SYMPTOMS MANAGEMENT

IN PALLIATIVE CARE PATIENTS

 PENDAHULUAN

• Merupakan inti dari perawatan paliatif

• Tidak hanya berfokus pada satu aspek namun
harus komprehensif meliputi fisik, sosial, emosional,
financial dan spiritual
SYMPTOMS PRE VALE NCE IN C ANCE R, CHF,
COPD, NE URODE GE NE RATIVE PATIE NTS
 PRINSIP UMUM DALAM MANAJEMEN
GEJALA PADA PASIEN PALIATIF

• Fokus pada pasien dan tidak pada penyakit

• Terapkan pendekatan HOLISTIK
• Manajemen bersifat individualistic, sesuai kebutuhan
individu pasien
 EFFECTIVE SYMPTOMS MANAGEMENT

Evaluation
• Penyebab gejala
• Dampak pada kehidupan pasien
• Terapi yang sudah diberikan
Explanation
• Diberikan kepada pasien dan keluarga
terdekat pasien tentang penyebab dan
pilihan perawatannya
 EFFECTIVE SYMPTOMS MANAGEMENT

Management Monitoring
• Individualized to the particular patient • Review the impact of treatment
• Treat any reversible causes regularly

• Use non-drug treatment when • Paying attention to detail

available
• Keep drug treatment as simple as
possible
• Seek advise when necessary
 PENGKAJIAN NYERI
• Good pain assessment is vital for
effective treatment
• Many patients have more than one
pain
• Assess each pain separately and
identify the cause of pain
• Pain may be constant or intermittent
• Ask about character, onset, intensity
and severity, duration, exacerbating
factor, relieving factor, effect on
function, sleep and mood, and
associated symptoms
• Using structured pain assessment
tool
PAIN PERCEPTION
WHO PAIN LADDER
 PRINCIPLES OF ANALGESIC USE

• BY MOUTH
• BY THE CLOCK
• FOR THE INDIVIDUAL
• ATTENTION TO DETAIL
 DYSPNEA

• Unpleasant perception of breathing

• Subjective experience
• Tachypnea (frequent respiration), hyperventilation (deep
respiration)
• TOTAL breathlessness: pathophysiologic (cause), sensoric
(perception), affective (anxiety, anger, depressed mood),
cognitive (thoughts), behavioral
ETIOLOGY DYSPNEA
TOTAL DYSPNEA
 MANAGEMENTS

• Treat the underlying causes

 MANAGEMENTS OF DYSPNEA

• Non pharmacological symptomatic interventions

• Pursed lip breathing
• Mobility aids
• Pulmonary rehabilitation:Yoga,Tai Chi
• Complementary therapy: hypnotherapy, aromatherapy,
meditation, etc
• Education and self managements
 MANAGEMENT OF DYSPNEA

• Pharmacological symptomatic interventions

• Opioids:
• Regular, oral, low-dose morphine is the first-line pharmacological treatment for severe chronic
breathlessness, which persists despite non-pharmacological measures
• All patients starting opioids should be offered prophylaxis for constipation with laxatives and, as needed,
antiemetics
• Benzodiazepine:
• Because of significant risk of sedation and delirium, benzodiazepines should not be used for breathlessness as
first-line pharmacological therapy
• Benzodiazepines may be used with caution in patients with cancer for the relief of breathlessness with
associated anxiety if opioids are not effective
• Supplemental Oxygen
• Begin titration at 2 L (readjust dose and recheck need of supplemental oxygen)
 DELIRIUM

• A state which develops in a • Predisposing factor:

short period (usually a few • Age > 70 years
hours to day) • Recent surgery

• 90% of patients at the end of • History of previous delirium

life • Dementia
• Visual or hearing impairment
• Delirium often not recognized
• Alcohol addiction
• Opioids
• Approaching death
 TREATMENT OF DELIRIUM

• Treat precipitating factor if • Non pharmacological:

possible • Ensure a safe environment
• Haloperidol 0.5-2 mg orally • Fixation or restrain??

• Persistent restlessness: • Avoid loud sounds

benzodiazepine • Maintain day-night rhythm
 FATIQUE

• Persistent feeling of extreme • IMPACTS:

tiredness, weakness or lack of
energy
• Subjective feeling
• Difficulty of sleeping
• Difficulty carrying out
activities
• Difficulty concentrating
• Low mood
• Lack of motivation
 ETIOLOGY

• Illnesses : cancer, COPD, Heart Failure, CKD

• Treatments: chemotherapy, radiotherapy
• Anaemia
• Depression
• Poor nutrition
• Sleep disturbance
• Efek samping obat
 MANAGEMENTS FATIQUE

• All patients should be screened for fatique

• The severity and impact on daily life should be assessed
• Treat the cause
• Conserving energy
• Medical treatment : transfusi darah, obat peningkat nafsu makan,
antidepresant
• Physical activity
• Complementary therapies : massage, meditation
 SUMMARY

• TREAT THE PATIENT, NOT ONLY THE SYMPTOMS

• TREAT THE CAUSE OR PRECIPATING FACTOR IF POSSIBLE
• USE NON PHARMACOLOGICAL AND PHARMACOLOGICAL
TREATMENT
• PAY ATTENTION TO BOTH THE PATIENT AND THE FAMILY