Symptom Management in Palliative Care: Part 2

Scott Akin MD

Scott.akin@hsd.cccounty.us

Outline

• Pain control: That was part #1 of this talk…e-mail me for a copy

• Depression

• Dyspnea

• Nausea and vomiting

• Anorexia

Depression in Palliative Care

• Common: numbers hover around 30%

• Misunderstood– Myth that all dying patients “should” be

depressed, and it is a “normal” part of dying

• Underdiagnosed– Clinicians fearful of upsetting patients

• Undertreated: only 10% in one study

Depression

• Sadness, grief, depressed mood, and feeling of loss are all appropriate responses to dying…but

• Feelings of hopelessness, worthlessness, helplessness, guilt, no desire for pleasure…are NOT

• Bottom line: – Depression is NOT a normal part of dying

– Depression is an illness, with symptoms that need to be recognized and treated

How Do You Diagnose Depression?

• DSM-IV….But not really set up for the medically ill. Many depressive symptoms in medically ill patients may be a result of their medical illness or treatment.

• Careful interview.• Consider simple 1-2 word screening tools:

– Are you depressed?– Have you been depressed for most of the time for the

past 2 weeks?– One of the above + loss of interest of usual activities.

Treatment of Depression

• First, relieve uncontrolled symptoms (pain, nausea, dyspnea, etc.)

• Psychosocial interventions– Psychotherapy– CBT

• Pharmacologic interventions

Treatment of Depression: Drugs

• Not much data in palliative care setting• As when treating depression in other settings, use

side effect profile-Poor appetite/insomnia: Mirtazapine (Remeron)-neuropathic/other pain: TCAs, duloxetine (cymbalta), venlafaxine (effexor) -Fatigue/psychomotor slowing: activating SSRI

(fluoxitine, venlafazine) or psychostimulants• The “default” is probably an SSRI…unless

Depression in Last Weeks of Life

• SSRIs need 4-6 weeks to work, so why start one if your patient is in last weeks of life?

• Instead, use pychostimulants such as methylphenidate (Ritalin) or modafinil (Provigil)– Very rapid onset of action (hours)

– Start low (2.5 of methlyphenidate daily) and titrate upwards slowly

– You should see effect after 1-2 doses

Dyspnea

• “discomfort in breathing”• “breathlessness”• “Shortness of breath”• “uncomfortable awareness of breathing”

--------------------------------------------Dyspnea is a SUBJECTIVE sensation, for which the

standard of assessment is the patient’s self-report (different from tachypnea which is an OBJECTIVE, measured number)

Dyspnea

• Common in cancer patients (21-78%)• Common in non cancer patients

– 70% Dementia patients– 68% terminal HIV/AIDS patients– 65% CHF patients– 56% COPD patients– 50% ALS patients– 36% CVA patients

Dyspnea Treatment

* Goal in terminally ill: Improve subjective sensation expressed by patient

* In order to do that you must think about cause…– Sometimes interventions may be consistent

with patient’s goals of care…– Other times they may not be…

Causes of Dyspnea“BREATH AIR”

• Bronchospasm: Nebs and steroids?• Rales: Stop IVF, diuretics, antibiotics?• Effusions: Tap?• Airway obstruction: Change diet? Suction?• Thick secretions: Thin with: -Atropine

drops– Nebulized saline (3%) -Glycopyrrolate – Nebulized NAC (mucomyst) -scopolamine

(patch)

Hemolgobin low: Transfusion?

Causes of Dyspnea“BREATHE AIR”

• Anxiety: *Sit upright, bedside fan, music-Benzos if primary anxiety (if anxious

because sobopiates) -antidepressants

• Interpersonal issues: emotional support• Religious concerns: emotional support,

coordinate connection with chaplain/spiritual advisor

Treatment of Dyspnea

• General Measures– Proper positioning: vertical (if comfortable)…or

compromised lung down if horizontal– Modify activity level (bathroom aids, wheelchair)– Instruct on pursed lip breathing– Fan (?stim V2, decreasing dyspnea perception)– Open windows– Avoid strong odors– Keep room cool…humidifier– Family/friends at bedside

Treatment of dyspnea

• Opioids: FIRST LINE– Decrease receptor response to elevated CO2

– Vasodilitation/preload reduction

– Anxiolytic -Nebulized opoids? Not yet…

• Which one to use? Probably doesn’t matter– Morphine 2.5-5 mg PO q 4 hours titrate

– Hydrocodone 2.5-5mg PO q 4 hrs up

– Oxycodone 5mg PO q 4 hours 25-50%

– Hydromorphone 1-2mg PO q 4 hours q 12 hrs

Treatment of Dyspnea

• Oxygen: Interestingly, there is no clear evidence that O2 works to relieve dyspnea any better than air…even in hypoxemic patients (studies poor).

• Anxiolytics: Anxiety usually response to dyspnea.– 4 of 5 RCTs found no benefit of benzos in dyspnea.– Benzos more for refractory dyspnea worsened by

anxiety symptoms…(although some try when one cannot titrate the opioid up further due to side effects).

– Lorazepam is probably 1st choice (fast onset of action, and lasts 4-6 hours).

Next topic: Nausea and Vomiting

• What is the cause?– Opioids

– Other drugs

– Constipation CORRECT

– PUD THE

– Autonomic insufficiency UNDERLYING

– Metabolic abnormalities CAUSE

– Bowel obstruction

– Increased ICP

Nausea and Vomiting

• Opioid induced n/v (stimulation of CTZ)– Mild nausea tends to be self-limited with time– If not, or severe symptoms, change to other

opioid– Consider long acting opioids to lessen the

potential fluctuation of levels which can stimulate the CTZ

Nausea and Vomiting

• Opioid induced n/v– Best drugs to treat:

• Haloperidol* (Haldol: THE most potent anti-dopinergic)• Prochlorperazine* (compazine: Potent anti-dopa, weak antihis)• Promethazine* (phenergan: Antihistamine, weak anti-dopa)• Scopolamine (especially if vestibular symptoms)• Diphenhydramine (benadryl….Careful in elderly)

• Metabolic induced n/v: – Correct the metabolic derangement– Best drugs to treat: Dopamine antagonists* as above

Nausea and Vomiting

• Constipation induced n/v– First step: prevention

• Everyone on opioids gets DSS + cathartic (senna, ducolax)

• Hydration, physical activity

– If develops despite prophylaxis• 1st r/o obstruction (rectal examdisimpaction helped by

mineral oil, glycerine supp, saline enemas)

• then treat with osmotic laxative (lactulose, PEG, Mag citrate)

Nausea and Vomiting

• Constipation induced n/v– If patient too nauseated to take pos

• Sodium Phos (fleet) enema

• Bisocodyl suppository

– Refractory constipation induced n/v: • Neostigmine

• opioid antagonists – oral naloxone (?systemic absorption)

– SQ methylnaltrexone (selective peripheral antagonist)

Nausea/vomiting

• Dysmotilityabdominal distension (gastric stasis)– Common in pts on opioids/anticholinergics

– Pts c/o early satietynausea (not fasting n/v)• Metoclopramide (5-10mg PO qHS and qAC…or higher):

don’t use in renal failure, Parkinson’s

• DON’T USE Promethazine (phenergan)…which is an anticholinergic

• Anorexia or increased ICP– Dexamethasone (2-4mg PO bid-QID)

Nausea/vomiting

• Anticipatory nausea:– Benzos: Lorezepam (0.5-2mg q 6 hrs)…avoid as single

agent (very weak antiemetic).

• Vestibular nausea:– Scopolamine.– Promethazine (Phenergan).

• Chemotherapy induced nausea/vomiting:– 5HT3 antagonists (Ondansetron 4-8mg q 6 hours).

• Also in postoperative setting, or sometimes after other agents have failed. Can cause mild headache, constipation.

Anorexia-Cachexia

• ACS (Anorexia Cachexia Syndrome)– Loss of body weight (muscle mass and fat) in the

setting of cancer…predicts 3-6 month survival

------vs------

• General anorexia/cachexia at the end of life– Reflects end result of metabolic, neuroendocrine

cascade (ketones, uremia, etc)…part of disease process

– Probably universal in the dying process

Anorexia-Cachexia

– Frequent cause of considerable concern for families.

– Goals of treatment:• Symptomatic not nutritional.

• Establish therapeutic relationship with patient/family.

• Emphasis on social aspects of eating (pleasure, nurturing, bonding experience).

• Education, Education, Education.

Anorexia/Cachexia

• Reversible causes?– Pain -Dry Mouth– Nausea -Candidiasis– Constipation -Gastritis– Depression -Iatrogenic (XRT, chemo)

Anorexia/Cachexia

• Appetite stimulants.– Rare to use…mostly when underlying cause

cannot be addressed, and in setting of being consistent with patient’s goals of care.

– Consider time limited “therapeutic trial” in selected patients after discussing goals of care (goal might be to gain strength/independence which can be reevaluated weekly for a few weeks).

Appetite Stimulants

• Megesterol acetate (megace)– Initially for AIDS associated wasting– No change in muscle mass– “Increases” weight (of >5% in only 15-20% of

patients) by increasing water retention and fat deposition…over 6-8 weeks

– No survival benefit…risk of thrombosis– If decide to use it, use elixir (cheaper, easier),

start at 400mg daily800mg daily

Appetite Stimulants

• Coricosteroids (dexamethasone, prednisone).– Have temporary effect (up to a few weeks) on appetite

without increase in body mass…used mostly if prognosis measured in weeks and if other target symptoms might respond to steroids also (nausea, bronchospasm, bone pain).

– May increase energy for brief period.

– Side effects! (mood swings, elevated BP, inc glucose).

– Stop if no benefit within a week or so.

Appetite Stimulants

• Others: Data mixed and routine use not recommended.– Eicosapentaenoic acid (omega 3 fish oil).– Thalidomide (in HIV/AIDS).– Melatonin.– NSAIDs.– Cannabinoids…(i.e. dronabinol).

Hydration at end of life

*Arguments for:– Dehydrationelectrolyte

problemsconfusion.– Dying patients more comfortable if hydrated (?)– Withholding fluid might set precedent for

withholding other therapies which might be appropriate (patients labeled “comfort care”).

Hydration at end of life

*Arguments against:

-No evidence fluids significantly prolong life.

-Interferes with acceptance of death.

-Less UOPless need for bed pain, urinal, foley.

-Less GI fluidless vomiting.

-Less pulm secretions/cough/congestion/edema

-Electrolyte disturbances/uremia may lead to decreased level of consciousnessless suffering.

What to avoid

• “The tube feeding death spiral”– Patient admited for massive stroke/urosepsis with

advanced underlying dementia– Can’t swallow/aspirating/losing weight tube feeds– Patient agitated with NGTremoves– NGT replacedrestraints placed– Aspiration PNA develops moved to ICU/pulse ox– Repeat PNA 3-4 more times– Family meeting– Death

Summary

• Depression: recognize and treat at end of life– Don’t forget about psychostimilants

• Dyspnea = subjective sensation. Goal of therapy is patient telling you they are better– Treat underlying cause (if appropriate)– Opiates are first line

Summary

• Nausea/vomiting: – Consider cause before treating– Most common cause is medication related

which is most effectively treated with Dopamine antagonists:

– Haldol >Compazine > Phenergan

• Anorexia/cachexia– Educate families– Medications not that helpful