Palliative Medicine: Physical

Aspect
TAN LIP SHENG
 • An approach that improves the quality of
life of patients and their families facing
the problem associated with life-
threatening illness, through the

What is
prevention and relief of suffering by
means of early identification and
impeccable assessment and treatment of

palliative pain and other problems, physical,

psychosocial and spiritual

care ?
World Health Organisation (2002)
 • A holistic approach(physical,

Scope of
psychological, spiritual, social) to patients
with:
• Malignant diseases

palliative • Other non-curable, life-limiting or

terminal illnesses

care
• Motor Neuron Disease
• MS, Parkinson’s Disease
• Advanced organ failure (cardiac,
respiratory, renal)
• Dementia, Learning disability
 • It’s not all about dying but living!

• Palliative care is an approach that

IS respects life and aims to help patients live
their life to the fullest
PALLIATIVE • relieving physical symptoms, patients are
CARE ALL able to focus on other important issues
such as spirituality and psychosocial
ABOUT wellbeing

DEATH AND • supporting family during a time of great

stress and difficulty also aims to enable
DYING? family members and loved ones to cope
with grief and move forward after
bereavement
 • Early in the course of an illness and can be
WHEN DO in conjunction with other treatments that
are intended to prolong life  to address

PATIENTS distressing symptoms before all treatment

options are exhausted

NEED • But not all patients need to be referred

early

PALLIATIVE • All clinicians should know how to treat

pain, basic symptoms, communicate bad
news, listen and understand ethical
CARE? decision making in order to support
patients wherever they may be
Management of physical
symptoms
Physical symptoms
• Cancer pain
• Respiratory symptoms – breathlessness, cough, hiccup
• Gastrointestinal symptoms – N & V, constipation, diarrhoea , anorexia,
intestinal obstruction, oral care
• Neurological symptoms – delirium, disorders of sleep and
wakefulness, spinal cord compression,
• Skin care - malignant cutaneous wounds, pressure ulcer, oedema
Cancer Pain
another lecture
RESPIRATORY SYMPTOMS
1.Breathlessness
• Subjective experience of breathing discomfort - short of breath, air hunger
• Panic and anxiety further worsens the breathing discomfort – viscous cycle
• Possible causes:
• Respiratory
• Cardiovascular
• Anemia
• Superior vena cava obstruction
Breathlessness
Treat the underlying causes
Symptomatic management of breathlessness
• If unable to reverse underlying cause – pharmacological
• Opioid therapy, eg. morphine and other opioids
• Effective in relieving dyspnoea

• Benzodiazepine
• Useful in panic with hyperventilation and fear of suffocation
• Eg lorazepam

• Non-pharmacological measures
• Relaxation techniques (reduce anxiety and muscle tension)
• Chest physiotherapy (percussion, breathing retraining).
• Positioning (postural drainage, lung expansion)
• Directing air to the face (fan, wide spaces, open window).
• Supplemental oxygen especially if hypoxic.
• Energy-conserving measures (pacing, leaning on support)
RESPIRATORY SYMPTOMS
2. Cough
• Cough is reported in up to 50% of patients with terminal cancer and in up to
80% of patients with lung cancer
• a result of mechanical and chemical irritation of receptors in the respiratory
tracts
• Irritating and distressing to patients
Management – Cough
• Like breathlessness, reversible causes should be treated
• Symptomatic treatment
• Wet cough (aim to promote mucous clearance)
• nebulized normal saline,
• mucolytics – bromhexine
• chest physiotherapy
• Dry cough (aim to suppress cough)
• Lozenges
• Diphenhydramine
• Opioids
• Dry up secretion in dying patients (too weak to cough)
• Hyoscine
RESPIRATORY SYMPTOMS
3. HICCUPS
• POSSIBLE CAUSES
• Via vagus nerve - gastric distension, gastritis, GERD, hepatic tumors, ascites/abdominal distension/intestinal
obstruction
• Via phrenic nerve - diaphragmatic irritation, intracranial tumors (especially brainstem lesions), leptomeningeal
disease, traumatic brain injury, stroke.
• Systemic - renal failure, electrolyte imbalance (hyponatraemia, hypokalaemia, hypocalcaemia), corticosteroids.
• Management :
• Pharyngeal stimulation (block afferent impulse from vagus nerve)
• Sipping cold water, applying pressure to the soft palate with an inverted spoon, Valsalva manoeuver
• Reduce gastric distension
• Pro-kinetics – metoclopramide, domperidone, erthromycin.
• Encourage small, frequent meals.
• Relax diaphragmatic muscle - baclofen
• Suppress central hiccup reflex –haloperidol, chlorpromazine, phenytoin.
Gastrointestinal symptoms
1. N & V
Assessment – N & V
• Comprehensive assessment is necessary as causes may be multi-factorial.
• History
• Vomiting in relation to oral intake – is this mechanical?
• Recent change in bowel habits – constipation / obstruction? o Fever, symptoms of infection?
• Headache, neurological symptoms – raised ICP?
• Drug history – opioids, chemo, digoxin, antibiotics, NSAIDs
• Physical Examination
• Dehydrated and lethargic – uraemia, hypercalcaemia, sepsis o Abdominal distension, organomegaly, ascites
• Indentable faecal masses – severe constipation
• Papilloedema or focal neurology – brain metastasis
• Investigations
• Renal profile
• Serum calcium
• Urinalysis
• Abdominal xray – constipation vs obstruction
• CT brain / abdomen depending on possible diagnosis
Management - N & V
• Correct any reversible causes, example:
• Stop medications that might contribute to nausea and vomiting
• Consider surgical interventions for mechanical obstruction (stenting,bypass, stoma)
• IV Dexamethasone 8-16mg daily for brain metastasis. Consider radiotherapy.
• IV Bisphosphonate and hydration for hypercalcaemia.
• If not possible to correct underlying cause, relieve symptoms with anti-emetics by IV or subcutaneous
route:
• Dopamine antagonist – Metoclopramide, haloperidol
• 5-HT3 antagonist – granisetron, ondansetron (mainly chemo induced n & v)
• Antihistamine – promethazine
• • Non-Pharmacological measures
• Avoid or limit foods that might trigger nausea and vomitting o Take small, frequent meals
• weets or candies might be helpful
• Sit upright after meals or with head elevated
• Optimize oral hygiene
Gastrointestinal symptoms
2. Constipation

• ASSESSMENT:
• Always assess frequency, amount and consistency of stools.
• Digital rectal examination to assess impacted faeces in rectum.
• Abdominal x-ray to look for impacted faeces.
Management – constipation
Goal is to achieve bowel movement once daily, normal amount and soft but formed stool.
Stimulant laxatives
• Bisacodyl (dulcolax) 5-10mg daily-TDS o Senna (senokot) 15-30mg daily-TDS
• Osmotic laxatives
• Lactulose 10-20mls daily-TDS
• Macrogol (forlax, movicol) 1-3 sachets daily-TDS
• Sodium phosphate (fleet) 30mls PRN if severe constipation
• Lubricant softner
• Liquid paraffin
• Avoid bulk forming laxatives containing fibre which may worsen constipation in debilitated patients.
• Combination of laxatives may be used and by rectal route as needed.
• Encourage fluid intake and mobilise patient if possible.
• Always anticipate opioid induced constipation and prescribe laxatives prophylactically.
Gastrointestinal symptoms
3. Diarrhoea
Gastrointestinal symptoms
4. Anorexia
Gastrointestinal symptoms
5. Intestinal obstructions
Gastrointestinal symptoms
6. Oral care – halitosis, xerostomia, stomatitis
• Oral problems affect the majority of palliative care patients and have great
impact on the quality of life.
• Saliva with its various components gives major protection to the tissues of the
oral cavity keeping it moist and clean, maintaining an intact mucosa.
• Reduction in production of saliva and poor oral hygiene are the main
etiologies contributing to oral problems.
• Dry mouth may be due to mouth breathing, medications and reduced oral
intake.
• Chemotherapy, irradiation and local tumor invasion may lead to broken
mucosa.
Oral care
1. Halitosis
• unpleasant or foul-smelling breath, which is socially unacceptable.
MANAGEMENT

• Optimise Oral Hygiene

• regular cleaning of teeth and tongue.
• dental flossing (using preferably unwaxed floss).
• saliva stimulant / substitute, i.e. pineapple chunks / pilocarpine.
• refreshing mouth wash (avoid alcohol based mouthwash which may lead to worsening
mouth dryness)
• for heavily furred tongue or necrotic tumors, consider gargling with sodium bicarbonate
mouthwash, chlorhexidine 0.2% or povidone iodine 1% (Betadine mouthwash)
• Treat Infections
• oral candidiasis
• use local or systemic metronidazole for suspected anaerobic nfections (due to necrotic
tumour)
Oral care
2. Xerostomia – dry mouth
• is often associated with difficulties with speech, chewing or
swallowing, the need to keep drinking and loss of taste.
Oral Care
3. Stomatitis
• Painful inflammatory, erosive and ulcerative condition affecting the
mucous membrane lining of the mouth
Neurological symptoms
1. DELIRIUM
• Acute confusional state, which is a result of mental clouding, is
common in people who are dying. If irreversible, it may be an
indication of impending death and can be most distressing for
patients, family and staffs.
Assessment
• Clinical presentation is typically abrupt in onset with impairment of
consciousness and fluctuating symptoms (‘sundowner effect’).
Confusion Assessment Method (CAM)
Confusion Assessment Method (CAM) for screening:
• Acute Change From Baseline - fluctuation of symptoms during the day
• Inattention – difficulty focusing, easily distracted
• Disorganised thinking – incoherence, rambling, irrelevant conversation,
illogical flow of ideas
• Altered level of consciousness – any state other than alert and calm
• (Diagnosis of Delirium requires prescence of feature 1 and 2 as well as
one of the latter 2 features.
Management
• Treat the underlying organic causes if identifiable and treatable
• Treat fever, hypoxia, dehydration, constipation, fear and anxiety and pain if
possible
• Ensure there is safe and secure environment – have adequate staffing,
remove potentially dangerous objects, ideally have mattress on the floor
• Prevent sensory overstimulation
• Psychological interventions
• Reassurance
• Orientating aids such as clock, presence of supportive family
• Emotional support
• Cognitive strategies such as validation and repetition during lucid periods
Management – cont’d
• Antipsychotics medications (in combination with above measures):
• Haloperidol is the drug of choice.
• Initial dose 0.5-1.5mg PO or SC at night
• If acute severe delirium 0.5-1mg SC every 1-2 hours PRN
• Usually, dose to settle patient < 5mg/24h but may be used up to maximum of
20mg/24h (risk of extrayramidal symptoms)
• Other atypical antipsychotics may also be used if available including Risperidone,
Olanzapine, Quetiapine (less extrapyramidal effects)
• Sedatives (should not be used alone in most cases of delirium as they may aggravate
symptoms particularly if inadequate doses are used, so use with an antipsychotic)
• SC Midazolam 2.5-5mg
• T. Lorazepam 0.5-1mg PO or Sublingually (use oral tablet)
Neurological symptoms
2. DISORDERS OF SLEEP AND WAKEFULNESS (INSOMNIA)
• Sleep is a physiological need that should not be taken for granted.
Sleep deprivation leads to many problems in the medically ill
including fatigue, daytime somnolence, mood disorders and
demoralisation. Sleep is therefore an important aspect of good overall
symptom management.
Neurological symptoms
3. SPINAL CORD COMPRESSION
• Occurs in 3-5% of patients with advanced cancer. Cancers of the
breast, bronchus and prostate, account for >60% of cases. Most occur
in the thorax. There is compression at more than one level in 20%.
Below the level of L2 vertebra, compression is of the cauda equina (ie
peripheral nerves) and not the spinal cord.
Clinical presentation
• Symptoms:
• Pain >90% o
• Weakness >75%
• Sensory level >50%
• Sphincter dysfunction >40%
• Pain often predates other symptoms and signs of cord compression by
several weeks or months. Pain may be caused by:
• Vertebral metastasis
• Root compression (radicular pain)
• Cord compression (funicular pain)
• Muscle spasm
assessment
• History and clinical findings with high index of suspicion
• any cancer patient presenting with numbness, weakness or urinary retention should be taken
seriously
• X-rays of spine shows vertebral metastasis and/or collapse at the appropriate level
in 80%
• Bone scans are sensitive to detect bone metastasis but not specific to confirm
spinal cord compression.
• MRI is the investigation of choice, CT with myelography may be helpful if MRI is not
available.
• Even without an MRI, it is possible to correlate clinical findings (ie. Level of
neurology and pain) with other radiological findings which may provide sufficient
evidence to confirm cord compression.
MANAGEMENT
• Although often insidious in onset, spinal cord compression should be treated
as an emergency.
• Dexamethasone, dose used varies greatly, consider 16-32mg PO daily for 5-7
days then reduce the dose gradually over 2-3 weeks
• Urgent radiation therapy, concurrently
• Decompression surgery, if there is:
• deterioration despite radiotherapy and dexamethasone
• a solitary vertebral metastasis
• Patients with paraparesis do better than those who are totally paraplegic. Loss
of sphincter function and rapid onset of complete paraplegia (<48h) is a bad
prognostic sign.
SKIN CARE
1. MALIGNANT CUTANEOUS WOUNDS
• Malignant cutaneous wounds develop due to fungating ulceration of
superficial malignant lesions in the skin, breast, abdominal or chest
wall as well as lymph nodes.
• Problems arising from this includes pain, bleeding, infection, exudates
and malodour leading to psychological distress.
Management
• Malignant wounds will not heal despite cleansing, dressing and debridement.
This should be clear to the patient and family that the goals of management
include:
• Keeping the wound neat and clean o Prevent infection
• Reduce pain
• Reduce odour
• Reduce bleeding
• Daily dressing with normal saline to irrigate and clean wound helps reduce
infection and helps patients feel dry and clean after removing previous soaked
dressings.
• if wounds are large, irrigating in the bathroom with a shower hose withwarm
water may be most suitable
Management – cont’d
• For large exudative wounds, gamgee pads may be used with calcium alginate
dressings. (At home a simple cheap alternative could include disposable baby diapers)
• Wound pain should be treated with systemic short acting opioids given 30 minutes
prior to dressing. Topical lignocaine gel may also be useful.
• Malodour may be reduced by:
• Applying topical metronidazole (T. Metronidazole 400mg may be crushed and mixed with
lignocaine gel and applied into wound)
• Oral/IV metronidazole if severe
• Live-culture yoghurt topically
• Manuka honey topically
• Activated charcoal (crush 2 tablets and place within a piece of gauze then apply on top of the
inner layer of dressing)
Management – cont’d
• Infection may be treated commonly with systemic antibiotics eg. co-
amoxiclav
• For bleeding wounds:
• Initially apply simple direct pressure with gauze
• Topical adrenaline 1:1000 apllied to gauze topically
• Consider topical transexamic acid (may use IV solution appliedto gauze
topically. Oral Transexamic acid power may also be applied topically)
• If possible refer for palliative radiotherapy to bleeding wound
Skin care
2. Pressure ulcers
• Prevention is the most important approach.
• All patients who are increasingly unwell and immobile should be
assessed for risk of pressure sores and preventative measures such as
regular turning and use of ripple mattresses should be applied
• Sometimes however, pain may cause difficulty in moving patients and
preventing pressure sores can be difficult.
Skin Care
3. Oedema
• Oedema is common in patients with advanced illnesses and is often a result of multiple factors
including immobility, lymphatic failure, hypo-albuminaemia, salt and water retention and disease
processes such as cardiac and renal disease.
• Patients are often very concerned with oedema as it is an obvious sign indicating that their body
is unwell.
THE END