Symptom Management in Palliative Medicine Part 3

Malignant Ulcers

For uncomplicated malignant ulcers, pain relief and wound care are managed in the same way as pressure ulcers. Malignant wounds can present special problems, however, which may include bleeding, exudate, infection, odor, and disfigurement. A bleeding malignant ulcer should be treated with radiation therapy, topical sucralfate, or topical tranexamic acid. Dirty ulcers should be debrided, which can be accomplished chemically. Altered body image from disfiguring wounds can be lessened with cavity foam dressings. Furthermore, empathetic listening is often therapeutic in itself. Anxiety, anger, or depression needs specific support, however47 [see Clinical Essentials: XI Management of Psychosocial Issues in Terminal Illness].

Foul-Smelling Wounds

Odors may be very distressing to patients, families, and care-givers and may lead to poor quality of care, as even professional caregivers tend to avoid sickening smells. Odors are usually due to anaerobic infections or poor hygiene. Treat superficial infections with topical metronidazole or silver sulfadiazine. These agents are expensive, however; and if a less costly alternative is required, a diluted hydrogen peroxide solution can be used.37 For soft tissue infections, add systemic metronidazole to topical management.

To control odors, place a pan containing kitty litter or activated charcoal under the patient’s bed, provide adequate room ventilation, place an open cup of vinegar in the room, or burn a candle. Special charcoal-impregnated dressings placed over the odorous wound may also be helpful.37

Psychiatric Symptoms

Adjustment disorders, depression, anxiety, dementia, and delirium are the most common psychiatric problems encountered in dying patients.50,51 Depending on their severity, management of these psychiatric problems may be within the capacity of the primary care physician or may require referral [see Clinical Essentials: XIManagement of Psychosocial Issues in Terminal Illness].

Delirium

Delirium occurs in roughly 75% of terminally ill patients.52,53 Symptoms of delirium include inability to maintain attention, waxing and waning of consciousness, psychomotor changes, disturbance of sleep-wake cycle, disorientation, visual or auditory hallucinations, and problems with memory and language.54 Other terms often used synonymously with delirium include acute confusional state, metabolic encephalopathy, and sun-downing. In contrast to dementia, delirium is more rapid in onset (developing over hours to days), fluctuates in severity, is potentially reversible, and is associated with a lesser degree of memory impairment.

Table 6 A Progressive Bowel Regimen for Patients Receiving Opioid Therapy45*

Step 1 Docusate, 100 mg b.i.d. Senna, 1 tablet q.d. or b.i.d.

Step 2 Docusate, 100 mg b.i.d. Senna, 2 tablets b.i.d. Bisacodyl rectal suppositories, 1-2 after breakfast

Step 3 Docusate, 100 mg b.i.d. Senna, 3 tablets b.i.d. Bisacodyl rectal suppositories, 3-4 after breakfast

Step 4 Docusate, 100 mg b.i.d. Senna, 4 tablets b.i.d. Lactulose or sorbitol, 15 ml b.i.d. Bisacodyl suppositories, 3-4 after breakfast

Step 5 Sodium phosphate or oil-retention enema; if no results, add a high-colonic tap-water enema

Step 6 Docusate, 100 mg b.i.d. Senna, 4 tablets b.i.d. Lactulose or sorbitol, 30 ml b.i.d. Bisacodyl rectal suppositories, 3-4 after breakfast

Step 7 Docusate, 100 mg b.i.d. Senna, 4 tablets b.i.d. Lactulose or sorbitol, 30 ml q.i.d. Bisacodyl rectal suppositories, 3-4 after breakfast

*The bowel regimen is started at the time of or before the initiation of opioid therapy, and it should be continued for the duration of opioid therapy. The clinician should start with step 1 and progress through higher steps until an effective regimen is found.

Table 7 Treatments for Constipation

Laxative type	Mechanism	Agent	Dosage	Comment
Stimulant	Irritate the bowel and increase peristaltic activity	Prune juice	120-240 ml q.d. or b.i.d.
		Senna	1-2 tablets p.o., q.h.s.	Titrate to effect; < 8 tablets b.i.d.
		Bisacodyl	10-15 mg p.o., h.s.; or 10 mg p.r., after breakfast	Titrate to effect
Osmotic	Draw water into the bowel lumen, increase overall stool volume	Lactulose	30 ml p.o., q. 4-6 hr	Titrate to effect
		Sorbitol, 70% solution	2 ml/kg, up to 50 ml p.o., q.d.-t.i.d.
		Milk of magnesia	1-2 tbsp, q.d.-t.i.d.
		Magnesium citrate	1-2 bottles p.r.n.
		Polyethylene glycol solution	1-4 L p.o.	Drink 8 oz q. 10 min until consumed
		Polyethylene glycol powder	17 g (1 tbsp) powder in 8 oz water, q.d.	2-4 days may be required to produce a bowel movement; increase dose as needed
Detergent (stool softeners)	Increase water content in stool by facilitating the dissolution of fat	Docusate sodium	1-2 capsules p.o., q.d.-b.i.d.	Titrate to effect
		Docusate calcium*	1-2 capsules p.o., q.d.-b.i.d.	Titrate to effect
Prokinetic agents	Stimulate the bowel’s myenteric plexus, and increase peristaltic activity and stool movement	Metoclopramide	10-20 mg p.o., q. 6 hr
Lubricant stimulants	Lubricate the stool and irritate the bowel, increasing peristaltic activity and stool movement	Glycerin suppositories	Daily
		Mineral oil or peanut oil enema	Daily
Large-volume enemas	Soften stool by increasing its water content; distend the colon and induce peristalsis	Warm-water enema	Daily	Addition of soapsuds irritates bowel wall to induce peristalsis
High-colonic enemas	Utilize gravity to bring fluid to more proximal parts of bowel	2 L of water or saline warmed to body temperature, hung on I.V. pole at ceiling level	Run in over 30 min, repeat q. 1 hr

*Not available in the United States.

Delirium is a multifactorial syndrome, involving preexisting risk factors and precipitating factors that occur during hospital-ization. Factors that predispose a patient to delirium include vision impairment, severe illness, cognitive impairment, and de-hydration.55 In older patients, cognitive impairment that is so mild as to be inapparent when they are well may nevertheless increase the risk of delirium. Precipitating factors include the use of physical restraints, malnutrition, taking more than three drugs, bladder catheter use, and any iatrogenic event.55 Prevention of delirium can be accomplished by targeting risk factors.55

Management of delirium in the terminally ill patient includes correction of the cause and provision of symptomatic relief. Identification and treatment of underlying diseases or conditions is paramount—for example, give antibiotics for sepsis or oxygen for shortness of breath. In patients with underlying dementia, the possibility of untreated pain deserves special consideration. In the past, physicians were taught that the use of narcotic analgesics is dangerous in patients with dementia because those agents cause delirium. That is not true of a demented patient who becomes agitated or belligerent because of pain, however; in those cases, a dose of a narcotic analgesic may calm the patient within an hour or so. The risk of undertreating severe pain should be of greater concern, both medically and ethically, than the risk of worsening delirium with analgesic medications.

Additional means of treating delirium include minimizing any sensory impairments by providing appropriate eyeglasses or hearing aids and maintaining a quiet, familiar, and reassuring setting.

Table 8 Local Measures for Oral Problems47

Dry mouth

Semifrozen fruit juice

Frequent sips of cold water or water sprays

Petroleum jelly rubbed on lips

Dirty mouth

Regular brushing with soft toothbrush and toothpaste

Pineapple chunks

Cider and soda mouthwash

Infected mouth Tetracycline mouthwash, 250 mg every 8 hr (one capsule dissolved in 5 ml water)

Painful mouth

Topical corticosteroids: betamethasone, 0.5 mg in 5 ml water, as mouthwash; or triamcinolone in carmellose paste

Coating agents: sucralfate suspension as mouthwash, carmellose paste, carbenoxolone

Topical anesthesia: benzocaine or lozenges containing local anesthetics

It is important to maintain communication with the patient, using frequent reorientation; familiar objects, places, and people; and avoidance of stimulus overload or deprivation.

Pharmacologic symptom relief is best achieved with the use of an antipsychotic agent such as haloperidol or risperidone [see Table 10]. Benzodiazepines or sedatives should be used only if antipsychotic agents fail.57

Terminal Delirium

Delirium may be an irreversible part of the dying process. Many terminally ill patients have escalating restlessness, agitation, or hallucinations that can be relieved only with sedation.58 When death is imminent, reversing the underlying causes of delirium is not possible. Instead, the clinician should focus on the management of the symptoms associated with the terminal delirium and bring comfort to the patient and family.

Benzodiazepines are widely used in the management of terminal delirium because they are anxiolytics, amnestics, skeletal muscle relaxants, and antiepileptics. Oral lorazepam (1 to 2 mg as an elixir, or the tablet predissolved in 0.5 to 1.0 ml of water and administered against the buccal mucosa) should be given every hour as needed; it will settle most patients at a daily dose of 2 to 10 mg. The lorazepam can then be given in divided doses, every 3 to 4 hours, to keep the patient settled. For a few extremely agitated patients, high doses of lorazepam—20 to 50 mg or more per 24 hours—may be required. A midazolam infusion (1 to 5 mg S.C. or I.V. every 1 hour, preceded by repeated loading boluses of 0.5 mg every 15 minutes to effect) may be a rapidly effective alternative.37

Palliative sedation When terminal delirium cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness, it may be necessary to resort to palliative sedation. Most physicians define palliative sedation as the act of purposely inducing and maintaining a pharmacologically sedated and unconscious state, without the intent to cause death.

Once palliative sedation is initiated, the dosage of the sedative agent should not be increased unless the patient awakens or becomes restless, tachypneic, or tachycardic. Increasing the level of sedation in the absence of a clinical indication might imply that the physician is intending to hasten death, which if true would cross the line between palliative sedation and physician-assisted suicide or euthanasia [see Clinical Essentials: IXPalliative Care].59

Table 9 Risk Factors for Pressure Ulcers

Intrinsic	Extrinsic
Malnutrition	Pressure
Protein	Shear
Vitamin C	Trauma
Zinc	Friction
Diminished mobility	Crumpled bedclothes
Tissue fragility	Restraints
Anemia	Bed rails
Dehydration	Poor hygiene
Hypotension	Hospital equipment
Poor peripheral perfusion	Oxygen tubing
Incontinence	Heart monitor wires
Neurologic deficit
Sensory
Motor
Older age
Coma
Moribund state

Table 10 Drug Treatment for Agitation or Delirium²⁸

Acute	Haloperidol, 0.5-5 mg p.o., p.r., I.M., I.V., or S.C.; titrate until calm Chlorpromazine, 1 mg I.V. q. 2 min until calm
	Haloperidol, 0.5-5 mg p.o. or p.r., b.i.d. (maximum dose, 100 mg/day)
	Thioridazine, 10-25 mg p.o., b.i.d. (maximum dose, 800 mg/day)
Chronic	Risperidone, 0.5 mg p.o., b.i.d.; increase by 0.5 mg b.i.d. q. 24 hr (maximum dose, 6 mg/day)
	Chlorpromazine, 10-50 mg p.o. or p.r., b.i.d. (maximum dose, 500 mg/day)
	Olanzepine, 2.5-15 mg p.o., q.d.

Terminal Wean

Mechanical ventilation is often tried in patients with respiratory distress, when there is hope that their condition will improve. This is best referred to as a time-limited trial. If reversal of the acute medical condition proves unsuccessful, the physician needs to discuss discontinuance of ventilation with the family.

Terminal ventilation withdrawal should be approached with attention to ensuring the patient’s comfort and to enhancing the family’s access to the bedside. Miles60 recommends a 10-step protocol, which applies to unconscious patients dependent on a ventilator:

1. Shut off and remove all monitors and alarms from the patient’s room.

2. Remove equipment that impedes access to the patient’s hands (e.g., intravenous lines, pulse oximeter, restraints). Hands are for holding.

3. Remove encumbering or disfiguring devices from the bedside.

4. Invite the family to be with the patient.

5. Quietly and personally request that pressors be turned off and that intravenous infusions be set to keep veins open.

6. Watch for distressing symptoms, such as agitation, tachyp-nea, or seizures; treat appropriately (e.g., with diazepam) if they appear.

7. Turn the fraction of inspired oxygen (FIO2) down to 20% and observe the patient for respiratory distress.

8. If the patient appears comfortable, remove the endotra-cheal tube with a clean towel in hand.

9. Educate and debrief the house staff and nursing staff about the process.

10. Consider contacting the family during the bereavement period, whether by letter or visit.

The goal is for a peaceful, pain-free death for the patient and a supportive, comfortable environment for the family and friends. It is important to warn family that a patient removed from the ventilator may live for hours to days afterward and to reassure them that all measures necessary to ensure comfort during the dying process will be used.

Symptom Management in the Last Hours of Life

The final hours of living can be some of the most important ones for the patient and for family. Managed well, they can lead to a peaceful death and healthy grief and bereavement.

During the final hours, patients usually need skilled care around the clock. Ideally, the environment will allow family and friends both easy access to their loved one and privacy. All who are present should presume that the unconscious patient hears everything.

It is important to be knowledgeable about the normal physiologic changes that occur in the last hours and to educate the patient’s family about them. Reassure the family that dehydration in the final hours of living does not cause distress and may stimulate endorphin release that adds to the patient’s sense of well-being. Moaning and groaning, although frequently misinterpreted as pain, is often terminal delirium (see above). Decreased hepatic and renal function lead to the accumulation of metabolites, which may cause terminal delirium. Use only essential medications and dose them accordingly.37

In the final hours of life, many persons in semiconscious or unconscious states are unable to swallow saliva reflexively or to cough up mucus. This inability to clear secretions from the oropharynx and trachea results in the so-called death rattle— noisy respiration as the secretions move up and down with expiration and inspiration. Explain the reason for the death rattle to the family and administer an anticholinergic drug to reduce pharyngeal secretions (e.g., hyoscine, as a single parenteral dose or by continuous infusion, or scopolamine by patch).61 At times, it may be necessary to reposition the patient or to suction the airway gently with a soft catheter. Reassure the family that despite the way the breathing sounds, the patient is not uncomfortable.

The removal of the body too soon after death can be even more upsetting to the family than the moment of death, so give the family time with the body.37 After the patient has died, follow-up with the family is important to ensure that grief and bereavement are progressing normally [see CE: X Management of Psychosocial Issues in Terminal Illness].