11/7/2016

1

Francine Arneson, MD

Palliative Medicine Medical Director

Burt 72 year old male with a history of DM, HTN, and

CKD

Creatinine 2.1 baseline

History of smoking

Presented with cough, severe back pain

Workup revealing lung mass, multiple liver lesions, and multiple bony lesions in the spine

Liver biopsy pending

Symptom Management Always looking for lowest dose to achieve

symptom management to limit side effects

Sometimes need to choose between comfort and alertness

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Pain AssessmentHistory and physical

• PQRST:• Provocative/Palliative factors: What makes it better or worse• Quality: Sharp, burning, stabbing….• Region, radiation, referral: Where does it hurt, does it move• Severity• Temporal factors: onset, duration, fluctuations

• Type of pain:• Neuropathic • Nociceptive

• Somatic : Skin, soft tissues, bone, joints• Visceral

• Prior evaluations, treatments

• Psychosocial assessment: impact on function, what does pain mean to the patient

• Patient expectation and goals

• Patient concerns• Nonmalignant pain in palliative medicine, S. Weinstein, D. Walsh, R. Fainsinger, K. Foley, et al

Pain Assessment

Treatment: Etiology○ Reversible (ie fractured hip)

○ Other treatment options (radiation, injections)

Pain Managment

Severity

Classes of pain medications Non-opioid analgesics

○ NSAIDs

○ Acetaminophen

Opiods

Adjuvant analgesics

WHO Analgesia ladder

• Non-opioid• +/- adjuvant

Mild Pain

• Opioid• +/- Non-opioid• +/- Adjuvant

Moderate Pain • Opioid

• +/- Non-opioid• +/- Adjuvant

Severe Pain

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Narcotics

• Mu-agonist

• Equivalent doses, conversions

• Route of administration• Long acting: Cannot crush, can deliver rectally• Short acting

• Contraindications• Avoid morphine in renal failure

Narcotics Oral

Morphine, Oxycodone, Hydormorphone available in long acting formulations Morphine, Oxycodone, Hydrocodone, and Hydromorphone avaiable in short acting

formulations

Transdermal Difficulty swallowing Decreased GI absorption ? Lower risk of constipation Increased absorption with heat

IM avoided, painful and no phamalogical advantage Parenteral/SQ

Morphine, hydromorphone, fentanyl, methadone

Rectal Most can be used rectally, including long acting narcotics Variable absorption

Sublingual Lipophilic meds absorbed quite well through oral mucosa Fentanyl and methadone Hydrophilic drugs have minimal absorption

Narcotics

• Side effects• Constipation• Nausea• Anorexia• Itching• Somnolence• Confusion• Dry Mouth• Urinary retention• Myoclonus• Fatigue • Anti-tussive

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Burt

Next Steps:

A. Start pain meds

B. Consult hospice

C. Complete a history and physical

Burt: C- History and Physical

Pain in back has been poorly controlled, currently 8/10, worse with movement and at night when trying to sleep, started about a month ago and has gotten progressively worse, mid-back

Has been to ER (6 days ago) and given hydrocodone 5mg, which decreased pain to 6/10, but ran out of meds so returned to ER last night and was admitted for workup given abnormal CXR, mild hypoxia, and uncontrolled pain

Has also been taking tylenol 1000mg four times per day and the hydrocodone 4 times per day until he ran out yesterday

The pain has kept him up at night, and is so severe at times that he has felt nauseous, nausea has been worsening over the past week with 2 bouts of emesis yesterday

Normally has 2 BM’s per day, but has only had one BM since ER visit one week ago

Burt- What do we do next?

A. Start oral morphine (roxanol) at 5 mg q6h prn

B. Start ibuprofen

C. Give a dose of IV dilaudid now, and order prn IV dilaudid

D. Start dexamethasone

E. Consult radiation oncology

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Opioids in Renal Failure

• Morphine• Codeine

Not Recommended

• Hydromoprhone• Oxycodone• Hydrocodone

Use with Caution

• Fentanyl• Methadone

Safest

Nausea

Definition A feeling of sickness with an inclination to

vomit Dictionary.com

Nausea

A: Anxiety/AnticipationV: VestibularO: ObstructiveM: Meds/MetabolicI: Infection/InflammationT: Toxins

Basic and Clinical Pharmacology

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NauseaMechanism Drugs Good For Use In Notes

Serotonin Antagonist Ondansetron (Zofran)Granisetron (Kytril)Dolasetron (Anzemet)

ChemotherapyRadiation

Dopamine Antagonist HaldolChlorpromazine (Thorazine)Prochlorperazine (Compazine)Olanzapine (Zyprexa)

Medication relatedMetabolic related

Can cause dystoniaCan prolong QTc

Anti-histamine Diphenhydramine (Benadryl)Hydroxizine (Vistaril)Promethazine (Phenergan)

VestibularGut receptor

Caution in elderly

Pro-kinetic Agents Metaclopramide (Reglan) Gastric Stasis GI dysmotility

Both dopamine and 5-HT3 antagonist activity

Corticosteroids(unknown mechanism)

DexamethazonePrednisone

Increased ICPMultiple

Beware of long term side effects

NK-1 ReceptorAntagonist

Aprepitant (Emend) Delayed chemotherapy induced

Cannabinoid Receptor Blocker

Dronabinol (Merinol) Poor evidence for efficacy

Benzodiazepines Lorazepam (Ativan)Diazepam (Valium)

AnticipatoryAnxiety

Nausea

Regardless of the etiology…. Assess the cause

Reverse what is reversible

Start with a drug from one class and schedule it

Add a drug from another class

Constipation

Definition: A condition in which there is difficulty in emptying the bowels, usually associated with hardened feces. Dictionary.com

Common

Approaches 90% prevalence

with opioid use

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Constipation

Causes: Inadequate fiber

intake

Inadequate fluid intake

Altered bowel habits

Lack of physical activity

Medications:○ Opioids

○ NSAIDs

○ Tricyclicantidepressants

○ Haldol

○ Anti-parkinson agents

○ Diuretics

○ CCB’s

○ Calcium

○ Iron

Constipation

Non-Pharmacologic Treatments Increase fluid intake

Increase fiber (cautiously)○ Must be accompanied by increased fluids

Increase physical activity

Privacy

Constipation

PharmacotherapyCategory Agents Notes

Stimulant Laxative SennaBisacodyl

- Increases enteric muscle contraction/ GI motility- Stimulate mesenteric plexus

Osmotic Laxatives Non-absorbable sugar molecules:- Polyethelyne glycol - Lactulose- SorbitolPoorly absorbed salt-based molecules: - Milk of magnesia - Magnesium citrate

- Limited intestinal absorption increase in colonic intra-luminal water through oncoticpressure. -With increased intra-luminal volume and distension, reflex peristalsis subsequently occurs. -The increase in intra-luminal water also leads to softer stool and allows for easier intestinal transit

Stool Softeners Docusate - Often not adequate alone with opioids

Bulking Agents Fiber Use caution, can “cement” if not enough fluid

Lubricants Mineral Oil Lubricates

Suppositories/Enemas -Bisacodyl: Stimulate rectosigmoid-Glycerin: Lubricant and osmotic agent-Enema: Soften stool and flush it out

Peripheral mu-receptor antagonist

Methylnaltrexone - Refractory opioid inducted constipation

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Constipation

When using narcotics, never forget to think about a bowel regimen

Easier to prevent than fix

Burt

Bowel regimen!!

Violet 98 year old female admitted to hospice care for end stage

COPD, FEV1 15%, on chronic home O2 at 3L

Co-morbid CAD, HTN, DM, AFTT, 20 # weight loss in past 4 months

Cognitively sharp

Moderate dyspnea at rest, severe with minimal exertion, requires 5 minutes of recovery following getting up to the bathroom

Requiring assistance with bathing, getting dressed, toileting independently

Recently admitted to the hospital with pneumonia

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Violet

On hospice admission patient and her son met with the hospice team to create her care plan

Medication recommendation for dyspnea: Liquid morphine 5mg (0.25ml, 20 mg/ml)

q3h prn

Violet

Two days after admission, son calls hospice nurse because mom is really sleepy, not able to get up to the bathroom

Hospice nurse visits

Son misunderstood medication dosing and delivered 2.5ml…… x 2 (50mg)

Narcotics

• Large therapeutic window

• Therapeutic index= Toxic dose/effective dose Valium (100:1)

Morphine (70:1)

Alcohol (10:1)

Digoxin (2:1)

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Dyspnea Complex uncomfortable sensation that includes:

Air hunger Work/effort Chest tightness

Subjective Can be influenced by physical, psychological, social, and spiritual factors

Often described as: Can’t get air Smothering Chest feels tight Breathing feels heavy Breathing is shallow Suffocating Can’t get a deep breath Breathing takes more work

Dyspnea: 3 Categories

1. Work of Breathing- Increased respiratory effort from obstructive or restrictive pathologies

Obstructive Disease: COPD

Bronchitis

Thick Secretions

Tracheobronchial malignant obstruction

Restrictive Disease:• Parenchymal (Fibrosis, radiation,

drugs)

• Pleural (Effusion, pneumothorax, cancer)

• Chest Wall (trauma, neuromuscular, obesity)

Dyspnea: 3 Categories

Hypoxia:-Impaired diffusion across membranes

-Fluid or bacteria overload

-Impaired cardiac pump (valve, ischemia, arrhythmia)

-Anemia

Hypercapnia:-Central in acid-base balance

-Excess of CO2 sends signal to the brain resulting in dyspnea

Chemical Causes (Hypercapnia and Hypoxia) Oxygen= FUEL

Carbon Dioxide= WASTE

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Dyspnea: 3 Categories

Neuromechanical Dissociation Mismatch between brain expectation and

the signal it receives

Example:○ Anxiety: Short, fast breaths

Volumes lower than brain expects

Leads to worsened dyspnea

Dyspnea: Pathophysiology

Dyspnea: Assessment

Subjective Patient report is gold standard of severity

History and Physical

Workup for reversible/treatable conditions Depending on goals of care

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Dyspnea: Correctable AbnormalitiesB: Bronchospasm- Duonebs, steroid

R: Rales- Decrease volume in, diuretics, if pneumonia consider treating

E: Effusions- Thoracentesis, PleurX

A: Airway Obstruction/Aspiration- Suction, modified diet, aspiration precautions

T: Thick Secretions- If strong cough, loosen with guaifenesin, if dying glycopyrrolate

H: Hemoglobin Low- Consider transfusion

A: Anxiety- Fan, calming music, relaxation techniques, counseling, treat underlying dyspnea, can use benzo/SSRI

I: Interpersonal Issues- Social/financial issues, SW and counseling, respite

R: Religious Concerns- Chaplaincy support

Dyspnea Treatment- General Measures Reduce need for exertion

Reposition: Upright, bad lung down, pursed-lip breathing

Skin care for buttocks

Improve Air Circulation Fan or open windows- Study supports decrease in dyspnea (V2, trigeminal nerve) Adjust humidity, temperature Avoid strong odors, fumes, smoke Increase O2 flow temporarily

Address Anxiety and Reassure Spiritual support, companionship (isolation can exacerbate) Discuss meaning of symptoms Anticipate plan for when symptoms worsen Identify triggers Relaxation strategies

Dyspnea: Opioids First line pharmacologic agents

for dyspnea in advanced disease

Mechanism not well understood:○ Decrease chemoreceptor

response to hypercapnia○ Increase peripheral vasodilation○ Decrease in cardiac preload○ Decrease anxiety and subjective

feeling of dyspnea

Increase exercise tolerance in COPD

Improve dyspnea in CHF and terminal cancer

No studies demonstrate a superior agent

Treating for respiratory distress Tachypnea Nasal flaring Retractions Grunting

Respiratory depression follows sedation, unlikely if patient is arousable

Careful with naloxone: Completely blocks opioidreceptors

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Dyspnea: Anxiolytics

Trigger Causing Dyspnea

Panic

Quick Shallow

Breathing

Worsened Dyspnea

Worsened Panic

Opioids remain first line

Benzodiazepines can be used in conjunction for refractory symptoms

Clonazepam good choice for chronic dyspnea

Lorazapam a good shorter acting choice

Anxiety

Chronic: SSRI’s

Acute, episodic: Benzos

Underlying symptom causing distress (pain, etc)

Secretions Congestion from volume overload

Diuresis

Upper Airway Secretions If strong cough and able to clear airway

○ Cough/suction○ Guaifenesin to loosen

Weak cough, unable to clear airway, bothersome to patientand family○ Anticholinergics

Glycopyrrolate Atropine drops Scopolamine

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Delirium Acute onset

Need to know baseline mental status

Fluctuating Course Waxes and wanes over hours or days

Altered level of Consciousness Hyperactive Hypoactive Mixed

Inattention

Cognitive Impairments Altered Orientation Disorganized thought Delusions or hallucinations (visual or auditory) Emotional lability Disruption of sleep wake cycle Psychomotor agitation or retardation Memory impairment

Delirium Common

Can persist for weeks to months

Risk Factors Limited cognitive reserve (previous brain insult) Sleep disturbance Serious medical problem Auditory or visual impairment Hospitalization ICU admission

Delirium: Assessment History and Physical

Common and

Treatable

•Medications•Medication Withdrawal• Infections•Constipation or Urinary Retention•Uncontrolled Pain

Less Common

but Treatable

•Electrolyte Disturbance•Anemia causing Hypoxemia•Dehydration•Immobilization•Depression and Social Isolation•Vision and /or Hearing Impairment•Emotional Distress•Unfamiliar Environment

Less Common and Less Treatable

•Organ Dysfunction at End Stage•Cardiac Failure•Pulmonary Failure•Renal Failure•Liver Failure•Neurological Failure

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Delirium: Management

Non-Pharmalogical Strategies• Reorientation and cognitive stimulation

• Vision and hearing assessment

• Removal of unecessary lines, catheters, restraints

• Proper sleep/wake cysles

• Relaxation techniques

• Music

•Address psychosocial and spiritual concerns

•Change environment or bring familiar objects

Pharmalogical Strategies• Common Psychtropics

• Haldol• Quetipine• Olanzapine• Risperidone• Valproic Acid

• Always think of uncontrolled pain

• In hyperactive delirium may have to add a benzodiazepine

• In hypoactive delirium may consider a stimulant

• In refractory terminal delirium, may consider palliative sedation

Treat reversible causes if it aligns with patient goals Critical

Can be dangerous to patients and caregivers (increased mortality) Emotionally disturbing

Fatigue

Persistent sense of tiredness that interferes with usual functioning

Typically unrelieved by rest

May affect both physical and mental capacity

Very common in end-stage disease

Fatigue Potentially Reversible Causes

Endocrine dysfunction (thyroid, hypogonadism)

Anemia

Malnutrition

Depression

Pain

Infection

Chronic comorbids

Medications

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Fatigue

Energy banking, Exercise, Education regarding realistic goals

Drug Therapy Stimulants○ Methylphenidate

○ Modafanil

Steroids