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Flashcards in Non-Pain 1 Deck (23):

When managing non-pain symptoms, should choose treatment strategies that support the patient's goals of care

- Age
- Functional Status
- Overall Needs
- Rate of change of the disease
- Life expectancy


Don't treat the symptoms, treat the _____ of the disease whenever possible



Goal setting with Geriatrics

- Are the goals achievable?
- Are the goals beneficial?
----extend life or improve comfort?
- How will the results be measured... timeframe to reassess and decide whether to continue or stop the intervention.


Most common non-pain symptoms in palliative care

- Constipation
- Nausea and vomiting
- Diarrhea
- Bowel Obstruction
- Anorexia and Cachexia
- Delirium
- Depression
- Dyspnea


Dyspnea is common is which diseases?

- Cancer
- Dementia

- Tends to worsen as death approaches


Assessing Dyspmea

- Dyspnea is SUBJECTIVE
- Self-report the gold standard
- RR, signs of increased WOB, oxygen saturation, and other tests DON'T correlate with patient reporting dyspnea
- Rx is dependent upon prognosis, goals of care, risks and benefits of tests/interventions


Causes of Dyspnea

BREATH AIR mneumonic
- Bronchospasm
- Rales
- Effusion
- Airway obstruction
- Thick Secretions
- Hemoglobin is low
- Anxiety
- Interpersonal issues
- Religious concerns


Treatment for Dyspnea

- Oxygen
- Opioids (first line)
- Anxiolytics (treat anxiety, not dyspnea)
- General Measures
- Alternative, Complimentary- things like acupressure, acupuncture, meditation, massage
- Non-invasive ventilator support (CPAP)


General, non "medical" interventions for treating dyspnea

- Reduce exertion/energy expenditure
- Reposition the patient- upright or the compromised lung down
- Provide skin care for the buttocks
- Improve air circulation
- Address anxiety and provide reassurance
- Discuss any patient, family, or staff concerns about using opioids to relieve dyspnea


General things to assess with Dysphagia

- "difficulty swallowing"
- Discern whether it is neurologic or non-neurologic---- things like solids progressing to liquids (obstruction) and simultaneous solids and liquids (neurologic)
- Conservative management can ameliorate dysphagia for the majority of patients
---- emphasize good oral hygiene


Reversible causes of anorexia

- Aches and Pains
- Nausea and GI dysfunction
- Oral Candidiasis
- Reactive (or organic) depression
- Evacuation problems (constipation, retention)
- Xerostomia (dry mouth)
- Iatrogenic (radiation, chemo, drugs)
- Acid-related problems (gastritis, peptic ulcers)


Anorexia Treatment

Appetite stimulants-
-- megestrol Acetate
-- Corticosteroids
-- Eicosapentaenoic acid
-- Thalidomide
-- Cannabinoids
Artificial Nutrition and Hydration
-- Enteral feedings (tube)
-- Parenteral feeding
-- The benefits of artificial nutrition for palliative care patients are difficult to identify


Reframing Requests for artificial Hydration and Nutrition

- Validate their concern
- Suggest other alternative interpretation
- share more info and give alternative explanation and suggestions


Nausea and Vomiting- General

- In seriously and terminally ill patients, these two symptoms are extremely common.
- Nausea and vomiting can cause significant distress
- Can usually be controlled in over 90% of patients


Treatment strategies for Nausea and vomiting

- Select an antiemetic agent based on the likely cause, pathway mediating the symptoms, and neurotransmitters involved
- Other general measures, like small and frequent meals, frequent small sips of fluids, avoiding strong odors or unpleasant tastes, and address nonphysical symptoms like psychological, social, and spiritual


Malignant Bowel Obstruction

- 1/2 of ovarian and GI cancer patients have this
- Patients diagnosed with this have a median survival of 3 months
- High symptom burden


Treating Malignant Bowel Obstruction

- Management dependent upon functional status, goals of care, expected survival

- Surgical- limited evidence of the benefit and QoL
- Endoscopic techniques- stents (if single point of obstruction)
- Medical management- the mainstay of Rx


Delirium signs/symptoms

- Acute Onset
- Fluctuating
- Altering levels of consciousness- hyperactive, hypoactive, or mixed
- Cognitive impairments
-- Altered orientation
-- Altered organization of thought
-- Altered perceptions
-- memory impairment


What causes Delirium in elderly patients

- other are infection, constipation, urinary retention, and uncontrolled pain


Assessing Delirium

- Identify potentially reversible causes
- Treat underlying cause
- Use low dose non-sedating antipsychotics
- AVOID benzodiazepines- and NEVER use without an antipsychotic


Issues with delirium

- High incidence
- VERY distressing to patients and family members
- Cause of discord between family members and health care professionals
- aggressive preventative measures


Preventative Measures for Delirium

- Prevent dehydration
- Remove unnecessary catheters/IVs, restraints
- Reduced light and sound at night with minimal interventions
- Decrease environmental stimuli
- Sleep, music, massage


Key points from this lecture!!

- Most patients receiving palliative care have multiple symptoms
- Screening assessment is key to identifying the symptom constellation
- Detailed history and comprehensive PE are needed to determine most probably cause
- Treatment strategies should be determined by the patient's goals of care and directed at treating the underlying cause whenever possible!