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SYMPTOM CONTROL IN PALLIATIVE CARE

SYMPTOM CONTROL IN PALLIATIVE CARE. OUTCOMES. TO IDENTIFY SYMPTOMS PREVALENT IN PALLIATIVE CARE. TO RECOGNISE THE RANGE OF SYMPTOM RELIEF THAT IS AVAILABLE TO CLIENTS TO EXPLORE THE VIABLE ALTERNATIVES TO COMMON APPROACHES IN SYMPTOM CONTROL. COMMON SYMPTOMS. Cancer Other

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SYMPTOM CONTROL IN PALLIATIVE CARE

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  1. SYMPTOM CONTROL IN PALLIATIVE CARE

  2. OUTCOMES TO IDENTIFY SYMPTOMS PREVALENT IN PALLIATIVE CARE. TO RECOGNISE THE RANGE OF SYMPTOM RELIEF THAT IS AVAILABLE TO CLIENTS TO EXPLORE THE VIABLE ALTERNATIVES TO COMMON APPROACHES IN SYMPTOM CONTROL.

  3. COMMON SYMPTOMS Cancer Other Pain 84% 67% Breathlessness 47% 49% Nausea & Vomiting 51% 27% Insomnia 51% 36% Confusion 33% 38% Depression 38% 36% Loss of Appetite 71% 38% Constipation 47% 32% Incontinence 37% 33% This is taken from a survey in the Middle East (Pallestine)

  4. PAIN Probably the most common and feared symptom. Pain relief is the most important aim of symptom control We will work through pharmacological approaches and non-pharmacological approaches.

  5. WORLD HEALTH ANALGESIC LADDER Step 3 – Severe Pain Morphine, Diamorphine (anti emetics) Step 2 – Moderate Pain Codeine + Adjuvant + consider laxatives Step 1 – Mild Pain Aspirin or Paracetamol + Adjuvant

  6. PAIN ASSESSMENT Use established assessment tools, including specialist tools for clients with limited or no capacity. Evaluate degree and position of pain and monitor effects of medication. The aim is to control the pain so that the client is pain free. Use regular doses. Continual assessment is required. Pain experienced between doses is known as ‘breakthrough pain’ which should be treated in its own right.

  7. OPIODS: ADVERSE EFFECTS Sedation Nausea & Vomiting Constipation Dry Mouth Can depress respirations in high doses potentially causing respiratory arrest.

  8. ROUTES OF ADMINISTRATION- For as long as possible this should be predominately oral. This can be by tablet or liquid, depending on the preparation. When administration by mouth becomes problematic consider a syringe pump. A range of medications can be mixed together in this system. Review this with the pharmacy and Medical Practitioner. Rectal administration of medication is not widely used and is often not tolerated by clients.

  9. When Morphine cannot be used • If the client cannot take Morphine due to nausea, vomiting, swallowing difficulty or severe renal impairment. • Alternatives are Oxycodone or Fentanyl.

  10. ADJUVANTS • NSAIDS (e.g. Diclofenac) • Good for Liver pain, inflammatory pain, soft tissue infiltration, bone metastases • STEROIDS (e.g. dexamethasone) • Good for Raised ICP, Nerve compression, soft tissue infiltration, liver pain. • GABAPENTIN - good for nerve pain • AMITRIPTYLINE - nerve pain • CARBAMAZEINE - nerve pain NSAIDS = Non Steriodal Anti- inflammatory drugs

  11. NON PHARMACOLOGICAL APPROACHES • TENS (Transcutaneous Electrical Nerve stimulation) • Physiotherapy • Acupuncture • Relaxation Therapy • Visualisation and Distraction. • Positioning and Support

  12. NAUSEA & VOMITING • DEFINITIONS • Nausea: an unpleasant feeling of the need to vomit, often accompanied by autonomic symptoms such as salivation and cold sweating. • Retching: rhythmic, laboured, spasmodic movements of the diaphragm + abdominal muscles • Vomiting: forceful expulsion of gastric contents through the mouth

  13. CONSEQUENCES Physical effects • Dehydration, malnutrition, anorexia, weight loss Psychological effects • Threat to survival and self image, anxiety, depression, anger Social effects • Inability to prepare food, eat with others, curtailment of leisure activities

  14. PREVALENCE Nausea • 30-70% in advanced cancer • 25-30% in non malignant disease in last year of life Vomiting • 20-45% in advanced cancer • 30% during 1st week of opiodtreatment • It’s a significant symptom

  15. VOMITING PATHWAY AND BENEFICIAL DRUGS

  16. ASSESSMENT • Evaluate each symptom separately • Relative severity of Nausea Vs Vomiting • Relief / persistence of nausea after vomiting • Timing of vomiting / triggers • Frequency of vomiting & time of day • Content and volume of vomitus • Distinguish vomiting from expectoration & regurgitation • Associated symptoms i.e. blood, bile

  17. CLINICAL PICTURE • Chemical / metabolic • Gastric stasis • Bowel obstruction • Raised Intracranial pressure • Movement related • Vagal stimulation • Chemotherapy induced

  18. CHEMICAL / METABOLIC • Cause: Drugs (morphine, cytotoxic), hypercalcaemia, uraemia, infection • Symptoms: severe persistent nausea, little relief from vomiting, small vomits +/- retching • Anti-emetic: • 1)Haloperidol • 2) Levomepromazine • 3) Ondansetron

  19. GASTRIC STASIS • Causes: drugs (opiates, anticholinergics), outflow obstruction (hepatomegaly, ascites, tumour) • Symptoms: large vomits, nausea often relieved by vomiting, early satiety, regurgitation • Anti-emetic: • 1)Metoclopramide • 2) Domperidone Plus: Antiflatulent, Dexamethasone

  20. BOWEL OBSTRUCTION • Causes: subacute obstruction or new onset total obstruction • Symptoms: gut distension • Anti-emetic: • With colic: • 1)Cyclizine and HyoscineButylbromide • 2) Cyclizine and Haloperidol • 3) Levomepromazine • Without colic: • 1)Metoclopramide • Plus Faecal softener

  21. RAISED INTRACRANIAL PRESSURE • Causes: direct stimulation of the vomiting centre • Symptoms: vomiting worse in the morning and headache. Raised ICP • Antiemetic • 1)Cyclizine • 2) Levomepromazine Plus: Dexamethasone

  22. MOVEMENT INDUCED N&V • Causes: travel sickness, middle ear infection. Viral neuronitis, Menieres, Ototoxic drugs, cerebellopontine tumours. • Symptoms: Nausea &/or Vomiting on movement • Anti-emetic: • 1)Cyclizine • 2) Scopolomine 3) Stemitil

  23. VAGAL STIMULATION • Causes: pharyngeal irritation (tumour, candida, sputum) Stretched liver capsule, constipation • Anti-emetic: • 1)Cyclizine • 2) Ondansetron Plus: Hyoscinehydrolbromide Glycopyronium (dry up secretions)

  24. ROUTES OF ADMINISTERING ANTI-EMETICS • Oral – only effective before vomiting commences. • Sub lingual/buccal – ensure correct positioning of tablet. • Rectal – not always acceptable to patients. • Parenteral – IM, IV or S/C, as bolus dose or continuous infusion.

  25. NON-PHARMACOLOGICAL MEASURES • Relaxation • Calm, reassuring environment • Small snacks, bland food • Avoid odours • Attention to food preparation • Mouth care • Acupuncture / acupressure • NG / PEG • Stents

  26. SUMMARY FOR TREATMENT • Choice of anti-emetic should not be fixed • 4-step regime: • Establish probable cause of N&V • Consider pathways / receptors • Choose most appropriate anti-emetic • Review regularly Remember - 1/3rd of Patients may require combination anti-emetics

  27. BREATHLESSNESS • Difficult, laboured or uncomfortable breathing. • Significant symptom in malignant and non-malignant disease. • Affects quality of life and ability to function independently. • Usually poorly assessed and therefore managed.

  28. CAUSES OF BREATHLESSNESS • Non- Malignant: COPD Pneumonia Pneumothorax Heart Failure Atrial Fibrillation Pulmonary Embolism COPD = Chronic Obstructive Pulmonary Disease

  29. Malignant: Pleural effusion SVCO Tumour bulk Stridor Pericardial effusion Cancer within chest Lymphangitis SVCO = Superior Vena Cava Obstruction

  30. ASSESSMENT • Clarify pattern of breathlessness. Precipitating / alleviating factors and associated symptoms. • Look for reversible causes (e.g. infection, pleural effusion, anaemia, arrhythmia, pulmonary embolism or bronchospasm. • Check Oxygen saturation. • Use established assessment tools. • Explore fears, impact on functional abilities and quality of life.

  31. MEDICATION • Bronchodilators (stop if no benefit) • Steriods (Dexamethasone – stop if no effect after a week) • Opiods (e.g. Morphine - can reduce breathlessness at rest or in the terminal phase). • Benzodiazepines (for anxiety relief e.g. Lorazepam or Diazepam) • Oxygen (Only if Hypoxic Sats<90%)

  32. NON DRUG TREATMENT • Physiotherapy • Use of a Fan (hand held electric) • Relaxation • Distraction & Visualisation • Positioning

  33. CONSTIPATION • An understanding of the patient’s normal, accepted bowel habit is essential when planning treatment. • All patients on opioids require a laxative, prescribed regularly (not prn) • A combination of stimulant and softener is usually required • Laxative doses often need to be increased along with increased doses of opioids

  34. ASSESSMENT • A daily assessment is required. • Normal frequency of stool ? • Current frequency of stool ? • Stool consistency ? • Stool size/ volume ? • Is there blood or mucus in the stool ? Ease of passage ? The aim of treatment is the comfortable passage of faeces without rectal treatment

  35. TREATMENT • OPTION A • Codanthramer 1-2 capsules once daily • OR • Codanthramer 5-10 ml once daily • Codanthramer is a combination laxative (stimulant/softener) which aids compliance, but it is only licensed for use in terminally ill patients

  36. OPTION B • Bisacodyl 5mg tablet once daily • AND • Docusate sodium 100mg capsule bd

  37. THE REVIEW • We have tackled the main areas of symptom control. • The other factors of care will be covered in other sessions.

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