FS

Palliative Care Symptom Management: Dyspnea and Delirium

Palliative Care Symptom Management: Dyspnea and Delirium

  • Context and goals

    • Today (and tomorrow) focuses on symptom management in palliative settings, especially when curing is not always possible but relief of distress is achievable.
    • Objective: illustrate how proactive symptom prevention and management can relieve distress for patients with advancing illness.
    • WHO definition principles:
    • Early identification and impeccable assessment and management of physical, psychosocial, and spiritual problems.
    • Palliative care intends neither to hasten death nor to prolong life.
    • Care should be provided alongside disease-directed therapies, not only after all disease-directed options are exhausted.
    • Five additional symptoms typically emphasized (apart from pain):
    • dyspnea (shortness of breath),
    • delirium or confusion,
    • constipation,
    • nausea and vomiting,
    • and the symptom complex of anorexia, cachexia, and fatigue.
    • For today: focus on dyspnea and delirium; tomorrow covers constipation, nausea/vomiting, anorexia/cachexia, and fatigue.
    • Core principle: patients with advanced disease may have multiple concurrent symptoms that interact and influence each other (e.g., pain worsened by sleep deprivation or anxiety about morphine refill).
    • Symptoms can have multiple causes (e.g., underlying disease, treatment side effects, frailty). Might require a multi-pronged approach (e.g., antibiotics plus morphine plus steroids) rather than a single-cause model.
    • Mindset shift: move from single-cause, single-intervention thinking to a broader, multi-angle management approach; aim for symptom relief and improved comfort/quality of life, not solely disease control.

  • The symptom-management pathway (overview)

    • Stepwise flow: comprehensive history → assessment → examination → identify causes and severity → assess impact on quality of life → consider investigations with concern for burden of investigation → correct reversible causes → consider non-pharmacological interventions → consider pharmacological interventions (start with first-line) → reassess and adjust; involve palliative-care and disease-specific experts as needed.
    • Burden of investigation is a key consideration in home or palliative settings: avoid unnecessary tests that would unduly burden the patient or disrupt family life; empirical treatment may be appropriate in some home settings.
    • Baseline approach: good history, physical examination, review of current medications, and understanding patient perceptions and expectations about symptoms and causes.
    • Goals and expectations: aim to improve comfort and QoL, relieve distress, and avoid interventions that prolong life at all costs; set realistic goals for symptom response (e.g., using scales to track improvement).
    • Multidisciplinary involvement: involve physiotherapists, occupational therapists, and other specialists for non-pharmacological interventions; collaborate with the care team for comprehensive care.
    • Guidelines and resources: APCC clinical guidelines for palliative care symptom management; EM Guidance; APMS (APM) guidance for palliative symptom management.

  • Assessment and prioritization in symptom management

    • Comprehensive assessment basics: identify multiple symptoms, their causes, severity, and impact on QoL; prioritize management according to patient- and family-centered impact rather than isolated symptoms.
    • OPQRSD framework to characterize symptoms:
    • O: onset
    • P: provocation (what makes it worse or better)
    • Q: quality
    • R: region and radiation
    • S: severity
    • D or T: timing (onset speed, duration, pattern) — note: text uses OPQRSD but describes T as timing; use this mapping: O, P, Q, R, S, T.
    • Symptom scales: plot symptom intensity on a scale to monitor response (e.g., pain scale example given: "my pain was an 8, after two days of morphine, it’s down to a 5").
    • Holistic approach to symptom management: consider physical, psychological, social, and spiritual dimensions; include caregiver support.
    • Distinguish reversible vs non-reversible causes when addressing delirium/dyspnea; correct reversible factors when possible.
    • The aim of investigations: balance benefits with burden, avoid unnecessary tests, especially in home or hospice settings; empirical treatment may be appropriate with careful monitoring.

  • Addressing reversible causes and initial management approach

    • Correct reversible causes whenever possible (low-hanging fruit).
    • Non-pharmacological interventions first (immediate applicability, empowers patients and families):
    • breathing techniques, positioning, environmental adjustments, airflow/ventilation improvements, hydration, and comfort measures.
    • education: explain causes, expected responses, and patient/family preferences.
    • Involve multidisciplinary team for non-pharmacological strategies (physiotherapists, OTs).
    • Consider the patient’s understanding and expectations, and tailor management to preferences and prognostic context.
    • If symptoms persist after addressing reversible causes, move to pharmacological interventions and continue disease-directed treatment in parallel if feasible.
    • Parallel care: address the underlying disease when possible (e.g., ART for HIV; radiotherapy for painful vertebral metastases), while managing symptoms.
    • When to switch from first-line to second-line pharmacological therapy: reassess diagnosis and response; consider alternative or additional empirical treatments; involve specialists as needed.

  • First-line pharmacological management principles

    • Prefer oral route first; start with low regular dosing and titrate up as needed.
    • If symptoms are not adequately relieved, reconsider diagnosis or treatment strategy (second-line interventions).
    • Always consult palliative-care specialists and disease-specific specialists as appropriate (renal failure, cancer, etc.).
    • Useful online guidelines:
    • APCC clinical guidelines for palliative care symptom management
    • EM Guidance (APM guidance) on palliative symptom management

  • Underlying disease and treatment goals in parallel care

    • Symptom relief should occur alongside disease-directed care when possible.
    • Delineate that symptom-focused interventions can often be provided without waiting for disease-directed therapies to finish; coordinate with specialists to optimize both symptom relief and disease control.

  • The OPQRSTD acronym and symptom-tracking in practice

    • Reiterate OPQRSD (Onset, Provocation, Quality, Region, Severity, Timing) as a tool to characterize symptoms.
    • Use symptom scales to quantify response to treatment; track changes over time to assess progress and adjust plans.

  • Dyspnea (shortness of breath): pathophysiology and management framework

    • Dyspnea is a subjective sensation of breathing difficulty not necessarily tied to exertion; mechanism involves an imbalance between ventilatory demand and capacity.
    • Potential mechanisms reducing capacity to respond:
    • decreased lung volume or ventilatory ability (e.g., neuromuscular weakness, diaphragmatic dysfunction)
    • decreased lung perfusion (e.g., thrombus/PE)
    • increased secretions causing airway obstruction
    • Urgency: relief of dyspnea is an urgent priority due to impact on QoL, mood, mobility, communication, and self-care ability.
    • Link between anxiety and dyspnea: tachypnea and fear can create a vicious cycle; breaking this cycle is a key component of management.
    • Management approach: dual strategy
    • non-pharmacological interventions (breathing techniques, positioning, environmental adjustments, air flow, cool environment, etc.)
    • pharmacological interventions (lowering anxiety, reducing sensation of breathlessness) while simultaneously addressing the underlying cause.
    • In the palliative setting, the focus is not on optimizing SAT/Blood Gas results but on comfort and patient-reported relief; SAT monitoring goal is to ensure comfort rather than normalization of numbers in many cases.
    • Mouth moisture is often neglected but important: tachypnea can dry the mouth and worsen the sensation of dyspnea; practical measures include ice chips and water spray to keep the mouth moist.
    • Cause-directed vs symptom-directed interventions: many reversible causes (infection, secretions, effusions, bronchospasm) may respond to targeted treatments, but some (destruction of lung tissue from chronic disease or metastases) may be irreversible; plan accordingly for symptom control when reversibility is limited.
    • Burden of intervention: compare lower-burden tests/treatments (pleural tap) to high-burden options (intercostal drain) and align with patient preferences and goals.
    • Practical considerations:
    • Manage oxygen therapy carefully to avoid psychological dependence; home oxygen may be difficult to obtain and may be inappropriate in some palliative contexts.
    • Oxygen saturation targets: often avoid excessive reliance on supplemental oxygen; consider low-flow oxygen when needed and aligned with goals and burdens.
    • Pharmacological options for dyspnea (general classes, not specific drug names):
    • Morphine (mainstay): low-dose morphine reduces dyspnea by lowering pulmonary pressures, reducing central sensation of breathlessness, and dampening the respiratory drive that fuels anxiety. Typical home-use example: 2.5\,\text{mL every } 4\,\text{hours} (as per session); used at low doses for dyspnea relief.
    • Benzodiazepines (e.g., midazolam or lorazepam): for significant anxiety-related dyspnea, particularly when anxiety exacerbates dyspnea; administer under appropriate supervision.
    • Oxygen considerations: home oxygen access and patient safety; avoid fostering dependence; discuss goals and risks with patient and family.

  • Delirium and confusion in palliative care

    • Definition and scope: delirium is a state of mind characterized by acute confusion with recent onset and fluctuating severity; a collective term for various causes of acute confusion rather than a single diagnosis.
    • TIMTOF mnemonic (helps identify causes):
    • Drugs (e.g., morphine, benzodiazepines)
    • Infection
    • Metabolic disturbances (e.g., hypocalcemia or other metabolic derangements)
    • Trauma to the head / subdural hemorrhage
    • Hypoxia (hypoxic state)
    • Raised intracranial pressure or CNS involvement (brain metastases, CSF obstruction)
    • Other precipitating factors: recent environmental changes (e.g., admission to ER from home), pain, dehydration, constipation; delirium is often multifactorial.
    • Management approach in palliative care:
    • This is a medical emergency to be addressed quickly, with attention to prognosis and goals of care.
    • Identify and correct reversible causes when possible (e.g., infection, metabolic issues, dehydration, pain, constipation).
    • Consider the patient’s prognosis and preferences when deciding on interventions and the intensity of workups.
    • Non-pharmacological strategies to support dignity and environment (stable lighting, familiar items, quiet environment, gentle orientation).
    • Pharmacological management when needed: haloperidol or benzodiazepines may be used to control agitation and improve comfort; aim to minimize restraints.
    • Patient and family considerations:
    • Nursing staff challenges with delirious patients (risk of undignified handling); emphasize dignity and appropriate care, including appropriate use of sedation when necessary.
    • If delirium occurs at home, ensure caregivers understand symptoms and safe management strategies; avoid coercive measures such as tying or restraining the patient.
    • Terminal agitation: a recognized syndrome in the final hours to days of life; decisions about comfort-focused care and preferred interventions should be guided by prognosis and patient/family wishes.

  • Putting it all together: practical implications and ethical considerations

    • Holistic care and patient-centered goals
    • Recognize and respect patient goals and preferences; avoid over-treatment that imposes burden without meaningful benefit.
    • Set realistic, incremental goals for symptom reduction (e.g., reduce a dyspnea intensity by a certain number of points over the first days of treatment).
    • Communication and education
    • Explain to patients and families what is happening, why certain interventions are chosen, and what outcomes are expected.
    • Discuss the probable cause and the expected time course for response to treatment; set expectations about not always achieving complete symptom resolution.
    • Restraints and dignity
    • Avoid physical restraints for delirious patients; sedated management may be more dignified and safer; ensure appropriate nursing care to protect dignity.
    • Multidisciplinary approach and support
    • Leverage physiotherapists, OTs, nurses, social workers, and spiritual care for comprehensive symptom relief and patient-family support.

  • Close-out: key takeaways to guide practice

    • In palliative care, aim for comfort, QoL, and relief of distress in the context of the patient’s prognosis and goals.
    • Manage symptoms with a structured approach: assess, identify causes, correct reversible factors, apply non-pharmacological strategies, then use pharmacology with a stepwise, patient-centered plan.
    • For dyspnea, address both the physiological causes and the anxiety cycle; use morphine at low doses for rapid relief of breathlessness in appropriate patients, with careful monitoring and escalation as needed.
    • For delirium, promptly identify and treat reversible causes, avoid protracted cognitive decline where possible, and maintain dignity and communication with patient and family.
    • Use established guidelines (APCC, EM Guidance, APMS/APM) to inform practice and stay aligned with best-practice recommendations.

  • Quick reference reminders (practical tips)

    • Use OPQRSD to characterize symptoms: onset, provocation, quality, region, severity, timing.
    • Consider burden of investigations; avoid unnecessary tests in home/palliative settings; empirical treatment may be appropriate with ongoing review.
    • Start with non-pharmacological interventions before pharmacological ones; involve families in implementing these measures.
    • When pharmacologic management is needed, begin with oral, low-dose, regularly scheduled dosing; escalate only as needed and in consultation with specialists.
    • Keep the patient and family informed about goals, expected responses, and possible trade-offs with interventions (e.g., nutrition issues with bowel obstruction).

  • Connections to broader principles

    • Aligns with foundational palliative-care tenets: relieve suffering, protect dignity, support families, and integrate care with disease-directed therapies when feasible.
    • Emphasizes proactive symptom control, ethical consideration of burdens and benefits, and the central role of communication in care planning.
    • Reinforces that symptom management often requires a multidisciplinary, patient-centered approach across physical, psychological, social, and spiritual domains.

  • Examples and scenarios highlighted in the session

    • Dual-approach example: treating possible lower respiratory tract infection while continuing to manage dyspnea with morphine and supportive care, even when the precise cause is uncertain (e.g., infection vs metastases).
    • Bowel obstruction example for goal-setting: acknowledge limited ability to reverse the obstruction but focus on what can be improved (e.g., symptom relief, comfort, and meaningful meals occasionally) and align with patient preferences.
    • Pleural effusion management: compare pleural tap (low-burden) versus intercostal drain (high-burden) to illustrate how patient preferences and goals influence intervention choices.

  • Specific numerical and technical references

    • Dyspnea management dose example: 2.5\,\text{mL every } 4\,\text{hours} (morphine for dyspnea relief at low dose).
    • Oxygen saturation consideration: target to avoid excessive dependence; home oxygen considered only with clear indications and appropriate settings; generally hold when not aligned with goals.
    • SpO₂ monitoring reference in palliative contexts: avoid fixating on normalization of values; prioritize patient comfort and symptom relief when numbers don’t reflect patient experience.

  • Notes on the educational context and resources referenced

    • The session links symptom management to a broader curriculum, highlighting ongoing sessions focused on end-of-life symptom relief and the integration of palliative care principles across clinical practice.