1、Common Physical Symptoms at the End of Life:Pulmonary and GI Symptoms nMike Marschke,MDMr.M-Chronic SmokernMr.M,78 YO,is a lifetime smoker.Dyspnea began 5 years ago.nintubated twice in the past year.nSince last admission 2 mos ago always needs 2-3 l/min nasal cannula oxygen,even at rest.nHe has lost
2、 15 lbs,has a persistent cough,with gray phlegmnHe is on steroids and nebulizers What is Dyspnea?nSubjective sense that you need to breath,that you hunger air.nMechanismnRespiratory Center of Medulla nChemo receptors sensing low O2,hi CO2nMechano receptors(J receptors)in lung,respiratory muscles,and
3、 diaphragmnVascular congestion-CHFnCerebral CortexMeasurements?npO2,pCO2,O2 satsnPeak flowsnPulmonary function tests measuring lung volumes and flowPrognosis 6 mos.:nClass IV respiratory failure(=dyspnea at rest)nFrequent ER/hospital stays,recurring pulmonary infections,intubationsnpO2 56mmHg,O2 sat
4、 50Dr.arrivesnMr.K is sitting in a reclining chair.nFeels“breathless”with minimal exertion.nBreathing is“heavy and suffocating”.nNo apparent precipitating infection etc.EvaluationnPhysical exam-distant breath sounds,coarse crackles at bases bilaterally,RR=32 at rest,takes breathes in mid-sentence.n
5、tachycardic at 100/minnRecent Weight loss of 15lbs.in 6 months.n2+edema bilateral lower extremitiesThe Bargainer nHas no wish to be“brutalized”.He knows his emphysema will kill him someday.nHe has executed a DNRnHe wants to feel better but does not want to go back into the hospital.nWhat about CXR,l
6、abs?Assess causenComplete assessment may lead to treatable condition.nPleural effusionnPneumothoraxnAnemianPEnCHFnPneumonia CXR FindingsnMass occluding R bronchus nPost obstruction atelectasisnTreatment optionsnBronchoscopynRadiationnSupportivenWeigh risk/benefits and patient wishesOxygennPulse oxim
7、etry not helpful go on symptomsnPotent symbol of medical carenExpensive,noisy,hot,uncomfortable for somenFan may do just as wellOpioidsnRelief not related to respiratory ratenNo ethical or professional barriersnSmall dosesnCentral and peripheral actionnInhaled morphine works peripherally but may ind
8、uce bronchospasmAnxiolyticsnSafe in combination with opioidsnlorazepamn0.5-2 mg po q 1 h prn until settlednthen dose routinely q 46 h to keep settledNonpharmacologic interventions.nReassure,work to manage anxietynBehavioral approaches,eg,relaxation,distraction,hypnosisnOther CAM aromatherapies(Eucal
9、yptus,Bergomot),massage,healing touchnLimit the number of people in the roomnOpen windowNonpharmacologic interventions.nEliminate environmental irritantsnKeep line of sight clear to outside nReduce the room temperaturenAvoid excessive temperatures.Nonpharmacologic interventionsnIntroduce humiditynRe
10、positionnelevate the head of the bednmove patient to one side or othernEducate,support the family4 Weeks Later in HospicenMore dyspneic and semi-comatosenLots of upper airway noise with wheezes more prevalentnGets agitated at times,cyanoticnDifficult swallowing pillsnAt times when sleeping family fe
11、els he is choking to deathFinal hours of carenEducate the family-no surprisesnDouble effect?nOral secretions can be lessened by keeping patient dry,scopalamine patch,levsin(anti-cholenergics)nUse opioids/benzodiazepams as needednSuctioning difficult for patient and likely not to be able to get deep
12、enoughGastrointestinal Sx:EOLnAnorexia 60-80%nXerostomia 55-70%nNausea 15-30%nVomiting 15-25%nConstipation 50%nDiarrhea 10%AnorexianCorticosteroidsnMegestrol acetatenDronabinol nOther causes gastritis/PUD PPIs,early satiety/reflux Reglan,oral thrush anti-fungals.nRealize patient usually VERY comfort
13、able with this!Dry MouthnHyposalivationnMouth care and gum/candy,popsiclesnArtificial salivanOral swabs/wash clothnPilocarpine 5mg tidnMucositisnDiphenhydramine,dexamethasone,lidocaine,and nystatin swish and swallowNausea/vomitingAnxiety,fear,anticipatory,psychologic factors,increased intra-cranial
14、pressureDopaminergic(narcotic induced and many others)Serotinergic(chemo induced)Histamine(labrynthitis,meds)Vagally mediated(ulcers,masses,irritations)Reflux,gastritis,regurgitation,masses,ulcers,gastric outlet obstructionSmall bowel obstruction,impactionRenal(pyelonephritis,stones),liver(hepatitis
15、,cirrhosis),gall bladder,uterineA Mechanistic ApproachnCentral nIncreased pressures(tumor,swelling,hydrocephalus)steroids,RT,surgerynAnxiety,fear,anticipatory benzodiazipines,psychotherapynChemo-trigger Receptor Zone(narcotics,other meds,many GI causes)nAnti-dopaminergics prochlorperazine(compazine)
16、,haloperidol,droperidol,trimethobenzamide(Tigan),metoclopramide(Reglan),promethazine(phenergan)nCan be given PO,suppository,some IM/IV,some even in a paste formA Mechanistic ApproachnNausea Center(chemotherapy induced)nAnti-serotinergics ondansetron(Zofran),granisetron(Kytril),dolasetron,palonosetro
17、nnIV,PO,and expensivenVestibular-ocular reflex(with vertigo)nAnti-histamines Benedryl,Antivert,AtaraxnAnti-cholinergics-ScopolaminenOro-pharyngeal vagal lidocaine swish and swallow,treat the lesionA Mechanistic ApproachnGastro-esophageal nReflux/regurg prokinetic agents like metoclopramide(reglan),H
18、2 blockers/Proton pump inhibitorsnGastritis/ulcers H2 blockers/PPIsnDelayed gastric emptying(narcotics,DM)metoclopramidenGastric outlet obstruction NG suction,surgeryA Mechanistic ApproachnIntestinalnObstruction NG suction,surgery,NPO with Octreotide(Sandostatin)nImpaction remember to check rectal e
19、xam may need manual dis-impaction,enemasnOther organs try to treat underlying cause if possible,may also respond to meds effecting CRZOther agents for nauseanCAM aromas(peppermint,ginger),herbs(ginger,cola),mind-focusing(meditation),acupuncturenDronabinol(marijuana)nCombination suppositories/gels nB
20、DR(Benadryl,Decadron,Reglan)nCan add ativan,Tigan,compazine and othersConstipationnDefined:nhard,infrequent stools,needing to strain for 10 minutesnUncomfortable feelingnIncidence-nUS nutrition-Male 8%Fem.21%nHospice 80%nHospice on narcotics 90%nHospital 66%;Home 22%PhysiologynMeal passes out of sto
21、mach into small intestine,with the addition of gastric,pancreatic,and biliary secretionsnTransit time is 1-2 hrs thru the small intestine,where digestion and absorption takes placenLarge bowel transit time is 1-3 days,where bulk of water is removed and stool is formednFinal BM when rectal ampula fil
22、ls,increase abdomenal pressure,relax anal sphincter and“the brown river flows”Constipation causes:nMedicationsnopioidsncalcium-channel blockersnanticholinergicnDecreased motilitynIleusnMechanical obstructionnDiet(lo fiber,hi meat and starch)nMetabolic abnormalities(hi Ca)nSpinal cord compressionnDeh
23、ydrationnAutonomic dysfunction(DM)nMalignancyOpioids do Two things:nBlock Bowel(opioid receptors in mesenteric plexus and bowel wall)nDecrease propulsionnIncrease sphincter tonenIncrease bowel tonenBlock pain/discomfort with packed bowelManagementof constipationnGeneral measuresnestablish what is“no
24、rmal”nregular toiletingngastrocolic reflexnCheck impaction 98%in rectal vault hard packed in stool to large to evacuatenDiet hi fiber(greens,fruits,bran),fluids,additive fibers(avoid with opioids at EOL)nSpecific measuresnstimulantsnosmoticsndetergentsnlubricantsnlarge volume enemasStimulant laxativ
25、esnPrune juice nSenna(Senokot)nCasanthranol(Pericolace)nBisacodyl(Dulcolax)*Good preventatives with opioid useOsmotic laxativesnLactulose or sorbitol nMilk of magnesia(other Mg salts)nMagnesium citratenPolyethylene Glycol(Miralax)*Good add-ons if stimulants not enough with opioid induced constipatio
26、nDetergent laxatives(stool softeners)nSodium docusatenCalcium docusatenPhosphosoda enema prnProkinetic agentsnMetoclopramide nCisapride Lubricant stimulantsnGlycerin suppositoriesnOilsnmineralnpeanutLarge-volume enemasnWarm waternSoap sudsMr.L 62 yo with Colon cancerMr.L has end-stage metastatic col
27、on cancer,diagnosed 6 months ago,with liver mets,ascites,carcinomatosis.He failed chemo,now in hospice for 2 wks.Over 2 days he has had persistent vomiting,unrelieved with compazine,steroids,ativan,with reglan making it worse.Over this time his abdomen has become very distended,he has crampy peri-um
28、bilical pain,and he has not had a BM in 7 days.Lately,his vomit smells slightly fecal-like and is brown.He is miserable and wants to die now!Mr.L exam,tests?PE In distress-Abdomen distended and tense,tympanitic-Bowel sounds hyper-Abdomen diffusely tender-No stool in vault on rectal,hemoccult negativ
29、eTests KUB and upright abd x-ray shows dilated loops of bowel and multiple air-fluid levelsObstructionnVomiting 90+%,Pain 75%nHyperparastalsisnAbsent bowel sounds complications,perforationnX-ray-dilated loops,air-fluid levels on uprightnContrast only if surgical candidate nConsider SurgeryConservati
30、ve ManagementnAntiemeticsnHaloperidol,phenothiazinesnScopalamine nOctreotide-somatostatinnDexamethasonenAtivanConservative managementnAnticholinergicsnAnalgesics:nOpioids,SQ/IVnConsider NG suction(though very uncomfortable)nKeep PO intake limited(what goes in must come up!)Hospice emergenciesnAcute
31、arterial bleed either GI or pulmonary source(though also could be peripheral artery/aorta)nFrom above throwing up bright red blood,from below bright red blood per rectum,from abd aorta get acute rapid distention of abdomen(left side first),then cold pulseless feetnUsually the end catastrophic event but LOTS of anxiety,hard for family to watch,may have acute pain,then passes outnMorphine/ativan right awaynRed towels to hide the bloodnMay need emergent hospitalization for family sake
