Memorial University of Newfoundland - PDF document

Memorial University of Newfoundland Presented at Wednesday at NoonÑAsk the Consultanter the storm-tossed ocean of terminal illness,the beacon of palliative care shines brightlyfrom the tripartite base of symptom control, com-munication, and family support. The light from allthree needs to be focused on any given problem, asthe patient and family move toward the end-of-lifestage and beyond. 1.Symptom control is a concept of relieving thepatientÕs distress, rather than offering the comfort2.Between the parties involved (oncologist, fam-ily physician, nurse, social worker, clergy, family,offers consistent messages to smoothÑbut rarelycompletely settleÑtroubled waters.ocusing on TLCin Palliative Care DavidÕs twitchingpresented with dyspnea and weakness. He has liver, bone, and brain metastases.On examination, David was suffering fromDavidÕs wife is overwhelmed with his care andHis opioid was rotated from morphine tohydromorphone 10 mg every four hours with abreakthrough of 5 mg hydromorphone every onehours, he required three doses of lorazepan andno breakthrough doses of hydromorphone.his twitching had decreased. 3.Wrapping up the palliative trio is family sup-port. All families need support embroidered withkindness and understanding and, all too often,direction and instruction. The patient with familyin tow, not the illness, becomes the locus of care. witching, jerking and seizuringith all the tissue breakdown and chemical imbal-ances that accompany the dying process, IÕm sur-prised patients donÕt demon-Multifocal myoclonus is apainless, yet distressing,about. The causes include:opioid toxicity, ypercalcemia (don't forgetthe unknown.If the patient is near death or has refused furtherinvestigations, the workup is at the bedside andinvolves a review of medications, a careful physi-cal examination, and a discussion with the patientand/or family.Opioid rotation is the current phrase used toand the start of another. Morphine, for example, ismetabolized in the liver, and the breakdown prod-ucts are excreted via the kidneys. In renal failure,these breakdown products accumulate and blockpatientÕs morphine requirements rapidly increasewithout a consequent increase in comfort. Commonly, a patientÕs morphine needs willincrease as the illness progressed and the painincreases, but in such cases the morphine contin-ues to relieve the pain. In morphine toxicity situa-tions, the drug stops working. Stopping the mor-phine and switching to immediate-release hydro-morphone will allow the morphine breakdownproducts to be excreted. If toxicity is the cause, theclopramide may help relieveoclonus, while investigat-ing for hypercalcemiadepends on the performancepatient is in the last few daysphysically able to withstandthe intravenous (IV) fluidsed to correct this imbalance.commonly in frail patients with multiple bonymetastases, and with cancer of the lung. Low-doseclonazepam (0.5 mg to 1 mg twice daily) helps.treated acutely in the usual way with IV diazepamand dilantin before the patient is switched to oralmedications. As the illness progresses and thepatient becomes less able to swallow, parenteralmedications are needed. I have had good resultsday, or 90 mg at bedtime given through a subcuta-neous port. alliative CareThe Canadian Journal of CME / December 2003 Moving a near-dyingpatient down to adiology may causemore suffering thanerall benefit. What about treating near-death?Moving a near-dying patient down to radiologymay cause more suffering than overall benefit.Similarly, blood tests are often difficult because offriable veins. As well, the family sits around andries about the test results. They remain worrieduntil your next family meeting. No tests usuallymeans the patient and family are calmer and anxi-Also what are you going to do with theresults? Will the always-abnormal investiga-tions help, or just leave you and the familywith unanswerable questions? What then?More tests? Perhaps a consultation with acolleague, who might or might not know theamily dynamic as well as you? Our aim hereis to relieve distress, not cause more.How do I treat delirium?The workup for delirium is well-document-ed, but in the end-of-life circumstance thephysician needs to consider the performanceBedside evaluation is quite appropriate if thepatient is within days of death. Considerthis: the therapies to investigate and ÔcureÕdelirium can be extensive and uncomfort-able. The correction of the multiple causes of deliri-um needs to be tempered by the preferences andphysical reserve of the patient. A complete investi-gation and aggressive therapy are indicated earlyin the last days. The family needs to be informed asalliative Care Methods of aiding a patient to breathAsk the patientÕs anxiety-laden visitors to step outof the all-too-crowded roomon a fan, open a window, and offer the Prescribe AtivanequiredPrescribe nebulized saline, which has Sometimes, all above drugs are needed at once to what is going on. I find that carefully explainingperception of whatÕs happening will help mostpatientÕs sedation.minal delirium occurs as the patient starts todie, and can last up to a week. The patient mayshow symptoms all the way from a little bit of rest-lessness to full-blown psycho-motor agitation withaggression and screaming. Up to 30% of dyingpatients require sedation (Table 1).Although terminal delirium occurs in 40% ofpatients, the severe form occurs perhaps 1% of theMalignant bowel obstructionBowel obstruction is traditionally treated by reliev-nasogastric tube and suction. The plan is to relaxthe bowel, allowing the obstruction to release.When the obstruction is caused by cancer, andhen the surgeon reports further surgery will notbe contemplated, the patient is still suffering andneeds relief. A low obstruction will permit somepatients to ingest food but regurgitate every sooften (possibly twice a day), while those with ahigh blockage will vomit after every ingestion. ain relief is given subcutaneously through autterfly needle with a rubber injection tip.Maxeran(metoclopramide) should be avoided, asits prokinetic action may worsen the vomiting. Theinsertion of a gastrotomy or nasogastric tube mayhelp patients with a high obstruction, but rarelyhelp those with a lower bowel blockage. Surgerymay relieve the obstruction, but post-operativecomplications are frequent and severe, and leaveerybody involved wishing they had tried medicalmanagement instead. Parenteral fluids may begiven through a lower abdominal site subcuta-neous, butterfly set up at a rate of 500 cc to 750 cctwice daily. How do I treat shortness ofbreath?The physician should consider the relief ofreversible airways disease and drainage of excesspleural fluids in assisting a patient who is short ofbreath. If, as is often the case, neither is possible(because the disease is not reversible or the patientis too sick or too fed up to have a pleurocentesis),the physician can try to relieve the symptom. Small doses of morphine (half the four-hourdose or 5 mg to 10 mg orally every hour as need-ed) usually help the patient rest, and decrease airhunger. Very frail, elderly persons might need less(2.5 mg morphine), but generally the doses are inthe 5 mg to 10 mg range. The drug dilates periph-eral vessels, diverting fluid from the chest, anddecreases air hunger without changing the oxygensaturation or level of alertness. There are otherys to aid breathing as well (Table 2).When assessing a patient who is acutely short ofbreath, I find it helpful to sit (not stand) quietly atthe bedside and take the patientÕs pulse and respi-ness provides an opportunity for the patient andamily to calm down. Rushing about ordering X-rays, oxygen satu-rants and tubes makes the patient more distressedand sends the family into a tizzy. The next thingou know, the whole extended family is at the doordemanding explanations. What do I do about dehydration?he use of IV fluids in patients with advanced can- alliative CareThe Canadian Journal of CME / December 2003 eeks of life, most have lost considerableeight. The albumin is often below 20, andthe muscle mass has decreased considerably.Cancer somehow changes the sensation oftaste, and previously loved foods becomeunpalatable or even nauseating. Smells ofcooking food can induce nausea. Appetite isreatly diminished in this population, as isfood intake. As the disease progresses, fluidintake drops off to nothing. Still, suchpatients rarely (if ever) complain abouthunger. Remember to moisten the mouth, torelieve the sensation of dry mouth.The low colloid osmotic pressure preventsthe retention of the fluid in the vasculature,so ÒrehydrationÓ fluid becomes:ankle edema, thereby decreasing ambulation, pulmonary edema and pleural fluid, causingincreased shortness of breath, andascites leading to increased nausea and vomit-Setting up and keeping an IV line in situ is dif-icult because of the friable veins. Also, the IVpump, with its 50-times-a-day alarming mecha-nism, puts a physical barrier between a dyingpatient and the family. Although patients rarelydelighted when I say Òno more IVs,Ó many familymembers still labour under the false impressionthat IV fluid is somehow food.I hold a discussionabout food and fluid intake in every patient andamily situation. The discussion is daily with someuitous use of the IV. Patients are always more com-fortable without an IV, so such discussions end upalliative Care Symptom control relieves the patientÕs distressrather than offering the comfort that comes withcure.Multifocal myoclonus is a painless, yet distressing,Hypercalcemia occurs more commonly in frailMoving a near-dying patient down to radiologymay cause more suffering than overall benefit. The correction of the multiple causes of deliriumneeds to be tempered by the preferences andphysical reserve of the patient.The physician should consider the relief ofbreath. being held with the family. Tact, understanding,kindness, and compassion are needed in greatquantities here. Giving in to wacky demands, oroffering up medical rudeness doesnÕt make any-body more comfortable. As comfort is what pallia-with advanced cancer is not indicated. alliative Care www.stacommunications.com For an electronic version of The Canadian Journal of CME 1.Edmonton Regional Palliative Care Program:www.palliative.org2.Palliative Care Education:wwwpccchealth.org/pced CME