End-of-Life Care: Symptom Management (Part 2)
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers.Educational grant provided by Women's Health and Education Center (WHEC).
Successful treatment of symptoms experienced by the person facing the end-of-life transition requires collaboration of the patient, family, physicians, nurses, social workers, spiritual guides and other care providers. Symptom management is a complex process requiring ongoing attention and diligence to promote comfort. Appropriate symptom management depends on the patient and the family working in partnership with the healthcare provider members of the team. Together the patient and the family-centered team participate in ongoing assessment directed at finding effective treatments for all patient and family and require interdisciplinary symptoms and to find treatments that will successfully relieve the symptoms. Since multiple symptoms are commonly experienced by the person with a life-limiting illness, it is usual for multiple therapies to be needed. Careful attention to mechanisms of action and medication interactions is needed to prevent unnecessary toxicity from treatments. Often one therapy will produce an unpleasant side effect that requires another therapy for adequate relief. Effective symptom management requires the health professional team to have a strong commitment to total symptom relief, knowledge about therapy effects and side effects.
The purpose of this document is the best management of symptoms in end-of-life situations. Before initiating a symptom management approach, pharmacologic or non-pharmacologic, clinicians should allow patients time to express their thoughts and concerns. This simple step has led to better outcomes and when carried out in a supportive environment, has been almost as effective as more advanced techniques. Continual reassessment of symptoms is necessary to ensure adequate management of symptoms. It may be helpful for patients or a family member to keep a pain or symptom diary to note which measures have or have not provided relief and the duration of relief. This information will help clinicians determine the efficacy of specific therapeutic options and modify the treatment plan as necessary. The discussion of interventions in this document focuses on the care of adults. This document discusses the symptoms: Anorexia and Cachexia; Diarrhea; Sleep Disturbances; and Delirium.
ANOREXIA and CACHEXIA
Definition / Overview
Anorexia and cachexia are two conditions that are commonly found in advanced disease. Anorexia is defined as a loss of desire to eat or a loss of appetite associated with a decrease in food intake (1). The symptoms of anorexia (loss of appetite) and cachexia (weight loss) often occur in tandem. While anorexia encompasses a loss in the desire to eat along with decreased food intake, cachexia involves wasting and a general lack of nutrition. An altered body image may cause distress for the patient, but anorexia/cachexia is often more distressing for the family than for the patient. A major concern of family is that the patient is “starving to death.” However, studies have shown that increasing food intake does not always correlate with an increase in weight, and neither is associated with better function or survival.
Anorexia and/or cachexia occur in 21% to 92% of adults with life-limiting disease, with the highest rates found among patients with cancer (2). Anorexia/cachexia can occur as a result of several other symptoms, such as constipation, nausea, mucositis, and depression. Decreased gastric emptying, dysphagia, fat malabsorption, and pancreatitis may also be causes (2). Treatment-related causes include change in taste sensations (leading to food aversions) and mucositis, both of which may be a side effect of chemotherapy or radiation. Psychologic, social, and spiritual distress can also affect the patient’s appetite.
Pharmacologic Management of Anorexia and Cachexia
|Drug||Dose Range||Findings||FDA Approval|
|Megestrol acetate||400-800 mg/day||Increased appetite, food intake, and weight||For the treatment of anorexia, cachexia, or unexplained weight loss in patients with AIDS|
|Dronabinol||2.5-20 mg, twice daily (before lunch and dinner||Stimulated appetite and improved body weight||For anorexia associated with weight loss in people with AIDS|
|Metoclopramide||10 mg, 3 times daily||Enhanced appetite in people with early satiety||For nausea and vomiting|
|Recombinant human growth hormone||0.1 mg/kg SC at bedtime (max: 6 mg)||Increased lean body mass and improved physical endurance and quality of life among people with HIV-related cachexia||For HIV-related wasting or cachexia (with concomitant antiretroviral therapy)|
|Oxandrolone (anabolic steroid)||5.20 mg/day||Increased body weight and lean body mass in cachexia related to HIV and COPD||Adjunctive therapy to promote weight gain after weight loss following extensive surgery, chronic infection, or severe trauma and for some patients without a definitive pathophysiologic cause of weight loss|
|Ghrelin||Not defined||Increased lean body mass in people with end-stage renal disease, COPD, and heart failure||Not approved|
AIDS: acquired immune deficiency syndrome; COPD: chronic obstructive pulmonary disease; HIV: human immunodeficiency virus; SC: Subcutaneous; FDA: Food and Drug Administration (US).
Preventive measures for anorexia/cachexia include effective management of pain and gastrointestinal symptoms (nausea, diarrhea, or constipation), ensuring good dentition and properly fitting dentures, and promoting good nutrition.
The focus of the physical examination is on the oral cavity, with evaluation of the mucous membranes, teeth, gingiva, and lips. In addition, the physician should assess weight loss and muscle wasting, determine if there is loss of strength, and look for signs and symptoms of confusion, anxiety, or depression. In obtaining the patient’s history, the physician should ask about other gastrointestinal symptoms (nausea and constipation) and changes in smells and tastes.
Non-pharmacologic interventions are most appropriate, unless an underlying cause (other than advanced disease itself) is found. The goals of management are to improve enjoyment of food, to increase the sense of well-being, and to enhance a sense of normalcy in daily activities. The patient should be encouraged to try favorite foods, to eat small frequent meals, and to drink high-calorie nutritional supplements. The healthcare team should also educate the family about the reasons for the loss of appetite, noting that the patient does not feel hunger. Family members may also feel better if they are asked to prepare special foods for the patient.Patients may benefit from appetite enhancers, and megestrol acetate is the most widely used drug in this setting because of its effect of increasing both appetite and body weight (3). The optimal dose of megestrol acetate is not well defined, but appetite stimulation has occurred at low doses, and the dose can be titrated to response. Side effects may be dose related and include edema, hypercalcemia, adrenal suppression, and thromboembolic disease (1). The use of megestrol acetate may be limited by its high cost (4).
Other pharmacologic interventions include medroxyprogesterone acetate, another appetite stimulant that has a side effect profile similar to that of megestrol acetate. Corticosteroids also improve appetite and promote a sense of well-being, with dexamethasone being the most commonly used drug in this class (5). The results with this drug have been similar to those with megestrol acetate, but the side effects can be troublesome (sleep disturbances, edema, delirium, weakness, dysphoria, hyperglycemia, and immunosuppression). The use of corticosteroids should not be long-term. Ondansetron has been associated with a significant improvement in enjoyment of food, but the drug has no effect on body weight (6). Hydrazine sulfate and pentoxifylline were once used to improve appetite, but no benefit has been demonstrated for either drug.
Diarrhea is marked by the frequent passage of loose, watery stools. For patients at the end of life, diarrhea is a distressing symptom and can lead to fatigue, asthenia, insomnia, and anorexia. Diarrhea can also result in dehydration and electrolyte imbalance. In addition, the patient’s activities may be limited because of the need for frequent visits to the bathroom.
The prevalence of diarrhea among adults with life-limiting disease varies widely, ranging from 3% to 90%, with the highest rates reported among patients with AIDS (7). Partial bowel obstruction, irritable bowel syndrome, microbial infestations, and fecal impaction are other causes. In addition, diarrhea is a common side effect of antibiotics, caffeine, and drugs such as antihypertensives, antacids containing magnesium, some non-steroidal anti-inflammatory drugs (NSAIDs), potassium supplements, quinidine, thiazide diuretics, retroviral agents, theophylline and metoclopramide (8).
No appropriate measures to prevent diarrhea are available.
A detailed history is the cornerstone of assessing patients for diarrhea. The patient should be asked about the onset of diarrhea, dietary habits and food intolerances, and medications (7). The patient should also describe bowel movements in terms of frequency, color, and consistency. If possible, a stool specimen should be evaluated.
The American Gastroenterological Association developed guidelines for the treatment of chronic disease in the general clinical setting, but no guidelines are available for the management of diarrhea in palliative care (9). Treatment of an underlying condition is the optimal approach to managing diarrhea. The clinician should review the medication list and discontinue or reduce the dose of any medication that may be the cause. Non-pharmacologic approaches to managing diarrhea include avoiding gas-forming and bulky foods, hot spices, fats, alcohol, and milk until diarrhea is controlled. The patient should be encouraged to drink plenty of fluids to avoid dehydration; beverages with added electrolytes, such as sports drinks, can help maintain proper electrolyte balance.
Pharmacologic management includes the use of bulk-forming agents, adsorbents, and opioids (10). Kaolin and pectin (Kaopectate), available over the counter, is a combination of adsorbent and bulk-forming agents. However, it provides modest relief and it may take up to 48 hours to be effective (10). Loperamide (Imodium) is the drug of choice for diarrhea because its side effect profile is better than that for codeine or diphenoxylate (Lomotil). The initial dose of loperamide is 4 mg, with an additional 2 mg after each loose stool. The package insert for loperamide notes that the maximum daily dose in a 24-hour period is 16 mg, but doses of up to 54 mg a day have been used as part of palliative care with few adverse events (10). Octreotide has been effective for profuse secretory diarrhea associated with HIV infection and can be used to treat refractory diarrhea (9). The use of octreotide for diarrhea in the palliative setting is usually off-label, as the drug is FDA approved for the treatment of diarrhea and flushing associated with metastatic carcinoid tumors. Octreotide is administered as a continuous subcutaneous infusion at a rate of 10–80 mcg/hr until improvement of symptoms (10). Infectious diarrhea should be treated with an appropriate antibiotic. A systematic review found probiotic agents to be of benefit in the management of acute infectious diarrhea (10).
As defined, insomnia refers to a variety of sleep disturbances, including difficulty falling asleep and difficulty staying asleep (insufficient amount of sleep or frequent awakenings), that results in impaired function during the day (11). The most frequent type of insomnia among people at the end of life is difficulty staying asleep, primarily because of pain (12). A lack of sufficient sleep affects the quality of life by contributing to daytime fatigue and weakness, exacerbating pain, and increasing the potential for depression. Family members also become distressed when the patient is unable to sleep, which, in turn, may increase the burden on caregivers.
Insomnia is common among the general population, and rates reported for adults with life-limiting disease are even higher, ranging from 9% to 83% (12). The highest rates have been found among patients with end-stage renal disease.
The primary difference between insomnia in the general population and in people with life-limiting diseases is that insomnia in the latter group is usually secondary to the life-limiting disease or its symptoms (13). Overall, uncontrolled pain is the most common contributor to the inability to sleep well (13). Other common physical symptoms such as dyspnea, nocturnal hypoxia, nausea and vomiting, pruritus, and hot flashes are also causes of insomnia. Restless legs syndrome may be a substantial contributor to the disruption of sleep in persons with end-stage renal disease (14). In addition, many psychologic conditions associated with a life-limiting disease can cause insomnia; depression, anxiety, delirium, spiritual distress, and grief can make it difficult to fall or remain asleep (15). Insomnia is a side effect of many drugs, most notably corticosteroids, antidepressants, decongestants, opioids, and some antiemetics (15). Patients also may have difficulty sleeping because of disruptions in the normal sleep-wake cycle that result from inactivity and napping during the day. Lastly, stimulants, such as caffeine, and alcohol may keep patients from falling asleep easily.
Adequate relief of pain and other symptoms is the mainstay of preventing insomnia. The most effective preventive measure is limiting the amount of time in bed during the day and restricting the amount of daytime sleep. Encouraging patients to increase activity during the day, as tolerated; to adhere to a regular schedule with limited naps; and to avoid caffeine and alcohol in the afternoon and evening can help lead to more healthy sleep patterns.
Few patients with life-limiting diseases report insomnia, and few clinicians pursue sleep symptoms in their patients (16). Clinicians should obtain a sleep history from all patients, following guidelines developed by the American Academy of Sleep (see below). The Epworth Sleepiness Scale has been recommended as an assessment tool (17).
Questions to obtain a sleep history
Clinicians should evaluate patients physically as well as psychologically for signs and symptoms that have been identified as contributors to sleep disturbances.
- What is your primary problem with sleep: difficulty falling asleep, waking up frequently during the night, and/or poor quality of sleep?
- When did your sleep problems begin?
- How often do you have trouble sleeping (every night, most nights)?
- Have you ever taken any medication for sleep problems in the past? If so, what did and did not help?
- What do you do before you go to bed?
- What is your bedroom environment like?
- How do you feel (physically and emotionally) in the evening?
- What is your average sleep-wake schedule?
- How long does it typically take you to fall asleep?
- What factors make it longer for you to fall asleep?
- What factors shorten your sleep?
- How often do you awaken during the night?
- When you awaken during the night, how long are you awake?
- Do you have symptoms that cause you to awaken during the night?
- What do you do to try to fall back asleep after awakening during the night?
- How many hours do you sleep each night (on average)?
- Do you nap during the day? If so, how often and for how long?
- Do you feel sleepy during the day?
- How do your sleep problems affect you during the day?
- Do you have mood disturbances? Feel confused? Feel like your symptoms are worse?
The American Academy of Sleep has developed an evidence-based guideline for the evaluation and management of chronic insomnia in adults and a practice parameter for the psychologic and behavioral treatment of insomnia, but neither offers specific guidelines for managing insomnia at the end of life (18). Non-pharmacologic interventions should be implemented first, with pharmacologic therapy added to the treatment plan if these interventions are not effective (18). Optimizing sleep habits can be useful, especially if they are begun early in the course of the disease.
The non-pharmacologic approaches used to prevent insomnia are also the primary management strategies. Among the recommended behavioral strategies are the following (19):
- Stimulus control therapy: Training the patient to re-associate the bed and bedroom with sleep and to re-establish a consistent sleep-wake cycle
- Relaxation training: Progressive muscle relaxation and reducing thoughts that interfere with sleep
- Sleep restriction: Limiting the time spent in bed to time spent sleeping
Cognitive behavioral therapy has also been reported to be effective when used in combination with behavioral interventions (20). No non-pharmacologic strategy has been found to be superior to another (20). These interventions are effective and recommended for older individuals and can also be effective for people with life-limiting disease when strategies are individualized according to the patient (20). Several drugs have been approved by the FDA for the treatment of insomnia; the classes of these drugs are sedative-hypnotics and benzodiazepines (see below). In addition, antidepressants and antihistamines are often used for insomnia, but this use is off-label.
Pharmacologic Management of Insomnia
|Zolpidem(Sedative-Hypnotics)||5-20 mg||Useful for sleep-onset insomnia; lower dose should be used for older or debilitated individuals or those with impaired hepatic function. FDA approved|
|Zaleplon(Sedative-Hypnotics)||5-20 mg||Useful for sleep-onset insomnia; lower dose should be used for older or debilitated individuals, patients with impaired hepatic function, and patients taking cimetidine. FDA approved./td>|
|Eszopiclone (Sedative-Hypnotics)||1-3 mg||Has favorable side-effect profile in older individual; FDA approved for long-term use.|
|Flurazepam (Benzodiazepines)||15-30 mg||Lower dose should be used for older individuals; long-acting effect increases risk of day-time drowsiness. FDA approved for insomnia.|
|Estazolam(Benzodiazepines)||0.5-2 mg||Lower dose should be used for older or debilitated individuals. FDA approved for insomnia.|
|Temazepam (Benzodiazepines)||7.5-30 mg||Lower dose should be used for older or debilitated individuals. FDA approved for insomnia.|
|Triazolam (Benzodiazepines)||0.125-0.25 mg||Lower dose should be used for older or debilitated individuals. FDA approved for insomnia.|
|Quazepam (Benzodiazepines)||7.5-15 mg||FDA approved for insomnia|
|Ramelteon (Melatonin Receptor Agonists)||8 mg||Useful for sleep-onset insomnia; FDA approved for long-term use.|
|Trazodone (Antidepressants)||50-150 mg||Not FDA approved for insomnia|
|Amitriptyline (Antidepressants)||10-100 mg||Not FDA approved for insomnia|
|Doxepin (Antidepressants)||75-150 mg||Not FDA approved for insomnia|
|Trimipramine (Antidepressants)||25-100 mg||Not FDA approved for insomnia|
|Diphenhydramine||25-50 mg||Non-prescription; not FDA approved for insomnia|
* Doses are given as guidelines; actual doses should be determined on an individual basis.
Among sedative-hypnotics, zolpidem (Ambien) is a short- to intermediate-acting drug used primarily for sleep-onset insomnia (21). Zolpidem is recommended by the National Comprehensive Cancer Network (NCCN) for insomnia as part of palliative care for people with cancer. Another sedative-hypnotic, eszopiclone (Lunesta), is intermediate-acting and is one of only two insomnia medications approved by the FDA for long-term use. A systematic search of the literature found no evidence from randomized controlled trials regarding the use of benzodiazepines in palliative care (21). However drugs in this class are the most commonly used drugs for the treatment of short-term insomnia in people with life-limiting disease. Benzodiazepines are effective in decreasing the time needed to fall asleep as well as the likelihood of waking up during the night (21). Their use should be short term, as their long-term efficacy has not been clearly defined, although this issue is not as important for patients with a limited life expectancy. Lorazepam (Ativan) is a recommended drug for insomnia in people with cancer. The long-acting effect of flurazepam (Dalmane) may be of benefit for some patients.
The antidepressant trazodone (Desyrel) is the preferred antidepressant for insomnia (although it is not FDA approved for this indication) (20). It is the drug of choice among tricyclic antidepressants because of its shorter half-life and its milder anticholinergic side effects. Antidepressants are especially useful for people who have anxiety or depression. The most recently FDA-approved drug for insomnia is ramelteon (Rozerem), a melatonin receptor agonist. This drug is short acting and used primarily for sleep-onset insomnia (19). Ramelteon is FDA approved for long-term use (20). For insomnia related to restless legs; a systematic review showed that dopamine agonists are effective, with cabergoline (Dostinex) and pramipexole (Mirapex) often having a greater efficacy than levodopa (L-Dopa) (21). Barbiturates are not recommended for insomnia because of the rapid development of tolerance (22). Two supplements promoted for sleep enhancement—melatonin and valerian—have not been shown to be effective for managing insomnia (22). Several factors must be considered when treating older patients with insomnia. For example, it has been recommended that benzodiazepines be avoided in older individuals because of side effects such as increased risk for falls, confusion, and “hangover”. However, these side effects must be considered in light of an individual's particular situation and weighed against the benefits. Eszopiclone and ramelteon have been studied in older individuals and have a favorable side-effect profile for that population. Lower doses are often recommended for older individuals.
Delirium is a disturbance of consciousness with reduced ability to focus, sustain, or shift attention, as well as changes in cognition (disorientation, memory deficit, language impairment) (23). Patients may seem confused or be restless, agitated, or combative. Delirium is often difficult to recognize because it shares diagnostic features with other symptoms, especially dementia and depression. As a result, delirium is often unrecognized or misdiagnosed and consequently inappropriately treated or not treated (23). Delirium is classified into three clinical subtypes: hypoactive, hyperactive, and mixed (24). Hypoactive delirium is characterized by lethargy, reduced awareness of surroundings, sedation, and psychomotor retardation, whereas hyperactive delirium is characterized by agitation, restlessness, hallucinations, hyper-vigilance, and delusions (24). In the palliative care setting, about half of patients with delirium will have the hypoactive subtype (24). Delirium can be extremely distressful for the patient and even more so for family members. The healthcare team can help alleviate family members' distress by educating them about the nature and cause of the syndrome and the potential for reversal. Encouraging them to participate in non-pharmacologic interventions may also help to provide a positive experience.
The prevalence of delirium among adults with life-limiting disease ranges from 6% to 93%, occurring most frequently among patients with cancer (25). Terminal delirium is a distinct entity that occurs within the last days or hours of life, and it is estimated to occur in 80% of dying patients (25).
Many factors may cause delirium, and although the cause is usually multifactorial, often no cause is found (26). In one comprehensive review, the primary contributor to delirium was unrelieved pain. Delirium is also often caused by medications, including several that are used in the end-of-life setting, such as opioids, corticosteroids, benzodiazepines, and NSAIDs. In addition, age, cognitive deficits, impaired vision/hearing, emotional stress, depression, and comorbidities are predisposing factors of delirium (25),(26).
Because of the substantial influence of unrelieved pain, adequate pain management can help prevent delirium. Prevention strategies are directed at minimizing precipitating factors, which include a high number of medications (more than six), dehydration, decreased sensory input, psychotropic medications, and a change in environment.
The diagnosis of delirium relies on identifying its two features: cognitive impairment and deficits in attention; these features can be assessed with the Mini-Mental State Examination (25). The Confusion Assessment Method (CAM) is considered to be the gold standard for distinguishing between delirium from other causes of altered mental status, and other tools to evaluate delirium include the Delirium Rating Scale, the Delirium Symptom Interview, and the Memorial Delirium Assessment Scale (35). Communication with the healthcare team and family is vital in assessing the patient to help determine the onset and course of delirium as well as signs indicative of the syndrome. Some specific ways to help determine if a patient has delirium include (27):
- Ask the patient "Do you feel 100% awake?" If they do not, ask "How awake do you feel?"
- Evaluate whether the patient is easily distracted;
- Test registration and immediate recall;
- Assess psychomotor disturbances by noting whether the patient is restless and agitated or slow and hypoactive;
- Ask the patient if he or she is seeing or hearing strange things;
- Ask the patient to state the days of the week or months backward, or to give a span of numbers frontward and backward;
- Ask the patient open-ended questions, and listen for incoherent speech or tangential thought processes.
Clinical assessment and physical examination should also be directed at ruling out underlying causes, such as infection or metabolic abnormalities, and the medication list should be reviewed carefully (27).
The treatment of an underlying cause, if identified, is a key step in managing delirium. Whether delirium can be reversed depends on the cause. Delirium caused by psychotropic medications, dehydration, or hypercalcemia is more likely to be reversible than delirium caused by hypoxia, metabolic abnormalities, or non-respiratory infections (28).
Several non-pharmacologic interventions have been successful in preventing and managing delirium (see below). If delirium is refractory to non-pharmacologic measures, medications may be prescribed. The American Psychiatric Association developed guidelines in 1999 for the treatment of delirium with antipsychotics (30). Level 1 evidence supports the use of haloperidol and chlorpromazine (Thorazine) (typical antipsychotics), and these drugs have the advantage of being available in formulations that allow for multiple routes of administration and of being the most cost-effective (29). Several systematic reviews have been done to determine the efficacy of antipsychotics for delirium, and although each review has identified only a few well-designed trials, the results have supported the continued use of these drugs (see below) (29),(31),(32). One of these reviews focused on patients with terminal illness; the review identified only one small study (30 subjects) eligible for analysis; haloperidol and chlorpromazine were equally effective, but the risk for cognitive impairment was slightly greater with chlorpromazine (31). In the other reviews, the efficacy of haloperidol was found to be similar to that of olanzapine, risperidone (Risperdal), and quetiapine (Seroquel) (atypical antipsychotics) (32). In two small nonrandomized studies—one involving hospitalized patients with cancer—aripiprazole (Abilify) was safe and effective for the treatment of delirium, especially the hypoactive subtype (34),(35). Mild-to-moderate delirium can be managed with low oral doses of antipsychotics, titrating the dose to optimum relief; higher doses can be used for severe delirium (33). For older patients and those with multiple comorbidities, treatment should begin with lower doses and titration should be slow (33). Factors to consider when selecting a drug include the side-effect profile, the patient's age and baseline mental status, the time to response, and the subtype of delirium (33).
Non-Pharmacologic Treatment Options for Delirium
- Review all medications; discontinue any unnecessary ones and replace those with a high likelihood of delirium as a side effect;
- Rotate opioids or lower the opioid dose;
- Provide orienting cues (e.g., calendar, clock, familiar objects) in the patient's room;
- Encourage family to sit with the patient;
- Encourage activities that are cognitively stimulating (e.g., word puzzles);
- Ensure good sleep hygiene;
- Minimize noise and interventions at bedtime;
- Encourage patient to get out of bed as much as possible;
- Provide visual and hearing aids, if appropriate
- Monitor for dehydration;
- Minimize use of devices/equipment that are immobilizing (e.g., catheter, intravenous lines).
Pharmacologic Options for Delirium
|Drug||Dose Range||Routes of Administration||Comments|
|Haloperidol||0.5-2 mg every 2-12 hours||PO, IV, IM, SC||Considered to be first-line treatment.|
|Chlorpromazine||12.5-50 mg every 4-6 hours||PO, IV, IM, SC, PR||Has more sedative effect than haloperidol, thus is preferred for patients with agitation.|
|Olanzapine||2.5-5 mg every 12-24 hours||PO||Sedation has been a dose-limiting effect; poorer response has been associated with older age, pre-existing dementia, and hypoactive subtype.|
|Risperidone||0.25-1 mg every 12-24 hours||PO||Response may be better with hypoactive subtype; orthostatic hypotension is possible adverse effect.|
|Quetiapine||12.5-100 mg every 12-24 hours||PO||Sedation and orthostatic hypotension are possible adverse effects.|
|Aripiprazole||5-30 mg every 24 hours||PO||Response may be better with hypoactive subtype.|
|Lorazepam||0.5-2 mg every 2-4 hours||IV, SC||May be added to treatment with haloperidol if agitation is refractory to high doses.|
PO: orally; IV: intravenously, IM: intramuscularly; SC: subcutaneously; PR: rectally.
The goal of treatment is to reach patients' baseline mental state, not to sedate them, and patients should be reassessed frequently until this goal is met. If agitation is refractory to high doses of haloperidol, the antipsychotic lorazepam may be helpful (32). The management of delirium also includes providing support to family, to help them cope with the condition. The management of terminal delirium will be discussed in Symptom Management Part 3 of this course.
Support for Early Integration of Palliative Care Services
Definition of palliative care by World Health Organization is: Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual ( 36). The landmark study (37) showed that ambulatory patients with newly diagnosed metastatic non-small cell lung cancer benefitted from receiving palliative care begun soon after diagnosis, during which time they also received standard oncologic care. Palliative care was provided to patients in the intervention group by a member of the palliative care team, which consisted of broad-certified palliative care physicians and advanced practice nurses. Importantly, patients in the standard oncologic care group received palliative care if a meeting was requested by the patient, family, or oncologist, but these patients did not cross over to the palliative care group or follow the protocol-specified program of palliative care (37). Data from other randomized studies show that early administration of supportive or palliative care – given in the context of standard oncologic care – to patients with newly diagnosed and advanced cancer is effective for improving the quality and cost of care for patients and their families, whatever the treatment outcome (38). Maintaining a focus on both symptom management and quality-of-life issues in patients with cancer throughout the course of illness is achievable by integrating cancer-directed therapy and palliative or supportive care. A paradigm shift has occurred to approaches that integrate disease-directed therapy and palliative care; such that palliative care is given throughout the continuum of disease, with the informed preferences of the patient incorporated into individualized treatment plans.
Palliative care enables patients to die without suffering and provides for grief counseling and bereavement services for a family adjusting to loss. Physicians and other healthcare professionals should strive to enhance their knowledge of key strategies to achieve high-quality palliative care, as detailed in this course. As a result of ongoing advances in medicine, the trajectory of illness for many diseases has shifted, yielding an increasing number of patients needing palliative care throughout the continuum of care and, especially, at the end of life. High-quality palliative care focuses on the physical, psychosocial, and spiritual well-being of the patient as well as the family. Care is provided by a palliative healthcare team composed of members who have expertise in communication, pharmacologic principles of pain management, symptom management and identification of psychosocial and spiritual symptoms.
End-of-Life Decision Makingwww.womenshealthsection.com/content/heal/heal022.php3
End of Life Care: Pain Assessment and Managementwww.womenshealthsection.com/content/gyno/gyno021.php3
End of Life Care: Symptom Management (Part 1)www.womenshealthsection.com/content/gyno/gyno023.php3
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