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Palliative Management Of:. Nausea And Vomiting Dyspnea Secretions Delirium. Mike Harlos MD, CCFP, FCFP Medical Director, WRHA Palliative Care Professor, University of Manitoba Faculty of Medicine. MECHANISM OF NAUSEA AND VOMITING. vomiting centre in reticular formation of medulla

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palliative management of
Palliative Management Of:
  • Nausea And Vomiting
  • Dyspnea
  • Secretions
  • Delirium

Mike Harlos MD, CCFP, FCFP

Medical Director, WRHA Palliative Care

Professor, University of Manitoba Faculty of Medicine

slide2

MECHANISM OF NAUSEA AND VOMITING

  • vomiting centre in reticular formation of medulla
  • activated by stimuli from:
    • Chemoreceptor Trigger Zone (CTZ)
      • area postrema, floor of the fourth ventricle
      • outside blood-brain barrier (fenestrated venules)
    • Upper GI tract & pharynx
    • Vestibular apparatus
    • Higher cortical centres
slide3

Cortex

CTZ

GI

VOMITING

CENTRE

Vestibular

slide5

PRINCIPLES OF TREATING NAUSEA & VOMITING

  • Treat the cause, if possible and appropriate
  • Environmental measures
  • Antiemetic use:
    • anticipate need if possible
    • use adequate, regular doses
    • aim at presumed receptor involved
    • combinations if necessary
    • anticipate need for alternate routes
slide6

D

D

D

5HT

5HT

5HT

5HT

2

2

2

M

M

M

VOMITING

CENTRE

H1

H1

CB1

H1

Effector

Organs

H1

CB1

Muscarinic

Cannabinoid

Dopamine

Serotonin

Histamine

slide7

From:

Nausea and vomiting associated with cancer chemotherapy: drug management in theory and in practice

Arch. Dis. Child.2004;89;877-880

E S Antonarakis and R D W Hain

slide9

DYSPNEA:

An uncomfortable awareness of breathing

slide10

DYSPNEA:

“...the most common severe symptom in the last days of life”

Davis C.L. The therapeutics of dyspnoea Cancer Surveys 1994 Vol.21 p 85 - 98

slide11

Approach To The Dyspneic Palliative Patient

  • Two basic intervention types:
  • Non-specific, symptom-oriented
  • Disease-specific
slide12

Simple Non-Specific Measures In Managing Dyspnea

  • calm reassurance
  • patient sitting up / semi-reclined
  • open window
  • fan
slide13

Non-Specific Pharmacologic Interventions In Dyspnea

  • Oxygen - hypoxic and ? non-hypoxic
  • Opioids - complex variety of central effects
  • Chlorpromazine or Methotrimeprazine - some evidence in adult literature; caution in children due to potential for dystonic reactions
  • Benzodiazepines - literature inconsistent but clinical experience extensive and supportive
slide14

TREAT THE CAUSE OF DYSPNEA -

IF POSSIBLE AND APPROPRIATE

  • Anti-tumor: chemo/radTx, hormone, laser
  • Infection
  • Anemia
  • CHF
  • SVCO
  • Pleural effusion
  • Pulmonary embolism
  • Airway obstruction
slide15

DISEASE-SPECIFIC MEDICATIONS

FOR DYSPNEA

  • Corticosteroids
          • obstruction: SVCO, airway
          • lymphangitic carcinomatosis
          • radiation pneumonitis
  • Furosemide
          • CHF
          • lymphangitic carcinomatosis
  • Antibiotics
  • Anticoagulation– pulm. embolus
  • Bronchodilators
  • Transfusion
opioids in dyspnea
Opioids in Dyspnea
  • Uncertain mechanism
  • Comfort achieved before resp compromise; rate often unchanged
  • Often patient already on opioids for analgesia; if dyspnea develops it will usually be the symptom that leads the need for titration
  • Dosage should be titrated empirically; may easily reach doses commonly seen in adults
  • May need rapid dose escalation in order to keep up with rapidly progressing distress
a common concern about aggressive use of opioids in the final hours
A COMMON CONCERN ABOUT AGGRESSIVE USE OF OPIOIDS IN THE FINAL HOURS

How do you know that the aggressive use of opioids for pain or dyspnea doesn\'t actually bring about or speed up the patient\'s death?

slide18

SUBCUTANEOUS MORPHINE IN

TERMINAL CANCER

Bruera et al. J Pain Symptom Manage. 1990; 5:341-344

slide19

Typically, with excessive opioid dosing one would see:

    • pinpoint pupils
    • gradual slowing of the respiratory rate
    • breathing is deep (though may be shallow) and regular
slide20

COMMON BREATHING PATTERNS IN THE FINAL HOURS

Cheyne-Stokes

Rapid, shallow

“Agonal” / Ataxic

slide22

Secretions - Prevalence At Study Entry And In Last Month Of LifeUK Children’s Cancer Study Group/Paediatric Oncology Nurses Forum SurveyGoldman A et al; Pediatrics 2006; 117; 1179-1186

managing secretions in palliative patients

Suctioning

Increased

Secretions

Mucosal

Trauma

Managing Secretions in Palliative Patients
  • Factors influencing approach management:
    • Oral secretions vs.. lower respiratory
    • Level of alertness and expectations thereof
    • Proximity of expected death
  • “Death Rattle” – up to 50% in final hours of life
  • At times the issue is more one of creating an environment less upsetting to visiting family/friends
  • Suctioning: “If you can see it, you can suction it”
slide24

CONGESTION IN THE FINAL HOURS

“Death Rattle”

  • Positioning
  • ANTISECRETORY: Scopolamine, glycopyrrolate
  • Consider suctioning if secretions are:
    • distressing, proximal, accessible
    • not responding to antisecretory agents
atropine eye drops for palliative management of secretions
Atropine Eye DropsFor Palliative Management Of Secretions
  • Atropine 1% ophthalmic preparation
  • Local oral effect for excessive salivation/drooling
  • Dose is usually 1 – 2 drops SL or buccal q6h prn
  • There may be systemic absorption… watch for tachycardia, flushing
definition
Definition

Etiologically non-specific global cerebral dysfunction associated with changes in LOC, attention, thinking, perception, memory, psychomotor behavior, emotion and the sleep/wake cycle

dsm iv criteria
DSM-IV Criteria
  • Change in consciousness with reduced ability to focus, sustain or shift attention
  • Change in cognition (e.g., memory, disorientation, change in language, perceptual disturbance) that is not dementia
  • Abrupt onset (hours to days) with fluctuation
  • Evidence of medical condition judged to be etiologically related to disturbance
characteristics
Characteristics
  • Abrupt onset
  • Disorientation, fluctuation of symptoms
  • Hypoactive vs.. hyperactive (restlessness, agitation, aggression) vs. mixed
  • Changes in sleeping patterns
  • Incoherent, rambling speech
  • Fluctuating emotions
  • Activity that is disorganized and without purpose
delirium types
Delirium Types
  • Hypoactive
    • confusion, somnolence,  alertness
  • Hyperactive
    • agitation, hallucinations, aggression
  • Mixed (>60%)
    • features of both
prevalence of delirium
Prevalence of Delirium
  • 20% - 44% on admission to a palliative care unit (common reason for admission)
  • 28% - 45% of patients developed delirium while on the palliative care unit
  • 68% - 90% prior to death
  • Lawlor et al (J Pall Care 1998)
    • n = 103 pts
    • 50% of episodes reversible
    • Terminal delirium in 88%
    • Hyperactive (5%) vs. hypoactive (47%)
    • Mixed (48%) most common
delirium versus dementia
Delirium versus Dementia

DeliriumDementia

Abrupt onset Insidious onset

Decreased/Fluctuating LOC LOC intact, alert

Erratic behaviour Consistent behaviour

Sleep/wake cycle change Minimal changes

Reversible (theoretically) Irreversible

slide33

Causes Of Delirium In Palliative Care

  • Tumour
    • Primary, metastatic, leptomeningeal, paraneoplastic syndrome
  • Metabolic / physiologic
    • hypercalcemia
    • Hyponatremia (hypernatremia less commonly)
    • ↑ or ↓ glucose
    • anemia, hypoxia
    • CO2
    • Renal or liver failure
  • Infection – UTI, pneumonia, biliary tract, wounds
  • Medication administration – opioids, antiemetics (esp. anticholinergic), sedatives, antisecretory
  • Medication / Drug withdrawal
  • Etc…..
management of delirium in palliative care
Management Of Delirium In Palliative Care
  • Environmental
    • Quite, private setting: single room if possible
    • Low lighting, calendar, clock, familiar objects
    • Minimal room changes with unnecessary distractions
  • Fix the Fixable – if possible and appropriate
  • Help family navigate complex choices and non-choices, dictated by how the patient would guide care if that were possible
  • Effective sedation – with frank discussion of anticipated course
    • If delirium irreversible, goal of care is sedation
    • Sedation does not hasten the dying process
    • Will facilitate meaningful visiting
    • Encourage communication, even though patient not interactive
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