Symptom Management in

Palliative Care

R.A.N.D.Ranaweera
B.Sc (Hon) Nursing (KDU)
Outline
• Essential elements of symptom management
• Physical symptoms
• Respiratory symptoms
• Loss, Grief and Bereavement
Categories of Symptoms
• Symptoms are mainly categories as Physical and
psychological
• There are three types of symptoms

1. Respiratory : Fatigue , Dyspnea

2. Gastrointestinal : Anorexia and Cachexia, Nausea and
Vomiting, constipation
3. Psychological: Depression, Anxiety, Loss, Grief and
Bereavement, Burnouts, Delirium, Terminal Restlessness.
Essential Elements of Symptom Management

• Remember that the uncontrolled symptoms create suffering

• Work collaboratively with the interdisciplinary team
• Follow the nursing process, assess , plan, intervene and reevaluate
• Consider the bio-psychosocial model/spiritual model for symptom
management
Essential elements cont….

• Consideration was given to age based population

E.g.: consider older people, who are suffering from Nausea and
Vomiting or Constipation.
The nurse can use jokes to get to know about the quality
0 -10 Scale work only for some people, it ha to be moderated in
the future
Physical Symptoms
Fatigue
“Please, please put me to bed. I don’t have the strength to keep
my arms on the pads of the wheelchair. I’m so tired that I’m just
going to collapse in a heap right here. I barely have the strength
left . . . to take a deep breath.” —An elderly cancer patient.
(Oxford Textbook of Palliative Care)
Definition
“A distressing, persistent, subjective sense of
physical, emotional and/or cognitive tiredness or exhaustion
related to cancer or cancer treatment that is not proportional
to recent activity and interferes with usual functioning.”
(NCCN, Fatigue Practice guideline panel)
Fatigue
• It is a highly subjective symptom
• Will not relieve by resting
• Has a significant impact on Physical, psychological, social and spiritual
well being
• This can be assessed by scales using 0 -10
Objective Data – Concerned with Fatigue
• Monitor vital signs to determine if fever or a rapid or weak pulse
present
• Observe patient’s ability to move about without experiencing
dyspnea or nausea
• Evaluate hydration status
• Test muscle strength, symmetry and endurance of upper and lower
extremities to determine if neurological changes present
• Evaluate medications, especially sedating medication
• Evaluate laboratory data :oxygenation status, hemoglobin, CBS,
Thyroid function
Management of Fatigue
• Develop a reasonable exercise plan
• Take frequent rest periods and use energy conservation techniques
• Provide assistance to develop independence and functional abilities
as long as possible
• Provide patient and family education on topics such as pain control,
nutrition, hydration, exercises, and energy conservation
Management of Fatigue
Pharmacological Management
Antidepressants – Sertraline, Serotonin Reuptake
Inhibitors

Anti-psychostimulants - Methylphenidate

Progestational Steroids -Megestrol Acetate

Hemopoetic Growth
Factors

Tumor Necrosis Factor

Alpha Blockade
 Management of Fatigue
Non-pharmacological Management
Lack of information or lack of preparation
- Explain complex nature of fatigue
and importance of communication of
fatigue level with health care providers.
Explain causes of fatigue in advanced
cancer and chronic progressive diseases
and evaluate fatigue level with each
visit.
Disrupted rest/sleep patterns - Evaluate/establish sleep routine - Minimizing time in bed helps patients feel
refreshed, avoids fragmented sleep, and
strengths
circadian rhythm.
Deficient nutritional status - Increased nutrition will raise energy level. Less
energy is needed for digestion with small, frequent
meals.
 Management of Fatigue
Non-pharmacological Management

Multi-symptom occurrence - Assess and control symptoms contributing

to or coexisting with fatigue such as:
Pain, sleeplessness, depression, nausea,
diarrhea, constipation, electrolyte
imbalances, dyspnea, dehydration,
infection.
Assess for symptoms of anemia and
evaluate for the possibility of pharmacologic
intervention or transfusion

Decreased energy reserves - Plan/Schedule Activities, Obtain Physical Therapy Consult:, Use Distraction/Restoration
Energy conservation helps to reduce fatigue burden
and efficiently use energy available.
Pleasant activities may reduce/relieve mental
(attentional) fatigue.
Dyspnea
• It is a subjective experience of breathing discomfort
• Most reported symptom experienced by patients with a life limiting
disorder.
• Dyspnea results from a “mismatch” between the afferent information
to the CNS and the outgoing motor command to the respiratory
muscles known as Neuroventilatory Dissociation
Dyspnea
Dyspnea
Pathophysiological Mechanism of Dyspnea
Increased ventilatory demand
Increased physiological dead space
Thromboemboli
Tumor emboli
Vascular obstructi
Hypoxemia
Depression, Anxiety
Impaired mechanical response/ventilatory pump impairment
Asthma, COPD, tumor obstruction
Respiratory muscle weakness : Cachexia, electrolyte imbalances,
peripheral muscle weakness, neuromuscular abnormalities
Components of Dyspnea Assessment
• Rate the severity on a scale from 0 -10
• Factors worsening or improving the symptoms
• Presence of chest pain / & other pain or symptoms
• Anxiety
• Effects of daily functioning and sleep
• Any issue or symptom that make dyspnea worse such as anxiety and
cough
Patient history : acute /chronic dyspnea, smoking, heart or lung
disease or concurrent medical condition
Physical Examination must include
• Elevated jugular pressure
• Bilateral crackles
• Respiratory rate and depth
• Use of accessory muscles
• Pain and respiratory movement
• Functional status
• Pursed lip breathing
• Cyanosis
• Inability to speak
Pharmacological Management
Gold Standard – Opioids
• Small doses of oral or parenteral opioids can be used to treat dyspnea
• Most of the patients who are breathless and anxious will start
Opioids+ Non Opioids (Corticosteroids, Anxiolytics, midazolam)
 Non Pharmacological Management
• Fans, Open windows, air conditioners circulate air to ease the
sensation of breathing
• Counselling to relieve anxiety associated dyspnea
• Pursed lip breathing – improve the strength of lung muscles, slow
respiratory rates and decrease small airway collapse.
• Energy conservation techniques – save energy, reduce fatigue
• Prop up the head – promote expansion of lungs, reduce chocking
sensation
• Educate patient and family members
• Music therapy – relaxation technique
 For Hypoxia Management
• Non invasive ventilator support including oxygen and positive
pressure ventilators can be used
• This has to be followed if all other methods are ineffective (venture
mask, oxygen line, nasal cannulas)
• Oxygen should be used to archive target saturation od 94 -98% for
most acutely ill patients
• 88-92% those who are risk of hypercapnic respiratory failiure
Other Interventions
• Blood transfusions
• Thoracentasis
• Endo bronchial laser therapy
• Radiation therapy to shrink the tumor
• Paracentasis
• Stent tube placement to open the air ways
Anorexia and Cachexia
Anorexia- Definition

Reduced or complete loss of desire to eat or a loss of appetite

associated with a decrease in food intake

• This is common among patients with advanced diseases

• Weight loss usually involves with the loss of fat not the muscle
• Found in advanced diseases.
• This could occur very early in some diseases
Anorexia and Cachexia
Cachexia- Definition
“State of general ill health and malnutrition marked by weakness and
emaciation (abnormal thin)”
• This is a complex syndrome usually involving anorexia along with
significant weight loss, loss of muscle tissue as well as adipose tissue
and this is a generalized weakness
• This is a multi factorial syndrome, anorexia, weakness, fatigue, weight
loss, depletion of muscles
• Occurs in 80% of the patients with cancer
Causes of Anorexia and Cachexia
Disease related
• This is most frequent in cancer (86%),
CHF (16-36%), COPD (30 -70%), HIV
(10-35%), Renal diseases (30-60%)
• Oral or systematic infections: Candida
• Delayed gastric emptying and ulcers
• Mal-absorbtion
• Bowel obstruction
• Raised ICP
Causes of Anorexia and Cachexia
Psychological related

• Depression exhibits many somatic

symptoms which include anorexia
Causes of Anorexia and Cachexia

Treatment related:
• Due to chemotherapy: taste changes
• Effects of radiation: bowel strictures
and fistulas
• Side effects: Nausea and vomiting,
constipation can result nutritional
impairment
How to Assess Anorexia and Cachexia
• Use patient’s history : identify involuntary weight loss or more than 5% within the
past 6 months
• Assessment of weight loss, muscle wasting, gastric stasis, loss of strength,
decreased fat (edema can mask wasting)
• Inspect the presence of skin breakdown
• Be cautious of any sign of increase in fatigue/weakness, signs & symptoms related
to depression and confusion
• Discuss the quality of life of the patient’s family
• Calorie count may value along with daily weight gain or loss
• Serum albumin concentration decreases when the nutritional status decreases
(Laboratory values )
Treatment of Anorexia and Cachexia
• Symptom management : if Nausea and vomiting, fatigue, depression,
taste disorders as an effect on A & C
• Enteral feeding (via nasoenteral tube, gastrostomy, or jejunostomy)
may be indicated in a small subset of terminally ill patients
• PPN or TPN for a subset of patients who meet the following criteria:
total gastrointestinal failure, limited life expectancy were TPN not
initiated, expected survival of more than a few months, and sufficient
performance status, QOL, and home environment for the successful use
of the intervention.
Treatment of Anorexia and Cachexia
• Pharmacological Treatment
Progestational agents : Megestrol acetate 160–800 mg/day, Improves
appetite, weight gain, and sense of well being
Corticosteroids: e.g.: Decadron 4 mg/day, Improves appetite and sense
of well being
Cannabinoids: Dronabinol 5–20 mg/day , Increases appetite and
decreases anxiety
Metoclopramide: 10 mg before meals ,Improves gastric emptying,
decreases early satiety, improves appetite
 Nausea & Vomiting
• Nausea and vomiting are common and significant symptoms
experienced by over 50% of patients with advanced diseases.

• There are multiple receptors in the central nervous system which

are involved in the development of nausea.

• Blocking of these receptors forms the basis of antiemetic

medications. These receptors are: dopaminergic, muscarinic,
cholinergic, histaminic, and serotonergic.
Causes Affecting Nausea & Vomiting
Gastrointestinal causes
• Gastric irritations
• Stasis
• Constipation
• Gastrointestinal obstruction
• Pancreatitis
• Ascites
• Liver failure
• Intractable cough
• Effects of radiation
Causes Affecting Nausea & Vomiting

Metabolic causes
• Hypercalecemia
• Uremia infection
• Usage of certain drugs
Causes Affecting Nausea & Vomiting
Other causes
• Raised Intra Cranial Pressure
• Pain
• Motion Sickness
• Anxiety
• Emitogenic sensory stimuli: emotional factors may lead t nausea
and vomiting, as a result of stimulation of emetic receptors in the
brain
• Treatment related : Radiation, Opioid use, Antibiotics,
Chemotherapy, NSAIDs, Antiretroviral Therapy
Assessment of Nausea and Vomiting
History:
• Consistency, intensity, exacerbating and relieving factors, frequency and
volume of emesis
• Emesis associated with position changes
• Presence of contributing factors (Vertigo, blood sugar levels and medications)
• Relationship to food intake
• Evaluation of the presence of constipation or impaction
• Presence of uncontrolled pain and infection
• Presence of anxiety and other emotional symptoms
Assessment of Nausea and Vomiting
Physical Assessment
• Oral examination
• Abdominal examination and evaluation to include bowel sounds and
presence of ascites.
• Possible assessment of the rectal vault (storage of stools in the rectal
vault indicate functional constipation)
Assessment of Nausea and Vomiting
Laboratory Values
• Renal and liver function tests
• Electrolytes and serum drug levels
• Radiologic test to include abdominal X-rays and or a head CT or MRI
• Assess the hydration in the patients who are vomiting in larger
amounts
 Antiemetic Drugs
It is much better to treat the underline cause
Treatment of Nausea and Vomiting
Treatment of Nausea and Vomiting
It is much better to treat the underline cause
• Anticholinergic : treat motion sickness, intractable vomiting, small
bowel obstructions (Scopolamine)
• Benzodiazepine: effective for nausea and vomiting as well as anxiety
(Lorazepam)
• Steroids: given alone or with other agents for nausea and vomiting,
which are induced by cytotoxicity (Dexamethasone)
• 5HT3receptor antagonists : Indicated for moderate to highly
emetogenic chemotherapy. Ideal for elderly and pediatric patients.
(Ondensetron)
Constipation
• It is a frequent symptom presenting at the end of life
• Impaired mobility
• Opioid usage slow gut mortality
• “less than three bowel movements per week is known
as constipation”
• It is a clinical syndrome not a symptom
 Causes of Constipation

• Intestinal obstruction- partial or complete (related with the

presence of a tumor in or compression of the bowel) – most
commonly seen in mesothelioma, ovarian and
gastrointestinal cancer
• Hypercalcemia and hyperkalemia
• Spinal cord compression or transection causes slow food
transmission
• Concurrent diseases can affect neurological transmission of
GI mortality (diabetes, colitis, hypothyroidism, )
 Causes of Constipation

• Constipation also occur due to: dehydration, depression,,

surgical adhesion cause scarring, inactivity, weakness,
loss of privacy, decreased abdominal muscle tone, pain
associated with bowel movement
 Causes of Constipation

Treatment related causes

• Serotonin antagonist, antiemetic (Ondensetron)
• Opioids
• Antidepressants
• Antacids
Assessment of Constipation

• This is the direct understanding of the patient’s

definition, experience of discomfort that might affect in
preventing and treating constipation
Assessment of Constipation
• Characteristics( Appearance, consistency) & frequency of
stool as compared to the normal bowel pattern
• Use of bowel medications
• Fluid intake
• Presence of anorexia, nausea and vomiting associated
with constipation
• Concurrent medical conditions
• Constipation problems prior to previous illnesses
Assessment of Constipation
• Careful assessment on over the counter drugs
• Perform abdominal examination; (Bloating and palpation for
tenderness, percussion and auscultation of bowel sounds,
abdominal x-ray may be necessary to ruleout bowel obstruction
• A digital assessment can rule out impaction (hard dry mass of
stool become stuck in the colon or rectum)
• The examination may reveal stool, tumor, or perhaps rectocele
(herniation /bulge of the front wall of the rectum in to the back
of the vagina)
• Complete visual examination – for hemorrhoids, ulceration or
rectal fissures. These sites may be painful and may be infected
as well.
 Treatment for constipation
• Give oral agents prior giving rectal agents of drugs
• However suppositories or enemas are considered when the patient
cannot tolerate the oral drugs
• Hard fecal impaction: use oil retention enema to soften the stool, prior
the digital removal
• For soft impaction: use Bisacodyl suppositories or saline enemas,
followed by prophylactically by vigorous scheduling of both stool
softener and stimulant
• Patient encouragement to use plenty of fluids and increase activity
Any Questions ?
Thank You !