PALLIATIVE CARECommon symptoms

By Dr Vanessa Kerai

Pain

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage.”

Important to identify the cause and type of pain in order to decide on management. Different types of pain respond to different analgesics.

Psycho-social factors like anxiety and depression, which may reduce tolerance to pain or exacerbated by pain, must also be assessed and treated.

What causes pain?

BONE

NERVE COMPRESSION/INFILTRATION

SOFT TISSUE INFILTRATION

VISCERAL

MUSCLE SPASMLYMPHOEDEMA

RAISED INTRACRANIAL PRESSURE

Cancer related pain

Surgery – post operative scars, adhesions

Radiotherapy – fibrosis

Chemotherapy - neuropathy

Pain classification

Nociceptive pain Results from chemical or physical stimulation of peripheral

nerve endings with the involvement of nociceptors. Somatic pain - arises from bone, joint, muscle, skin, or

connective tissue. It is usually aching or throbbing in quality and is well localized.

Visceral pain - arises from visceral organs, such as the GI tract and pancreas e.g tumour involvement of the organ capsule, obstruction of hollow viscus

Neuropathic pain Up to 40% of cancer-related pain may have a neuropathic

mechanism involved. Refers to pain arising from a primary lesion or dysfunction in

the peripheral or CNS. Central pain – usually an area of altered sensation

incorporating the painful area but commonly extending beyond it with no local disease to account for the pain.

Sympathetic maintained pain: associated with dysregulation of the autonomic nervous system.

Peripherally Generated Pain Painful polyneuropathies: Pain is felt along the distribution of

many peripheral nerves. Examples: diabetic neuropathy, alcohol-nutritional neuropathy, and those associated with Guillain-Barré syndrome.

Painful mononeuropathies: Usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve. Examples: nerve root compression, nerve entrapment, trigeminal neuralgia.

Analgesic ladder

Dyspnoea

It is common in patients with advanced disease, being present in up to 70% of patients with cancer.

The causes are often multiple and are associated with both physiological and psychological factors.

May be attributable to the presence of a primary tumour in the respiratory system, metastatic spread to the lungs, a pleural effusion, or advanced respiratory disease.

The causes of breathlessness can be described as:

1. Mechanical - airway obstruction or lung compression

2. Haematological – anaemia

3. Psychological - anxiety. Breathlessness can cause distress, fear, and disability.

When managing a patient with breathlessness you should ask yourself the following questions:

Is it appropriate to treat the underlying illness? Are there any potentially reversible causes of breathlessness,

e.g heart failure, infection, anaemia, pleural or pericardial effusion, pulmonary embolus, or pneumothorax?

How best can I treat any reversible causes, for example by draining an effusion?

Symptomatic treatment

Keep the patient propped up Keep the patient cool - consider using a fan Try nebulised saline or mecysteine for tenacious respiratory

secretions (mecysteine is a mucolytic) Try bronchodilators if you suspect bronchospasm, such as

nebulised salbutamol 2.5-5.0 mg four times a day. Consider oral or subcutaneous morphine or benzodiazepines,

or both, (SL lorazepam or SC midazolam) Consider prescribing oxygen, remembering that short term

oxygen therapy is not proved to confer significant benefit, unlike long term therapy in chronic respiratory conditions.

Supportive care

Explore the patient's fears Encourage simple breathing exercises and relaxation

techniques Discuss drug management with the patient, for example with

benzodiazepines. Lorazepam 0.5-1.0 mg as required may help patients with acute attacks of anxiety and diazepam 5.0 mg may help more chronic anxiety.

Discuss the patient's limitations and listen to the patient's and family's concerns.

Consider the need for equipment or aids and a package of community care

If the patient has severe or persistent problems consider referring them to a specialist service. 

Cough

In up to 50% of terminally ill patients and up to 80% in lung cancer patients.

Occurs as a result of mechanical and chemical irritation of receptors in the respiratory tract.

Management depends on the cause which may or may not be reversible and the clinical condition of the patient.

Infection Antibiotics

Lung tumour Radiotherapy

LVF/Pulmonary oedema Diuretics

Asthma/Bronchospasm BronchodilatorsCorticosteroids

Oesophageal reflux PPIMetoclopramide

Post-nasal drip Antibioitic if sinusitisNasal corticosteroid sprayNasal decongestant

Aspiration Speech therapist may be able to advise

Tracheo-oesophageal fistulaRadiotherapy induced pulmonary fibrosis

Covered metallic stentCorticosteroids

Dyspepsia

Gastro-oesophageal reflux/Oesophagitis Assessment Exclude or treat oesophageal candida Consider oesophageal spasm Review drugs which cause esophagitis – potassium, NSAIDs,

antimuscarinics Consider cardiac cause of pain

Treatment Raise head of bed to reduce reflux Consider paracentesis for tense ascites Metoclopramide if signs of gastric stasis or distension Antacid – gaviscon (for mild symptoms) PPI NSAID and steroid related dyspepsia Treatment Consider stopping or reducing dose of NSAID/steroids PPI for severe symptoms or proven pathology

Nausea and vomiting

Affects 40-70% cancer patients Common causes GI problems Pharyngeal irritation – e.g Candida, difficulty in expectorating

sputum Drugs – opioids, antibiotics, NSAIDs Metabolic – hypercalcaemia, renal failure Radiotherapy and chemotherapy Infection Pain Anxiety or fear Brain mets

Anti-emeticsINDICATION DRUG DOSE

Gastric Stasis Metoclopramide

Domperidone

PO: 10mg tdsSC infusion: 30-40 mg in 24hrs

Drugs/biochemical upset

Haloperidol SC infusion: 1.5mg – 5mg in 24 hrs

Raised ICPDistension of abdo or pelvic organs

CyclizineDexamethasone 4-16mg

PO: 50mg tdsSC infusion: 50-150 mg in 24 hrs

Bowel obstruction CyclizineOctreotideHyoscine

Radiotherapy Chemotherapy

Haloperidol DexamethasoneMetoclopramide

1.5 mg noct/bd4-8mg od20mg qds

Constipation

Constipation is often multifactorial in origin. Causes include:• A tumour within or pressing on the bowel wall• A tumour damaging the lumbosacral spinal cord, cauda

equina, or pelvic plexus• Hypercalcaemia• Dehydration• Diminished food intake, low fibre diet, and immobility• Drugs, such as opioids and anticholinergics• Concurrent disease, such as hypothyroidism, hypokalaemia,

or an anal fissure.• Often patients with cancer have more than one cause of their

constipation.

Determine and treat the cause

First diagnose the cause of the constipation. When managing a patient with constipation you should ask

yourself the following questions: Is it appropriate to treat the underlying illness? Check with a

specialist if in doubt Are there any potentially reversible causes of constipation, for

example dehydration or use of opioids? How best can I treat any reversible causes, for example by

encouraging a dehydrated patient to take more fluids? If you cannot find a reversible cause or if your initial treatment

does not work you may have to attempt symptomatic treatment.

Symptomatic treatment

Good fluid intake High fibre diet Identify and treat any hypercalcaemia You should titrate up the dose of laxatives until constipation is

controlled. Co-danthramer is licensed only for use in terminally ill

patients. It may colour the urine red and can cause a characteristic red rash over the buttocks and perineum. The risk is increased if the patient is incontinent of urine or faeces.

Generally avoid bulk forming laxatives, such as Fybogel, in patients with terminal cancer because these are not suitable for patients with a poor fluid intake, or when opioids have reduced bowel motility.

Recommendations for prescribing laxatives Type of constipation Mode of action Preparation/dose

Acute constipation or hard impaction Osmotic Microenema - one at night

Osmotic Phosphate enema - one mane

Osmotic Movicol

Soft impaction Stimulant Senna - two tablets at night

High impaction Stimulant Sodium picosulphate

Chronic constipation Stimulant Senna - two tablets at night

Osmotic Movicol - one to two sachets daily

Opioid induced constipation Softener and

stimulant Co-danthramer

Stimulant Senna - two tablets at night

Diarrhoea

Occurs in up to 10% of cancer patients on admission to hospice.

Common causes:

1) Imbalance of laxative therapy (should settle within 24 hrs if laxatives stopped and reintroduced at a lower dose).

2) Drugs (antibiotics, NSAIDs, iron, antacids)

3) Malignant partial intestinal obstruction and faecal impaction

4) Radiotherapy

5) Malabsorption (associated with ca pancreas, gastrectomy, ileal resection, colectomy).

6) Colonic or rectal tumour

7) Rare endocrine tumours (e.g carcinoid)

Investigations Faecal impaction needs to be excluded by abdominal and

rectal examination. Persistent watery diarrhoea with systemic upset which might

indicate an infective cause my requite investigation. Treatment Look for cause before using antidiarrhoeals General measures – increase fluids Non specific drug treatment Opioids – such as codeine or loperamide act via gut opioid

receptors to reduce peristalsis and increase anal sphincter tone.

Specific measures

Causes Treatment

Fat Malabsorption Pancreatin

Radiation diarrhoea Ondansetron 4mg tds

Pseudomembranous Colitis 1st line metronidazole 400mg tds2nd line vancomycin 125mg tds

Profuse secretory diarrhoea Somatostatin analogues (best given via syringe driver)

Ascites

Malignant ascites accounts for 10% of all cases of ascites and in up to 50% of all patient with ovarian cancer.

May be the presenting feature of the malignancy or be indicative of recurrence or metastatic spread.

It is caused by malignant peritoneal deposits irritating the serosa, blockage of subdiaphragmatic lymphatics and secondary sodium retention.

Symptoms: Abdominal distension, discomfort and pain Dyspnoea Nausea & vomiting Oesophageal reflux

Treatment options: Chemotherapy Paracentesis – poor prognosis Diuretics – if prognosis >4 wks, paracentesis unsuccessful or

unacceptable or leg oedema. Spironolactone is the drug of choice.

Peritoneovenous shunt – considered if persistent recurring ascites. Complications: shunt obstruction, sepsis.

Intestinal obstruction

Most commonly occurs with carcinoma of the ovary or bowel. Not uncommonly partial or subacute and often precipitated by

constipation. Severe constipation with faecal impaction can mimic

obstruction. Initial drug management: The optimum treatment is surgery, but often inappropriate in

advanced cancer.1) Relieve nausea and reduce vomiting as much as possible:

metoclopramide (may increase colic or vomiting in complete obstruction, but may resolve partial upper GI tract obstruction). Cyclizine 150mg + haloperidol 2.5mg/24 hrs. If nausea persists replace with levomepromazine.

2) Ensure constant pain is adequately relieved with diamorphine.

3) Stop any stimulant laxatives

Anorexia/Cachexia/Asthenia

Anorexia – absence or loss of appetite Cachexia – profound weight loss and catabolic loss of muscle

and adipose tissue. Asthenia – encompasses fatigue or easy tiring and reduced

sustainability of performance. Generalised weaknesss, poor concentration, impaired memory and emotional lability.

Occur in about 70% of patients with advanced cancer particularly pancreatic and gastric cancer.

Reversible causes must be excluded such as dysphagia (due to thrush, mucositis, ulceration), nausea and vomiting, constipation, pain, anxiety and depression.

If no reversible factors consider dexamethasone (continue if response after a few days).

Pruritus

Generalised pruritus in the absence of a rash may be due to: Cholestatic jaundice (commonest cause in advanced

malignancy) Renal failure Opioids Anaemia Thyroid disease Myeloma, lymphoma Paraneoplastic syndrome: breast, colon, lung, stomach ca Diabetes Treat the underlying cause

Lymphoedema

Excess accumulation of fluid in the body tissues caused by inadequate lymphatic drainage.

Treatment Explanation and information about lymphoedema Skin care to avoid dryness, cracking and infection Avoidance of trauma, including sunburn, venepuncture, or

vaccinations on the affected limb in order to minimise the chance of infection.

Massage Compression bandaging Compression garments Exercise

References

European Journal of Palliative Care, 1998; 5(2):39-45 Adult palliative care guidance 2006 Palliative care handbook 3rd edition BMJ learning module – palliative care in the community Palliative care, symptom control handbook for health professionals

Thanks for listening