Non-pain Symptoms

Note: This module is written by Dr. Syndey Morss Dy at Hopkins, and modified for the web. It is available from EPERC, End of Life Physician Education Resource Center.


Objectives
At the completion of this module, the majority of house staff will rate their knowledge as good or better on the following topics in palliative care

1. Definition & goals of palliative care in ambulatory patients.
2. Major symptoms affecting quality of life in ambulatory palliative care patients.
3. Role of assessing patient values and goals, and of patient and family education in palliative care.
4. Evaluation, differential diagnosis, and treatment options for the following symptoms...
...Dyspnea--Use of opioids and benzodiazepines
...Constipation--Best medications to use in palliative care
...Nausea and vomiting--Medications for different etiologies
...Anorexia, weight loss and cachexia--How to evaluate and treat
...Fatigue, weakness, and asthenia--Non-pharmacologic treatments
...Sleep disturbance--Differential diagnosis

Pretest questions

Q1. Definition of palliative care
The best descriptive term for palliative care is...

A. Treatment of those patients that are unable to make decisions for themselves.
B. Comfort care of patients in the last days to weeks of their life.
C. Care of patients who do not want resuscitation or artificial ventilation.
D. Treatment of pain in terminally ill patients.
E. Treatment of symptoms or suffering in seriously ill patients.

Correct answer is E


Q2. Treatment of dyspnea
You see a 75-year-old patient with end-stage cardiomyopathy in your clinic. At previous visits, you have discussed that he cannot be cured, is on maximal medical therapy, and probably will not live more than a year or two. He wants to avoid artificial ventilation, resuscitation, hospitalizations and invasive procedures. He has episodes of mild shortness of breath that seem due to dietary indiscretions with foods that he loves. He enjoys smoking.

Your most appropriate initial intervention is to...

A. Set a smoking quit date and refer to a stop-smoking support group.
B. Emphasize the importance of sticking to a strict, very-low-sodium diet.
C. Evaluate whether you could prescribe an additional diuretic dose to be taken as needed for these episodes.
D. Prescribe lorazepam, 0.5 mg po bid prn shortness of breath.

Correct answer is C


Q3. Treatment of nausea and constipation
The most appropriate initial treatment for palliative care patients with both chronic nausea and constipation, not controlled by laxatives, is usually...

A. Prochlorperazine
B. Senna
C. Lorazepam
D. Metoclopramide
E. Docusate sodium

Correct answer is D

Q4: Management of anorexia and weight loss
In clinic you see a patient with metastatic cancer in clinic with her daughter. Her daughter is concerned that she is currently eating very little, is losing a lot of weight, and has too little energy to do house work or to spend time with her grandchildren. She has already had a medical workup for these symptoms by her oncologist. Your most appropriate initial intervention is to...

A. Discuss possible placement of a feeding tube.
B. Evaluate further for treatable causes.
C. Start dexamethasone, 4 mg po qam.
D. Start megestrol acetate (Megace).
E. Educate the patient and daughter about what to expect in the dying process.

Correct answer is E


Q5: Management of sleep disturbance
The sleep medication that is best tolerated in elderly patients is...

A. Trazodone
B. Temazepam
C. Diphenhydramine
D. Lorazepam

Correct answer is A


Q6: Management of constipation
Which of the following agents has a mechanism of action that is NOT increasing intestinal motility?

A. Senna
B. Metoclopramide
C. Prune juice
D. Lactulose
E. Bisacodyl

Correct answer is D. Lactulose is an osmotic agent.



Long Questions

1. Palliative care--Definition and goals
You see R.L. for the first time in your clinic, after inheriting him from another physician. His wife brings him in a wheelchair with the help of van transportation provided by the city. He is an 85-year-old retired salesman with multiple complications of diabetes. He is blind, has had a mild stroke and heart attack. He cannot walk due to a left above-knee amputation and severe neuropathy in the remaining leg. He has moderate pain from the neuropathy, for which he has tried multiple medications. It is currently helped somewhat by gabapentin, but he is still uncomfortable most of the time. He developed worsening chronic renal failure about a year and a half ago, and in discussions with his doctor at that time, decided that he would not want dialysis, artificial ventilation, or resuscitation. However, his wife disagrees with this decision.

His creatinine has been stable at 5.0 for the past year. He was recently hospitalized for his second bout of endocarditis, and had six weeks of antibiotics in a nursing home, with which he did well. During the hospitalization, he was again judged competent to make his own decisions by the medicine attending. The discharge summary states that he was fully informed about what dialysis was and refused it again, but did want to receive antibiotics. In clinic, he has no complaints other than the leg pain. He has no fevers, shortness of breath, pedal or sacral edema, or pruritis. His MMSE is 27/30. He has no symptoms of depression.

Which one of the following choices is the most appropriate management approach at this time?

A. Refer to hospice for comfort care.
B. Try to convince Mr. L. to initiate dialysis, since his wife is his power of attorney and disagrees with his decision.
C. Adopt a palliative care approach, and consider starting opioids for his pain.
D. Refer to psychiatry to evaluate his competency.

Answer


2. Dyspnea
M.S. is a 67-year-old teacher with advanced pulmonary fibrosis. She has been intubated several times for prolonged periods with long rehabilitation. Recent pulmonary function tests: worsening lung function, FEV-1 of 0.7. No further treatment options available. After extended discussion with her pulmonologist and family, she requests not to be intubated again, since she would be unlikely to come off of the ventilator. She would also like to avoid invasive tests, such as bronchoscopy and arterial blood gases, and prefers to avoid hospitalization if possible.

She has chronic, mild breathlessness with minimal activity around the house. She often has coughing spells with minimal activity as well. Her cough is nonproductive, and she gets little benefit from bronchodilators. She already has a hospital bed, and lives on just one floor of her home. She would like to be able to do some things for herself. In particular, she enjoys cooking dinner for her family and caring for plants in her greenhouse during the afternoon.

She is on no medications, and has no pain. On 2 liters of home oxygen, her saturation is 97% and drops to 94% with slow walking. This reproduces her mild dyspnea. Exam: clear lungs, without evidence of pulmonary edema or pleural effusions and no pedal edema. CBC: normal.

Best initial treatment for this her dyspnea?

A. Sustained-release morphine, 30 mg po bid.
B. Codeine, 15-30 mg po q6h prn, to be taken 1/2 hr before desired activity. C. Lorazepam, 1 mg po bid.
D. Increase oxygen to 4 liters nasal cannula, as needed with exertion.
E. Supply patient with a pulse oximeter at home. Do not give opioids, since they might suppress her respiratory drive and cause respiratory arrest.

Answer

3. Nausea/vomiting
P.T. is a 92-year-old former steelworker with colon cancer metastatic to the liver. He has completed courses of chemotherapy and radiation, and, after discussion with his oncologist, has decided on a palliative care approach, with no more invasive tests or treatments. Right upper quadrant pain is well-controlled with extended-release morphine, 60 mg po bid, and dexamethasone, 4 mg po qam. He has daily bowel movements on senna plus docusate sodium, 1 tab bid. However, he complains of early satiety and nausea that limits his ability to eat.

What is the most appropriate initial treatment for this patient[base ']s nausea?
A. Reduce morphine to 30 mg po bid
B. Increase dose of senna plus docusate sodium to 2 tabs bid
C. Metoclopramide, 10 mg po
D. Lorazepam, 0.5 mg po q6h prn
E. Promethazine, 25 mg po bid

Answer

4. Constipation
A.R. is a 46-year-old mother of two with advanced ovarian cancer widespread within the abdomen who has exhausted all treatment options. However, she complains of persistent constipation and abdominal discomfort. She used to move her bowels once a day, but has been having difficulty passing stool; her last bowel movement was a week ago. She does not have nausea or vomiting. Her only current medication is transdermal fentanyl, 100 ug/h, which is controlling her pain well. On exam, she is afebrile but appears uncomfortable. Her abdomen is distended with a fluid wave. Bowel sounds are present but diminished. Her abdomen is mildly diffusely tender.

The most appropriate initial treatment for this patient[base ']s constipation would be...

A. Stop fentanyl
B. Senna plus docusate sodium, 1 tab po bid
C. H20 or soap suds enema, followed by regular senna plus docusate 1 tab po bid
D. Metoclopramide 10 mg po qid

Answer

5. Anorexia/cachexia
M.C. is a 53-year-old lab technician with severe chronic pulmonary disease. She has been intubated several times over the past year, and is now nearly bedbound because of dyspnea. She has lost 60 pounds in the past 4 months. She was formerly diabetic and hypertensive, but her blood sugars and blood pressure have normalized with her weight loss. Her pain is well- controlled with a long-acting morphine preparation, and she moves her bowels regularly. She does not complain of nausea or abdominal pain. She is not depressed. Her daughter comes to the visit with her, and both she and the patient are concerned about her thin appearance and poor appetite. The patient says that she used to really enjoy eating, but now finds food tasteless and unappealing. On exam, her oral mucosa is moist and clear of thrush, and her abdominal exam is unremarkable.

What is the most appropriate initial treatment for this patient[base ']s anorexia?


A. Placement of a feeding tube
B. Trial of megestrol acetate, 40 mg po qd
C. Trial of megestrol acetate, 200 mg po q6-8h
D. Trial of dexamethasone, 4 mg po qd
E. Chest and abdominal computerized tomography to look for evidence of cancer

Answer

6. Fatigue/weakness
T.L. is a 97-year-old woman with osteoarthritis, hypertension, and breast cancer metastatic to the bone. She lives independently, but complains of not having enough energy to go to the store or to her bridge club. Her independence and activities have always been extremely important to her. In previous discussions about her goals and values, she has told you that when she can[base ']t live alone any more she is no longer interested in living. She says that she is sleeping well, and has no symptoms of depression.

On exam, her blood pressure is 120/80, and her heart rate and rhythm are normal. The remainder of the exam is unremarkable. At a visit 3 weeks ago, a CBC, electrolyte panel, TSH, and EKG were normal. Recent imaging showed no evidence of metastatic disease to the spine. She is currently undergoing radiation treatment.

What is the most appropriate initial treatment for this patient's fatigue?

A. Evaluate for other reversible causes; if none are found, consider discussing discontinuing radiation therapy
B. Start dexamethasone, 4 mg po qam.
C. Trial of methylphenidate (a stimulant) in the morning and at noon
D. Refer to her oncologist; she may need more chemotherapy for advancing disease.

Answer


7. Sleep disturbance
G.E. is a 92-year-old mother of 10 with progressive dementia. Her youngest daughter, who lives with her but works during the day, indicates the patient isn[base ']t sleeping well. On further questioning, she says that the patient has complained of difficulty falling asleep, and that she is often sitting up in bed, still awake, when the daughter checks on her during the night. However, she does not appear to be confused or agitated, and does not wander around the house. She does not complain of early morning awakening. The caregiver during the day indicates she spends most of the day in a chair in front of a television, and naps frequently. She has no other medical problems, and her only medication is occasional acetaminophen for arthritis pains.

The most appropriate initial treatment for this patient would be to try to increase her activity so that she does not sleep as much during the day. If this were not effective, the most appropriate initial medication to try to help with her sleep would be...

A. Haloperidol, 2 mg po qhs
B. Diphenhydramine, 25 mg po qhs
C. Lorazepam, 1 mg po qhs
D. Sustained-release oxycodone, 10 mg po qhs
E. Trazodone, 25 mg po qhs

Answer

Post-test questions

1. R. M. is a 32-year-old patient with end-stage cystic fibrosis. He is not eligible for lung transplant and is receiving palliative care. He experiences daily episodes of shortness of breath in the evenings, which he rates as severe.

The most appropriate initial treatment for this patient's dyspnea is...

a. Ativan, 0.5 mg po qhs prn, may repeat x 1
b. Long-acting morphine, 10 mg po bid
c. Use his albuterol nebulizer until symptoms improve
d. Hydrocodone, 5-10 mg po q4h prn
e. Morphine sulfate, 5-10 mg po q4h prn

Correct answer is E


2. M.S. is a 93-year-old patient with severe dementia who is receiving palliative care. She seems comfortable during the day, but sleeps much of the time. However, she is often awake, confused, and upset at night, which is distressing to her family. She is on no other medications.

The most appropriate initial treatment for this patient's sleep disturbance is...

A. Relaxation therapy
B. Haloperidol, 2 mg po qhs
C. Trazodone qhs
D. Lorazepam 1 mg po prn confusion

Correct answer is B


3. The most appropriate initial treatment for opioid-induced nausea is...

A. Scopolamine
B. Promethazine
C. Prochlorperazine
D. Lorazepam

Correct answer C


4. The preferred treatment for prevention of constipation in terminally ill patients on opioids is...

A. Senna
B. Magnesium citrate
C. Sorbitol
D. Lactulose
E. Docusate sodium

Correct answer A


5. R.F. is a 57-year-old woman with esophageal cancer. She has lost a lot of weight, but she is alert and able to make decisions. She has had surgery and all possible treatments. Because of her disease and previous surgery, she is unable to eat or drink and it is impossible to place a feeding tube. She has a Karnofsky score of 50 (she is in bed more than 50% of the time, and this is progressive).

The most appropriate next step in the treatment plan is...
A. Set up home care for home total parenteral nutrition.
B. Discuss her options, goals and wishes, including the option not to have intravenous fluids.
C. Discuss her goals, wishes, and options, but do not include the option not to have intravenous fluids, because that would be unethical in this case.
D. Set up hospice and arrange for intravenous fluids.

Correct answer is B


6. Which of the following medications is NOT appropriate for treating anorexia in selected types of patients?

A. Androgens
B. Methylphenidate
C. Dexamethasone
D. Megestrol acetate

Correct answer is B. Methylphenidate can sometimes be used for fatigue.


General Books and References

Berger, A.; Portenoy, R.; and Weissman, D. Principles and Practice of Supportive Oncology. Lippincott-Raven. 1998. The book is divided into five sections: symptoms and syndromes-assessment and management, special interventions (e.g., hydration, nutrition), terminal care, ethics, and special topics (e.g., stress/burnout, care of patients with AIDS).

Bruera E, Neumann CM. Management of specific symptom complexes in patients receiving palliative care. Can Med Assoc J 1998; 158(13): 1717-1726. Available at http://www.cma.ca/cmaj/index.htm

Cassaret D, Kutner JS, and Abrahm J. Life after death: A practical approach to grief and bereavement. Ann Intern Med 2001; 134: 208-215.

Emanuel LL, von Gunten CF, Ferris FD. The Education for Physicians on End-of-life Care (EPEC) curriculum, 1999, Module 10: Common physical symptoms. Also see Module 6: Depression, Anxiety, Delirium. Available at http://epec.net/content/participantshandbook.html

Lynn, J, Childress JF. Must patients always be given food and water? Hastings Cent Rep. 1983 Oct;13(5):17-21.

Doyle, D.; Hanks, G.W.C.; and MacDonald, N. Oxford Textbook of Palliative Medicine. Oxford University Press. 1999. A 1,283-page comprehensive textbook covering all major topics of adult and pediatric palliative medicine. This is the major international reference textbook.

McCann, RM, Hall WJ, Groth-Juncker A. Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. JAMA 1994; 272(16): 1263-1266.

O'Brien, T, Welsh J, Dunn FG. ABC of palliative care: Non-malignant conditions. BMJ 1998; 316: 286-289. Available at http://www.bmj.com/cgi/content/full/316/7127/286. Also see the full series of articles in BMJ on palliative care at http://www.bmj.com/cgi/collection/palliative_medicine

Weissman, D. Fast Facts and Concepts. Available at: http://www.eperc.mcw.edu. Short synopses of many of the topics covered in this module.

Wrede-Seaman, L. Symptom management algorithms: A handbook for palliative care. Yakima, WA: Intellicard, 1999. Can be ordered at www.intelli-card.com.




If you need three more questions, here they are...

1. Which of the following is the most important first step when treating non-pain symptoms?

A. Order blood tests and x-rays
B. Complete a hitory and physical
C. Switch the patient's pain medicatino to an opiod
D. Order an appropriate adjuvant drug

Answer is B


2. When treating dyspnea, which of the following is not appropriate...

A. Reposition the patient
B. Improve airflow with a fan
C. Address patient and family anxieties about suffocation
D. Avoid the use of opiods


3. When treating nonpain symptoms in terminally ill patients, which of the following is unnecessary?

A. Continual reassessment
B. Involvement of the entire team
C. Weekly blood counts
D. Patient and family education

Last update: 7/17/02; 8:40:41 AM.