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Osteopathic EPEC

Osteopathic EPEC. Education for Osteopathic Physicians on End-of-Life Care. Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational use.

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Osteopathic EPEC

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  1. Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational use. American Osteopathic Association AOA: Treating Our Family and Yours American Osteopathic Association AOA: Treating Our Family and Yours

  2. Module 10 Common Physical Symptoms American Osteopathic Association AOA: Treating Our Family and Yours

  3. Objectives • Know general guidelines for managing non-pain symptoms • Understand how the principles of intended / unintended consequences and double effect apply to symptom management • Know the assessment, management of common physical symptoms • Optimize homeostasis by normalizing structure and function American Osteopathic Association AOA: Treating Our Family and Yours

  4. General management guidelines . . . • History, physical examination • Conceptualize likely causes • Discuss treatment options, assist with decision making American Osteopathic Association AOA: Treating Our Family and Yours

  5. . . . General management guidelines • Provide ongoing patient, family education, support • Involve members of the entire interdisciplinary team • Reassess frequently American Osteopathic Association AOA: Treating Our Family and Yours

  6. Intended vs unintended consequences • Primary intent dictates ethical medical practice American Osteopathic Association AOA: Treating Our Family and Yours

  7. Breathlessness (dyspnea) . . . • May be described as • Shortness of breath • A smothering feeling • Inability to get enough air • Suffocation American Osteopathic Association AOA: Treating Our Family and Yours

  8. . . . Breathlessness (dyspnea) • The only reliable measure is patient self-report • Respiratory rate, pO2, blood gas determinations DO NOT correlate with the feeling of breathlessness • Prevalence in the life-threateningly ill: 12 – 74% American Osteopathic Association AOA: Treating Our Family and Yours

  9. Anxiety Airway obstruction Bronchospasm Hypoxemia Pleural effusion Pneumonia Pulmonary edema Pulmonary embolism Thick secretions Anemia Metabolic Family / financial / legal / spiritual / practical issues Causes of breathlessness American Osteopathic Association AOA: Treating Our Family and Yours

  10. Managementof breathlessness • Treat the underlying cause • Symptomatic management • Oxygen • Opioids • Anxiolytics • Non-pharmacologic interventions American Osteopathic Association AOA: Treating Our Family and Yours

  11. Oxygen • Pulse oximetry not helpful • Potent symbol of medical care • Expensive • Fan may do just as well American Osteopathic Association AOA: Treating Our Family and Yours

  12. Opioids • Relief not related to respiratory rate • No ethical or professional barriers • Small doses • Central and peripheral action American Osteopathic Association AOA: Treating Our Family and Yours

  13. Anxiolytics • Safe in combination with opioids • lorazepam • 0.5-2 mg po q 1 h prn until settled • then dose routinely q 4–6 h to keep settled American Osteopathic Association AOA: Treating Our Family and Yours

  14. Non-pharmacologic interventions . . . • Reassure, work to manage anxiety • Behavioral approaches, e.g., relaxation, distraction, hypnosis • Limit the number of people in the room • Open window American Osteopathic Association AOA: Treating Our Family and Yours

  15. . . . Non-pharmacologic interventions • Introduce humidity • Use OMT to improve quality of respiration • Reposition • Elevate the head of the bed • Move patient to one side or other • Educate, support the family American Osteopathic Association AOA: Treating Our Family and Yours

  16. Non-pharmacologic interventions . . . • Eliminate environmental irritants • Keep line of sight clear to outside • Reduce the room temperature • Avoid chilling the patient American Osteopathic Association AOA: Treating Our Family and Yours

  17. Nausea / vomiting • Nausea • Subjective sensation • Stimulation • gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex • Vomiting • neuromuscular reflex • OMT can also be applied to decrease nausea and improve overall well-being American Osteopathic Association AOA: Treating Our Family and Yours

  18. Metastases Meningeal irritation Movement Mental anxiety Medications Mucosal irritation Mechanical obstruction Motility Metabolic Microbes Myocardial Causesof nausea / vomiting American Osteopathic Association AOA: Treating Our Family and Yours

  19. Pathophysiologyof nausea / vomiting ChemoreceptorTrigger Zone (CTZ) Cortex Vestibular apparatus Vomiting center Neurotransmitters • Serotonin • Dopamine • Acetylcholine • Histamine GI tract American Osteopathic Association AOA: Treating Our Family and Yours

  20. Dopamine antagonists Antihistamines Anticholinergics Serotonin antagonists Prokinetic agents Antacids Cytoprotective agents Other medications Managementof nausea / vomiting American Osteopathic Association AOA: Treating Our Family and Yours

  21. Dopamine antagonists • Haloperidol • Prochlorperazine • Droperidol • Thiethylperazine • Promethazine • Perphenazine • Trimethobenzamide • Metoclopramide American Osteopathic Association AOA: Treating Our Family and Yours

  22. Histamine antagonists (antihistamines) • Diphenhydramine • Meclizine • Hydroxyzine American Osteopathic Association AOA: Treating Our Family and Yours

  23. Acetylcholine antagonists(anticholinergics) • Scopolamine American Osteopathic Association AOA: Treating Our Family and Yours

  24. Serotonin antagonists • Ondansetron • Granisetron American Osteopathic Association AOA: Treating Our Family and Yours

  25. Prokinetic agents • Metoclopramide American Osteopathic Association AOA: Treating Our Family and Yours

  26. Antacids • Antacids • H2 receptor antagonists • Cimetidine • Famotidine • Ranitidine • Proton pump inhibitors • Omeprazole • Lansoprazole American Osteopathic Association AOA: Treating Our Family and Yours

  27. Cytoprotective agents • Misoprostol • Proton pump inhibitors American Osteopathic Association AOA: Treating Our Family and Yours

  28. Other medications • Dexamethasone • Tetrahydrocannabinol • Lorazepam • Octreotide American Osteopathic Association AOA: Treating Our Family and Yours

  29. Medications Opioids Calcium-channel blockers Anticholinergic Decreased motility Ileus Mechanical obstruction Metabolic abnormalities Spinal cord compression Dehydration Autonomic dysfunction Malignancy Constipation American Osteopathic Association AOA: Treating Our Family and Yours

  30. General measures Establish what is “normal” Regular toileting Gastrocolic reflex Specific measures Stimulants Osmotics Detergents Lubricants Large volume enemas Managementof constipation American Osteopathic Association AOA: Treating Our Family and Yours

  31. Stimulant laxatives • Prune juice • Senna • Casanthranol • Bisacodyl American Osteopathic Association AOA: Treating Our Family and Yours

  32. Osmotic laxatives • Lactulose or sorbitol • Milk of magnesia (other Mg salts) • Magnesium citrate American Osteopathic Association AOA: Treating Our Family and Yours

  33. Detergent laxatives(stool softeners) • Sodium docusate • Calcium docusate • Phosphosoda enema prn American Osteopathic Association AOA: Treating Our Family and Yours

  34. Prokinetic agents • Metoclopramide American Osteopathic Association AOA: Treating Our Family and Yours

  35. Lubricant stimulants • Glycerin suppositories • Oils (Caution – be aware of the risk of aspiration) • Mineral • Peanut American Osteopathic Association AOA: Treating Our Family and Yours

  36. Large-volume enemas • Warm water • Soap suds American Osteopathic Association AOA: Treating Our Family and Yours

  37. 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 American Osteopathic Association AOA: Treating Our Family and Yours

  38. . . . Constipation from opioids • Combination stimulant / softeners are useful first-line medications • casanthranol + docusate sodium • senna + docusate sodium • Prokinetic agents American Osteopathic Association AOA: Treating Our Family and Yours

  39. Causes of diarrhea • Infections • GI bleeding • Malabsorption • Medications • Obstruction • Overflow incontinence • Stress American Osteopathic Association AOA: Treating Our Family and Yours

  40. Management of diarrhea • Establish normal bowel pattern • Avoid gas-forming foods • Increase bulk • Transient, mild diarrhea • Attapulgite • Bismuth salts American Osteopathic Association AOA: Treating Our Family and Yours

  41. Managementof persistent diarrhea • Loperamide • Diphenoxylate / atropine • Tincture of opium • Octreotide American Osteopathic Association AOA: Treating Our Family and Yours

  42. Anorexia / cachexia • Loss of appetite • Loss of weight American Osteopathic Association AOA: Treating Our Family and Yours

  43. Managementof anorexia / cachexia . . . • Assess, manage comorbid conditions • Educate, support • Favorite foods / nutritional supplements American Osteopathic Association AOA: Treating Our Family and Yours

  44. . . . Managementof anorexia / cachexia • Alcohol • Dexamethasone • Megestrol acetate • Tetrahydrocannabinol (THC) • Androgens • Remeron American Osteopathic Association AOA: Treating Our Family and Yours

  45. Managementof 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 American Osteopathic Association AOA: Treating Our Family and Yours

  46. . . . Managementof fatigue / weakness • Dexamethasone • feeling of well-being, increased energy • effect may wane after 4-6 weeks • continue until death • Methylphenidate American Osteopathic Association AOA: Treating Our Family and Yours

  47. Fluid balance / edema . . . • Frequently associated with advanced illness • Hypoalbuminemia  decreased oncotic pressure • Venous or lymphatic obstruction may contribute American Osteopathic Association AOA: Treating Our Family and Yours

  48. . . . Fluid balance / edema • Limit or avoid IV fluids • Urine output will be low • Drink some fluids with salt • Fragile skin American Osteopathic Association AOA: Treating Our Family and Yours

  49. Skin • Hygiene • Protection • Support American Osteopathic Association AOA: Treating Our Family and Yours

  50. Pressure (decubitus) ulcers • Prolonged pressure • Inactivity • Closely associated with mortality • Easier to prevent than treat American Osteopathic Association AOA: Treating Our Family and Yours

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