Symptom Management

Symptom Management

The American College of Physicians has developed clinical guidelines, based on a systematic review of evidence and on a report by the Agency for Healthcare Research and Quality, to improve palliative care at the end of life. These guidelines provide strong recommendations for the regular assessment of patients at the end of life for symptoms of pain, dyspnea, and depression, and for therapies of proven effectiveness for these symptoms. For patients with cancer, these include the use of opioids, nonsteroidal anti-inflammatory drugs, and bisphosphonates for pain; tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions for depression; and opioids for unrelieved dyspnea and oxygen for short-term relief of hypoxemia. The guidelines do not address other variables of palliative care at the end-of-life or the management of other matters (e.g., nutritional support) because the quality of evidence is limited rather than because other issues or symptoms are unimportant.⁴³

3. As soon as the hospice admission and assessment is completed, the nurse develops a plan for symptom management and orders a comfort kit for M.P. Why are the components in this kit useful?

Some hospices use a general comfort kit that contains specific medications to manage symptoms commonly encountered by most hospice patients, or they order medications to treat anticipated symptoms for a specific patient. These medications are placed in the home or facility in which the patient resides. This facilitates the availability of medications to patients who encounter anticipated symptoms and are convenient when caregivers are instructed by the patient's primary

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care provider to provide the medication to the patient. Patients living with a life-threatening illness or nearing the end-of-life can encounter as many as 53 symptoms.⁴⁴ In one study, patients (n = 176) experienced an average of 6.6 to 6.8 distressing symptoms during the last week of life.⁴⁵ In general, the prevalence of each symptom is difficult to measure and demonstrates a high degree of variability. The prevalence of pain (43%-80%) in cancer patients, for example, varies with the primary site of advanced cancer.⁴⁵ Patients with terminal illnesses also experience nausea and vomiting (4%-44%), dyspnea (15%-79%), constipation (4%-65%), insomnia (7%-28%), delirium (4%-85%), anorexia (6%-74%), weight loss (58%-77%), and fatigue (13%-91%).^45-47 The disparity in symptom prevalence (Table 6-4) may be attributed to a host of variables (e.g., study design, patient population, underlying disease, inconsistent definitions). The occurrence of symptoms, however, can vary significantly, even within the last week of life, and the need for frequent assessments of patients cannot be overemphasized. Morphine, lorazepam, haloperidol, prochlorperazine suppositories, and an anticholinergic agent are commonly ordered for hospice patients.

Table 6-4 Symptom Prevalence in Advanced Cancer

Symptom % of Patients with Stated Symptom Vainio and Auvinen46 (%) Curtis et al.48 (%) Donnelly and Walsh47 (%) Conill et al.45 (First Evaluation) (%) Conill et al.45 (Second Evaluation) (%) Pain 51 NR 64 52.3 30.1 Nausea/vomiting 21 32/25 36/23 26.1/18.8 23/10.2 Dyspnea 19 41 51 39.8 46.6 Constipation 23 40 51 49.4 55.1 Insomnia 9 NR NR 34.7 28.4 Delirium NR NR NR NR NR Anorexia 30 55 74 68.2 80.1 Fatigue NR NR NR NR NR Weight loss 39 NR NR NR NR Weakness 51 NR NR 76.7 81.8 Confusion 8 NR NR 30.1 68.2 Dry mouth NR NR NR 61.4 69.9 Dysphagia NR NR NR 27.8 46.0 Anxiety NR 20 23 50.6 45.5 Depression NR 31 40 52.8 38.6 Diarrhea NR NR NR 8.0 6.8 NR, not reported.

Morphine. Every hospice cancer patient should have a short-acting opioid available for the palliation of unrelieved dyspnea and pain. Although morphine can cause respiratory depression, small doses are very effective in controlling dyspnea by multiple mechanisms: vasodilation, reduced peripheral vascular resistance, inhibition of baroreceptor responses, reduction of brainstem responsiveness to carbon dioxide (the primary mechanism of opioid-induced respiratory depression), and lessened reflex vasoconstriction caused by increased blood PCO₂ levels. Opioids can also reduce the anxiety associated with dyspnea and might also act directly on opioid receptors present in the airways^49-51 (Table 6-5).

Hospice patients generally do not have an easily accessible port (i.e., an IV line) into which medications can be easily administered. As a result, medications are primarily administered orally and, occasionally, by sublingual, buccal, transdermal, rectal, or subcutaneous (if an infusion is warranted) routes of administration. When patients lose the ability to swallow near the end of life (or have a condition that precludes swallowing), the sublingual or buccal routes of administration are the most useful, especially if drugs are lipophilic. Morphine is

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hydrophilic, and although some of it might be absorbed across the mucous membranes, the primary clinical effect probably results from gastrointestinal absorption after the drug has trickled down the back of the throat.

Table 6-5 Treatment of Dyspnea at End-of-Life

Nonpharmacologic methods Pursed lip breathing Upright position Relaxation Meditation Use of a fan or open window to circulate air over the face Pharmacologic therapy Systemic opioids (short acting) in small doses given orally, sublingually, or via injection can be given Q 1-2 hr PRN. Long-acting agents can be added to supplement routine use short-acting opioids.   Inhaled opioids deliver medication via nebulization directly into the airway, avoiding first-pass metabolism, allowing use of smaller doses, and minimizing side effects such as drowsiness. May cause local histamine release, leading to bronchospasm. Use nonpreserved sterile injectable products. More cumbersome and expensive due to use of nebulizer and nonpreserved parenteral products. Agents: morphine 2.5-10 mg in 2 mL 0.9% NaCl hydromorphone 0.25-1 mg in 2 mL 0.9% NaCl fentanyl 25 mcg in 2 mL 0.9% NaCl Generally given Q 2-4 hr PRN for breathlessness. Benzodiazepines are useful for the anxiety associated with breathlessness. From references 49, 50, 51.

Oral morphine sulfate (OMS), in a concentration of 20 mg/mL, is commonly packaged in a 30-mL bottle at the beginning of hospice care. This bottle of morphine can provide sixty 10-mg doses, and at this concentration, only 0.5 mL of morphine needs to be administered. Oxycodone or hydromorphone, in comparable adjusted doses, can be substituted for morphine when needed.

Lorazepam. A short-acting benzodiazepine (e.g., lorazepam 0.5 mg Q 4 hr PRN) is useful for the treatment of anxiety. Patients, especially those with respiratory symptoms, can experience episodes of extreme anxiety near the end-of-life. Caution should be used in not overusing these drugs in the elderly because they can increase the risk of falling or cause paradoxical reactions and worsen delirium or restlessness.

Haloperidol. Small doses of haloperidol (e.g., 0.5-1 mg) are useful for the treatment of restlessness, delirium, or nausea and vomiting.

Prochlorperazine. When patients cannot take oral medications to manage nausea and vomiting, rectal suppositories of prochlorperazine are often effective. Although drug therapy needs to consider the etiology of the nausea and vomiting, prochlorperazine is generally a good initial agent.

Anticholinergic. As death approaches, patients can have difficulty in clearing pharyngeal secretions, and as a result, generate a sound commonly known as a death rattle.⁵² Although patients are often unconscious at this point, this sound can be very distressing to those nearby. An anticholinergic (e.g., glycopyrrolate, hyoscyamine, scopolamine, atropine) can be administered in an attempt to dry these pharyngeal secretions. This treatment modality is usually initiated after the patient has become obtunded; if begun too early, patients might develop problems with thickened bronchial or pulmonary secretions, tachycardia, delirium, dry mouth, or other adverse anticholinergic effects. Glycopyrrolate, available in a tablet or injectable formulation, is a good choice for an anticholinergic because it minimally crosses the blood-brain barrier. The 1-mg tablets could be crushed and placed under the tongue Q 8 hr. Hyoscyamine is available as oral tablets, capsules, oral sustained-release tablets, sublingual tablets, oral liquid, oral solution, and injection. Either the sublingual tablets or oral solution of hyoscyamine can be given in a 0.125- to 0.25-mg dose sublingually Q 4 hr PRN. Scopolamine-transdermal patches have a slow onset of action (blood levels are detected 4 hours after application)⁵³ and are of limited utility in this situation. The oral administration of atropine ophthalmic solution 1% is convenient to administer and is cost effective. Assuming that 20 drops is approximately equivalent to 1 mL, patients can be given 0.5 to 1 mg (1-2 drops) of the atropine ophthalmic solution PO Q 4 hr PRN. Families and caregivers must be instructed not to use this in the eye.

4. The patient's nurse has difficulty finding OMS available from a pharmacy and difficulty in finding a pharmacy willing to accept a faxed prescription. Why is morphine so difficult to obtain?

Providing relief for pain or other symptoms with opioids is often difficult due to numerous barriers. Patients and caregivers are often fearful of opioids, or mistakenly believe these medications will cause addiction or hasten death.⁵⁴ Pharmacists can create barriers by not having opioids in the pharmacy, sometimes due to fear of robbery, fear of investigation by drug regulatory agencies, or insufficient appreciation of the usefulness of opioids in pain management and palliative care.⁵⁵ Pharmacists, who are inexperienced in providing service to hospice patients, might not be knowledgeable of federal regulations governing the provision of controlled substances to hospice patients. Federal statutes, as well as most state statutes, permit prescriptions for Schedule II controlled substances for hospice patients to be faxed. According to the Code of Federal Regulations (21CFR1306.11) paragraph (g): “A prescription prepared in accordance with Sec. 1306.05 written for a Schedule II narcotic substance for a patient enrolled in a hospice care program certified and/or paid for by Medicare under Title XVIII or a hospice program which is licensed by the state may be transmitted by the practitioner or the practitioner's agent to the dispensing pharmacy by facsimile. The practitioner, or the practitioner's agent, will note on the prescription that the patient is a hospice patient. The facsimile serves as the original written prescription for purposes of this paragraph (g) and it shall be maintained in accordance with Sec. 1304.04(h).”⁵⁶

The process of ordering controlled substances for use by hospice patients at home can take many hours, and sometimes as much as an entire day. Hospice providers should anticipate possible difficulties when placing orders for Schedule II controlled-substance medications.

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