E LLNNEECC Geriatric Curriculum E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium Session3: Nonpain Symptoms at the End of Life Fairfield

EE LLLL NNNN EEEE CCCC Geriatric CurriculumGeriatric Curriculum

E L N E C E L N E C Geriatric CurriculumGeriatric Curriculum

End-of-Life Nursing Education ConsortiumEnd-of-Life Nursing Education Consortium

Session3Session3Nonpain Symptoms at the Nonpain Symptoms at the End of LifeEnd of Life

Fairfield UniversityFairfield UniversityQuinnipiac UniversityQuinnipiac University

School of Nursing ELDER ProjectSchool of Nursing ELDER Project


ObjectivesObjectives

11 Identify common symptoms associated Identify common symptoms associated with end of lifewith end of life

22 Discuss the need for continual Discuss the need for continual assessmentassessment

3 Describe the role of various members of 3 Describe the role of various members of the palliative care team to assess and the palliative care team to assess and manage symptomsmanage symptoms


Symptom Management Requires- Symptom Management Requires-

bull Ongoing assessment and evaluationOngoing assessment and evaluationbull Requires interdisciplinary Requires interdisciplinary

teamworkteamwork


Common EOL SymptomsCommon EOL SymptomsCommon EOL SymptomsCommon EOL Symptoms

bull RespiratoryRespiratoryndash DyspneaDyspneandash CoughCough

bull GIGIndash AnorexiaAnorexiandash ConstipationConstipationndash DiarrheaDiarrheandash NauseaNauseandash VomitingVomiting

bull GeneralSystemicGeneralSystemicndash FatigueFatiguendash WeaknessWeakness

bull PsychologicalPsychologicalndash DepressionDepressionndash AnxietyAnxietyndash DeliriumDeliriumndash AgitationAgitationndash ConfusionConfusion


Case Study 6Case Study 6Mr C DyspneaFatigueMr C DyspneaFatigue

bull Mr C is a 75-year-old African American man with end-stage cardiac Mr C is a 75-year-old African American man with end-stage cardiac disease and long standing congestive heart failure including disease and long standing congestive heart failure including pulmonary edema He experienced his first myocardial infarction at pulmonary edema He experienced his first myocardial infarction at 45 years of age had a quadruple bypass procedure at 58 and repair of 45 years of age had a quadruple bypass procedure at 58 and repair of an abdominal aortic aneurysm at 62 He has been retired for 15 years an abdominal aortic aneurysm at 62 He has been retired for 15 years after working as an engineer He lives at home with his wife who is a after working as an engineer He lives at home with his wife who is a cancer survivor cancer survivor

bull He has led a very active life even after retirement but in the past few He has led a very active life even after retirement but in the past few months has experienced severe fatigue that leaves him unable to months has experienced severe fatigue that leaves him unable to participate in or enjoy previous activities He often says ldquoI feel as if I participate in or enjoy previous activities He often says ldquoI feel as if I have no ambitionrdquo and ldquoI canrsquot do anything anymore I am have no ambitionrdquo and ldquoI canrsquot do anything anymore I am worthlessrdquo In the past few weeks Mr C has been experiencing worthlessrdquo In the past few weeks Mr C has been experiencing shortness of breath initially relieved with oxygen Unfortunately the shortness of breath initially relieved with oxygen Unfortunately the dyspnea has progressed during the past week and he has developed a dyspnea has progressed during the past week and he has developed a dry cough He has no advance directivedry cough He has no advance directive


DyspneaDyspnea

bull Distressing shortness of breathDistressing shortness of breath

bull Difficulty breathingDifficulty breathing

bull Associated with anxiety depression Associated with anxiety depression and decreased quality of lifeand decreased quality of life


Assessment of DyspneaAssessment of Dyspnea

bull Clinical assessment- it is what the Clinical assessment- it is what the patient says it ispatient says it is

Derby et al 2010 Dudgeon 2010 Derby et al 2010 Dudgeon 2010



Treatment of DyspneaTreatment of Dyspneabull Oxygen therapyOxygen therapybull Pharmacologic treatmentsPharmacologic treatments

ndash opioidsopioidsndash bronchodilatorsbronchodilatorsndash diureticsdiureticsndash corticosteroids corticosteroids

Clemens amp Klaschik 2007 Derby et al 2010Clemens amp Klaschik 2007 Derby et al 2010 Dudgeon 2010 Jacobs 2003Dudgeon 2010 Jacobs 2003


Treatment of DyspneaTreatment of Dyspnea

bull Non-pharmacologicNon-pharmacologicndash Be calm and provide reassuranceBe calm and provide reassurancendash CounselingCounselingndash Pursed lip breathingPursed lip breathingndash Energy conservationEnergy conservationndash Fans elevation positioningFans elevation positioningndash Distraction relaxation exerciseDistraction relaxation exercise

Dudgeon 2010Dudgeon 2010


QuestionQuestion

bull What have you done to provide non-What have you done to provide non-pharmacologic treatment of dyspneapharmacologic treatment of dyspnea

bull How do you think Mr C would assess his How do you think Mr C would assess his QOLQOL


FatigueFatigue

bull SubjectiveSubjective

bull Commonly associated Commonly associated with many diseaseswith many diseases

bull Impacts all dimensions Impacts all dimensions of QOLof QOL

How is fatigue affecting Mr Crsquos QOLHow is fatigue affecting Mr Crsquos QOL


Causes of FatigueCauses of Fatigue

bull PsychologicalPsychological

StressStressAnxietyAnxietyDepressionDepressionFamily Family

bull Disease and Treatment relatedDisease and Treatment related

bull Why is Mr C so fatiguedWhy is Mr C so fatigued


Treatment of FatigueTreatment of Fatiguebull Non-drug strategies Non-drug strategies

Frequent rest periodsFrequent rest periodsEnergy conservationEnergy conservationPrioritize goalsPrioritize goalsPTOTPTOTMaintain nutrition amp hydrationMaintain nutrition amp hydration

bull Medical therapies Medical therapies Blood transfusionsBlood transfusionsCorticosteroidsCorticosteroidsAntidepressantsAntidepressants


Anorexia and CachexiaAnorexia and Cachexiabull AnorexiaAnorexia - loss of appetite usually - loss of appetite usually

with decreased intakewith decreased intake

bull CachexiaCachexia - lack of nutrition and - lack of nutrition and wastingwasting

bull Anorexia and cachexia often follow fatigueAnorexia and cachexia often follow fatigue

Wholihan 2010Wholihan 2010


A client in advanced stages of AIDS is reporting fatigue Which of the following assessment findings is commonly associated with the symptom of fatigue

a anorexia cachexia

b reduced serum calcium

c hyperthyroidism

d increased hemoglobinhematocrit


Causes of Anorexia and Causes of Anorexia and CachexiaCachexia

bull Disease relatedDisease relatedbull PsychologicalPsychologicalbull Treatment relatedTreatment related

bull What cultural consideration might need to be addressed What cultural consideration might need to be addressed with Mr Cwith Mr C



Assessment of Anorexia and Assessment of Anorexia and CachexiaCachexia

bull Physical findingsPhysical findingsbull Impact on function and QOLImpact on function and QOLbull Calorie countsdaily weightsCalorie countsdaily weightsbull Lab testsLab testsbull Skin breakdownSkin breakdown



Treatment of Anorexia and Treatment of Anorexia and CachexiaCachexia

bull Treat the causeTreat the causebull Dietary consultationDietary consultationbull Appetite stimulantsAppetite stimulantsbull Parenteral enteral Parenteral enteral

nutritionnutrition

bull What long term planning needs What long term planning needs to be addressed with Mr Cto be addressed with Mr C


Case Study 7Case Study 7ldquoMr Trdquo DiarrheaConstipationldquoMr Trdquo DiarrheaConstipation

bull bull Mr T is an 85-year-old Korean widower who has been in a nursing Mr T is an 85-year-old Korean widower who has been in a nursing

home for two years with progressive dementia He is unable to home for two years with progressive dementia He is unable to communicate with his two adult sons their wives his grandchildren communicate with his two adult sons their wives his grandchildren or with the staff In fact the family visits infrequently and is obviously or with the staff In fact the family visits infrequently and is obviously distressed when they observe Mr T He has been unable to ambulate distressed when they observe Mr T He has been unable to ambulate requiring full assistance with transferring to or from a chair requiring full assistance with transferring to or from a chair

bull He had several episodes of aspiration one year ago when a feeding He had several episodes of aspiration one year ago when a feeding tube was placed He had significant diarrhea when tube feedings were tube was placed He had significant diarrhea when tube feedings were first started However in the past few months he has been first started However in the past few months he has been constipated requiring disimpaction several times each month During constipated requiring disimpaction several times each month During the past week he has had frequent episodes of liquid diarrhea the past week he has had frequent episodes of liquid diarrhea


ConstipationConstipation

bull Infrequent passage Infrequent passage of stoolof stool

bull Stool that is hard ampStool that is hard amp difficult to pass difficult to pass bull Frequent symptom Frequent symptom

in palliative carein palliative carebull Prevention is keyPrevention is key

bull What family teaching is essentialWhat family teaching is essential

Economou 2010 Sykes 2004Economou 2010 Sykes 2004


Causes of ConstipationCauses of Constipation

bull Decreased fluid and food intakeDecreased fluid and food intakebull Decreased physical activityDecreased physical activitybull MedicationsMedicationsbull Chronic illnessChronic illness

bull What cultural considerations need What cultural considerations need

to be addressed for Mr Tto be addressed for Mr T


Assessment of ConstipationAssessment of Constipationbull Bowel historyBowel historybull Physical symptomsPhysical symptoms

Rubbing abdomenRubbing abdomenRestlessnessRestlessnessChange in behaviorChange in behaviorCrying resisting careCrying resisting care

bull Abdominal assessmentAbdominal assessmentbull Rectal assessmentRectal assessmentbull Medication reviewMedication review

Economou 2010Economou 2010


Treatment of ConstipationTreatment of Constipationbull MedicationsMedications

SenokotSenokot Peri-Colace Peri-Colace DulcolaxDulcolax Others Others

bull DietaryfluidsDietaryfluidsbull Comfort measures privacyComfort measures privacybull Key-anticipate amp preventKey-anticipate amp prevent

bull What long term planning should be What long term planning should be considered for Mr Tconsidered for Mr T

Berger et al 2007 Economou 2010Berger et al 2007 Economou 2010


A client with terminal cancer has been prescribed fentanyl and dilaudid for pain Which of the following goals would be essential to include in the clients plan of care

a Client will remain continent of urine and stool

b Client will have usual bowel pattern

c Client will not report dyspnea

d Client will not report fatigue


Which of the following clients is at the highest risk for developing constipation

a A 48-year-old with metastatic cancer of the spine on high doses of opioids who has dehydration

b A 76-year-old with cancer of the bowel who has begun treatment for Clostridium difficile

c An 85-year old with hepatic encephalopathy who is receiving prescribed neomycin (Mycifradin) and lactulose

d A 90-year-old with uterine cancer and laboratory evidence of hypocalcemia and hyperkalemia


The home health worker is caring for a client at the end of life who has a recent history of constipation Which of the following may mean that there is fecal impaction

a foul smelling diarrhea

b sudden onset of liquid stool

c fatty looking stools

d blood and mucous strands in stool


Case Study 2 Mr Hayesldquo NauseaCase Study 2 Mr Hayesldquo Nauseadepressiondepression

bull Mr Hayes is a 73-year-old with metastatic colon cancer which has Mr Hayes is a 73-year-old with metastatic colon cancer which has spread throughout his abdomen He has been a resident in your NH spread throughout his abdomen He has been a resident in your NH for about 6 months and recently developed intractable nausea and is for about 6 months and recently developed intractable nausea and is experiencing rapid weight loss He is barely capable of managing any experiencing rapid weight loss He is barely capable of managing any activities of self care He is very embarrassed and distressed by this activities of self care He is very embarrassed and distressed by this

bull Mr Hayes has been found to have a non-resectable partial small Mr Hayes has been found to have a non-resectable partial small

bowel obstruction He asks How much longer do I have and Can bowel obstruction He asks How much longer do I have and Can we speed this up ldquoI donrsquot want my daughter to see me sufferrdquo ldquoI we speed this up ldquoI donrsquot want my daughter to see me sufferrdquo ldquoI donrsquot want to be in painrdquo The patient admits to feeling down but donrsquot want to be in painrdquo The patient admits to feeling down but denies any suicidal ideation He is clearly concerned about becoming a denies any suicidal ideation He is clearly concerned about becoming a burden to his family He is a devout Catholic and mentions to the NA burden to his family He is a devout Catholic and mentions to the NA that he is certain his symptoms and suffering are a punishment for his that he is certain his symptoms and suffering are a punishment for his having a divorce ten years ago having a divorce ten years ago


DepressionDepression

bull Ranges from sadness to suicidalRanges from sadness to suicidalbull Often unrecognized and undertreatedOften unrecognized and undertreatedbull Occurs in 25-77 of terminally illOccurs in 25-77 of terminally illbull Estimated to occur in 22 of nursing Estimated to occur in 22 of nursing

home residentshome residents

AGS 2002 Coyle 2010 Dahlin 2009AGS 2002 Coyle 2010 Dahlin 2009


Causes of DepressionCauses of Depression

bull Physical pain illnesses Physical pain illnesses medications sensory medications sensory deficitsdeficits

bull Psychological loss grief Psychological loss grief memory problemsmemory problems

bull Social isolation conflicted Social isolation conflicted relationshipsrelationships

bull Biological family history Biological family history geneticsgenetics

bull MedicationsMedicationsndash Why is Mr Hayes depressedWhy is Mr Hayes depressed


DepressionDepressionbull Depression is the most frequently observed symptom

in the terminally ill ndash Observed in 77 of persons with far-advanced cancer

bull Suggested questions to assess depressionndash ldquoCan you describe your mood for merdquo

ndash ldquoHow long have you felt this wayrdquo

ndash ldquoWhat is the feeling of depression like for yourdquo

ndash ldquoHave you noticed changes in your level of interest in normal activitiesrdquo

ndash ldquoHow would you rate your feeling of depression on a 1-to-10 scalerdquobull copy2001 DJ Wilkie amp TNEEL Investigators

(Isaacs 1998)


MOOD SCALE (short form)

Choose the best answer for how you have felt over the past week

1 Are you basically satisfied with your life YES NO

2 Have you dropped many of your activities and interests YES NO

3 Do you feel that your life is empty YES NO

4 Do you often get bored YES NO

5 Are you in good spirits most of the time YES NO

6 Are you afraid that something bad is going to happen to you YES NO

7 Do you feel happy most of the time YES NO

8 Do you often feel helpless YES NO

9 Do you prefer to stay at home rather than going out and doing new things YES NO

10 Do you feel you have more problems with memory than most YES NO

11 Do you think it is wonderful to be alive now YES NO

12 Do you feel pretty worthless the way you are now YES NO

13 Do you feel full of energy YES NO

14 Do you feel that your situation is hopeless YES NO

15 Do you think that most people are better off than you are YES NO

Answers in bold indicate depression Although differing sensitivities and specificities have been obtained across studies for clinical purposes a score gt 5 points is suggestive of depression and should warrent a follow-up interview Scores gt 10 are almost always depression

httpwwwstanfordedu~yesavageGDSenglishshortscorehtml



PHQ-9 PHQ-9

bull Scoring add up all checked boxes on PHQ-9Scoring add up all checked boxes on PHQ-9

ndash For every 1048627 Not at all = 0 Several days = 1For every 1048627 Not at all = 0 Several days = 1

ndash More than half the days = 2 Nearly every day = 3More than half the days = 2 Nearly every day = 3

bull Interpretation of Total Score - Total Score Depression SeverityInterpretation of Total Score - Total Score Depression Severity

ndash 1-4 Minimal depression1-4 Minimal depression

ndash 5-9 Mild depression5-9 Mild depression

ndash 10-14 Moderate depression10-14 Moderate depression

ndash 15-19 Moderately severe depression15-19 Moderately severe depression

ndash 20-27 Severe depression20-27 Severe depression

bull PHQ9 Copyright copy Pfizer Inc All rights reserved Reproduced with permission PRIME-MD reg is aPHQ9 Copyright copy Pfizer Inc All rights reserved Reproduced with permission PRIME-MD reg is abull trademark of Pfizer Inctrademark of Pfizer Incbull A2662B 10-04-2005A2662B 10-04-2005


Pharmacological Interventions Pharmacological Interventions for Depressionfor Depressionbull AntidepressantsAntidepressantsbull StimulantsStimulantsbull NonbenzodiazepinesNonbenzodiazepinesbull SteroidsSteroids

bull Do you think Mr Hayes would benefit from medicationDo you think Mr Hayes would benefit from medication


Nondrug Interventions for Nondrug Interventions for DepressionDepressionbull Empathetic listeningEmpathetic listeningbull Assurance and supportAssurance and supportbull Concrete informationConcrete informationbull Symptom managementSymptom managementbull RelaxationimageryRelaxationimagerybull CounselingCounseling

bull What nondrug therapy might work best for Mr HayesWhat nondrug therapy might work best for Mr Hayes


Mr HayesMr Hayesbull When would be a good time to talk to Mr When would be a good time to talk to Mr

Hayes about palliative care and an Hayes about palliative care and an advance directiveadvance directive

bull Is an additional suicide assessment Is an additional suicide assessment indicated indicated

bull How might various members of the team How might various members of the team contribute to Mr Hayesrsquo carecontribute to Mr Hayesrsquo care


Suicide AssessmentSuicide Assessment

bull Do you think life isnrsquot worth livingDo you think life isnrsquot worth livingbull Have you thought about how you Have you thought about how you

would kill yourselfwould kill yourself


Key Palliative Care Team RolesKey Palliative Care Team Roles

bull Patient advocacy Patient advocacy bull Assessment Assessment AssessmentAssessment Assessment Assessmentbull Pharmacologic treatmentsPharmacologic treatmentsbull Non-pharmacologic treatmentsNon-pharmacologic treatmentsbull Patientfamily teachingPatientfamily teachingbull PresencePresence


ConclusionConclusion

bull Multiple symptoms are commonMultiple symptoms are commonbull Coordination of care with physicians Coordination of care with physicians

and other team membersand other team membersbull Use drug and nondrug treatmentUse drug and nondrug treatmentbull Patientfamily teaching and supportPatientfamily teaching and support


Last questionhellipLast questionhellip

bull What one practice improvement can What one practice improvement can you begin as a result of attending this you begin as a result of attending this sessionsession


References References

City of Hope amp the American Association of City of Hope amp the American Association of Colleges of Nursing 2007 Revised 2010 TheColleges of Nursing 2007 Revised 2010 The End-of-Life Nursing Education Consortium End-of-Life Nursing Education Consortium (ELNEC)- Geriatric Training Program and (ELNEC)- Geriatric Training Program and

Curriculum is a project of the City of Hope (Betty Curriculum is a project of the City of Hope (Betty R Ferrell PhD FAAN Principal Investigator) in R Ferrell PhD FAAN Principal Investigator) in collaboration with the American Association of collaboration with the American Association of

Colleges of Nursing (Pam Malloy RN MN OCN Colleges of Nursing (Pam Malloy RN MN OCN Co-Investigator)Co-Investigator)

Supported by DHHSHRSABHPRDivision of Nursing Supported by DHHSHRSABHPRDivision of Nursing Grant D62HP06858Grant D62HP06858


ObjectivesObjectives

11 Identify common symptoms associated Identify common symptoms associated with end of lifewith end of life

22 Discuss the need for continual Discuss the need for continual assessmentassessment

3 Describe the role of various members of 3 Describe the role of various members of the palliative care team to assess and the palliative care team to assess and manage symptomsmanage symptoms




teamworkteamwork












DyspneaDyspnea


















QuestionQuestion




FatigueFatigue























a anorexia cachexia


c hyperthyroidism














nutritionnutrition









































































(Isaacs 1998)























PHQ-9 PHQ-9













































teamworkteamwork












DyspneaDyspnea


















QuestionQuestion




FatigueFatigue























a anorexia cachexia


c hyperthyroidism














nutritionnutrition









































































(Isaacs 1998)























PHQ-9 PHQ-9





















































DyspneaDyspnea


















QuestionQuestion




FatigueFatigue























a anorexia cachexia


c hyperthyroidism














nutritionnutrition









































































(Isaacs 1998)























PHQ-9 PHQ-9















































DyspneaDyspnea


















QuestionQuestion




FatigueFatigue























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c hyperthyroidism














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(Isaacs 1998)























PHQ-9 PHQ-9











































DyspneaDyspnea


















QuestionQuestion




FatigueFatigue























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c hyperthyroidism














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(Isaacs 1998)























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QuestionQuestion




FatigueFatigue























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c hyperthyroidism














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(Isaacs 1998)























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FatigueFatigue























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c hyperthyroidism














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(Isaacs 1998)























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FatigueFatigue























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c hyperthyroidism














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(Isaacs 1998)























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FatigueFatigue























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c hyperthyroidism














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(Isaacs 1998)























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FatigueFatigue























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c hyperthyroidism














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(Isaacs 1998)























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FatigueFatigue























a anorexia cachexia


c hyperthyroidism














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(Isaacs 1998)























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c hyperthyroidism














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c hyperthyroidism














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c hyperthyroidism














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(Isaacs 1998)























PHQ-9 PHQ-9



























































































(Isaacs 1998)























PHQ-9 PHQ-9





















































































(Isaacs 1998)























PHQ-9 PHQ-9















































































(Isaacs 1998)























PHQ-9 PHQ-9









































































(Isaacs 1998)























PHQ-9 PHQ-9



































































(Isaacs 1998)























PHQ-9 PHQ-9






























































(Isaacs 1998)























PHQ-9 PHQ-9

























































(Isaacs 1998)























PHQ-9 PHQ-9


















































(Isaacs 1998)























PHQ-9 PHQ-9
































































PHQ-9 PHQ-9












































PHQ-9 PHQ-9











































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Documents

E LLNNEECC Geriatric Curriculum E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium Session3: Nonpain Symptoms at the End of Life Fairfield