Approach to symptom control near the end-of-life

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Egbert Curtis
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1 Approach to symptom control near the end-of-life 18 Sept 2011 Dr Alethea Yee Senior Consultant, Department of Palliative Medicine National Cancer Centre,Singapore

2 What is end of life? No precise definition The period of time marked by disability or disease that is progressively worse until death. Final stage of the journey of life..

3 For the purpose of this talk, we will define EOL as the last week to days of life

4 THE LAST DAYS OF LIFE Nowadays many younger healthcare workers have little personal or professional experience in caring for the dying Yet 58% of deaths occur in hospital (Singapore Demographic Bulletin 2003, Registry of Births and Deaths)

5 LAST DAYS IN ACUTE HOSPITAL Patients often have troublesome symptoms, resuscitation not consistently discussed (SUPPORT study, JAMA 1995) Even when death was expected, patients could be subjected to CPR (Seah, Low, Chan. SMJ 2005)

6 The Last Days of Living How people die remains in the memory of those who live on - Dame Cicely Saunders

7 There is only 1 chance to get it right! Good care at the end-of-life Significant personal and family growth Bad care at the end-of-life Incomplete life closure Suffering occurs Bereavement prolonged and difficult

8 IS THE PATIENT DYING? Diagnosing dying can be difficult Some guiding features : progressive deterioration very weak drowsy may be disoriented difficulty swallowing abnormal breathing, cool peripheries No reversible cause (esp if acute onset) or treatment would be futile or patient does not want treatment

9 Symptoms in the last week of life Fatigue 83% Pain 48% Dyspnea 50% Confusion 36% Anxiety 31% Depression 28% Nausea n vomiting 25% Klinkenberg JPSM Jan 2004

10 Symptoms in the last 48 hours Moist breathing 56% Pain 51% Agitation 42% Incontinence of urine 32% Breathlessness 22% Retention 21% Nausea & vomiting 14% Sweating 14% Jerking, twitching 12% (200 patients, 1990)

11 Principles of symptom management at EOL Goal of care is comfort and dignity Often parenteral route is needed (iv or sc) unless NGT already in situ. Rectal route if patient refused needling Stop all non- essential medications Continue opioids if already on Drugs alone not enough!- psychological support of patient and family is essential

12 Pain management Decide on etiology and mechanism of pain WHO ladder still applies Know opioid conversions from oral to parenteral/ topical Review, review, review

13 WHO LADDER Step 1 MILD PAIN paracetamol NSAIDs/COXIBs Step 2 MODERATE PAIN Codeine Tramadol Step 3 SEVERE PAIN Morphine Fentanyl Oxycodone Methadone Hydromorphone Nerve blocks Spinal analgesia

14 Opioid conversions Codeine to oral morphine 10:1 Tramadol to oral morphine 5:1 Oral morphine to oral oxycodone 2:1 30mg oral morphine ~ 12ug/h patch =12ug/h infusion Oral morphine to iv/ sc morphine 3:1

hospice 78% of those surviving only 1 day (National Hospice

15 Dyspnea at the EOL May be a poor prognostic sign Prevalence increases closer to death 55% dyspnoeic on admission to hospice 78% of those surviving only 1 day (National Hospice Study, UK) Distressing to patients and families (many studies confirm this)

16 Opioids for dyspnea Good evidence to show that oral or parenteral opioids can improve dyspnea (Jennings 2002, Abernathy 2003) No effect on effort tolerance No evidence for nebulised morphine Most studies on non-cancer patients

17 Do opioids hasten death? No difference in survival between high doses vs low doses ( Bercovicah et al 1999, Morita et al 1998) Patients on opioids vs those without : No sig difference in survival or correlation bet opioid dose and time of death (Brescia 1992, Chates 1998)

18 Do opioids hasten death? No difference between rate of dose increase and survival (Sykes & Thorns 2000) Those who had >2 fold increase in dose lived sig longer than those who did not (22 days vs 9 days) (Bengoechea et al 2010) Patients who received morphine during withdrawal of ventilatory support lived longer than those who did not (Wilson 1992, Mazer et al, 2011)

19 Do opioids hasten death? Not if used properly

20 Do opioids cause respiratory Evidence from this comes from acute settings (post-op/ trauma ) depression? Effects of large iv bolus is different from gradual titration to effect

21 Opioids for dyspnea How to Use Start low if opioid naive eg 2.5mg 4h or 0.2mg/h Titrate against severity of dypsnea Optimum starting dose, choice of opioid not clear Most studies use morphine Local evidence (unpublished) shows good effect with iv/ sc fentanyl in severe renal impairment

22 Anxiolytics Psychological factors have a role Depressed/anxious patients more breathless Limited evidence for benzodiazepines but widely used Navigante et al 2006 : midazolam as adjunct to morphine improves dyspnea in cancer

23 Anxiolytics S/L lorazepam mg prn (t1/ hr) Iv or sc midazolam (t1/2 5hrs) eg 5-10mg/24 hrs; 2-5mg prn Phenothiazines (eg Haloperidol) : Evidence derived from COPD. May be useful for fear, especially at end of life

24 Do sedatives hasten death? Evidence does not suggest so Prospective study of matched cohorts (n=518) : no difference in survival between those sedated and those not ( Maltoni et al, Ann of Onco 2009) Similar findings by Sykes and Thorns (Lancet Onc 2003)

Cranston et al 2008, Philip et al 2006).

25 Oxygen Easy to start, difficult to stop patients and families expect it! Evidence suggests oxygen no better than air (fan) in relief of dyspnea ( Cranston et al 2008, Philip et al 2006). May be beneficial in hypoxic cancer patients (SaO2 <90%) who is breathless Does not help mildly or nonhypoxic cancer patients

26 Terminal Delirium Deterioration in cognitive function with fluctuations in conscious level leading to disorientation and confusion near the EOL 68-88% of all cancer patients Physical /+ psychological causes

27 Terminal Delirium - causes PHYSICAL PSYCHOLOGICAL Full bladder/rectum Uncontrolled pain Metabolic Drugs Intracranial lesions Hypoxia Post-ictal Anxiety Denial Fear of dying Fear of losing control Unfinished business Spiritual distress Distress at leaving family

Terminal Delirium -approach Manage underlying physical cause as appropriate Address psychological distress Antipsychotics and sedatives mainstay of Mx Start with Sc/iv Haloperidol

28 Terminal Delirium -approach Manage underlying physical cause as appropriate Address psychological distress Antipsychotics and sedatives mainstay of Mx Start with Sc/iv Haloperidol 5-10 mg/24h. Often needs stat dose of midazolam eg 1-5mg to calm patient first before haloperidol infusion May need midazolam infusion eg 5-30mg/24h Phenobarbitone infusion last resort

29 Noisy terminal breathing More distressing for relatives than for patient. Explanation & reassurance Stop iv fluids Positioning and gentle suction of secretions from oral cavity Sc/iv buscopan mg prn/4 h or mg/24h infusion Sc/iv scopolamine mg prn/4h or mg/24h infusion Sc/iv glycopyrronium 0.2mg prn/4h or mg/24h infusion

30 Care of The Family Explain what is happening Get them involved with simple tasks of caring (mouth, skin care) Encourage them to talk to and touch the patient Opportunities for parting words Religious and cultural considerations

31 Care of the Dying Pathway Encourages anticipation of problems Remind nurses to provide consistently high standard of EOL care Reduces paperwork Consistent standard of documentation Reduces dependence on palliative care team

32 CDP pilot in an oncology ward

33 CDP pilot in an oncology ward Staff survey of 46 nursing staff 2 months into the pilot more than half of the staff felt that the use of CDP has raised awareness about end-of-life care That the CDP is a useful teaching tool for healthcare workers

34 What people need most when they are dying is relief from distressing symptoms of disease, the security of a caring environment, sustained expert care and assurance that they and their families will not be abandoned. Craven and Wald 1975

35 Thank you

Care in the Last Days of Life

Care in the Last Days of Life Introduction This guideline is an aid to clinical decision making and good practice in person-centred care for patients who are deteriorating and at risk of dying. The patient