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To prevent and relieve suffering, and promote quality of life at every stage of life

Common Symptoms
Frank D. Ferris, MD
Medical Director, Palliative Care Standards CENTER FOR PALLIATIVE STUDIES
San Diego Hospice and Palliative Care
Education and Research in the Art and Science of Palliative Care

Department of Family and Preventative Medicine, UCSD School of Medicine


Department of Family and Community Medicine, and Joint Center for Bioethics, University of Toronto

Objectives

Know general guidelines for managing non-pain symptoms Know how to assess and manage common symptoms

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Publications / presentations

General guidelines . . .

History, physical examination Conceptualize likely causes

Discuss treatment options


Assist with decision making

. . . General guidelines

Provide education, support Involve entire interdisciplinary team

Reassess frequently

HIV Wasting

HIV Wasting

Loss of weight > 10% of baseline with fever, weakness, diarrhea > 30 days
inadequate nutrient intake excessive nutrient loss metabolic dysregulation

Management of anorexia / cachexia . . .

Assess, manage comorbid conditions Educate, support Favorite foods / nutritional supplements

. . . Management of anorexia / cachexia


Alcohol Megestrol acetate

Dexamethasone
Dronabinol Androgens, eg, testosterone

Fatigue / Weakness

Management of 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

. . . Management of fatigue / weakness

Dexamethasone
feeling of well-being, increased energy effect may wane after 4-6 weeks continue until death

Methylphenidate

Fever / Sweats

Management of fever / sweats


Paracetamol (acetaminophen) NSAIDs, eg, ibuprofen

Corticosteroids, eg, dexamethasone


Anticholinergics, eg, scopolamine Rehydration Bathing, drying

Nausea / Vomiting

Nausea / vomiting

Nausea
subjective sensation stimulation
gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex

Vomiting
neuromuscular reflex

Causes of nausea / vomiting


Metastases Meningeal irritation Movement Mental anxiety

Mechanical obstruction Motility Metabolic Microbes

Medications
Mucosal irritation

Myocardial

Pathophysiology of nausea / vomiting


Chemoreceptor Trigger Zone (CTZ) Cortex

Vomiting center
Neurotransmitters Acetylcholine Dopamine Histamine Serotonin

Vestibular apparatus

GI tract

Management of nausea / vomiting

Dopamine antagonists Antihistamines Anticholinergics Serotonin antagonists

Prokinetic agents Antacids Cytoprotective agents Other medications

Acetylcholine antagonists
(anticholinergics)

Scopolamine Atropine

Dopamine antagonists

Haloperidol
Prochlorperazine Metoclopramide (also prokinetic)

Histamine antagonists
(antihistamines)

Diphenhydramine Meclizine

Hydroxyzine

Serotonin antagonists

Ondansetron Granisetron

Antacids

Antacids
H2 receptor antagonists
cimetidine ranitidine

Proton pump inhibitors


omeprazole

Cytoprotective agents

Misoprostol Proton pump inhibitors


omeprazole

Other medications

Dexamethasone
Tetrahydrocannabinol

Lorazepam
Octreotide

Constipation

Constipation

Medications
opioids calcium-channel blockers anticholinergic

Metabolic abnormalities Spinal cord compression Dehydration Autonomic dysfunction Malignancy

Decreased motility Ileus

Mechanical obstruction

Management of constipation

General measures
establish normal bowel pattern regular toileting gastrocolic reflex

Specific measures
stimulants osmotics detergents lubricants large volume enemas

Stimulant laxatives

Prune juice Senna

Casanthranol
Bisacodyl

Osmotic laxatives

Milk of magnesia (other Mg salts) Lactulose

Polyethylene glycol
Sorbitol Magnesium citrate

Surfactant laxatives
(stool softeners)

Sodium docusate Calcium docusate

Phosphosoda enema prn

Prokinetic agents

Metoclopramide

Lubricant stimulants

Glycerin suppositories Oils


mineral
peanut

Large-volume enemas

Warm water Soap suds

Constipation from 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

. . . Constipation from opioids

Combination stimulant / softeners are useful first-line medications


casanthranol + docusate sodium senna + docusate sodium

Prokinetic agents

Diarrhea

Causes of diarrhea

Infections GI bleeding Malabsorption, eg, lactose intolerance Medications, eg, HAART Obstruction, eg, cancer Overflow incontinence Stress

Management of diarrhea

Establish normal bowel pattern Treat underlying cause

Avoid gas-forming foods


Increase bulk, i.e., fiber Transient, mild diarrhea
bismuth salts

Management of persistent diarrhea

Rehydration
Oral salt containing fluids Parenteral

Loperamide Diphenoxylate / atropine Tincture of opium Octreotide

Shortness of Breath (Dyspnea)

Breathlessness (dyspnea) . . .

Described as
shortness of breath

a smothering feeling
inability to get enough air suffocation

. . . Breathlessness (dyspnea)

Only reliable measure is patient selfreport

Respiratory rate, pO2, blood gas determinations DO NOT correlate with the feeling of breathlessness Prevalence 12 74%

Causes of breathlessness

Anemia Anxiety Airway obstruction Bronchospasm Hypoxemia

Pleural effusion Pulmonary edema Pulmonary embolism Thick secretions Family / financial / legal / spiritual / practical issues

Infections
Metabolic

Management of breathlessness . . .

Treat the underlying cause


antibiotics avoid fluid overload dry secretions

Mechanical ventilation

. . . Management of breathlessness

Symptomatic management
oxygen opioids anxiolytics nonpharmacologic interventions

Oxygen

Pulse oximetry not helpful Potent symbol of medical care

Expensive
Fan may do just as well

Opioids

Small doses Central and peripheral action

Relief not related to respiratory rate


No ethical or professional barriers Do not shorten life

Anxiolytics

Safe in combination with opioids


lorazepam
0.5-2 mg po q 1 h prn until settled then dose routinely q 46 h to keep settled

Nonpharmacologic interventions . . .

Reassure, work to manage anxiety Behavioral approaches, eg, relaxation, distraction, hypnosis Limit the number of people in the room

Open window

Nonpharmacologic interventions . . .

Eliminate environmental irritants Keep line of sight clear to outside

Reduce the room temperature


Avoid chilling the patient

. . . Nonpharmacologic interventions

Introduce humidity Reposition


elevate the head of the bed
move patient to one side or other

Educate, support the family

Common Symptoms

Summary