Clinical Conditions and Symptom Management:...

Clinical Conditions and Symptom Management:

Common Distressful Symptoms

VNAA Blueprint for Excellence PATHWAY TO BEST PRACTICES

VNAA Best Practice for Hospice and Palliative Care

Why These Symptoms? Uncomfortable physical and psychological symptoms at the end-of-life

are common. Many of these symptoms are typical during the final hours while others occur early on in the trajectory of decline. This

module reviews the following common distressful symptoms that occur at the end-of-life: Anxiety, Bowel Management – Constipation, Bowel Management – Diarrhea, Death Rattle, Delirium, Depression, Fatigue,

Hemorrhage, Nausea/Vomiting, Wounds.

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Definition of Best Practices

1. Symptoms are treated according to patient/caregiver preferences that are discussed and documented. (NCP, 2013).

2. Caregivers are educated on how to manage symptoms and what to expect in the final hours.

3. Clinical documentation should include tools as part of the assessment process to provide a way to document decline objectively.

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Clinical Interventions/Actions

• Train staff to recognize the trajectory of dying including likely symptoms, and proactively develop a plan for managing symptoms with the patient and caregiver.

• A history and physical is needed to identify etiology and guide treatment decisions (Coyne and Panke, 2011)

• Interdisciplinary teamwork is essential.

• Written information on specific symptoms should be available to staff to leave in the home.

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Anxiety

Anxiety is characterized by excessive worry and apprehension that is difficult to control. It can be associated with restlessness or feeling

keyed-up or on edge, difficulty concentrating, irritability, muscle tension and sleep disturbances.

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Critical Interventions/Actions - Anxiety

Staff training should include:

• The goal should be to prevent disabling anxiety or panic attacks and ameliorate anxiety that is contributing to other symptoms such as shortness of breath (EPERC #145, 2009).

• Focus should be on physical signs, behaviors, the patient’s experience and potential causes (e.g. medications).

• Both non-pharmacologic and pharmacologic interventions should be utilized.

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Tools • Anxiety screening and severity questions are included

in the ESAS. • The National Comprehensive Cancer Network®

(NCCN®) Distress Thermometer*– asks patient to rate distress from 0 (none) to 10 (Extreme distress) – *Linked with permission from the NCCN Clinical Practice

Guidelines in Oncology (NCCN Guidelines®) for Distress Management V.1.2014. © 2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

• Brief Symptom Inventory– a short version of the SCL90-R instrument.

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http://www.npcrc.org/files/news/edmonton_symptom_assessment_scale.pdf

http://www.nccn.org/patients/resources/life_with_cancer/pdf/nccn_distress_thermometer.pdf



http://www.pearsonclinical.com/psychology/products/100000450/brief-symptom-inventory-bsi.html?Pid=PAbsi

Bowl Management - Constipation

Constipation is defined as having fewer than 3 bowel movements per week and is often characterized by straining, lumpy or hard stools that

are difficult to expel. Constipation occurs in 50% of hospice patients with the incidence increasing to 70-100% in cancer patients.

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Bowl Management – Constipation – Best Practice

All patients who are on opioids are started on a bowel regimen to help prevent constipation.

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Critical Actions/Interventions - Constipation

Documentation should include the presence of bowel sounds, the frequency of stools, and any recent bowel changes.


• Ways to prevent constipation.

• Evaluation of drugs for their tendency to be constipating.

• Individualize treatment plans based on etiology and severity of the condition.

• What a bowel regimen typically

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Bowel Management - Diarrhea

Diarrhea is defined as the abrupt onset of 3 or more loose stools per day (Medscape, Reference). It is a common disorder in its acute form

and has many causes. Although less prevalent in hospice patients than constipation, it is often very distressing to patients and stressful for

caregivers. Effects are significant as patients suffer from skin breakdown, dehydration, fatigue and embarrassment.

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Critical Interventions/Actions - Diarrhea

Documentation should include attention to medications and the character and frequency of stools by using the National Cancer Institute Scale of Severity of Diarrhea.


• Treatment is determined by the underlying cause.

• Maintain hydration.

• Anti-diarrheals can be used judiciously.

• A clear liquid diet is indicated and advanced as the diarrhea resolves.

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Critical Interventions/Actions - Diarrhea

Staff training -2

• Additional goals should be to maintain skin integrity and dignity.

• Medications that can be considered include opioids, absorbents, adsorbents, antisecretory, anticholinergics, and alpha adrenergic agonists.

• Causes include infections, malabsorption, co-morbid conditions and treatment related.

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Death Rattle

Death rattle is defined as a type of noisy breathing related to retained secretions that sounds like snoring or rattling during the inspiratory and expiratory phases of respiration. It is common in nearly 25% of dying patients (Montagnini 2004). It is a strong predictor of death.

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Critical Interventions/Actions – Death Rattle

• Educate caregivers verbally and in writing about what to expect in the final hours and that death rattle in normal. Written information should be made available.

• Use of anticholinergic medications (NCI #7, 2014) is mixed with no conclusive evidence that these medications are helpful.

• Documentation should include one of the suggested tools listed below.

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Critical Interventions/Actions – Death Rattle

Staff Training should include:

• Non pharmacologic interventions are the mainstay of treatment.

• There are many proposed causative factors.

• It is a strong predictor of death (Wilders, 2002), and very distressing to caregivers and healthcare professionals.

• Typically heard in the patient’s final hours as the patient often cannot clear secretions.

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Tools – Death Rattle Respiratory Distress Observation Scale (RDOS) (Campbell, 2010) –

This is an adult observational scale that evaluates indicators of

respiratory distress including heart rate, respiratory rate,

restlessness, accessory muscle use and other indicators. It has

been validated for use by trained caregivers, but not yet for use by caregiver members.

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http://homecareinformation.net/handouts/hen/Respiratory_Distress_Observation_Scale.pdf



Delirium

Delirium is defined as acute onset of waxing and waning confusion, decreased attention span, disorganized thinking and altered level of

consciousness. It is extremely common in the last days of life. As many as 80% of patients develop delirium near death.

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Critical Interventions/Actions - Delirium


• How to recognize delirium and pinpoint possible reversible causes.

• Assessment is based on a comparison of the patient’s mental status to baseline. It should include a thorough medication review and all non-essential drugs should be discontinued. (Montagnini and Moat, 2004)

• Interventions are based on the assessment and treatment of predisposing and precipitating factors (Close & Long, 2012; Ross, 2001; NCI #7, 2014)

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Critical Interventions/Actions - Delirium

Staff training-2

• Patients with agitated or hyperactive delirium may be treated with Haloperidol (Close, J, Long, CP)

• Provide for a safe and calm environment and use of other non-pharmacologic treatments help minimize agitation.

• Terminal delirium is extremely common in the last days of life and is treated with supportive care.

• Patients with a significant change in arousal level, orientation and cognitive function may be experiencing delirium.

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Tools - Delirium

• CAM – Confusion Assessment Method – validated in multiple patient age groups and settings – Adapted from: Inouye SK, et al. Ann Intern Med. 1990;

113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program, LLC. Not to be reproduced without permission

• Memorial Delirium Assessment Scale (MDAS) is used to rate the severity of delirium.

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http://www.hospitalelderlifeprogram.org/private/cam-disclaimer.php?pageid=01.08.00




http://www.delirant.info/DreamHC/Download/MDAS.pdf

Other Resources – Delirium

• See VNAA Procedure Manual 18th Edition p 179 for further information and references.

• See http://consultgerirn.org/topics/palliative_care/want_to_know_more

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http://consultgerirn.org/topics/palliative_care/want_to_know_more

http://consultgerirn.org/topics/palliative_care/want_to_know_more

Depression

Depression is a mood disorder that is clinically manifest as diminished interest/pleasure, depressed mood, loss of pleasure in almost all

activities. Depression occurs in 25-75% of those at the end of life. Depression should never be ignored.

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Critical Interventions/Actions - Depression

• Incorporate a depression screening tool into documentation to be used for all patients.

• Suicide assessment may be indicated for individuals with suicidal ideations or tendencies.

• A multi-symptom assessment tool that includes assessments of well-being as well as depression can be helpful.

• Treatment resources can be identified both internally and externally in the community.

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Critical Interventions/Actions - Depression


• Assessment that includes physical changes such as loss of appetite, weight loss, situational factors, and medications.

• There are two classic questions to ask the patient: (1) “In the past month, have you felt depressed, down or hopeless?” and (2) “During the past month, have you felt little interest or pleasure in doing things?”

• Antidepressants are the primary medications used to treat depression.

• In the final days/hours additional medications are likely not indicated.

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Tools/Resources

• See VNAA Procedure Manual 18th Edition p. 405-409.

• Geriatric Depression Scale- a basic screening measure for depression in older adults.

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http://0101.nccdn.net/1_5/378/1f0/0e9/VNAABlueprint_Geriatric-Depression-Scale--Short-Form-.pdf

Fatigue

Fatigue is the patient experience of overwhelming exhaustion and tiredness and is reported in up to 90 percent of patients at the end of

life. (Anderson, et.al.) It is a major source of frustration and devastation for patients as they near end-of-life.

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Critical Interventions/Actions - Fatigue

• Fatigue assessment of the whole person is essential: mind, body and spirit (Anderson, et.al. 2010)

• Utilize a fatigue assessment tool to help document decline.

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• Management strategies including management of symptoms and underlying causes.

• Preventing fatigue by balancing activities with rest.

• Energy conservation techniques and rest are the mainstay of non-pharmacologic management.

• Fatigue may arise from medical treatment or psychological conditions.

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Staff training - 2

• For a patient expected to be in hospice care relatively long term, treatment may be offered to address underlying causes

• Possible pharmacologic interventions include: antidepressants, corticosteroids, psycho stimulants and medical treatments such as blood products.

• During the final hours, fatigue and weakness are expected as a normal part of the transition and is irreversible. This fatigue is treated with supportive care.

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Tools- Fatigue

• Fatigue is a domain assessed in multi-symptom assessment tools such as the Edmonton Symptom Assessment (ESAS).

• Numerous fatigue scales exist, asking a patient’s level of fatigue on a scale of ‘0’ no fatigue to ‘10’ extreme fatigue. It is efficient, especially if used consistently.

• A numeric rating scale can also be used to explain the impact of fatigue on activity and quality of life.

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http://www.npcrc.org/files/news/edmonton_symptom_assessment_scale.pdf

Hemorrhage

Hemorrhage, or excessive bleeding is a relatively rare occurrence in hospice care according to the National Institutes of Health (NCI #12, 2014). It is more likely to occur with head and neck cancers, stomach and esophageal cancer, and leukemia or clotting disorders. It is very

upsetting to patients and caregivers so should be anticipated based on the patient’s diagnosis.

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Critical Interventions/Actions - Hemorrhage

• If bleeding is anticipated it is important to prepare the caregiver and plan to follow the patient’s wishes about interventions.

• Written information should be left in the home and the care plan updated to reflect patient’s wishes.

• If the patient is at risk for terminal hemorrhage, discuss alternative care settings.

• Caregiver and patient education is crucial because of the distressing nature of heavy bleeding.

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Staff education should include:

• Seepage of blood from eroded areas may signify an impending hemorrhage, but more often, hemorrhage is sudden.

• Hemorrhage is signified by heavy bleeding. It may be uncontrolled, not self-limiting and not reversible at the end of life.

• Keep the patient clean; use dark colored towels or pad to minimize appearance of blood.

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Staff education - 2

• Keep non-sterile gloves in the home to use if you need to clean up after any bleeding episodes.

• Provide companionship, empathetic listening and therapeutic presence.

• Medications should be present in the home that can provide sedation, anxiety relief and pain relief. Fast acting sedation may be used.

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Nausea/Vomiting

Nausea is the very unpleasant feeling of being about to vomit. Vomiting is the spitting up of the contents of the stomach. It’s

associated with a feeling of nausea and strong contractions of the abdominal muscles. It is one of the most distressing symptoms and can occur in patients with any terminal condition. There are many causes of nausea and vomiting. Nausea is present in 70% and vomiting in 30% of

patients at the end of life.

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Critical Interventions/Actions - Nausea/Vomiting

Documentation should include a history and physical with primary attention to an abdominal assessment and identification of potential

contributory factors.

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Critical Interventions/Actions - Nausea/Vomiting


• Underlying causes that can be treated if possible

• Non pharmacologic interventions should be included in the care plan.

• Many medications are available.

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Wounds

Wounds are open disruptions in skin integrity. Pressure ulcers occur in 14-28% of patients in hospice care (McDonald and Lesage 2006) while

malignant or fungating wounds occuring in 5-19% of patients with metastatic disease (Alexander 2009).

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Critical Interventions/Actions - Wounds

• Documentation should include identification of all wound locations, etiology, pressure ulcer stages and risk factors. Evaluation should include the existence of pain, infection, odor, and moisture due to incontinence.

• Goals of care should be discussed with the patient and caregiver to help determine what interventions are needed.

• Depending on treatment preferences, antibiotics are a consideration when an infection is present.

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Critical Interventions/Actions - Wounds

Staff training should include: • Occlusive or layered dressings used to prevent seepage or odors. • Training caregivers to provide frequent changing of bandages that

may improve the appearance of wounds. • In the patient’s final days or hours it may be a treatment preference

not to routinely reposition the patient. • Some patients enter hospice with existing wounds. Others may

acquire wounds such as pressure ulcers that result from immobility, poor nutrition and poor perfusion.

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Tools

• Braden Scale – A widely used tool to predict the risk of pressure ulcers. Six criteria are examined: Sensory perception; Moisture; Activity; Mobility; Nutrition and Friction and Shear.

• See VNAA Procedure Manual 18th Edition – Section 24.

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http://www.healthcare.uiowa.edu/igec/tools/pressureulcers/bradenscale.pdf

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