Symptom Management. Dr Rosalie Shaw

Transcription

1 Symptom Management Dr Rosalie Shaw

2 Thank you for inviting me The story of Shariffha

3 The goals of palliative care To relieve suffering To ensure normal functioning in daily life for as long as possible To achieve quality of life To give dignity to the patient even at the time of death

4 Common problems Pain 64% Weakness 62% Weight loss 56% Anorexia 48% Constipation 33% Dyspnoea 27% Nausea and vomiting 13% Sore mouth 55% Fungating wounds 12% Dysphagia Early satiety Oedema. Tay WKJ et al Annals of Academy of Med Singapore :

5 Non-physical problems Anxiety Depression Anger Disruption of personal, social & work relationships Increased reliance on family members & friends There are complex interactions between physical & non-physical sources of distress.

6 Pain is a significant problem in only about 2/3 of cancer patients and this pain can usually be well controlled. Sometimes minor symptoms trouble patients more than pain or shortness of breath (e.g. constipation, weight loss, weakness and poor appetite, sore mouth, fungating wounds).

7 Principles of management: Evaluate the symptom If possible, determine the cause of the symptom Disease progression? Treatment? Other illnesses e.g. arthritis? Debility and weakness? Investigations only if this will determine treatment Will treatment improve the symptom significantly?

8 Principles of management: Evaluate the patient Status of disease? Well? Deteriorating? Dying within days? Wishes of patient and family? What is appropriate for this patient at this time?

9 Principles of management: Treatment Non-pharmacological treatment? Nursing measures (e.g. fan if breathless, cool bath if fever, warm drink if anxious) Non-drug treatment Radiotherapy especially if bone metastases Surgery especially if fracture Chemotherapy Nerve block

10 Principles of management: Treatment with medications Keep regimes simple Give minimum number of medicines Give minimum number of tablets Choose drugs that have more than one action e.g. haloperidol anti-emetic and mild sedative Give once or twice a day if possible, rather than three or four times a day

11 Principles of management: Treatment with medications Review frequently Symptoms change and new symptoms appear Ensure compliance by explanation and written instructions for the patient and family

12 Constipation A very troublesome symptom for many patients Constipation can occur even in paient with no oral of enteral intake Anticipate and prevent constipation by starting laxative when starting opioids

13 Constipation Per rectal examination is essential An abdominal xray may be helpful Suspect fecal impaction if diarrhoea and incontinence

14 Drugs used in constipation Important Contact cathartics o senna (Senokot) o bisacodyl (Dulcolax) Osmotic cathartics o lactulose o magnesium salts Suppositories & enemas o glycerin / bisacodyl o sodium biphosphate Less Important Lubricants o mineral oil (Agarol) Fibre* o psyllium (Metamucil, Normacol) *Avoid fibre laxatives in palliative care patients.1

15 ภาพน ง 14.1 port Rosalie Shaw, 6/3/2549

16 The very constipated patient Clear from the top and the bottome Big doses of senna e.g. 3 tablets stat & 3 tablets tds for 3 days Daily suppositories or enemas for 3 days Manual removal of feces if impacted High colonic enema if rectum is empty

17 Cachexia and Anorexia Progressive wasting in patients with advanced cancer Clinical features: Lethargy Muscle wasting Loss of weight Anaemia

18 Aetiology of Cachexia Malnutrition Anorexia Malabsorption Protein loss due to vomiting or diarrhoea Weakness Altered metabolism of protein, carbohydrate and lipid Related to tumor necrosis factor and other factors

19 Whose problem is it? The patient? The family? The doctor? The nurse? The dietician?

20 Management of anorexia Explanation to relatives: Not starving to death Control nausea Relieve constipation Treat sore mouth Consider steroids or progestagens (e.g. megestrol) Small attractive tasty meals Nutritional supplements are only helpful if actually taken by the patient!

21 Dry mouth & sore mouth Causes: medications radiotherapy mouth breathing inability to swallow in terminal phase chemotherapy herpes simplex aphthous ulcers Candidiasis (thrush)

22 Management of sore mouth General measures Keep mouth moist - sips (Sweet drinks may encourage thrush.) Mouth care every 4 hours clean teeth (remove dentures) rinse mouth well with water Oil or petroleum jelly (Vaseline) to lips. Do not use lemon & glycerin swabs

23 If mucositis Treat with fluconazole / nystatin if candidiasis, Acyclovir if herpes simplex Kenalog in orabase ointment or Sucralfate - crush tablets to make a thin paste Xylocaine viscous 2% solution before eating Food at room temperature or chilled Avoid highly spiced or acid foods Moisten food with soups or sauces

24 Fungating tumours Cause great misery Ugly Bad smell Exudate Pain Bleed

25 Management of fungating wounds Clease with saline or clean water (Does not have to be sterile) Debride if necessary Control odour Metronidazole powder Providone-iodine (Betadine)

26 Management of fungating wounds Control exudate Change outer dressing as necessary

27 Management of fungating wounds Control pain Change dressing as infrequently as possible Soak off dressings to remove. Give analgesic 30 before dressing. Regular analgesic (e.g. paracetamol or NSAID) Mylanta applied to ulcer may decrease burning pain.

28 Management of fungating wounds Control bleeding Non-stick dressings Adrenalin 1:1000 direct to bleeding point Sucralfate paste (crushed tablet in water soluble gel) Gelfoam /Silver nitrate Radiotherapy

29 Management of fungating wounds These wounds will not heal The goal is patient comfort

30 Why is symptom management important? Reduce suffering Maximize comfort Preserve function Prevent complications Prolong survival

31 Conclusion the important questions Does the patient feel better after the intervention? Feeling better is not about medications. Our kindness and concern may be more important than our medications. Small changes may make a lot of difference to the patient. We cannot expect to fix the problem. Symptoms will change and new symptoms may appear.

32 A helpful reminder God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference. Reinhold Neibuhr