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To prevent and relieve To prevent and relieve suffering, and promote suffering, and promote
quality of life quality of life at every stage of lifeat every stage of life
To prevent and relieve To prevent and relieve suffering, and promote suffering, and promote
quality of life quality of life at every stage of lifeat every stage of life
Common SymptomsCommon Symptoms
Frank D. Ferris, Frank D. Ferris, MDMDMedical Director, Palliative Care Standards Medical Director, Palliative Care Standards
CCENTERENTER F FOR OR PPALLIATIVEALLIATIVE S STUDIESTUDIESSan Diego Hospice and Palliative CareSan Diego Hospice and Palliative Care
““Education and Research in the Art and Science of Palliative Care”Education and Research in the Art and Science of Palliative Care”
Department of Family and Preventative Medicine, Department of Family and Preventative Medicine, UCSD School of MedicineUCSD School of Medicine
Department of Family and Community Medicine, Department of Family and Community Medicine, andand
Joint Center for Bioethics, University of TorontoJoint Center for Bioethics, University of Toronto
Frank D. Ferris, Frank D. Ferris, MDMDMedical Director, Palliative Care Standards Medical Director, Palliative Care Standards
CCENTERENTER F FOR OR PPALLIATIVEALLIATIVE S STUDIESTUDIESSan Diego Hospice and Palliative CareSan Diego Hospice and Palliative Care
““Education and Research in the Art and Science of Palliative Care”Education and Research in the Art and Science of Palliative Care”
Department of Family and Preventative Medicine, Department of Family and Preventative Medicine, UCSD School of MedicineUCSD School of Medicine
Department of Family and Community Medicine, Department of Family and Community Medicine, andand
Joint Center for Bioethics, University of TorontoJoint Center for Bioethics, University of Toronto
ObjectivesObjectives
Know general guidelines for managing non-pain symptoms
Know how to assess and manage common symptoms
www.CPSOnline.info
Publications / presentations
Know general guidelines for managing non-pain symptoms
Know how to assess and manage common symptoms
www.CPSOnline.info
Publications / presentations
General guidelines . . .General guidelines . . . History, physical examination
Conceptualize likely causes
Discuss treatment options
Assist with decision making
History, physical examination
Conceptualize likely causes
Discuss treatment options
Assist with decision making
. . . General guidelines. . . General guidelines Provide education, support
Involve entire interdisciplinary team
Reassess frequently
Provide education, support
Involve entire interdisciplinary team
Reassess frequently
HIV WastingHIV Wasting
HIV WastingHIV Wasting
Loss of weight > 10% of baseline with fever, weakness, diarrhea > 30 days
inadequate nutrient intake
excessive nutrient loss
metabolic dysregulation
Loss of weight > 10% of baseline with fever, weakness, diarrhea > 30 days
inadequate nutrient intake
excessive nutrient loss
metabolic dysregulation
Managementof anorexia / cachexia . . .
Managementof anorexia / cachexia . . . Assess, manage comorbid
conditions
Educate, support
Favorite foods / nutritional supplements
Assess, manage comorbid conditions
Educate, support
Favorite foods / nutritional supplements
. . . Managementof anorexia / cachexia. . . Managementof anorexia / cachexia Alcohol
Megestrol acetate
Dexamethasone
Dronabinol
Androgens, eg, testosterone
Alcohol
Megestrol acetate
Dexamethasone
Dronabinol
Androgens, eg, testosterone
Fatigue /WeaknessFatigue /
Weakness
Managementof fatigue / weakness . . .
Managementof fatigue / weakness . . . Promote energy conservation Evaluate medications Optimize fluid, electrolyte intake Permission to rest Clarify role of underlying illness Educate, support patient, family Include other disciplines
Promote energy conservation Evaluate medications Optimize fluid, electrolyte intake Permission to rest Clarify role of underlying illness Educate, support patient, family Include other disciplines
. . . Managementof fatigue / weakness. . . Managementof fatigue / weakness Dexamethasone
feeling of well-being, increased energy
effect may wane after 4-6 weeks
continue until death
Methylphenidate
Dexamethasone feeling of well-being, increased energy
effect may wane after 4-6 weeks
continue until death
Methylphenidate
Fever /SweatsFever /Sweats
Management of fever / sweatsManagement of fever / sweats Paracetamol (acetaminophen)
NSAIDs, eg, ibuprofen
Corticosteroids, eg, dexamethasone
Anticholinergics, eg, scopolamine
Rehydration
Bathing, drying
Paracetamol (acetaminophen)
NSAIDs, eg, ibuprofen
Corticosteroids, eg, dexamethasone
Anticholinergics, eg, scopolamine
Rehydration
Bathing, drying
Nausea /VomitingNausea /Vomiting
Nausea / vomitingNausea / vomiting
Nausea subjective sensation
stimulation • gastrointestinal lining, CTZ, vestibular
apparatus, cerebral cortex
Vomiting neuromuscular reflex
Nausea subjective sensation
stimulation • gastrointestinal lining, CTZ, vestibular
apparatus, cerebral cortex
Vomiting neuromuscular reflex
Causesof nausea / vomitingCausesof nausea / vomiting Metastases
Meningeal irritation
Movement
Mental anxiety
Medications
Mucosal irritation
Metastases
Meningeal irritation
Movement
Mental anxiety
Medications
Mucosal irritation
Mechanical obstruction
Motility
Metabolic
Microbes
Myocardial
Mechanical obstruction
Motility
Metabolic
Microbes
Myocardial
Pathophysiologyof nausea / vomitingPathophysiologyof nausea / vomiting
CortexCortexCortexCortex
Vestibular Vestibular apparatusapparatusVestibular Vestibular apparatusapparatus
GI tractGI tractGI tractGI tract
ChemoreceptorChemoreceptorTrigger Zone (CTZ)Trigger Zone (CTZ)
ChemoreceptorChemoreceptorTrigger Zone (CTZ)Trigger Zone (CTZ)
NeurotransmittersNeurotransmitters AcetylcholineAcetylcholine DopamineDopamine HistamineHistamine SerotoninSerotonin
NeurotransmittersNeurotransmitters AcetylcholineAcetylcholine DopamineDopamine HistamineHistamine SerotoninSerotonin
Vomiting centerVomiting centerVomiting centerVomiting center
Managementof nausea / vomitingManagementof nausea / vomiting Dopamine
antagonists
Antihistamines
Anticholinergics
Serotonin antagonists
Dopamine antagonists
Antihistamines
Anticholinergics
Serotonin antagonists
Prokinetic agents
Antacids
Cytoprotective agents
Other medications
Prokinetic agents
Antacids
Cytoprotective agents
Other medications
Acetylcholine antagonists(anticholinergics)
Acetylcholine antagonists(anticholinergics)
Scopolamine
Atropine
Scopolamine
Atropine
Dopamine antagonistsDopamine antagonists Haloperidol
Prochlorperazine
Metoclopramide (also prokinetic)
Haloperidol
Prochlorperazine
Metoclopramide (also prokinetic)
Histamine antagonists (antihistamines)
Histamine antagonists (antihistamines) Diphenhydramine
Meclizine
Hydroxyzine
Diphenhydramine
Meclizine
Hydroxyzine
Serotonin antagonistsSerotonin antagonists Ondansetron
Granisetron
Ondansetron
Granisetron
AntacidsAntacids Antacids
H2 receptor antagonists cimetidine ranitidine
Proton pump inhibitors omeprazole
Antacids
H2 receptor antagonists cimetidine ranitidine
Proton pump inhibitors omeprazole
Cytoprotective agentsCytoprotective agents Misoprostol
Proton pump inhibitors omeprazole
Misoprostol
Proton pump inhibitors omeprazole
Other medicationsOther medications
Dexamethasone
Tetrahydrocannabinol
Lorazepam
Octreotide
Dexamethasone
Tetrahydrocannabinol
Lorazepam
Octreotide
ConstipationConstipation
ConstipationConstipation Medications
opioids calcium-channel
blockers anticholinergic
Decreased motility
Ileus
Mechanical obstruction
Medications opioids calcium-channel
blockers anticholinergic
Decreased motility
Ileus
Mechanical obstruction
Metabolic abnormalities
Spinal cord compression
Dehydration
Autonomic dysfunction
Malignancy
Metabolic abnormalities
Spinal cord compression
Dehydration
Autonomic dysfunction
Malignancy
Managementof constipationManagementof constipation General measures
establish “normal” bowel pattern
regular toileting
gastrocolic reflex
General measures establish
“normal” bowel pattern
regular toileting
gastrocolic reflex
Specific measures stimulants
osmotics
detergents
lubricants
large volume enemas
Specific measures stimulants
osmotics
detergents
lubricants
large volume enemas
Stimulant laxativesStimulant laxatives
Prune juice
Senna
Casanthranol
Bisacodyl
Prune juice
Senna
Casanthranol
Bisacodyl
Osmotic laxativesOsmotic laxatives
Milk of magnesia (other Mg salts)
Lactulose
Polyethylene glycol
Sorbitol
Magnesium citrate
Milk of magnesia (other Mg salts)
Lactulose
Polyethylene glycol
Sorbitol
Magnesium citrate
Surfactant laxatives(stool softeners)Surfactant laxatives(stool softeners)
Sodium docusate
Calcium docusate
Phosphosoda enema prn
Sodium docusate
Calcium docusate
Phosphosoda enema prn
Prokinetic agentsProkinetic agents
Metoclopramide Metoclopramide
Lubricant stimulantsLubricant stimulants
Glycerin suppositories
Oils mineral
peanut
Glycerin suppositories
Oils mineral
peanut
Large-volume enemasLarge-volume enemas
Warm water
Soap suds
Warm water
Soap suds
Constipationfrom opioids . . .Constipationfrom opioids . . . Occurs with all opioids
Pharmacologic tolerance developed slowly, or not at all
Dietary interventions alone usually not sufficient
Avoid bulk-forming agents in debilitated patients
Occurs with all opioids
Pharmacologic tolerance developed slowly, or not at all
Dietary interventions alone usually not sufficient
Avoid bulk-forming agents in debilitated patients
. . . Constipationfrom opioids. . . Constipationfrom opioids Combination stimulant / softeners
are useful first-line medications casanthranol + docusate sodium
senna + docusate sodium
Prokinetic agents
Combination stimulant / softeners are useful first-line medications
casanthranol + docusate sodium
senna + docusate sodium
Prokinetic agents
DiarrheaDiarrhea
Causes of diarrheaCauses of diarrhea Infections GI bleeding Malabsorption, eg, lactose intolerance Medications, eg, HAART Obstruction, eg, cancer Overflow incontinence Stress
Infections GI bleeding Malabsorption, eg, lactose intolerance Medications, eg, HAART Obstruction, eg, cancer Overflow incontinence Stress
Management of diarrheaManagement of diarrhea Establish “normal” bowel pattern
Treat underlying cause
Avoid gas-forming foods Increase bulk, i.e., fiber
Transient, mild diarrhea bismuth salts
Establish “normal” bowel pattern
Treat underlying cause
Avoid gas-forming foods Increase bulk, i.e., fiber
Transient, mild diarrhea bismuth salts
Managementof persistent diarrheaManagementof persistent diarrhea Rehydration
Oral salt containing fluids Parenteral
Loperamide Diphenoxylate / atropine Tincture of opium Octreotide
Rehydration Oral salt containing fluids Parenteral
Loperamide Diphenoxylate / atropine Tincture of opium Octreotide
Shortnessof Breath(Dyspnea)
Shortnessof Breath(Dyspnea)
Breathlessness (dyspnea) . . .Breathlessness (dyspnea) . . . Described as
shortness of breath
a smothering feeling
inability to get enough air
suffocation
Described as shortness of breath
a smothering feeling
inability to get enough air
suffocation
. . . Breathlessness (dyspnea). . . Breathlessness (dyspnea) Only reliable measure is patient self-
report
Respiratory rate, pO2, blood gas determinations DO NOT correlate with the feeling of breathlessness
Prevalence 12 – 74%
Only reliable measure is patient self-report
Respiratory rate, pO2, blood gas determinations DO NOT correlate with the feeling of breathlessness
Prevalence 12 – 74%
Causes of breathlessnessCauses of breathlessness Anemia
Anxiety
Airway obstruction
Bronchospasm
Hypoxemia
Infections
Metabolic
Anemia
Anxiety
Airway obstruction
Bronchospasm
Hypoxemia
Infections
Metabolic
Pleural effusion
Pulmonary edema
Pulmonary embolism
Thick secretions
Family / financial / legal / spiritual / practical issues
Pleural effusion
Pulmonary edema
Pulmonary embolism
Thick secretions
Family / financial / legal / spiritual / practical issues
Managementof breathlessness . . . Managementof breathlessness . . . Treat the underlying cause
antibiotics
avoid fluid overload
dry secretions
Mechanical ventilation
Treat the underlying cause antibiotics
avoid fluid overload
dry secretions
Mechanical ventilation
. . . Managementof breathlessness. . . Managementof breathlessness Symptomatic management
oxygen
opioids
anxiolytics
nonpharmacologic interventions
Symptomatic management oxygen
opioids
anxiolytics
nonpharmacologic interventions
OxygenOxygen
Pulse oximetry not helpful
Potent symbol of medical care
Expensive
Fan may do just as well
Pulse oximetry not helpful
Potent symbol of medical care
Expensive
Fan may do just as well
OpioidsOpioids
Small doses
Central and peripheral action
Relief not related to respiratory rate
No ethical or professional barriers
Do not shorten life
Small doses
Central and peripheral action
Relief not related to respiratory rate
No ethical or professional barriers
Do not shorten life
AnxiolyticsAnxiolytics
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
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 . . .Nonpharmacologic interventions . . . Reassure, work to manage anxiety
Behavioral approaches, eg, relaxation, distraction, hypnosis
Limit the number of people in the room
Open window
Reassure, work to manage anxiety
Behavioral approaches, eg, relaxation, distraction, hypnosis
Limit the number of people in the room
Open window
Nonpharmacologic interventions . . .Nonpharmacologic interventions . . . Eliminate environmental irritants
Keep line of sight clear to outside
Reduce the room temperature
Avoid chilling the patient
Eliminate environmental irritants
Keep line of sight clear to outside
Reduce the room temperature
Avoid chilling the patient
. . . Nonpharmacologic interventions
. . . Nonpharmacologic interventions Introduce humidity
Reposition elevate the head of the bed
move patient to one side or other
Educate, support the family
Introduce humidity
Reposition elevate the head of the bed
move patient to one side or other
Educate, support the family
Common Symptoms
Summary
Common Symptoms
Summary