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Clinical Review for the
Hospice and Palliative Nurse Presented By:
Laura Scherer RN, BSN, CHPN
Symptom Management
Part 1 GI Management
1
Objectives
1. Part 1 will define gastrointestinal symptoms present at
the end of life.
2. Identify possible etiologies of symptoms at the end of
life.
3. Assess for the physical and psychosocial aspects of the
symptoms that are common at the end of life.
2
Objectives
4. Describe pharmacological and nonpharmacological
interventions for common symptoms that can be included
in the plan of care at the end of life.
5. Describe the patient and family instructions needed for
patients and families at the end of life.
3
Domains of
Quality Palliative Care
Clinical Practice Guidelines of Quality Palliative Care
Domain 2: Physical Aspects of Care
Guideline 2.1 Pain, other symptoms, and side
effects are managed based upon the best available
evidence, with attention to disease-specific pain
and symptom, which is skillfully and systematically
applied.
4
Anorexia and Cachexia
Anorexia
loss of appetite resulting in the inability to eat
Cachexia
physical wasting and malnutrition usually associated with
chronic disease
5
Anorexia and Cachexia
Prevalence
Commonly found in patients with advanced
disease
80% of cancer patients
6
Anorexia/Cachexia
Causes
Disease Related
Infections
Delayed gastric emptying
Metabolic alterations
Pain
7
Anorexia/Cachexia
Causes
Treatment Related
Medications
Chemotherapy
Radiation
8
Anorexia/Cachexia
Causes
Psychological and/or spiritual distress
Often overlooked
Depression may exhibit somatic symptoms
9
Anorexia/Cachexia
Assessment
Patient reports
Muscle wasting
Weight loss
Lab values
Intake patterns
10
Anorexia/Cachexia
Pharmacological Interventions
Megestrol acetate (Megace®)
Metoclopramide (Reglan®)
Dexamethasone (Decadron®)
Dronabinol (Marinol®)
11
Anorexia/Cachexia
Non-pharmacological Interventions
Treat underlying symptoms
Emotional support
Nutritional support
12
Anorexia/Cachexia
Non-pharmacological Interventions
Enteral and parenteral nutrition
13
Anorexia/Cachexia
Patient & Family Education
Support patient’s wishes
Discuss intake during dying process
Explore meaning of food
Address emotional needs
Redirect caring
14
Anorexia/Cachexia
References
1. Kemp C. Anorexia and cachexia, In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006:169-176.
2. Bednash G, Ferrell BR. End-of-life nursing education consortium (ELNEC). Washington, DC: Association of Colleges of Nursing; 2009.
3. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003.
15
Dehydration
Normal physiologic process at the end of life
Decreased desire for fluids
Symptoms vary
16
Causes of
Dehydration
Loss of normal body water
Isotonic dehydration
Eunatremic dehydration
Hypotonic dehydration
17
Assessment for
Dehydration
Mental status changes
Confusion, restlessness
Intake and output
Elderly may have decrease perception of thirst
Urine output reduced
18
Assessment for
Dehydration
Weight loss
Reduced skin turgor
Skin and mouth assessment
Postural hypotension
Lab values
Increased hematocrit
Serum sodium
19
Treatment of
Dehydration
Ethical considerations
Benefits vs. burdens
Review expected course of illness
Artificial hydration
Misperceptions
20
Treatment of
Dehydration
Use least invasive approach possible
Oral
Provide appropriate mouth care
Proctoclysis
21
Treatment of
Dehydration
NG/GT
NG uncomfortable
Hypodermoclysis
Subcutaneous fluid administration
IV
22
Treatment of
Dehydration
IV
Monitor for over hydration
23
Dehydration
Patient & Family Education
Oral/enteral/parenteral fluids
Instruct more than one person
Allow ample time for instruction and return
demonstration
24
Dehydration
Patient & Family Education
Review benefits/burdens of artificial nutrition &
dehydration
Address emotional needs
Assist in redirecting ways of caring
25
Dehydration
References
1. Emanuel L. von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003.
2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC). Washington, DC: Association of Colleges of Nursing; 2009.
3. Kedziera P, Coyle N. Hydration, thirst, and nutrition. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006: 239-248.
4. Kazanowski M. Symptom management in palliative care. In: Matzo, ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life. New York, NY: Springer; 2006: 319-344.
26
Nausea and Vomiting
Nausea
Subjectively perceived
Unpleasant sensation experienced in the back of the
throat and epigastrium, which may or may not result
in vomiting
Vomiting
expelling of stomach contents through the mouth
27
Nausea and Vomiting
Prevalence
Common in patients with advanced disease
70% of patients experience nausea
30% of patients experience vomiting
Patients under 65 and women
Stomach, breast and gynecological cancer
AIDS
28
Causes of
Nausea and Vomiting
Physiological Causes
Gastrointestinal
Metabolic
Central nervous system
Psychological
Emotional
Disease related
Treatment related
29
Nausea and Vomiting
Associated with
Opioid therapy
Uremia
Hypercalcemia
Constipation
Bowel obstruction
30
Assessment
of Nausea and Vomiting
History of disease
Effectiveness of prior treatments
Precipitating factors
Self-reporting tools
Physical
Diagnostic testing
31
Nausea and Vomiting
7 Steps for Antiemetics
1. Identify cause
2. Identify pathway of cause
3. Identify neurotransmitter receptor
4. Select potent antagonist for that receptor
5. Select a route
6. Titrate dose & administer ATC
7. If symptoms continue, additional
treatment
32
Nausea and Vomiting
Antiemetics
Butyrophenones
Indication: opioid-induced nausea, chemical and
mechanical nausea
Medications
Haloperidol (Haldol)
Droperidol (Inapsine)
33
Nausea and Vomiting
Antiemetics
Protokinetic agents
Indication: gastric stasis, ileus
Medications
Metoclopramide (Reglan)
Domperidone (Motilium)
34
Nausea and Vomiting
Antiemetics
Cannabinoids
Indication: second-line antiemetic
Medication
Dronabinol (Marinol)
35
Nausea and Vomiting
Antiemetics
Phenothiazines
Indications: general nausea and vomiting, not as
highly recommended for routine use in palliative care
Medications
Prochlorperazine (Compazine)
Thiethylperazine (Torecan)
Trimethobenzamide (Tigan)
36
Nausea and Vomiting
Antiemetics
Antihistamines
Indications: intestinal obstruction, peritoneal
irritation, increased intracranial pressure,
vestibular causes
Anticholinergics
Indication: motion sickness, intractable
vomiting, or small bowel obstruction
37
Nausea and Vomiting
Antiemetics
Steroids
Appear to exert antiemetic effect as a result of
antiprostaglandin activity
Most effective in combination with other agents
Benzodiazepines
Indication: effective for nausea and vomiting as well
as anxiety
38
Nausea and Vomiting
Antiemetics
5-HT3 receptor antagonists
Indicated for post-operative nausea and vomiting and
chemotherapy
ABHR
Compounded antiemetics
39
Nausea and Vomiting
Antiemetics
Octreotide (Sandostatin®)
Indications: nausea and vomiting associated with
intestinal obstruction
DimenhyDRINATE (Dramamine®)
Indications: nausea, vomiting, dizziness, motion
sickness
40
Non-pharmacological
Treatment of Nausea and Vomiting
Oral care
Cool damp cloth
Decrease noxious stimuli
Loose-fitting clothes
Fresh air or fan
41
Non-pharmacological
Treatment of Nausea and Vomiting
Behavioral complementary therapies
Interventions individually based
Cultural considerations
42
Nausea and Vomiting
Patient and Family Education
Assessment of nausea and vomiting
Problem solving
Family’s role
Instruct when to call healthcare provider
43
Nausea and Vomiting
References
1. Berry PH, ed. Core Curriculum for the Generalist Hospice and
Palliative Nurse. 2nd ed. Dubuque, IA: Kendal/Hunt; 2005.
2. King C. Nausea and vomiting. In: Ferrell BR, Coyle N, eds. Textbook of
Palliative Nursing. 2nd ed. New York, NY: Oxford University Press;
2006: 177-194.
3. Bednash G, Ferrell BR. End-of-life nursing education consortium
(ELNEC - Geriatric). Washington, DC: Association of Colleges of
Nursing; 20072005.
4. Kazanowski M. Symptom management in palliative care. In: Matzo
ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the
End of Life. New York, NY: Springer; 2006: 319-3442001:327-361.
5. Mannix K. Gastrointestinal symptoms. In: Doyle D, Hanks GWC,
MacDonald N, eds. Oxford Textbook of Palliative Medicine. 3rd New
York, NY: Oxford University Press: 2005:1998464-468: 489-499.
44
Bowel Obstruction
Prevalence
Related to site of disease
Tumors of splenic flexure obstruct 49% of the time
Rectum or rectosigmoid obstruct 6% of the time
45
Bowel Obstruction
Occlusion of the lumen or absence of the normal
propulsion
Intralumen obstruction
Extramural obstruction
Mechanical obstruction
Metabolic disorders
Medications
46
Assessment of
Bowel Obstruction
Assess within palliative care goals
Bowel history
Pain
Palpate abdomen
Rectal exam
Location of obstruction
47
Treatment of
Bowel Obstruction
Prevention
Principles
Goal of treatment is prevention whenever possible
Verify cause of obstruction: tumor vs. fecal
impaction
If stool, goal is to move the stool down through the
intestinal tract
Avoid stimulant laxatives - usually increase
discomfort and may cause intestinal wall rupture
48
Treatment
Bowel Obstruction
Pharmacolologic
Octreotide (Sandostatin®)
Scopolamine
Opioids
Antiemetics
49
Treatment of
Bowel Obstruction
Pharmacolologic
Corticosteroids
Antispasmodic
Laxative / Antidiarrheal
50
Treatment of
Bowel Obstruction
Surgical
Considered within context of established palliative care
goals
51
Treatment of
Bowel Obstruction
Non-pharmacological
Avoid hot drinks
Avoid big meals
Consider NG
52
Bowel Obstruction
Patient & Family Education
Review causes
Discuss treatment options
Educate to prevent
Instruct when to call healthcare provider
Review medications
Review dietary recommendations
53
Bowel Obstruction
References
1. Economou DC. Bowel management: constipation,
diarrhea, obstruction, and ascites. In: Ferrell BR, Coyle
N, eds. Textbook of Palliative Nursing. 2nd ed. New
York, NY: Oxford University Press; 2006: 219-238.
2. Kazanowski M. Symptom management in palliative
care. In: Matzo ML, Sherman DW, eds. Palliative Care
Nursing: Quality Care to the End of Life. New York,
NY: Springer; 2006:319-344.
3. Emanuel L. von Gunten C, Ferris F. The Education for
Physicians on End of Life Care (EPEC) Curriculum.
Washington, DC: American Medical Association; 2003
54
Constipation
Infrequent passage of stool
Increases with age
Frequent with illness and at the end of life
Results from some medications
Opioids!
55
Constipation
Prevalence
10% of general population
Increases with age
Effects more than 50% of patients in a palliative care
unit or in hospice
Frequently seen symptom at the end of life
Undertreated by nurses and doctors
Can be very embarrassing for some patients
Prevention is the key!
56
Causes of
Constipation
Disease Related
Cancer
Diabetes
Hypercalcemia
Medication Related
Other
Dehydration
Inactivity
Depression
57
Assessment for
Constipation
Bowel history
Abdominal assessment
Rectal Assessment
58
Assessment for
Constipation
Physical assessment
Diagnostic tests
Medication review
Prescription
Over the counter
Herbals
59
Pharmacological
Treatment of Constipation
Laxatives
Lubricant laxatives - lubricate the stool surface & soften
the stool leading to easier bowel movement
Surfactant/detergent laxatives
Reduce surface tension, increase absorption of fluids and
fats into stool which soften it can increase peristalsis
60
Pharmacological
Treatment of Constipation
Combination medications
Osmotic laxatives
non-absorbable sugars that exert an osmotic effect in
primarily the small intestine
Osmotic suppositories
Glycerine suppositories: Soften stool by osmosis and act
as lubricant
61
Pharmacological
Treatment of Constipation
Laxatives
Saline laxatives - increase gastric, pancreatic, & small
intestinal secretions, & motor activity throughout the
intestine
62
Pharmacological
Treatment of Constipation
Bowel stimulants
Bowel stimulants - Work directly to irritate bowel &
stimulate peristalsis;
Use with caution when liver disease present
63
Pharmacological
Treatment of Constipation
Bulk Laxatives
Provide bulk to the intestines to increase mass -
stimulates bowel to move
64
Pharmacological
Treatment of Constipation
Enemas
Soften stool by increasing water content
65
Opioid Induced
Constipation
Opioid Induced Constipation
Opioids
bind to mu–opioid receptors in the central nervous system – provide analgesia
also bind to peripheral mu–opioid receptors in the gastrointestinal tract, inhibiting bowel function – opioid induced constipation (OIC).
Pharmacologic / non-pharmacologic treatment
Oral erythromycin
Metoclopramide
66
Pharmacological
Treatment of Constipation
Methylnaltraxone / (Relistor®)
Inhibits opioid induced decreased gastrointestinal
motility and delay in gastrointestinal transit time
Does not affect opioid analgesic effect
Subcutaneous route / Dose according to weight
Decrease dose with renal impairment
50% of patients had a bowel movement within 30
minutes to 4 hours of the first injection
67
Non-pharmacological
Treatment of Constipation
Prevention
Manage side effects of pain medication
Encourage fluid and fiber intake
Encourage activities
Intervene only if causing distress
Cultural Considerations
68
Constipation
Patient & Family Education
Monitor bowel patterns
Encourage fluid intake
Encourage dietary intake
Encourage activity
Instruct when to call healthcare provider
69
Constipation
References
1. Economou DC. Bowel management: Constipation, diarrhea,
obstruction, and ascites. In: Ferrell BR, Coyle N, eds. Textbook of
Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006: 219-238.
2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium
(ELNEC ). Washington, DC: Association of Colleges of Nursing,
2009.
3. Sykes N. Constipation and diarrhea. In: Doyle D, Hanks G,
MacDonald N, eds. Oxford Textbook of Palliative Medicine. New
York, NY: Oxford, 2005: 483-490.
70
Constipation
References
4. McMillan S, Williams F. Validity and reliability of the constipation
assessment scale. Cancer Nursing 1989;12:183-188.
5. Emanuel L, von Gunten C, Ferris F. The education for Physicians on
End of Life Care (EPEC) Curriculum. Washington, DC: American
Medical Association, 2003.
6. Kazanowski M. Symptom management in palliative care. In: Matzo
ML, Sherman D W, eds. Palliative care nursing: Quality care to the
end of life. New York, NY: Springer, 2006: 319-344.
71
Diarrhea
Frequent passing of loose, non-formed stool
More severe in HIV-infected patients and bone
marrow transplant patients
72
Diarrhea
Prevalence
Considered a main symptom in 7-10% of hospice patients
Especially prevalent in the HIV patient
43% of bone marrow transplant patients develop diarrhea
related to radiation
Occurs in 10% of cancer patients
73
Causes of
Diarrhea
Disease related
Psychologically related
Treatment related
74
Assessment of
Diarrhea
Bowel history
Assess frequency and nature of diarrhea in last 2 weeks
Complaints of pain or abdominal cramping
Rapid onset may indicate fecal impaction with overflow
Colonic diarrhea: watery stools in large amounts
Malabsorption: foul smelling, fatty, pale stools
Diet history
Treatment history
Medication review
75
Assessment of
Diarrhea
Physical assessment
Abdominal assessment
Examine stools for signs of bleeding
Evaluate for signs of dehydration
76
Pharmacological
Treatment for Diarrhea
Opioids
Suppress forward peristalsis and increase sphincter tone
Loperamide (Imodium®)
Bulk forming agents
Promote absorption of liquid / increase thickness of stool
Psyllium (Metamucil®
Antibiotics
Steroids
Somatostatins
Slows transit time by decreasing secretions
Octreotide (Sandostatin) 77
Non-pharmacological
Treatment for Diarrhea
Dietary management
Initiate a clear liquid diet
Eat small, frequent, bland meals
BRAT diet
Low residue diet
Increase fluids in diet
Consider homeopathic remedies
78
Non-pharmacological
Treatment for Diarrhea
Psychosocial interventions
Provide support to patient and family
Recognize negative effects of diarrhea on quality of life
Sitz baths
Cultural Considerations
Many cultures modest – may prevent reporting
79
Diarrhea
Patient & Family Education
Respect level of comfort during discussions
Monitor frequency and consistency
Instruct when to contact healthcare provider
Provide skin care
80
Diarrhea
References
1. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC - Geriatric). Washington, DC: Association of Colleges of Nursing, 2007.
2. Economou DC. Bowel management: Constipation, diarrhea, obstruction, and ascites. In: Ferrell BR, Coyle N, eds. Textbook of palliative nursing. 2nd ed. New York, NY: Oxford, 2006: 219-238.
3. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association, 2003.
81
Questions
82
Thank You
