End of Life Symptom Management

Dec 3, 2014Mudit Dabral

Rosene Pirrello

Understand concept of death

Identify & manage common symptoms

Objectives

Everyone will die

<10% suddenly

>90% prolonged illness

Time course unpredictable

Need to review the plan regularly

Last Hours of Living

Affirms life

Regards dying as a normal process

Neither hastens nor postpones death

Relieves symptoms

Palliative Care

Integrates medical, psychological & spiritual aspects of care

Is often a support system to patients & family

Palliative Care

Anorexia (loss of appetite)

Cachexia (Weight loss)

Gradual Symptoms

Medications Depression Nausea Dysphagia Odynophagia Any advance disease

Anorexia & Cachexia

Reversible causes –Medications side effectsPainNauseaConstipationDepression

Anorexia & Cachexia

Lift dietary restrictions Environmental pleasantries Socialization Small portions Oral hygiene

Anorexia - Cachexia

Metoclopramide

Magesterol acetate

Anorexia - Cachexia

? Given up

? Not fighting

Fatigue

Little is known about Pathophysiology & treatment

Fatigue

Reversible Causes: Medications Dehydration Anemia Electrolyte imbalance Suboptimal sleep

Fatigue

Give patient permission to rest

Clarify the role of underlying disease

Fatigue

Steroids

Dexamethasone (2-20mg/d)

Psychostimulants (methylphenadate 2.5-15 mg q AM & noon)

Fatigue

Medications Decreased motility Impaction Mechanical obstruction Dehydration Metabolic (Hypercalcemia, Hypokalemia)

Constipation

Treat the cause

Laxatives - Stimulants, Osmotic

Prokinetics

Constipation

Nausea, vomiting

Pain

Hospitalized patients: 14%-56% Dying patients 80%-90%

Terminal Delirium

End of Life

Can contribute to complicated & prolonged grief disorder

Diminishes opportunity for closure of relationships

Terminal Delirium

Reversible 50% Pain Constipation Urinary retention Hypercalcemia, Hepatic failure, Hypoxia Infection Dehydration Medications

Delirium

Major organ failure

Hypoxic encephalopathy

Terminal Delirium

Create a familiar environment

Reassure family

Give permission to die

Touch

Treatment - Terminal Delirium

Benzodiazepines - Lorazepam, Midazolam

Neuroleptics - Haloperidol, Chlorpromazine

Treat seizures

Treatment - Terminal Delirium

Dyspnea Altered breathing patterns Low tidal volume, Cheyne-Stroke respirations Accessory muscle use Last few reflex respiratory efforts “Death rattle”

Respiratory Changes

Fears – Suffocation

Support family

Oxygen may prolong dying process

Purpose of treatment is relief of unpleasant sensation.

Respiratory Changes

Opioids (MS2.5 -20mg) Steroids (prednisone 10-20mg 3x a day,

Dexamethasone 8 mg per day) Anxiolytics (Lorazepam 0.5-2mg q 6 hrs) Diuretics Bronchodilators Anticholinergics (scopolamine patch,

Glycopyrrulate 1 mg-2mg q 6-8hrs )

Dyspnea - Treatment

Care in the last hours is

as important as at any other time in life

Overall Message

QUESTIONS?