5th Year Palliative Care

Common symptom

management

Dr Sarah Hanrott

Specialty doctor, Sobell House

March 2019

Common symptoms at the end of life

1. Dyspnoea

2. Delirium, anxiety, agitation, acute

confusion

3. Nausea and vomiting

4. Constipation

5. Pain

Principles of symptom management

Comprehensive & holistic

Are there any reversible causes?

Non pharmacological methods

Adjust one thing at a time

Balance symptom benefit with adverse effects/burden of drugs

1. Dyspnoea

Dyspnoea

Fan therapy,

Physio: breathing techniques

Reassurance … (Oxygen)

Then….

Opioids

Benzodiazepines

Secretions

Fan Therapy (Simon and Bausewein, 2009)

Hand held fan

Standing fan

Open window

Flow of air to the face, nasal mucosa, pharynx may alter ventilation

Exact mechanism unclear

Postulated that cold receptors in the nose arising from the trigeminal nerve give sensory input to effect respiration and decrease breathlessness

Significant benefit has been evidenced in COPD patients

Techniques

Breathing – Thinking – Functioning

Techniques that patients can initiate themselves increase self efficacy and can have a positive impact on QoL in chronic illness

Much evidence and techniques are extrapolated from COPD

Breathing Techniques

Positions of ease

Pacing/prioritisation/planning (the 3 P’s)

“Blow as you go”

Energy conservation

Visualisation

Acupressure

Acupuncture

Anxiety management/relaxation

Breathing Techniques

Breathing control

With hand positioning

Pursed lip breathing

Rectangular breathing

Things to consider

Large meals may be difficult due to coordinating eating and breathing

Small energy dense meals throughout the day may help (simon and Bausewein,

2009)

Encouraging expiration

Decreasing CO2 so as to activate the brains respiratory centre more effectively

Pharmacological treatments for breathlessness?

Opiates: low dose morphine 2.5-5mg as needed – if more than 2 doses in 24 hours, convert to slow release morphine. ( NB lower doses in COPD – 1mg bd)

Evidence: 50% improved with 10mg od SR morphine, 90% improved with 20mg od (Currow et al 2011)

No evidence low doses suppress respiration

Benzodiazepines – only use if anxiety exacerbating breathlessness: e.g. Lorazepam 0.5mg SL or PO bd PRN.

Or at the end of life if distressed – e.g Midazolam 2.5 -5mg SC hourly as needed.

Secretions

If patient unconscious, not distressed, then reassurance to loved ones necessary, not always necessary to treat.

Hyoscine butylbromide 20mg SC qds – use PRN, if helps, then use in syringe driver.

Use midazolam if distressed.

2. Anxiety, agitation, delirium, confusion

Anxiety/ Agitation

OR

Delirium/ confusion

Anxiety/ agitation :

Diazepam 2 – 5 mg tds PO prn

Lorazepam 0.5- 1 mg PO bd prn

Midazolam 2.5-5mg SC hourly prn

Non pharmacological: explore fears etc, environment.

Delirium:

REVERSIBLE??: drugs, (?toxicity), pain, metabolic, infection, RETENTION, CONSTIPATION.

Haloperidol 0.5 – 5mg SC or PO tds.

2nd line: Levomepromazine 2.5 – 5mg SC qds – can titrate up (sedating antiemetic).

3. Nausea & vomiting

Causes in Advanced Disease?

Causes in Advanced Disease? • Disease related - Site of tumour

• GI, gynae, peritoneal, pelvic with Intestinal obstruction – lower and upper Constipation Ascites Gastric stasis Gastric dysmotility

• Respiratory Cough

• Brain

Brain metastases Raised intracranial pressure

Causes in Advanced Disease?

• Metabolic Hypercalcaemia Renal failure Hyperglycaemia Hypoglycaemia

• Drugs/treatments Opioids SSRIs Iron supplements Digoxin toxicity Antibiotics Steroids Chemotherapy and radiotherapy

• Psychological Sense of smell Fear and anxiety

Pain

Nausea and Vomiting

• Treat reversible aetiology:

• CONSTIPATION

• Hypercalcaemia … other metabolic

• Drugs: can any be discontinued?

• SC route (same dose as PO)

Receptor affinities of antiemetics

Agonist/Antagonist AChM

Ant H1

Ant 5HT2

Ant D2 Ant

5HT3 Ant

5HT4 Ag

Metoclopramide (PO/IV/SC)

++ (+) ++

Domperidone (PO) ++

Haloperidol (PO/SC) +++(*)

Cyclizine (PO/IV/SC) ++ +++

Ondansetron (PO/IV) expensive, constipating

+++

Levomepromazine (PO/SC) (Nozinan)

+ + ++ +(*) * Prokinetic effect of metoclopramide and domperidone is partly attributed to D2 antagonism –

however there is no evidence that haloperidol or other neuroleptics have prokinetic activity.

Antiemetic choices

Metoclopramide: prokinetic + central effect

Indication: gastric stasis and toxic causes.

Dose 10mg tds po/sc (can go to 20mg qds).

Alt: Domperidone 10mg tds (if risk of EPSE with metoclopramide)

Haloperidol Indication: toxic/chemical causes.

Dose 0.5-1.5mg nocte po/sc up to tds.

Alt levomepromazine 6.25-12.5 mg starting.

Both sedating – esp if also delirious.

Cyclizine: slows gut and central effect

Indication: bowel obstruction/ raised ICP/motion sickness.

Dose: 50mg tds po/sc (SC – painful/erythema)

Other - Dexamethasone, Midazolam, Ondansetron

Routes of Administration

Give regularly, ensuring a PRN dose is available

Orally (tablets/ solution)

Regular sub-cut via a butterfly needle

24 hour syringe-driver

IV

Oral, IV and sc

doses are the same

N&V: obstruction

• How do you manage malignant bowel obstruction?

Causes of bowel obstruction

Cancer related

Intrinsic – bowel Ca

Extrinsic – often gynae with peritoneal, omentum spread, nodal disease.

Lymphoma

Treatment-related (adhesions/radiation)

Impaction (see causes of constipation)

Benign (hernia)

Surgical Management

Is it technically feasible?

Is the patient fit enough?

Is the patient likely to benefit?

It is appropriate?

Medical management of bowel obstruction

Incomplete obstruction

Aim get bowel moving

1. Metoclopramide

50-100 mg/24h in CSCI, starting at

30-60 mg and increase.

Stop if causes colic

2. Bowel care as indicated

3. +/- dexamethasone (poor evidence)

4. +/-levomepromazine

Complete obstruction:

Aim reduce gut motility & secretions

1. Stop metoclopramide

2. Use cyclizine or haloperidol or

levomepromazine

3. If large volume vomit: add hyoscine

butylbromide or octreotide

4. +/- NGT (Ryles tube)

5. Bowel care as indicated

6. +/- dexamethasone

4. Constipation

Constipation

Defined as difficulty in defaecation

Incidence in palliative care = 50%

of which 63% are not taking opioids

Laxatives needed in 87% of pts using opioids

Causes of constipation

Causes

Disease-related

Hypercalcaemia

Site of malignancy

immobility

poor nutrition (decreased intake)

poor fluid intake

dehydration (vomiting, polyuria, fever)

weakness

Drugs:

Opioids

Anticholinergics (cyclizine, tricyclics)

5HT3 antagonists

ondanestron

Diuretics

How does morphine make you constipated?

Acts on m2 receptors to :- reduce peristalsis increase sphincter tone impair rectal sensitivity blockade water secretion increase water absorption

Constipation results in …

Pain

Abdominal distension

Nausea and vomiting

Distress and lack of dignity

Overflow diarrhoea

Agitation

Urinary retention

Management of constipation

Examination and investigation

Ward level observations

Think about contributing causes.

Treatment of constipation

Faecal softeners: Docusate 100 mg bd->200mg tds

Osmotic agents: Lactulose, Macrogol (Laxido/ Movicol)

Stimulants: Senna (large bowel only), danthron (mainly large bowel)

Rectal measures: suppositories and enemas

Glycerol suppository 4 g

Bisacodyl supp 10 mg

Phosphate enema

Arachis oil enema

Other measures – eg urinary catheter, new drugs coming

5. Pain

Types of pain

• Somatic (soft tissues, muscle, bone)

• Visceral (smooth muscle)

• Neuropathic

• Phantom

Pain management: non-opioids

Paracetamol

1g qds (<50 kg use 500 mg qds)

Oral (incl liquid) or IV

Side effects are rare

NSAIDS

Ibuprofen 400 – 800 mg tds oral

Naproxen 250 – 500 mg bd oral

Co-prescribe: PPI or ranitidine if regular use

SE:

renal

bleeding (care with LWMH, aspirin, steroids)

cardiac

Opioids

Weak opioids

Codeine (15 – 60 mg qds) oral*

Tramadol (50 – 100 mg qds) oral*

Strong

Morphine (oral, SC, IV)*

Oxycodone (oral, SC, IV)*

* Seek specialist help in renal impairment:

Moderate renal impairment: use lower doses at reduced frequency

Severe may need to switch to fentanyl/alfentanil:

Fentanyl (patches [s/l, sc]) and alfentanil (SC)

Seek senior / specialist advice before prescribing.

Morphine

Morphine sulphate immediate release (i/r)

Oramorph Liquid 10 mg/5 mL

Onset: ½ hour,

lasts: 4 hours

(Sevredol tablets: 10 mg, 20 mg and 50 mg)

Morphine sulphate modified release e.g. Zomorph

Onset: 2-6 hours,

lasts: 12 hours (regular twice daily dosing)

Capsules and tablets (5 mg, 10mg, 30mg, 60mg, 100mg, 200mg)

Morphine

Start with lowest effective dose

Titrate up opioid naïve: morphine (I/R) 2.5 -5 mg every 1 – 4 hours.

Convert to bd modified release Eg patient using average of 6 PRNs/day each of 5 mg = 30 mg total/day

=15 mg morphine MR (MST) bd

Common side effects of morphine

Constipation

Nausea

Sedation

Myoclonus (toxic)

Hallucinations, delirium … (toxic)

Itch

Respiratory depression (rare with careful prescribing)

Non-addictive

Opioid Conversions

Co-prescribing

Laxatives

Antiemetics

Reassurance

Syringe drivers