Dr Sharon Chadwick HOSF 2012
SYMPTOM CONTROL FOR ADVANCED RESPIRATORY
DISEASEDR SHARON CHADWICK
CONSULTANT IN PALLIATIVE MEDICINEHOSPICE OF ST FRANCIS
Dr Sharon Chadwick HOSF 2012
COPDPulmonary fibrosisBronchiectasis Pulmonary hypertension Cystic fibrosis
WHICH DISEASES?
Dr Sharon Chadwick HOSF 2012
SymptomsSYMPTOM COPD FIBROSIS
Dyspnoea +++ ++++
Anxiety ++++ ++++
Depression +++ +
Immobility +++ ++++
Fatigue +++ +
Pain +++ +
Constipation +++ +
Nausea + +
Oedema ++ +
Dry mouth ++ +
Insomnia ++ ++
Dr Sharon Chadwick HOSF 2012
KEY CONSIDERATIONS IN COPD
Often have high anxiety levels
Frequent fliers May have osteoporosis Think about reduction
in doses of nebulisers Need to assess relative
contribution of anxiety/pure dyspnoea
Dr Sharon Chadwick HOSF 2012
KEY CONSIDERATIONS IN PULMONARY FIBROSIS
Rapidly progressive disease Catastrophic dyspnoea Cough sometimes problematic May affect younger patients Highly likely to require morphine/midazolam
at the end of life for symptom control
PLEASE CONSIDER PALLIATIVE CARE REFERRAL
Dr Sharon Chadwick HOSF 2012
Optimise medical management Pulmonary rehabilitation Oxygen assessment Non-pharmacological
◦ Breathing control/relaxation◦ Pacing◦ Hand held fan
Pharmacological◦ Opioids◦ Benzodiazepines
Breathlessness
Dr Sharon Chadwick HOSF 2012
Is the breathlessness worrying the patient? Is the problem primarily breathlessness or
anxiety? Are current interventions being used
appropriately?
Breathlessness
Dr Sharon Chadwick HOSF 2012
Breathlessness
Anxiety◦ Explore reasons ◦ Consider
benzodiazepines (lorazepam 0.5mg od)
◦ CBT
Breathlessness◦ Explore triggers◦ Encourage pacing◦ Consider morphine
(2.5mg od)
May need to use both in some patientsSTART LOW, GO SLOW!!
Dr Sharon Chadwick HOSF 2012
Psychological issues
Dr Sharon Chadwick HOSF 2012
Anxiety Fear of the future-fear of dying, fear of
being dead, worsening symptoms, loss of independence, concern for the carer, financial issues
Failure to adjust to loss of function, feeling of should be doing more
Reluctance to use oxygen out of home environment and to use wheelchair.
Reluctance to ‘give in to the illness’
Psychological issues
Dr Sharon Chadwick HOSF 2012
Acknowledge difficulties Explain benefits of doing things differently Explore ways that things might change and
look different Giving the patient control
‘A different way to fight the disease’
Psychological issues
Dr Sharon Chadwick HOSF 2012
A Holistic Approach
Use of CBT techniques◦ Stop negative thoughts◦ Pleasure vs mastery◦ Goal setting◦ Life grid◦ Diary
Dr Sharon Chadwick HOSF 2012
When to think palliative care Advanced respiratory disease with complex
physical, psychological, spiritual or social problems
Continued severe symptoms despite optimal medical management
Repeated hospital admissions i.e more than 3 per year
End-stage disease for whom hospital admission may not be the best option in the event of worsening dyspnoea
Dr Sharon Chadwick HOSF 2012
The patientand carer
The GP
Chest Consultant
Palliative Care
Consultant
Respiratory nurse
specialistPalliative care
nurse specialist
District nurses
Occupational therapists
Physiotherapists
Carers
Community matrons
Dr Sharon Chadwick HOSF 2012
In the last year of life 32% of patients dying
from COPD have three or more
hospital admissions
Elkington H, White P, Addington-Hall J, Higgs R, Edmonds P. The Healthcare needs of chronic obstructive pulmonary disease patients in the last year of life.
Palliat Med 2005; 19: 485-491
Dr Sharon Chadwick HOSF 2012
GSF Prognostic Indicator GuidanceThree triggers for Supportive/ Palliative Care are suggested-
to identify these patients we can use any combination of the following
methods:
1. The surprise question ‘Would you be surprised if this patient were to die in the next 6-12 months’
2. Choice/ Need - The patient with advanced disease makes a choice for comfort care only, not ‘curative’ treatment, or is in special need of supportive / palliative care eg refusing renal transplant
3. Clinical indicators - Specific indicators of advanced disease for each of the three main end of life patient groups - cancer, organ failure, elderly frail/ dementia
Dr Sharon Chadwick HOSF 2012
Breathlessness and anxiety are the main symptoms (but check for others)
Remember non-pharmacological interventions
Consider palliative care referral for any respiratory patient struggling with physical or psychological symptoms
Consider palliative care referral for all pulmonary fibrosis patients
ADVANCE CARE PLANNING!!!!!
Conclusions
Dr Sharon Chadwick HOSF 2012
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