DOCSLIB.ORG

Dyspnea: the Top Things You Need to You Know!

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Dyspnea: the Top Things You Need to You Know! Dyspnea: The top things you need to you know! Dr. Megan Sellick & Dr. Lawrence Lee Edmonton Zone Palliative Care Program Faculty / Presenter Disclosure • Faculty: Dr. Lawrence Lee • Relationships with commercial interests: • Grants/Research Support: none • Speakers Bureau/Honoraria: none • Consulting Fees: none • Other: none Faculty / Presenter Disclosure • Faculty: Dr. Megan Sellick • Relationships with commercial interests: • Grants/Research Support: none • Speakers Bureau/Honoraria: none • Consulting Fees: none • Other: none Disclosure of Commercial Support • This program has received financial support from: none • This program has received in-kind support from: none Objectives By the end of our time together, you will be able to : • Recognize the subjective nature of dyspnea • Provide an initial management plan for dyspnea (non-pharmacological and pharmacological) • Briefly describe “palliative sedation” and describe the medication used Dyspnea This man has metastatic lung cancer. Which of the following is the best measure of his dyspnea? A- respiratory rate B- use of accessory breathing muscles C- oxygen requirements D- oxygen saturations E- all of the above F- none of the above (patient’s report is best) Dyspnea Definition: “feeling like one cannot breathe well enough” American Thoracic Society: “a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.” Dyspnea Overall Management Approach: Screen+Assess Identify Cause(s) Management Underlying Cause Symptoms Dyspnea Screen for it ESAS-R ECG of symptoms (here and now) Patient completes if possible Dyspnea/Shortness of breath is included Dyspnea Assessment: History Duration Onset Pattern Severity: Rest vs Exertion Triggers/Alleviating Factors Physical Examination Dyspnea Cause Investigations* Treatments* Identify + Pleural Effusion CXR Thoracentesis Manage Pneumonia CXR + Bloodwork Antibiotics Underlying Airway Imaging +/- Radiation Causes Obstruction Bronchoscopy Stenting/Steroids Lymphangitic Imaging: CXR/CT Steroids Carcinomatosis in accordance Anemia Bloodwork Blood Transfusion with Goals of COPD Bronchodilators, Steroids CHF Cardiac meds, Lasix Care* ALS BiPAP Dyspnea Symptomatic Management: Non-Pharmacological Fan Position: leaning forward, head up Avoid irritants Avoid exacerbating activities: mobilization, transfers, constipation Dyspnea *Symptomatic Management: Pharmacological Oxygen Opioids Other Therapies Dyspnea Symptomatic Management: Oxygen Useful for patients with hypoxia Use cautiously in patients with severe COPD (ie. CO2 retainers) Role in non-hypoxic patients less clear: some may still benefit Not clear whether it is the oxygen or the airflow that is helpful Dyspnea Symptomatic Management: Oxygen When used for comfort, oxygen should be titrated to: A-Improved Oxygen Saturations (ie. O2>95%) B-Reduce Tachypnea (ie. Decrease respiratory rate) C-Decrease Work of Breathing D-All of the Above E-None of the above (titrate to decrease pt’s sensation of dyspnea) Dyspnea Symptomatic Management: Oxygen When using O2 for comfort: No need to start if the patient is not complaining of dyspnea No need to continue measuring oxygen saturations at end of life Increase O2 around periods when patient has more dyspnea (ie. Could increase on exertion) Dyspnea Symptomatic Management: Opioids Which is the following is true regarding the use of opioids for dyspnea: A- They block lung opioid receptors to decrease the sensation of dyspnea B- Opioids diminish the sensation of being short of breath in the brain C- They reduce the respiratory rate and allow the patient to rest D- All of the above E- None of the above Dyspnea Symptomatic Management: Opioids Opioids are safe and effective for dyspnea When you “start low and go slow”, low risk of respiratory depression Similar to cancer pain, they can be provided ATC + PRN (ie. Morphine 2.5 mg PO q6h + q1h PRN for shortness of breath) Diminish the sensation of dyspnea in the brain Nebulized opioids do not show significant benefit Dyspnea Symptomatic Management: Anxiolytics Anti-psychotics: helpful in managing dyspnea-related anxiety Haldol 1 mg PO/SC q12h-q4h ATC + q1h PRN Olanzapine 2.5-5 mg PO/Zydis q12h-q4h ATC + q1h PRN Nozinan 6.25-25 mg PO/SC q12h-q4h ATC + q1h PRN Dyspnea Palliative Sedation • Process of inducing/maintaining deep and permanent sleep in order to relieve refractory symptoms in palliative pts who are close to death. NOT EUTHANASIA • Most common indications: delirium, dyspnea • ?Risk of hastening death → No evidence! • Midazolam: Benzodiazepine with short t1/2 easily titratable by SC infusion Dyspnea Palliative Sedation: Communicating with Family • Discuss proactively • Review understanding of illness/prognosis, goals of care • Sedation used only if symptoms refractory to all other measures • Patient will lose ability to communicate • Usually irreversible, with death from underlying illness occurring within days Dyspnea Take Home Messages • Dyspnea is what the patient self-reports • Screen for dyspnea • Determine and treat underlying causes when possible/appropriate • Use oxygen if it helps and titrate it to comfort, not oxygen saturations • Opioids are safe and effective for symptomatic management of dyspnea • Treat the anxiety component of dyspnea if it is present • Palliative sedation is available for intractable dyspnea .
Load more

Recommended publications
  • Sedation for Palliative Purposes Guideline
    1 Sedation for Palliative Purposes Guideline July 18, 2017 July 18, 2017 2 WRHA Regional Committee Members Co-Chairs Dr. Mike Harlos, Medical Director, WRHA Adult and Pediatric Palliative Care Program Lori Embleton, Program Director, WRHA Palliative Care Program Committee Members Jawad Barlas, Pharmacy, Riverview Health Centre Joanne Browning RN, Critical Care, Health Sciences Centre Dr. Garnet Crawford, WRHA Palliative Care Physician Consultant Jennifer Dunsford RN, WRHA Regional Ethics Dr. Aviva Goldberg, Pediatric Nephrology and Ethics Dr. Duane Hartley, Family Medicine and Palliative Care Dr. Tim Hiebert, Internal Medicine Dr. Chris Hohl, Pediatrics Pat Murphy, Clinical Ethicist, St. Boniface Hospital Janice Nesbitt RN, Clinical Nurse Specialist, WRHA Palliative Care Program Dr. Shaundra Popowich, Womens’ Health Tracy Thiele RN, WRHA Projects Manager and Liaison George Webster, Clinical Ethicist, St. Boniface Hospital Luana Whitbread RN, Clinical Nurse Specialist, WRHA Long Term Care Dr. Kim Wiebe, Critical Care Dr. Cornie Woelk, Prairie Mountain Health Physician July 18, 2017 3 WRHA Clinical Practice Guideline: Sedation for Palliative Purposes (SPP) WRHA Regional Committee Members ……………………………………………………………………………………… 2 Purpose and Scope of guideline ……………………………………………………………………………………………….. 4 Levels of Evidence ……………………………………………………………………………………………………………………. 5 Definition …………………………………………………………………………………………………………………………………. 5 Sedation for Palliative Purposes vs. Medical Assist in Dying ……………………………………………………… 6 Indications …………………………………………………………………………………………………………………………………
    [Show full text]
  • Euthanasia, Assisted-Suicide, and Palliative Sedation: a Brief Clarification and Reinforcement of the Moral Logic Peter A
    Online Journal of Health Ethics Volume 14 | Issue 2 Article 4 Euthanasia, Assisted-Suicide, and Palliative Sedation: A Brief Clarification and Reinforcement of the Moral Logic Peter A. DePergola II University of Massachusetts eM dical School - Baystate; College of Our Lady of the Elms, [email protected] Follow this and additional works at: https://aquila.usm.edu/ojhe Part of the Applied Ethics Commons, Bioethics and Medical Ethics Commons, Medical Humanities Commons, and the Palliative Care Commons Recommended Citation DePergola, P. A. (2018). Euthanasia, Assisted-Suicide, and Palliative Sedation: A Brief Clarification and Reinforcement of the Moral Logic. Online Journal of Health Ethics, 14(2). http://dx.doi.org/ 10.18785/ojhe.1402.04 This Article is brought to you for free and open access by The Aquila Digital Community. It has been accepted for inclusion in Online Journal of Health Ethics by an authorized editor of The Aquila Digital Community. For more information, please contact [email protected]. Euthanasia, Assisted Suicide, and Palliative Sedation: A Brief Clarification and Reinforcement of the Moral Logic Peter A. DePergola II University of Massachusetts Medical School College of Our Lady of the Elms ABSTRACT A persistent misunderstanding of the moral distinctions between the practices of euthanasia, assisted suicide, and palliative sedation suggests a critical need to revisit the relationship each shares with licit medical practice in the context of palliative care. To that end, this essay grounds its arguments in two, straightforward premises: (i) the licitness of medical practice is largely determined by the balance between (a) good ends, (b) proportionate means, (c) appropriate circumstances, and (d) benevolent intentions; and (ii) whereas palliative sedation employs criteria A-D (above), both euthanasia and assisted suicide fail to secure criteria A-C.
    [Show full text]
  • Continuous Deep Palliative Sedation: an Ethical Analysis
    Continuous Deep Palliative Sedation: An Ethical Analysis Dr Lalit Kumar Radha Krishna Senior Consultant in Palliative Medicine MBChB Liverpool, MRCP (London), MA in Ethics in Cancer and Palliative Care (Keele) A thesis submitted For the degree of Doctor of Philosophy Centre for Biomedical Ethics National University of Singapore 2013 i ii Acknowledgements For those who have inspired me, guided me, stood with me and supported me For my parents who made me the man I am & For my wife and son who inspire me to be more ~ words fail iii iv Table of Contents Declaration ................................................................................................................... i Acknowledgement ....................................................................................................... iii Summary ................................................................................................................... xiii List of Tables.............................................................................................................xvii List of Figures............................................................................................................xix Acronyms....................................................................................................................xxi INTRODUCTION ......................................................................................................1 Controversies surrounding the application of palliative sedation and terminal sedation ...............................................................................................2
    [Show full text]
  • Palliative Sedation in Patients with Cancer Marco Maltoni, MD, and Elisabetta Setola, MD
    Communication between patients, their relatives, and health care staff is very important when administered palliative sedation. Photo courtesy of Lisa Scholder. Organic Walk, 16" × 24". Palliative Sedation in Patients With Cancer Marco Maltoni, MD, and Elisabetta Setola, MD Background: Palliative sedation involves the use of sedative medication to relieve refractory symptoms in patients by reducing their level of consciousness. Although it is considered an acceptable clinical practice from most ethical points of view, palliative sedation is still a widely debated procedure and merits better un- derstanding. Methods: The relevant medical literature pertaining to palliative sedation was analyzed and reviewed from various technical, relational, and bioethical perspectives. Results: Proportionate palliative sedation is considered to be the most clinically appropriate modality for performing palliative sedation. However, guidelines must be followed to ensure that it is performed correctly. Benzodiazepines represent the first therapeutic option and careful monitoring of dosages is essential to avoid oversedation or undersedation. Conclusions: Proportionate palliative sedation is used to manage and relieve refractory symptoms in patients with cancer during their last days or hours of life. Evidence suggests that its use has no detrimental effect on survival. A different decision-making process is used to manage the withdrawal of hydration than the process used to determine whether proportionate palliative sedation is appropriate. Communication
    [Show full text]
  • The Waterloo Wellington Palliative Sedation Protocol
    The Waterloo Wellington Palliative Sedation Protocol Waterloo Wellington Interdisciplinary HPC Education Committee; PST Task Force Chair: Dr. Deborah Robinson MD CCFP(F), Focused practice in Oncology and Palliative Care Co-chairs: Cathy Joy, Palliative Care Consultant, Waterloo Region Chris Bigelow, Palliative Care Consultant, Wellington County Revision due: November 2016 Last revised and activated: November 13, 2013 Committee responsible for revisions: WW Interdisciplinary HPC Education Committee Table of Contents Purpose and Definitions .................................................................................................................... 2 Indications for the use of PST .............................................................................................................. 3 Criteria for Initiation of PST ............................................................................................................... 4 Process ............................................................................................................................................. 4 Documentation for Initiation of PST .................................................................................................. 5 Medications ......................................................................................................................................... 6 1st Line (Initiating PST) ...................................................................................................................... 6 2nd Line (When 1st
    [Show full text]
  • Edmonton Zone Palliative Care Program
    Palliative Sedation Guideline Edmonton Zone Palliative Care Program Title: Palliative Sedation GUIDELINE Date Approved: Original version in September 2006 and revised in October 2015 Approved By: Edmonton Zone Palliative Care Program, Practice Development and Quality Committee Date of Next Review: October 2018 A. PURPOSE: To provide guidance when considering Palliative Sedation as a form of palliation for intractable symptoms in an appropriate setting and time frame. B. STAKEHOLDER INVOLVEMENT: • This guideline was developed by health care professionals with expertise in palliative care. The disciplines of nursing, pharmacy and medicine were represented with additional consultation with ethics and spiritual care • Patients’ views and preferences were not specifically sought in developing the guideline, given the medically frail nature of this population. However, the guidelines reflect the developers’ observations of patients’ experiences • The guideline is intended for use by palliative care consultants, as well as other physicians and nurses involved in the care of palliative care patients • Although the guideline has not been piloted among target users, it reflects current practice in the Edmonton Zone Palliative Care Program C. DEVELOPMENT: • The articles were identified through a search of MEDLINE from 1985 to 2005, using the search term “sedation”; subject heading “palliative care”, “terminal care”, “delirium”, “neoplasm”, “hypnosis”, and “sedative”; combined with “refractory symptom”, subject heading “palliative care”, “pain”,
    [Show full text]
  • Be a Hero to a Dying Patient: Symptom Management At
    BEAHERO TO A DYING PATIENT: SYMPTOM MANAGEMENT AT END- OF LIFE. Robert G. Wahler, Jr., Pharm.D., BCGP, FASCP, CPE Clinical Assistant Professor, UB SPPS Director, Clinical Pharmacy Services, Niagara Hospice 1 2019 Wahler RG LEARNING OBJECTIVES 1. Identify common symptoms experienced by patients with advanced illness. 2. Select or recommend medication options for specific palliative symptoms. 3. Discuss various pharmacologic interventions for common symptoms. 4. Define treatment measures in the last hours of life. 2 INTRODUCTION 2.8 million death/year in US, 1.4 million in hospice. It is important to address and manage each end-of-life symptom to improve the quality of life for the patient. An interdisciplinary team approach is beneficial throughout the care of the patient. This is evident when addressing more psychologically based symptoms, such as delirium. 3 INTRODUCTION The ASHP Guidelines on the Pharmacist's Role in Palliative and Hospice Care - Essential Clinical and Administrative Roles Direct patient care Optimize the outcomes of symptom management and palliative care patients through the expert provision of evidence-based, patient-centered medication therapy as an integral part of an interdisciplinary team Serve as an authoritative resource on the optimal use of medications in symptom management and palliative care Anticipate transitions of care when recommending, initiating, modifying, or discontinuing pharmacotherapy for pain and symptoms Medication order review and reconciliation Manage and improve the medication-use process in patient care settings Education and medication counseling Demonstrate excellence in the provision of medication counseling to patients, caregivers, and families Administrative roles 4 Ensure safe use of medications in the treatment of pain and symptoms Medication supply chain management Herndon CM, Nee D, Atayee RS, Craig DS, Lehn J, Moore PS, Nesbit SA, Ray JB, Scullion BF, Wahler RG, Waldfogel J.
    [Show full text]
  • Palliative Sedation Therapy (PST) Protocol Is an Interprofessional Peer- Reviewed, Evidence-Informed Clinical Resource
    The Waterloo Wellington Palliative Sedation Therapy Protocol Waterloo Wellington Interdisciplinary HPC Education Committee: PST Task Force Last Revised: December 2019 Next Review Date: December 2022 Table of Contents Purpose ______________________________________________________________________________ 1 Introduction __________________________________________________________________________ 3 Defining Palliative Sedation Therapy _____________________________________________________________ 3 When to Consider Palliative Sedation Therapy _______________________________________________ 5 Criteria for Initiating Palliative Sedation Therapy ____________________________________________ 7 Criteria _____________________________________________________________________________________ 7 Palliative Sedation Therapy Process ______________________________________________________________ 7 Patient Assessment ___________________________________________________________________________________ 7 Consent Process ______________________________________________________________________________________ 8 Care Planning ________________________________________________________________________________________ 8 Palliative Sedation Therapy Medications __________________________________________________ 11 Monitoring _________________________________________________________________________________ 12 Table 1. Common PST Medications ______________________________________________________________________ 15 Family and Team Support ______________________________________________________________
    [Show full text]
  • Position Statement on Euthanasia
    Position Statement on Euthanasia The Indian Association of Palliative Care opposes euthanasia in all its forms. Good symptom control through palliative care can pre-empt the request for euthanasia. Withholding or withdrawing treatment that is medically futile does not amount to euthanasia. The Indian Association of Palliative Care (IAPC) is an association of professionals devoted to the teaching, promotion and delivery of palliative care in the country. Palliative care includes support during therapy, end-of-life care and bereavement support to families. Specialists in the field of palliative care work closely with terminally-ill and dying patients, and are deeply concerned about euthanasia. The debate on euthanasia or mercy killing has been raging for some time in the country. The case of Aruna Shanbaug, who has been lying in a vegetative state in a hospital following a brutal assault more than 4 decades ago, has highlighted the need for a consensus on the issue. Euthanasia has been discussed at legislative levels and rules are being drafted for the approval of the Parliament. The Supreme Court has called for opinions of individuals and organizations working in this area. Members of the IAPC feel it is important to respond to the court. Palliative care specialists the world over are united in their understanding of what euthanasia is, and what it is not. Euthanasia can never be passive, and the very terminology “passive euthanasia” is tragic and scientifically unsound.i Withholding or withdrawing futile treatments or measures that merely prolong life, is medically and ethically right, and is not “euthanasia”. Freedom from pain is a fundamental human rightii and the physician is bound to use drugs or procedures to alleviate pain and suffering.
    [Show full text]
  • Guideline for Palliative Sedation
    Guideline for Palliative Sedation Royal Dutch Medical Association (KNMG) Committee on National Guideline for Palliative Sedation Royal Dutch Medical Association (KNMG) Utrecht, The Netherlands Januari 2009 KNMG Guideline for Palliative Sedation 2009 1 © Royal Dutch Medical Association (KNMG) Postbus 20051 3502 LB Utrecht Tel. 0031 (0)30 282 3322 Fax 0031 (0)30 282 3326 Email [email protected] For the online knowledge file on palliative sedation, see the website www.medischcontact.tv (Guideline in a downloadable form (also suitable for a PDA), e-learning, Web TV broadcast, articles and links) KNMG Guideline for Palliative Sedation 2009 2 Contents page Summary 5 1 Introduction 12 2 What is palliative sedation? 2.1 Relationship between palliative care and palliative sedation 17 2.2 Definition of palliative sedation 18 2.3 Structure of the guideline 20 2.4 Empirical data on the extent of the practice of palliative sedation 20 3 Indications and preconditions for palliative sedation 3.1 Indications for palliative sedation 22 3.2 Preconditions for continuous sedation 25 3.3 An exceptional situation 26 4 The decision-making process 4.1 Timely and open communication 28 4.2 Reasons for considering palliative sedation 29 4.3 Determining whether indications for palliative sedation are present 29 4.4 Discussion with the patient and/or his representative 31 5 Administration of fluids 35 6 Good medical practice 6.1 Preparations 38 6.2 The initiation of sedation 38 6.3 Proportionality 39 6.4 Drugs and method of administration 39 6.5 Morphine
    [Show full text]
  • Palliative Pharmacological Sedation for Terminally Ill Adults (Review)
    Cochrane Database of Systematic Reviews Palliative pharmacological sedation for terminally ill adults (Review) Beller EM, van Driel ML, McGregor L, Truong S, Mitchell G Beller EM, van Driel ML, McGregor L, Truong S, Mitchell G. Palliative pharmacological sedation for terminally ill adults. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD010206. DOI: 10.1002/14651858.CD010206.pub2. www.cochranelibrary.com Palliative pharmacological sedation for terminally ill adults (Review) Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 PLAINLANGUAGESUMMARY . 2 BACKGROUND .................................... 3 OBJECTIVES ..................................... 3 METHODS ...................................... 3 RESULTS....................................... 6 Figure1. ..................................... 7 Figure2. ..................................... 11 Figure3. ..................................... 12 DISCUSSION ..................................... 15 AUTHORS’CONCLUSIONS . 16 ACKNOWLEDGEMENTS . 16 REFERENCES ..................................... 17 CHARACTERISTICSOFSTUDIES . 19 DATAANDANALYSES. 37 APPENDICES ..................................... 37 CONTRIBUTIONSOFAUTHORS . 38 DECLARATIONSOFINTEREST . 39 SOURCESOFSUPPORT . 39 DIFFERENCES BETWEEN PROTOCOL AND REVIEW . .... 39 Palliative pharmacological sedation for terminally ill adults (Review) i Copyright © 2015 The Cochrane Collaboration.
    [Show full text]
  • Refractory Symptoms and Palliative Sedation Therapy Guideline Refractory Symptoms and Palliative Sedation Therapy Hospice Palliative Care Program • Symptom Guidelines
    Hospice Palliative Care Program Symptom Guidelines Refractory Symptoms and Palliative Sedation Therapy Guideline Refractory Symptoms and Palliative Sedation Therapy Hospice Palliative Care Program • Symptom Guidelines How can Palliative Care help you manage difficult symptoms? What about refractory symptoms? Palliative care aims to relieve suffering and to help patients and families with life limiting illness live as actively as possible with good quality of life, neither hastening nor postponing death. Although many palliative patients experience symptoms, most are well managed when appropriate medications and treatments are used. The FH Hospice Palliative Care (HPC) Symptom Guidelinesare valuable evidence based resources to help manage symptoms. http://www.fraserhealth.ca/EN/hospice_palliative_care_symptom_guidelines/ At times, symptoms prove more difficult to manage or do not respond to commonly used medications. In these cases, palliative care consultation can provide a key interdisciplinary resource. Admission to a FH Tertiary HPC unit is available through contact with your Hospice Palliative Care (HPC) consultation team or Palliative Care physician. HPC team consultation is available 24/7 in Fraser Health. During the day – HPC consult team contacts http://fhpulse/clinical_programs/end_of_life/Pages/Default.aspx After 5pm and weekend – HPC Physician http://oncall/oncall/BrowseSchedules/Groups.aspx?TeamId=103 The NEW HPC Symptom Guideline‘Refractory Symptoms and Palliative Sedation Therapy’ will help health care teams determine when a symptom is refractory versus difficult to manage. Refractory symptoms are those where “all possible treatments have failed, or it has been determined that there is no method within the time frame and risk: benefit ratio the patient can tolerate”. (Levy & Cohen, 2005) Consultation is strongly recommended to determine if a physical symptom is refractory.
    [Show full text]