Symptom Management

Dr Rosalie Shaw

Thank you for inviting me …

The story of Shariffha

The goals of palliative care

To relieve sufferingTo ensure normal functioning in daily life for as long as possibleTo achieve quality of lifeTo give dignity to the patient even at the time of death

Common problemsPain 64%Weakness 62%Weight loss 56%Anorexia 48%Constipation 33%Dyspnoea 27%Nausea and vomiting 13%Sore mouth 55%Fungating wounds 12%DysphagiaEarly satietyOedema.

Tay WKJ et al Annals of Academy of Med Singapore1994 23: 191 - 196

Non-physical problems

AnxietyDepression AngerDisruption of personal, social & work relationshipsIncreased reliance on family members & friends

There are complex interactions between physical & non-physical sources of distress.

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).

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 treatmentWill treatment improve the symptom significantly?

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?

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 metastasesSurgery especially if fractureChemotherapyNerve block

Principles of management:Treatment with medications

Keep regimes simpleGive minimum number of medicinesGive 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

Principles of management:Treatment with medications

Review frequentlySymptoms change and new symptoms appearEnsure compliance by explanation and written instructions for the patient and family

Constipation

A very troublesome symptom for many patientsConstipation can occur even in paientwith no oral of enteral intakeAnticipate and prevent constipation by starting laxative when starting opioids

Constipation

Per rectal examination is essentialAn abdominal xray may be helpfulSuspect fecal impaction if diarrhoea and incontinence

Drugs used in constipation

ImportantContact catharticso senna (Senokot)o bisacodyl (Dulcolax)

Osmotic catharticso lactuloseo magnesium salts

Suppositories & enemaso glycerin / bisacodylo sodium biphosphate

Less ImportantLubricantso mineral oil (Agarol)

Fibre*o psyllium(Metamucil, Normacol)

*Avoid fibre laxatives in palliative care patients

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The very constipated patient

Clear from the top and the bottomeBig doses of senna e.g. 3 tablets stat & 3 tablets tds for 3 daysDaily suppositories or enemas for 3 daysManual removal of feces if impactedHigh colonic enema if rectum is empty

Cachexia and Anorexia

Progressive wasting in patients with advanced cancerClinical features:LethargyMuscle wastingLoss of weightAnaemia

Aetiology of Cachexia

MalnutritionAnorexiaMalabsorptionProtein loss due to vomiting or diarrhoeaWeakness

Altered metabolism of protein, carbohydrate and lipid Related to tumor necrosis factor and other factors

Whose problem is it?

The patient?The family?The doctor?The nurse?The dietician?

Management of anorexia

Explanation to relatives: “Not starving to death”Control nauseaRelieve constipationTreat sore mouthConsider steroids or progestagens (e.g. megestrol)Small attractive tasty mealsNutritional supplements are only helpful if actually taken by the patient!

Dry mouth & sore mouth

Causes:medicationsradiotherapy mouth breathinginability to swallow in terminal phasechemotherapyherpes simplexaphthous ulcers

Candidiasis (thrush)

Management of sore mouth

General measuresKeep mouth moist - sips

(Sweet drinks may encourage thrush.)Mouth care every 4 hours

clean teeth (remove dentures)rinse mouth well with waterOil or petroleum jelly (Vaseline) to lips.

Do not use lemon & glycerin swabs

If mucositis

Treat with fluconazole / nystatin if candidiasis, Acyclovir if herpes simplexKenalog in orabase ointment or Sucralfate - crush tablets to make a thin pasteXylocaine viscous 2% solution before eatingFood at room temperature or chilledAvoid highly spiced or acid foodsMoisten food with soups or sauces

Fungating tumours

Cause great miseryUglyBad smellExudatePainBleed

Management of fungatingwounds

Clease with saline or clean water(Does not have to be sterile)Debride if necessaryControl odour

Metronidazole powderProvidone-iodine (Betadine)

Management of fungatingwounds

Control exudateChange outer dressing as necessary

Management of fungatingwounds

Control painChange dressing as infrequently as possibleSoak off dressings to remove.Give analgesic 30’ before dressing.Regular analgesic (e.g. paracetamol or NSAID)Mylanta applied to ulcer may decrease burning pain.

Management of fungatingwounds

Control bleedingNon-stick dressingsAdrenalin 1:1000 direct to bleeding pointSucralfate paste (crushed tablet in water soluble gel)Gelfoam /Silver nitrate Radiotherapy

Management of fungatingwounds

These wounds will not healThe goal is patient comfort

Why is symptom management important?

Reduce sufferingMaximize comfortPreserve functionPrevent complicationsProlong survival

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.

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