Special Feature
Update in Palliative Care XI: Beyond Pain
By Thomas J. Smith, MD, FACP
George soros, the richest man in the world, watched his wife die of breast cancer. She was in pain, mostly ignored, or not ministered to by doctors who could have chosen to be there. There were no discussions about advanced directives, or prognosis and expectations. Having billions to give away, he started the Project on Death in America, in an attempt to change for the better how Americans die. He hired Kathy Foley to direct it, and he chose about 20 people a year for aid.
Now the American Medical Association has started the Education for Physicians on End of Life Care (EPEC), from which I just returned. The American Society of Clinical Oncology (ASCO) also plans a half-day symposium in 2000 at the annual meeting. Sign up for either, or both, if you get a chance.
I was initially unconvinced that palliative care was a specialty. After all, didn’t we all know how to give morphine? Well, actually not, given that more than half of the patients in academic hospitals died with unrelieved pain—palliative care works, and some people do it better than others.
Think back over the last 10 patients you have had die at home or in the hospital, and what distressed them or their families. Here is some of what I have learned in my three years.
Delirium is Common and Treatable
Ask a hospice nurse, and you will find that "terminal delirium" is one of the most common and troubling problems that distresses families with relatives near death. Moaning and delirium is upsetting to watch and is often interpreted as pain. But it’s not pain, and high accumulations of narcotics due to diminished renal clearance may be one of the most common causes. (See Table 1.)
| Table 1-Troubleshooting in Terminal Delirium Cases | |
| Cause | Solution |
| Too much narcotic | Don’t stop it! Just cut it in half. If that does not work, then stop it. |
| Too little renal clearance | In the patient with weeks to live consider a trial of hydration, with a switch to another narcotic at equivalent doses. |
| No definable reason | Reassure the family that it is a common pre-terminal event.Reassure them that it is not pain. Don’t treat unless it bothers someone. Who knows what they are seeing.* |
| *Haloperidol (0.25-1.0 mg syrup in the cheek, or rectal) works much better than benzodiazepines. | |
Agitation is Common and Treatable, too
Again, haloperidol wins hands down over benzodiazepines, when studied. It has a good anti-emetic effect and probably accounts for fewer falls and fractures. Start low at 0.25 mg or so and work up. (Editor’s note: Low doses of newer atypical’ antipsychotics, such as risperidone, are also effective alternatives.)
Terminal Nausea is Common and Treatable
No one really knows why, but it is common. And the best solutions are not XYZ-tron at $60 a day. Use a dopamine-receptor drug, such as metaclopramide 10-30 mg q 6 h, and some dexamethasone. It has the added advantage of enhancing bowel motility, too. (These tablets can be added to a suppository.) If that fails, try haloperidol 0.5-1.0 mg q 6 h or droperidol. If that doesn’t work, try another class of agents such as the serotonin receptor drugs (granisetron, ondansetron, etc.) or a benzodiazepine.
Terminal Dyspnea is Treatable
No need to be fancy here. Any narcotic will do if given as for pain, around-the-clock, and at the dose that works. Morphine works to reduce the work of breathing by relaxing the lung smooth muscle. Start with 5-10 mg q 4 h and titrate up to comfort, just like with pain. There is typically little or no effect on respiratory rate. Don’t start with pulse oximetry and ABGs since the goal is to relieve the suffering of labored breathing; it’s easier to not start them than to take them away once established.
If that does not work, try a fan blowing air across the patient (I know it sounds too simple, but try it once—it works). Then, oxygen (but remember it’s expensive and hard to stop), then try steroids (and next) benzodiazepines. For some patients, it takes a combo of morphine and benzodiazepines. Inhalers such as albuterol rarely work and are not worth trying.
Nebulized morphine/fentany/etc. had a brief run of popularity. And it works, but no better than nebulized saline in randomized clinical trials. It’s the narcotic, and we might as well give it P.O. or P.R.
The "Death Rattles"
This is the number one reason panicked families call me or hospice nurses. The dying person is usually in no distress, but it’s hard to watch. (See Table 2.)
| Table 2-Alleviating the "Death Rattle" | |
| Cause | Treatment |
| Ineffective clearance | Prop the patient up and to his/her side. |
| Too many secretions | Scopolamine patches, just like for seasickness. Rarely cause disorientation in the terminally ill (or hard to tell) but can cause problems in the frail elderly who are still mobile. Put them on before it gets too bad because it’s easier to prevent. |
Depression is the Norm, not the Exception
Depression can be hard to differentiate from the sadness and grief of dying. I have switched to the "Chochinov Test" of Dr. Harvey Chochinov:
"Are you Depressed?"
If the patient says no, or "Yes, this is terrible! I’m dying, and feel so hopeless, and I don’t have the energy to get up and I can’t sleep..." you have more than an 80% chance of being right in your diagnosis. Plus, you asked.
Typical antidepressants can work but may take weeks. Start them or get a psychiatric consultation (tough for the homebound). Consider starting a short course of methylphenidate (Ritalin) or some other stimulant at low doses (e.g., 2.5-5 mg in the morning and at noon) increasing to tolerance. This also works for the morphine patient who cannot wake up.
Dr. Kevorkian, the Pinata of Palliative Care
Dr. Chochinov noted in his sample of 200 dying patients that nearly one in 10 had clinical depression. Of those requesting euthanasia, six of 10 were depressed. Almost all the requests for physician-assisted suicide (PAS) came from the depressed group. Most of these requests changed after about two weeks. I won’t go over the six-step program to manage PAS, but someone’s clever phrase was too hard to pass up.
Hiccups
Antacid with simethicone (then try) metaclopramide 10-30 mg q 4-6 h (or cisapride 20 mg q 12 h, but try the low priced spread first) (and next) baclofen 5-10 mg q 6-12 h.
Chlorpromazine, the drug most often used, is too sedating and rarely effective. Don’t use prochlorperazine (Compazine) with metaclopramide (Reglan), as the first will block the prokinetic movement of the second and will increase the chance of extra pyramidal side effects.
Myoclonic Jerks
"Well, doctor, you’ve finally gotten him comfortable but he’s jerking all over as soon as he drifts off to sleep, do something about those seizures!"
| Table 3-Treating Myoclonic Jerks | |
| Cause | Solution |
| Normal reaction to narcotic | Reassurance. |
| Benzodiazepine (e.g., lorazepam 0.5-1 mg q 12 h, clonazepam, or diazepam). Consider a switch to a new narcotic, which can give a "honeymoon" period of several weeks. | |
| Hyponatremia or renal failure | Only treat if indicated. |
Myoclonic jerks ("sleepstarts") are normal and can happen with any narcotic. I have listed some of the most common causes and solutions here. Reassure the patient/family that these are not seizures, and only require treatment if bothersome. These movements are so characteristic that no diagnostic testing is needed other than a good clinician! (See Table 3.)
This isn’t Rocket Science, but there isn’t a lot of Science being done about it
The ASCO abstracts on palliative care this year were heavily skewed to fatigue, vomiting, and pharmaceutical interventions. Most of the above-mentioned material has been known for about 10 years but had not trickled down to mainstream oncologists like me.
There are some great places to learn more about these programs. Check out the EPEC website (http://www. ama-assn.org/ethic/epec/) or address (The EPEC Project, Institute for Ethics, American Medical Association, 515 N. State Street, Chicago, IL 60610, 312-464-4979) and sign up for a course. Much of it is old hat to oncologists, but a great refresher, and a way to then teach our colleagues in medicine, family practice, and surgery to practice these procedures. After all, we want them here for us when we die.
Take Home Message
First, when someone is dying, call hospice six weeks before they are dead, not six hours.
Second, when someone is dying, there is a lot you can do about it. Yes, I know it’s not reimbursed well, and it’s harder than choosing between Taxol and Taxotere, but this is why most of us chose to become doctors.
You can make the difference between a peaceful planned death at home, or a traumatic death that includes uncontrolled pain, ER visits, late night phone calls, and disgruntled family members. Either will be long remembered—it’s our choice. (Dr. Smith is Director of Cancer Education for the Massey Cancer Center at the Medical College of Virginia in Richmond.)
Suggested Reading
1. McDonald N. Palliative Medicine: A Case Based Manual. Oxford, New York, 1998.
2. Eguchi I, Klastersky J, Feld R. Current Perspectives and Future Directions in Palliative Medicine. Springer, New York, 1998.
3. WHO. Symptom Relief in Terminal Illness. Geneva 1998.
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