Pain and Symptom Management Best Practices

Clinicians often fail to assess patients’ symptoms, leading to incomplete control. Communication with patients and families is key. Best practice tips:

• Ask about pain and other common symptoms (shortness of breath, nausea, and anxiety) every day.
• Never leave a patient in pain without a plan.
• If a patient has pain or other uncontrolled symptoms early in the day, check back with them after they have received a treatment and re-evaluate.
• Verify home opioid dosage before prescribing in the hospital. Communicate with outpatient providers early and often.
• Engage the patient - ask them what works and why.
• Ensure patients are comfortable with the pain regimen plan.
• Make sure to set expectations with patient about pain treatment overnight, and sign-out to cross cover what can and cannot be done overnight.
• If first attempts at improving pain are unsuccessful, involve a specialist (e.g. pharmacist, palliative care service, pain service).

Nausea and Vomiting

• Obtain a thorough history and physical to determine severity and underlying etiology, mechanism, and triggers.
• Determine appropriate pharmacologic therapy based on the likely mechanism using the table below. Be sure to consider side effect profiles.
• Consider around-the-clock prophylactic therapy for severe symptoms or known emetogenic medications (e.g. cytotoxic chemotherapy); can stagger drugs from different classes (e.g. Zofran q8h staggered 4 hours from Compazine q8h).
• Combine multiple anti-emetics from different classes for refractory symptoms.
• Remember non-pharmacologic treatments - frequent small meals, avoiding strong smells or other triggers, acupuncture/acupressure, fresh air, or guided imagery.

Common Anti-emetics

Caring Wisely: Avoid topical lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol) (“ABH”) gel for nausea. Anti-nausea gels have not been proven effective in any large, well-designed trials, and their active ingredients are not absorbed to systemically effective levels.

Dyspnea

Subjective sensation of difficulty breathing (may not correlate with hypoxia)

• Non-pharmacologic treatment
  • Oxygen for patients with documented hypoxia (if patient tolerates cannula – titrate to symptoms, not to O2 sat).
    • For normoxic patients, the addition of oxygen via nasal cannula has not been shown to alleviate dyspnea.
  • Opening a window or providing a fan (stimulation of the trigeminal nerve alleviates sensation of dyspnea).
  • Address fear/concerns of patient and family, provide reassurance, discuss what to expect.
• Pharmacologic treatment
  • Opioids (often at lower doses than required for pain): reduce sensation of dyspnea, act as cough suppressant, decrease preload and sympathetic tone.
    • Starting dose: Morphine PO 2.5-5 mg q4h or Morphine 1-2 mg IV q2-3h. Can increase until symptom relief or side effect.
    • With acute, severe dyspnea, may need to dose IV opioids q10-15 minutes until relief and can consider starting a continuous infusion for persistent symptoms (palliative care can provide guidance).
    • Less evidence for benzodiazepines, but associated anxiety can also contribute to dyspnea (see anxiety below).
  • Secretions: Loosen with saline, expectorant (if able to cough/clear secretions); dry with anticholinergics (atropine or glycopyrrolate, see below).
  • Cough suppression: opioids

Anxiety

• Often exacerbated by untreated symptoms or medications (e.g. steroids, appetite stimulants).
• First, try and treat other contributing symptoms.
• Non-pharmacologic strategies: aromatherapy, massage therapy, mindfulness, SW and spiritual care support, integrative therapy, music or art therapy.
• For acute anxiolysis: Consider benzodiazepines, such as Ativan 0.5-2 mg PO/IV/SQ q6h prn.
• For longer term management: SSRI, SNRI.

Secretions

Pooling of secretions in upper airway/bronchi, aka “Death rattle”: common, more distressing to families than to patients.

• Prevention:
  • Position change may help decrease rattle
  • Stop fluids
  • Continue oral care
  • Avoid deep suction
• Treatment:
  • Atropine 1% ophthalmic solution: 1-2 drops SL q1-2h (avoid in patients who are awake as it crosses blood-brain barrier and can cause delirium/sedation)
  • Glycopyrrolate: starting dose 0.1mg – 0.2mg IV/SQ q4h (does not cross the blood-brain barrier)

Anorexia/Reduced PO intake

The great majority of patients in the terminal phase of an advanced serious illness stop eating and/or drinking before death, either voluntarily or because of associated symptoms. This is normal but can be extremely distressing to families and caregivers.

Treatment:

• Discuss expectations and natural history with family.
• Liberalize dietary restrictions, encourage food from home.
• Identify and address reversible causes of reduced intake: nausea, dry mouth, dysgeusia.
• There is no evidence that artificial nutrition prolongs life or improves comfort. Do not recommend feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
• Frequent small meals can often be more palatable than larger ones.
• Appetite stimulants: Majority of evidence is in cancer patients only.
  • Megestrol acetate (Megace): has been shown to increase appetite and weight, but not quality of life. Risk of thromboembolism and adrenal insufficiency.
  • Dronabinol (Marinol): studied in AIDS, not cancer. Found to be inferior to Megace in a large trial of cancer patients.
  • Corticosteroids have been shown to increase appetite in end-stage cancer patients; given multiple adverse effects, best for short-term use.
  • Other agents such as mirtazapine and olanzapine have been studied, but evidence is inconclusive.

References

Bickel K, Arnold R. Death Rattle and Oral Secretions, 2nd Edition. Fast Facts and Concepts. April 2008; 109.

Gordon WJ, Shega JW, Lynch B, Von Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life. JAMA. 2007:298:1196-1206.

Weissman DE. Dyspnea at End-of-Life, 2nd Edition. Fast Facts and Concepts. July 2005; 27. Re-edited March 2009