END OF LIFE SYMPTOM MANAGEMENT

AIMS

• To explore options for symptom relief in a dying patient

LEARNING OUTCOMES

• To recognise the symptoms experienced by patients at the end of their life
• To explore non-pharmaceutical options to bring relief and comfort

What are the common symptoms encountered at the end of life?

COMMON SYMPTOMS

• Pain
• Breathlessness
• Fatigue & weakness
• Anorexia
• Anxiety
• Low mood/depression
• Agitation
• Fear
• Insomnia
• Pressure ulcers

COMMON SYMPTOMS

• Nausea and Vomiting
• Dehydration
• Sore mouth, dry mouth
• Constipation/Diarrhoea
• Incontinence
• Retention
• Confusion
• Delirium, Halucinations
• Secretions
• Emergencies (palliative)

ARE SYMPTOMS DISEASE SPECIFIC?

PAIN

• Three quarters of patients suffer with pain at EoL
• This may be one, two or multiple pains
• Pain can be chronic, acute or psychological/emotional
• There is a concept called TOTAL PAIN

TOTAL PAIN

• SOCIAL - worry about family and finances, loss of job or income, loss of role, feelings of abandonment and isolation, worry about pets
• SPIRITUAL - why me? Why does God allow me to suffer? Is there purpose or meaning in life? Will I be forgiven for past wrongs?
• PSYCHOLOGICAL - anger at diagnosis, fear, feelings of helplessness, disfigurement
• PHYSICAL - adverse effects of treatments, chronic fatigue, other symptoms, e.g. that may be linked to disease

HOW CAN WE TREAT THIS PAIN?

• EMOTIONAL SUPPORT is a major factor
• Emotional support is needed for the patient and the family
• Ask and listen. Don't just jump in with solutions
• Be honest but be sure how much people want to know

TREATING PAIN

• Hot/Cold packs
• Positional
• Distraction
• Equipment, e.g. Mattress, profiling bed, pressure relieving equipment, commode.

DYSPNOEA

• There are multi factorial causes
• Anxiety can make breathlessness worse
• We need to intervene in the cycle of dyspnoea

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STRATEGIES

• Position of patient
• A fan
• Site bed near a window
• Distraction
• Provide information and support for family
• Consider breathing exercises e.g square breathing
• Mouth care

DELIRIUM/AGITATION

• 80% of people display these symptoms in their final days of life
• Includes restlessness, agitation, paranoia and combativeness
• Aetiology is multifactorial and investigations are mostly inappropriate at this stage
• Exceptions to this are urine retention or faecal impaction which should be managed/treated
• Distraction and emotional support are needed for patient and their loved ones

MOUTH PROBLEMS

• Dry mouth
• Candida (Thrush)
• Ulcers
• Soreness
• Halitosis
• Poorly fitting dentures
• Secretion or drooling, possibly as part of disease symptoms
• Adverse effect of chemotherapy or radiotherapy

MOUTHCARE

• Clean dentures and ensure they are a good fit
• Brush teeth and tongue using a very soft brush e.g. a baby's toothbrush
• Soft diet if tolerated
• Encourage sips of fluid
• Fresh pineapple juice is helpful due to the enzymes in the juice but it must be fresh
• Some people enjoy ice fragments or crushed ice but be aware of sensitive teeth issues
• Lip balm, artificial saliva, assisting patient to use a mouth wash

NAUSEA & VOMITING

• Multifactorial
• May be GI issues, pain, drugs or other treatments, anxiety, metabolic (electrolytes or endocrine), mouth problems, environmental such as odours or raised intracranial pressure

N&V SUPPORT

• Consider the smell of some foods, be sensitive to triggers
• Sometimes fatty food can be a trigger
• Offer small, frequent meals
• Ask the patient's preferences
• Review the quantity of meds being taken
• Complimentary therapies
• Odour control e.g. from a fungating tumour
• Offer vomit bowls, tissues and mouth wash
• Offer support. Maintain privacy and dignity

SECRETIONS - RESPIRATORY TRACT

• Breathing becomes noisy due to fluid pooling in the hypopharynx
• Prevalence as high as 92%
• Patients are usually semiconscious or unconscious at this stage
• Has a big impact on the family and carers, can be very distressing for them

INTERVENTIONS

• Explain to the family that the semiconscious or unconscious patient is not distressed by the rattle
• Positional changes can be helpful, for example sitting up or lying on the side

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CONCLUSIONS

• There are many common symptoms at the end stage of life which affect most patients whatever their disease
• Many non-pharmaceutical interventions involve psychological and emotional support for the family and patient
• There are lots of strategies that can be used to alleviate symptoms
• It is still useful to think about causes such as bladder or bowel issues as well as positional and environmental.

USEFUL RESOURCES

• Macmillan unit, RDH - 24 hour help line
• Derbyshire.eolcare.uk
• Specialist palliative care team & community nursing teams
• http://www.nhsiq.nhs.uk/media/2485900/duties_and_responsibilities_of_health... https://www.gov.uk/government/policies/end-of-life-care
• Many thanks to Rob Smith, inspirational teacher and nurse. Some of the data in this Haiku comes from his teaching session.