To prevent and relieve suffering,

and promote quality of life

at every stage of life
 Common Symptoms

Frank
Frank D.
D. Ferris,
Ferris, MD
MD
Medical
Medical Director,
Director, Palliative
Palliative Care
Care Standards
Standards
C ENTER F
CENTER OR P
FOR ALLIATIVE SSTUDIES
PALLIATIVE TUDIES
San
San Diego
Diego Hospice
Hospice and
and Palliative
Palliative Care
Care
““Education
Educationand
andResearch
Researchin
in the
the Art
Art and
and Science
Science of
of Palliative
Palliative Care”
Care”

Department
Department of
of Family
Family and
and Preventative
Preventative Medicine,
Medicine,
UCSD
UCSD School
School of
of Medicine
Medicine
Department
Department of
of Family
Family and
and Community
Community Medicine,
Medicine, and
and
Joint
Joint Center
Center for
for Bioethics,
Bioethics, University
University of
of Toronto
Toronto
Objectives
 Know general guidelines for
managing non-pain symptoms
 Know how to assess and manage
common symptoms

www.CPSOnline.info
Publications / presentations
General guidelines . . .
 History, physical examination
 Conceptualize likely causes
 Discuss treatment options
 Assist with decision making
. . . General guidelines
 Provide education, support
 Involve entire interdisciplinary team
 Reassess frequently
HIV Wasting
HIV Wasting
 Loss of weight > 10% of baseline with
fever, weakness, diarrhea > 30 days
 inadequate nutrient intake
 excessive nutrient loss
 metabolic dysregulation
Management
of anorexia / cachexia . . .
 Assess, manage comorbid
conditions
 Educate, support
 Favorite foods / nutritional
supplements
. . . Management
of anorexia / cachexia
 Alcohol
 Megestrol acetate
 Dexamethasone
 Dronabinol
 Androgens, eg, testosterone
Fatigue /
Weakness
Management
of fatigue / weakness . . .
 Promote energy conservation
 Evaluate medications
 Optimize fluid, electrolyte intake
 Permission to rest
 Clarify role of underlying illness
 Educate, support patient, family
 Include other disciplines
. . . Management
of fatigue / weakness
 Dexamethasone
 feeling of well-being, increased energy
 effect may wane after 4-6 weeks
 continue until death
 Methylphenidate
Fever /
Sweats
Management of fever / sweats
 Paracetamol (acetaminophen)
 NSAIDs, eg, ibuprofen
 Corticosteroids, eg, dexamethasone
 Anticholinergics, eg, scopolamine
 Rehydration
 Bathing, drying
Nausea /
Vomiting
Nausea / vomiting
 Nausea
 subjective sensation
 stimulation
• gastrointestinal lining, CTZ, vestibular
apparatus, cerebral cortex
 Vomiting
 neuromuscular reflex
Causes
of nausea / vomiting
 Metastases  Mechanical
 Meningeal obstruction
irritation  Motility
 Movement  Metabolic
 Mental anxiety  Microbes
 Medications  Myocardial
 Mucosal irritation
Pathophysiology
of nausea / vomiting
Chemoreceptor
Chemoreceptor Cortex
Cortex
Trigger
Trigger Zone
Zone (CTZ)
(CTZ)

Vomiting Vestibular
Vestibular
Vomiting center
center
apparatus
apparatus
Neurotransmitters
Neurotransmitters
 Acetylcholine

Acetylcholine
 Dopamine
Dopamine

GI
GI tract
tract
 Histamine

Histamine
 Serotonin

Serotonin
Management
of nausea / vomiting
 Dopamine  Prokinetic agents
antagonists  Antacids
 Antihistamines  Cytoprotective
 Anticholinergics agents
 Serotonin  Other medications
antagonists
 Acetylcholine antagonists
(anticholinergics)
 Scopolamine
 Atropine
Dopamine antagonists
 Haloperidol
 Prochlorperazine
 Metoclopramide (also prokinetic)
Histamine antagonists
(antihistamines)
 Diphenhydramine
 Meclizine
 Hydroxyzine
Serotonin antagonists
 Ondansetron
 Granisetron
Antacids
 Antacids
 H2 receptor antagonists
 cimetidine
 ranitidine
 Proton pump inhibitors
 omeprazole
Cytoprotective agents
 Misoprostol
 Proton pump inhibitors
 omeprazole
Other medications
 Dexamethasone
 Tetrahydrocannabinol
 Lorazepam

 Octreotide
Constipation
Constipation
 Medications  Metabolic
 opioids abnormalities
 calcium-channel
blockers
 Spinal cord
 anticholinergic compression
 Decreased motility  Dehydration
 Ileus  Autonomic
dysfunction
 Mechanical
obstruction  Malignancy
Management
of constipation
 General measures  Specific measures
 establish  stimulants
“normal” bowel  osmotics
pattern
 detergents
 regular toileting
 lubricants
 gastrocolic reflex
 large volume
enemas
Stimulant laxatives
 Prune juice
 Senna
 Casanthranol
 Bisacodyl
Osmotic laxatives
 Milk of magnesia (other Mg salts)
 Lactulose
 Polyethylene glycol
 Sorbitol
 Magnesium citrate
Surfactant laxatives
(stool softeners)
 Sodium docusate
 Calcium docusate
 Phosphosoda enema prn
Prokinetic agents
 Metoclopramide
Lubricant stimulants
 Glycerin suppositories
 Oils
 mineral
 peanut
Large-volume enemas
 Warm water
 Soap suds
Constipation
from opioids . . .
 Occurs with all opioids
 Pharmacologic tolerance developed
slowly, or not at all
 Dietary interventions alone usually
not sufficient
 Avoid bulk-forming agents in
debilitated patients
. . . Constipation
from opioids
 Combination stimulant / softeners
are useful first-line medications
 casanthranol + docusate sodium
 senna + docusate sodium
 Prokinetic agents
Diarrhea
Causes of diarrhea
 Infections
 GI bleeding
 Malabsorption, eg, lactose intolerance
 Medications, eg, HAART
 Obstruction, eg, cancer
 Overflow incontinence
 Stress
Management of diarrhea
 Establish “normal” bowel pattern
 Treat underlying cause
 Avoid gas-forming foods
 Increase bulk, i.e., fiber
 Transient, mild diarrhea
 bismuth salts
Management
of persistent diarrhea
 Rehydration
 Oral salt containing fluids
 Parenteral
 Loperamide
 Diphenoxylate / atropine

 Tincture of opium
 Octreotide
Shortness
of Breath
(Dyspnea)
Breathlessness
(dyspnea) . . .
 Described as
 shortness of breath
 a smothering feeling
 inability to get enough air
 suffocation
. . . Breathlessness (dyspnea)

 Only reliable measure is patient self-

report
 Respiratory rate, pO2, blood gas
determinations DO NOT correlate
with the feeling of breathlessness
 Prevalence 12 – 74%
Causes of breathlessness
 Anemia  Pleural effusion
 Anxiety  Pulmonary edema
 Airway obstruction  Pulmonary
embolism
 Bronchospasm
 Thick secretions
 Hypoxemia
 Family / financial /
 Infections
legal / spiritual /
 Metabolic practical issues
Management
of breathlessness . . .
 Treat the underlying cause
 antibiotics
 avoid fluid overload
 dry secretions
 Mechanical ventilation
. . . Management
of breathlessness
 Symptomatic management
 oxygen
 opioids
 anxiolytics
 nonpharmacologic interventions
Oxygen
 Pulse oximetry not helpful
 Potent symbol of medical care
 Expensive
 Fan may do just as well
Opioids
 Small doses
 Central and peripheral action
 Relief not related to respiratory rate
 No ethical or professional barriers
 Do not shorten life
Anxiolytics
 Safe in combination with opioids
 lorazepam
• 0.5-2 mg po q 1 h prn until settled
• then dose routinely q 4–6 h to keep settled
Nonpharmacologic
interventions . . .
 Reassure, work to manage anxiety
 Behavioral approaches, eg,
relaxation, distraction, hypnosis
 Limit the number of people in the
room
 Open window
Nonpharmacologic
interventions . . .
 Eliminate environmental irritants
 Keep line of sight clear to outside
 Reduce the room temperature
 Avoid chilling the patient
. . . Nonpharmacologic
interventions
 Introduce humidity
 Reposition
 elevate the head of the bed
 move patient to one side or other
 Educate, support the family
Common
Symptoms
Summary