Objectives Review 5 general principles of symptom management Review 5 general principles used to select (or deselect) treatment
SYMPTOM MANAGEMENT AT END-OF-LIFE
Discuss the assessment and treatment of: Anxiety Delirium Depression Nausea/Vomiting Pain
24TH Annual Clinical Update in Geriatric Medicine 4/8/16 Randy Hebert MD CMO Healthcare @ Home CONFIDENTIAL
5 General Principles of Symptom Management Look for reversible causes Most symptoms should be controlled within 24 hours Do not wait for next scheduled visit to follow up
Two questions:
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5 General Principles Used to Select (or Deselect) Treatment
Benefit? Risk? Timing/Intensity?
How much medication are you using? Does it work? ‒ Offer ATC dosing if >3 prn doses a day
Convenience? Cost?
Kill two birds with one stone Do not “prn” an ATC symptom 3
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Anxiety: Assessment
Assess for depression in all patients
Metabolic issues? Hypoxia Hyper/hypocalcemia Infection Urinary retention/constipation
Antidepressants (SSRI/SNRI) are preferred agents for chronic anxiety Avoid short acting benzodiazepines (xanax/restoril) if possible
Drug induced?
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Anxiety: Clinical Pearls
Poor pain control?
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Steroids Benzodiazepines (paradoxical) Bronchodilators Withdrawal (nicotine, alcohol, opiates, antidepressants) 5
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Benzodiazepines are associated with falls
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Delirium: Assessment
Depression: Assessment
Pneumonic: FATC
Two Questions:
Fluctuating with acute onset Attention poor, difficulty focusing, easily distracted Thinking disorganized, rambling, illogical Consciousness altered (hypo or hyper or mixed) Delirium: Fluctuating mental status & poor Attention & (disorganized Thinking OR altered Consciousness)
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Are you depressed? If yes, are there things you used to enjoy doing that you do not enjoy anymore
If the answer to both questions is yes, patient is likely depressed.
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Depression: Clinical Pearls
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Nausea/Vomiting: Clinical Pearls
SSRIs are not effective for pain If no contraindications, Haldol is the agent of choice
Antidepressants need 2-4 weeks to take effect
Consider Decadron—helps with pain, appetite, long t1/2
TCAs (tricyclics) should rarely be used
Assess hydration. Give IV fluids if necessary
Remeron may help with sleep and appetite
ABHR is not effective
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Pain: Treatment (opiates)
Pain: Clinical Pearls Opiates are generally very safe Morphine is the preferred opiate for pain Do not mix opiates—use one Most patient “allergies” are actually side effects Common side effects: Constipation (90%)—ALL patients need a bowel regimen Sedation (33%)—usually resolves in 3-7 days Nausea (33%)—usually resolves in 3-7 days 11
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A CASE
Pain: Clinical Pearls
58 WM with metastatic lung cancer to bone admitted to hospice. Received XRT to spine. PPS 60. PMH: CHF EF 45%
Opiates are generally very safe
MEDS: Lisinopril 20mg, Lasix 20 daily, ASA
Do not mix opiates—use one
PE unremarkable.
Most patient “allergies” are actually side effects
ROS: prn dull 7/10 low back pain. Feels “down”
Common side effects: Constipation (90%)—ALL patients need a bowel regimen Sedation (33%)—usually resolves in 3-7 days Nausea (33%)—usually resolves in 3-7 days
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Morphine is the preferred opiate for pain
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Depression: Assessment
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CASE Continues
Two Questions: Are you depressed? If yes, are there things you used to enjoy doing that you do not enjoy anymore
Pain and mood better on vicodin 5-10mg prn What do you want to ask?
If the answer to both questions is yes, patient is likely depressed. Feeling “Down” is not the same as being depressed
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5 General Principles for All Symptoms Look for reversible causes Most symptoms should be controlled within 24 hours Do not wait for next scheduled visit to follow up
Two questions: How much medication are you using? Does it work? ‒ Offer ATC dosing if >3 prn doses a day
OTHER PATIENT NAME: Pt resting in bed. Family present. Pt still weak. +1-+3 edema in BL extremities. Pt reports a good appetite. Pt reports a 4/10 ache in his R lower abdomen. Pt has only used 11 boluses in past 24 hours. Encouraged pt to use bolus if needed.
Kill two birds with one stone Do not “prn” an ATC symptom 17
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CASE Continues
5 General Principles for All Symptoms
You convert patient to MsContin 30 mg po bid and MsIR 7.5-15mg po q2hrs prn. He remains comfortable on that regimen for 2 months. You get called that he is throwing up, confused and “not taking his meds appropriately” for 2 days. PPS remains 60. What do you want to do?
Look for reversible causes Most symptoms should be controlled within 24 hours Do not wait for next scheduled visit to follow up
Two questions: How much medication are you using? Does it work? ‒ Offer ATC dosing if >3 prn doses a day
Kill two birds with one stone Do not “prn” an ATC symptom
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Delirium: Assessment
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Nausea/Vomiting: Clinical Pearls
Pneumonic: FATC Fluctuating with acute onset Attention poor, difficulty focusing, easily distracted Thinking disorganized, rambling, illogical Consciousness altered (hypo or hyper or mixed)
If no contraindications, Haldol is the agent of choice
Delirium: Fluctuating mental status & poor Attention & (disorganized Thinking OR altered Consciousness)
ABHR is not effective
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Consider Decadron—helps with pain, appetite, long t1/2 Assess hydration. Give IV fluids if necessary
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Pain: Treatment (opiates)
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CASE Continues You convert patient to Morphine 1mg/hr infusion and 3mg q 15min prn bolus You start haldol 0.5mg IV q6hrs atc and q2hrs prn n/v/delirium Bowel regimen You start antibiotics and IVF In two days he is back to baseline. What do you want to do?
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CASE Continues
Pain: Treatment (opiates)
His total IV morphine use is ~50 mg/day His OME is 150mg/day Convert him to oral morphine 75 mg po bid and MSIR 15mg q2hrs prn D/C his Haldol Finish his course of antibiotics
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