4/10/2018. Rationale symptom management. NCCN Palliative Care Guidelines. Satisfactory. Respiratory Symptoms. Dyspnea: Overview and Incidence

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Rationale symptom management Core Curriculum MODULE 3 PART II: SYMPTOM MANAGEMENT CARLA JOLLEY MN, ARNP, ANP-BC, AOCN, ACHPN WHIDBEYHEALTH PALLIATIVE CARE Just because we can.

. Assessment and interventions need to be addressed in the context of disease trajectory symptom distress/suffering benefits and burdens goals of care resources both financial and

1 Rationale symptom management Core Curriculum MODULE 3 PART II: SYMPTOM MANAGEMENT CARLA JOLLEY MN, ARNP, ANP-BC, AOCN, ACHPN WHIDBEYHEALTH PALLIATIVE CARE Just because we can..doesn t mean we need to.. Assessment and interventions need to be addressed in the context of disease trajectory symptom distress/suffering benefits and burdens goals of care resources both financial and caregiver NCCN Palliative Care Guidelines Years Years to months Months to weeks Weeks to days National Comprehensive Cancer Network Sign up for free Other supportive care guidelines Satisfactory Adequate symptom control Reduction of patient/family distress Acceptable sense of control Relief of caregiver burden Strengthen relationships Optimized quality of life Personal growth and enhanced meaning Respiratory Symptoms Dyspnea Cough (at a glance) Dyspnea: Overview and Incidence Subjective experience Most reported symptom 60-95% in those with advanced heart disease and copd 10-70% in advanced cancer 11-62% with renal disease Promotes disability, poor quality of life, and suffering Balkstra, 2015; Dudgeon,

Causes of Dyspnea Major pulmonary causes Major cardiac causes Major neuromuscular causes Other causes Causes of dyspnea in patients with cancer Dyspnea directly due to cancer Dyspnea indirectly due

2 Causes of Dyspnea Major pulmonary causes Major cardiac causes Major neuromuscular causes Other causes Causes of dyspnea in patients with cancer Dyspnea directly due to cancer Dyspnea indirectly due to cancer Dyspnea due to cancer treatment Dyspnea unrelated to cancer Assessment of Dyspnea Directions Use subjective report Clinical assessment Physical exam Diagnostic tests Patient experience Underlying cause Partner with one or two others We will review scenarios together one at a time with a break in between to confer Consider the questions and the place Joe is in his trajectory for each scenario Use the table with matrix to mark proposed interventions in appropriate columns Dudgeon, 2015 Treatment of Dyspnea Treating symptoms or underlying cause Pharmacologic treatments Opioids Nonopioids Treatment of Dyspnea (cont.) Nonpharmacologic Non-invasive ventilatory support (oxygen, positive pressure ventilation) if hypoxic Counseling Pursed lip breathing Energy conservation Fans, elevation Positioning Other Dudgeon, 2015; Quill et al., 2014 Dudgeon,

Symptom at a Glance: Cough Overview Causes Management Treatment of underlying causes Suppressant GI Symptoms Anorexia/cachexia Nausea/vomiting Xerostomia (at a glance) Dudgeon, 2015 Anorexia and

3 Symptom at a Glance: Cough Overview Causes Management Treatment of underlying causes Suppressant GI Symptoms Anorexia/cachexia Nausea/vomiting Xerostomia (at a glance) Dudgeon, 2015 Anorexia and Cachexia Anorexia: loss of appetite, usually with decreased intake Cachexia: lack of nutrition and wasting, result of metabolic abnormalities, etiology rarely reversible Causes of Anorexia and Cachexia Primary cause: under investigation Disease-related Psychological Treatment-related Wholihan, 2015 Wholihan, 2015 Assessment of Anorexia and Cachexia Physical findings Impact on function and QOL Calorie counts/daily weights Lab tests Skin breakdown Treatment of Anorexia and Cachexia Dietary consultation Medications: nccn guidelines for dosing Parenteral/enteral nutrition Odor control Counseling Wholihan, 2015 Wholihan,

Nausea and Vomiting Common in advanced disease Assessment of etiology is

Physiological (GI, metabolic, CNS) Psychological Disease-related

, 2015; Tipton, 2014 Assessment of Nausea and Vomiting Physical exam History

4 Nausea and Vomiting Common in advanced disease Assessment of etiology is important Acute, anticipatory, or delayed Causes of Nausea and Vomiting Physiological (GI, metabolic, CNS) Psychological Disease-related Treatment-related Other Chow et al., 2015; Tipton, 2014 Assessment of Nausea and Vomiting Physical exam History Lab values Dehydration Pharmacologic Treatment of Nausea and Vomiting Anticholinergics Antihistamines Steroids Prokinetic agents Other 4

5 Non-Drug Treatment of Nausea and Vomiting Distraction/relaxation Dietary Small/slow feeding Invasive therapies Symptom At a Glance: Xerostomia Dry mouth Difficulty in mastication, swallowing, and speech Can be caused by medications, radiation, and systemic diseases Blush & Larsen, 2015 Psychosocial Issues Anxiety Post-Traumatic Stress Disorder (PTSD) Delirium/agitation/confusion Anxiety Subjective feeling of apprehension Feelings of distress or tension from known or unknown stimuli Categories of mild, moderate, severe Two types of anxiety disorders: general anxiety disorder and post traumatic stress disorder (PTSD) Causes of Anxiety Physiological changes Medications and substances Pre-existing anxiety pre-diagnosis Uncertainty Assessment of Anxiety Physical symptoms Cognitive symptoms Questions for assessment Pasacreta et al., 2015 APA,

6 Pharmacologic Interventions for Anxiety Benzodiazepines Clonazepam Lorazepam Antidepressants SSRIs SNRIs Neuroleptics haloperidol, olanzapine Non-pharmacologic Interventions for Anxiety Empathetic listening Assurance and support Concrete information/warning Relaxation/imagery Post-Traumatic Stress Disorder (PTSD) PTSD is characterized by persistent/severe reaction to a traumatic event Combat Terrorist attacks Sexual or physical assault Accidents National/natural disasters Symptom clusters Avoidance Re-experiencing the event Hyperarousal Implications for EOL PTSD and End-of-Life Care Illness/death can be a PTSD activator Challenges social ties Delirium or flashbacks? Medication GOAL: Reduce PTSD symptoms and create an emotionally safe environment Grassman, 2015 Delirium/Agitation/Confusion Delirium - Acute change in cognition/awareness Agitation or withdrawal - Accompanies delirium Confusion - Disorientation, inappropriate behavior, hallucinations Delirium/Agitation/Confusion: Causes Medications Infection Hypoxemia Bladder distention Unrelieved pain Heidrich & English, 2015 Other 6

7 Delirium/Agitation/Confusion: Assessment Physical exam History Spiritual distress Other symptoms Heidrich & English, 2015 Delirium/Agitation/Confusion: Treatment Maintain Safety Pharmacologic Neuroleptics Monitor for side effects, withdrawal Eliminate non-essential/contributing medications Reorientation Relaxation/distraction Hydration Wounds Loss of skin integrity Pressure ulcers Malignant wounds Kennedy Terminal Ulcers Assessment of Wounds Characteristics Pain Psychosocial Caregivers Local Wound Care Issues: HOPES Treatment of Wounds Hemorrhage or bleeding: Consider dressing with calcium alginate for minor bleeding Odor: Apply topical metronidazole or use activated charcoal dressings Pain: Select dressings with atraumatic and nonadherent interfaces Exudate: moisture is contraindicated in nonhealable wounds, consider foams, alginates, and superabsorbent products based on diaper technology Superficial bacterial burden: use topical antimicrobial agents for superficial wound infection and systemic for deep and surrounding wound infection Frequent position changes Wound cleaning Dressings Provide analgesia Seek consultation Prevention is key Seaman & Bates-Jensen,

Dilemma: Assessing/Treating Wounds in Patients with Life-Limiting Illness Assess underlying cause What are the goals of care? Is it realistic that the wound will heal?

8 Dilemma: Assessing/Treating Wounds in Patients with Life-Limiting Illness Assess underlying cause What are the goals of care? Is it realistic that the wound will heal? Prevent further pressure ulcers/wounds Manage pain and odor Pressure ulcer may indicate organ failure One Final Reminder: Be Aware of Symptoms of Urgent Syndromes Superior vena cava obstructions Pleural effusion Pericardial effusion Hemoptysis Spinal cord compression Hypercalcemia Bobb, 2015 Conclusion Multiple symptoms are common Coordination of care with the interdisciplinary team Use drug and nondrug treatment Patient/family teaching and support 8

10/4/2017. Rationale symptom management. Satisfactory. NCCN Palliative Care Guidelines. Respiratory Symptoms. Dyspnea: Overview and Incidence

10/4/2017. Rationale symptom management. Satisfactory. NCCN Palliative Care Guidelines. Respiratory Symptoms. Dyspnea: Overview and Incidence Rationale symptom management Core Curriculum MODULE 3 PART II: SYMPTOM MANAGEMENT CARLA JOLLEY MN, ARNP, AOCN, ACHPN WHIDBEYHEALTH PALLIATIVE CARE Just because we can..doesn t mean we need to.. Assessment