistent vomiting, unrelieved with compazine, steroids, ativan, with reglan making it worse. Over this time his abdomen has become very distended, he has crampy peri-umbilical pain, and he has not had a BM in 7 days. Lately, his vomit smells slightly fecal-like and is brown. He is miserable and wants to die now!
Mr. L – exam, tests?PE – In distress
- Abdomen distended and tense, tympanitic- Bowel sounds hyper- Abdomen diffusely tender- No stool in vault on rectal,
hemoccult negativeTests – KUB and upright abd x-ray shows
dilated loops of bowel and multiple air-fluid levels
Obstruction Vomiting 90+%, Pain 75% Hyperparastalsis Absent bowel sounds –
complications, perforation X-ray - dilated loops, air-fluid levels
on upright Contrast only if surgical candidate Consider Surgery
Conservative Management Antiemetics
Haloperidol, phenothiazines Scopalamine Octreotide - somatostatin Dexamethasone Ativan
…Conservative management Anticholinergics Analgesics:
Opioids, SQ/IV Consider NG suction (though very
uncomfortable) Keep PO intake limited (what goes
in must come up!)
Hospice emergencies Acute arterial bleed – either GI or pulmonary
source (though also could be peripheral artery/aorta)
From above – throwing up bright red blood, from below – bright red blood per rectum, from abd aorta – get acute rapid distention of abdomen (left side first), then cold pulseless feet
Usually the end catastrophic event but LOTS of anxiety, hard for family to watch, may have acute pain, then passes out
Morphine/ativan right away Red towels to hide the blood May need emergent hospitalization for family sake