Management of Non-Pain Symptoms
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Management of Non-Management of Non-Pain SymptomsPain Symptoms
Junior Student RotationJunior Student Rotation
in Palliative Medicinein Palliative MedicineDouglas D. Ross, MD, PhDDouglas D. Ross, MD, PhD
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General Principles• Listen to the Patient.• Make a diagnosis before you treat:
– History, exam, [lab], working diagnosis
• Know the drugs you prescribe...• Keep it simple!• Not everything that hurts responds to
analgesics• There is always something that can be done.
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Prevalence of Symptoms in Patients with Cancer
Asthenia (fatigue) 74-90% Anorexia 44-85% Pain 62-76% Nausea 44-68% Constipation 35-65% Sedation/Confusion 60% Dyspnea 12-51%
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Urgent Symptoms
• Pathologic Fracture• Seizure• Spinal Cord Compression• Increased Intracranial Pressure• Superior Vena Cava Syndrome• Hypercalcemia
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Major Symptom AreasMajor Symptom Areas
• AnorexiaAnorexia
• Gastrointestinal:Gastrointestinal:– Oral / Dysphagia / Nausea-vomiting / Oral / Dysphagia / Nausea-vomiting /
constipation / bowel obstructionconstipation / bowel obstruction
• DyspneaDyspnea
• Delirium and terminal restlessnessDelirium and terminal restlessness
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Reversible causes of AnorexiaA Aches and Pains
N Nausea and GI dysfunction
O Oral Candidiasis
R Reactive/organic Depression
E Evacuation problems
X Xerostomia (dry mouth)
I Iatrogenic--chemo, radiation
A Acid related: GERD, PUD
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Before you place that IV or G-tube in a terminally ill patient....CONSIDER:
• Tube or forced feedings:– Do not prolong survival– Increase the discomfort– Aspiration, secretions, edema, ascites,
effusions, pulmonary congestion, nausea, diarrhea, use of restraints
• TPN is associated with decreased survival in terminal cancer patients
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Terminal patient refusal of food and water:
• Frequently more traumatic to the family than the patient
• Chronic/terminal starvation and dehydration per se are not uncomfortable
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Useful Interventions:• Sensible dietary advice:
– small portions of favorite foods– avoid foods with strong odors– do not force intake
• Family Conference• TRIAL of Appetite Stimulants
– Megace 80 to 200 mg tid or qid– Prednisone 1 to 2 mg qd or bid– Marinol 2.5 to 5 mg bid or tid
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Dysphagia:Some causes and treatments
• Dry mouth caused by radiation– Synthetic saliva q 1 to 2 hrs– Pilocarpine 5-10 mg tid **caution
• Dryness caused by drugs such as– Compazine, thorazine, amitryptyline
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Dysphagia, continued:Infectious causes and treatments
• Oral Candidiasis– Nystatin; Clotrimazole troches– Ketoconazole 200 mg qd x 14 d– Fluconazole 100 mg qd x 14 d
• Bacterial: periodontal disease
• Viral--Herpes simplex– Acyclovir 400 mg 5 times/day x 10 d
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Dysphagia, continued:More causes and treatments
• Reflux esophagitis• Mucosal damage--soothing agents
– Benadryl and kayopectate mouthwash– Viscous lidocaine– May require parenteral opioids
• Systemic dehydration– ice chips, sips of fluid, moist sponge stick
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Dyspnea
• “An uncomfortable awareness of breathing” (UNIPAC #4)
• DISTINGUISH dyspnea from hyperpnea and tachypnea
• DIAGNOSE and treat underlying cause when possible and reasonable
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Dyspnea, treatable causesDyspnea, treatable causes
BB BronchospasmBronchospasm
RR Rales--CHF, volume overloadRales--CHF, volume overload
EE EffusionsEffusions
AA Airway obstructionAirway obstruction
TT Thick SecretionsThick Secretions
HH Hemoglobin low--cautionHemoglobin low--caution
AA AnxietyAnxiety
II Interpersonal issuesInterpersonal issues
RR Religious concernsReligious concerns
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When to treat dyspnea symptomatically
• No treatable etiology identified
OR
• The treatments do not completely relieve the distressing symptom (dyspnea)
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Opioid Therapy for Dyspnea:Considerations
• safe and effective when titrated– start with usual anti pain doses, increase dose
30 to 50% q 4 to 12 hrs until patient is comfortable
• In COPD patients, opioids increase exercise tolerance with decreased breathlessness, reduce O2 need
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Opioid Therapy for Dyspnea Continued...
• Mild Dyspnea– Hydrocodone 5 mg q4h and q2h prn– Codeine (30 mg)- 1 tab q4h and q2h prn
• Severe Dyspnea– for patients on no or weak opioids
• Oxycodone 3-10 mg q4h and q2h prn• Oral morphine-3-10 mg q4h and q2h prn• Hydromorphone 0.5-2 mg q4h and q2h prn• Nebulized morphine...
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Therapy of Severe Dyspnea Continued...
• Patients already taking strong opioids...
• Consider the anxiety component of dyspnea:– ADD Benzodiazipines (short acting)
• mild: PO lorazapam 0.2 to 2 mg q8h• severe: may need midazolam titration-start with
0.25 mg SQ q hr--TITRATE
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Dyspnea: other considerations
• Use of Oxygen– Reserve for hypoxic patients??– Opioids are first choice for dyspnea, the
symptom– Use least invasive delivery--nasal prongs
• The terminal state– benzodiazepines
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Nausea and Vomiting• Frequency in terminal cancer:
– Nausea--50% to 60% of patients– Vomiting--30% of patients
• Can be controlled in 90% of cases
• Pathophysiology:– Cerebral cortex– Vestibular apparatus– Chemoreceptor trigger zone– Gastrointestinal tract
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Nausea and Vomiting:Nausea and Vomiting:Some treatable causesSome treatable causes
• Cortical:– CNS tumor– Intracranial pressure
– Anxiety, uncontrolled pain
• Vestibular / Middle ear– Vestibular disease– Middle ear infections
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Nausea and Vomiting:More treatable causes
• Chemoreceptor Trigger Zone– Drugs– Metabolic--e.g., renal, liver– Hyponatremia, Hypercalcemia
• Gastrointestinal Tract– Gastritis/esophagitis– Constipation, impaction– Obstruction– Tube feedings
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Persistent nausea...in a terminally ill patient
• Rule out bowel obstruction
• Start with– Haloperidol 1 mg PO or SC bid or tid, increase to 10
to 15 mg/day, as needed
• If needed, add:– Antihistamine (e.g., hydroxyzine) and /or– Metoclopramide (beware in bowel obstruction)– Other: Ondansetron (Zofran), Granisitron (Kytril),
methotrimeprazine (Levoprome)
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Bowel Obstruction...in advanced cancer
• Incidence--3% overall in Hospice– Ovarian Cancer: 5% to 42%– Colorectal Cancer: 10% to 30%
• Mechanism: mechanical, paralytic
• Symptoms...
• Surgery...limited usefulness in terminally ill cancer patients
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Bowel Obstruction...in advanced cancer
• GOAL: no cramps, no pain, minimal nausea, no more than 1 emesis/day
• Achieved IN MOST CASES– WITH analgesics, anticholinergic and
antiemetic drugs– WITHOUT the use of decompression tubes,
surgery or IV fluids
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Pharmacologic treatment of malignant bowel obstruction• Pain: strong opioids• Nausea:
– haloperidol, antihistamines, phenothiazines (anticholinegic effect);
– metoclopramide: may make sx worse in mechanical obstruction
• Mechanical: vomiting of GI secretions, cutaneous fistulas– Octreotide (Sandostatin)
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Octreotide (SandostatinTM)• Synthetic analogue of Somatostatin:
– Decreases intestinal secretion, bile flow– Increases intestinal absorption
• Adverse effects:– Dry mouth, Flatulence– Hypo- or hyperglycemia– Pain at injection site...
• Dosage and administration– 150g SC, bid OR
– 300g over 24h by SC infusion. Max. 600 g/day
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Delirium and terminal agitationDelirium and terminal agitation
• Delirium: up to 85% of terminal cancer patients
• Features may include– Clouding of consciousness, altered attention– Perceptual disturbances– Acute onset, fluctuating course
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Delirium--CausesD Drugs, especially psychotropics
E Electrolyte imbalance
L Liver failure
I Ischemia or hypoxia
R Renal failure
I Impaction of stool
U Urinary tract or other infection
M Metastases, other neurological
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Drug Treatment of Delirium
• Haloperidol 1-2 mg PO or SC q1h to calm the crisis, then q6-12 hr
• If more sedation is desired, or for the AIDS dementia complex, use– Thioridazine (Mellaril) 25-50 mg PO q1h until
calm then q6-12 hr OR– Chlorpromazine 25-50 mg PO or IV until calm
then q6-12 hr
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Severe Agitated Delirium
• Consider ADDING – Lorazepam (Ativan) 1-2 mg q1hr until calm
(PO, SL or IV)– Midazolam (Versed) 0.4-4 mg/hr continuous
SC infusion– Chlorpromazine (Thorazine) 100 mg q1h PO,
PR or IV until calm– Methotrimeperazine (Levoprome) 20 mg q1h
IM or IV, until calm
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Smelly Tumors• Cause: Necrotic exposed tumor mass
– Breast (25%), Lung 7%, Renal (5%), Colon (3%)
• Treatment– Pain Control– Debridement– Control odor: etiol. Bacteroides sp.
• apply METRONIDAZOLE gel (0.8%) + systemic treatment (200-400 mg PO tid)
• Charcoal Dressings• MAALOX
– Soak dressings off
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Other Non-pain Symptom Areas
• Pressure Sores• Stomas/fistulas• Edema/lymphedema• Pruritis/skin problems• Other GI-diarrhea,
ascites, impactions• Hemoptysis• Pleural effusions
• Incontinence• Urinary retention• Hematuria• Drug reactions• Seizures, other
neurological• Metabolic symptoms• Fever, infections
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SUMMARYNon-pain symptom management
• Listen to the Patient.• Make a diagnosis before you treat:
– History, exam, [lab], working diagnosis
• Know the drugs you prescribe...• Keep it simple!• Not everything that hurts responds to
analgesics• There is always something that can be done.