Published in the January 2008 issue of Today’s Hospitalist
When it comes to patients experiencing difficult or intractable symptoms, hospitalists need to look beyond the curative model that was drilled into them during training.
Medicine’s focus on underlying disease, to the near exclusion of patient-reported symptoms that may cause as much distress as the illness itself, can lead to suboptimal treatment of common symptoms like dyspnea or nausea, says Eva Chittenden, MD, hospitalist and acting director of the palliative care service at the University of California, San Francisco.
“Symptom management is extremely important to patients and families, but it’s not usually at the forefront of our minds,” says Dr. Chittenden. “We think about treating a CHF exacerbation, for example, but don’t always follow up to treat baseline shortness of breath once the patient is better.”
Hospitalists likewise don’t explore other common CHF symptoms such as pain, anxiety, depression or cachexia, she adds. While many of these symptoms should be addressed in the outpatient setting, “we should be aware of them because they can contribute to CHF exacerbations.”
Fortunately, Dr. Chittenden says, hospitalists can provide excellent symptom management “if they are willing to switch gears. “We’re often so focused on lengthening life,” she says, “that we overlook quality of life and don’t find out what is important or most worrisome to our patients.”
How to switch gears
To show how hospitalists can factor symptom management and quality of life into the treatment equation, Dr. Chittenden poses the case of a heart-failure patient who is on an ACE inhibitor, a beta-blocker, a diuretic and a statin. The patient might still be short of breath or bothered by frequent urination from the diurectic. Or she may worry that the beta-blocker is making her tired and depressed.
Or consider the end-stage cancer patient with multiple metastases who has terrible nausea from chemotherapy. Clinicians often undertreat nausea because they are focused on curing the disease. But “once you have metastatic cancer, it’s chronic and ultimately terminal,” says Dr. Chittenden. “We should focus not just on managing the disease, but also on treating symptoms to the best of our abilities.”
By adopting that simultaneous perspective, hospitalists whose CHF patients complain about side effects might want to have a candid discussion with patients about tradeoffs. That would help patients make an informed decision about whether to continue taking a particular drug. For cancer patients, such a tradeoff might mean broaching the subject of stopping chemo. That may not be an option for patients who may derive real benefits from being treated, even if you can’t get the nausea under control, she points out. But for patients getting little or no benefit, “the patient may want to stop chemo.”
According to Dr. Chittenden, key symptoms that often go unmanaged are nausea and vomiting, and dyspnea. Other important symptoms include fatigue, anorexia, cachexia, anxiety and depression.
Nausea (or nausea with vomiting) is common in patients with a range of illnesses, from cancer to abdominal disease. In fact, about 70% of patients with advanced cancer experience nausea, while 40% of patients nearing the end of life suffer from it. Nausea is often inadequately treated, in part because physicians don’t delve deeply enough into its possible causes.
Dr. Chittenden says that the first order of business is to identify what’s likely causing the nausea. Physicians should first suspect newly added medications and then an electrolyte imbalance.
Other culprits include brain and liver metastases, Dr. Chittenden explains, “and virtually anything that pushes on or stretches the stomach or intestines.” While most hospitalists know that low sodium, high calcium, and liver or kidney failure can incite nausea, many may not recognize another common cause: constipation.
Address the nausea’s underlying cause by, for instance, discontinuing an inciting medication, treating constipation or correcting an electrolyte abnormality. Dr. Chittenden matches the following first-line treatments with conditions:
“¢ Medications or electrolyte imbalance: Try antidopaminic agents such as haloperidol or prochlorperazine. For chemotherapy-induced nausea, use an antiserotonergic medication such as ondansetron.
“¢ Higher cortical structures (brain metastases, bleeds or increased pressure): Start with a steroid such as decadron.
“¢ Vagal afferent nerve (nausea from stretching or irritation of the GI tract or of solid organs such as the liver or kidneys): Treat the underlying cause “possibly constipation or gastroparesis “then try promethazine.
“¢ Vestibular apparatus: Start with an anticholinergic such as a scopolamine patch or an antihistaminic agent such as meclizine.
A stepwise approach
Hospitalists might have to make modifications as they go because some patients respond better to certain medications, regardless of the cause of the nausea.
Also think about other routes of administration for nauseous patients who do not tolerate oral medications. And if nausea is not controlled by one medication, try another in a different class. But “avoid medications in the same class, as you will increase the chances of side effects,” Dr. Chittenden says.
Steroids, which are considered the most potent antiemetics, should be the therapy of last resort. Because of side effects, the drugs should be used for only short periods in patients who still have many months to live. For significant nausea, schedule medications around the clock rather than as needed.
Dr. Chittenden also advises against using lorazepam for nausea control, except when anxiety or anticipatory nausea is significant. “Ativan is a poor antiemetic and shouldn’t be used first-line,” says Dr. Chittenden.
Treating dyspnea: difficult but do-able
Whether it occurs near the end of life or during a chronic illness, dyspnea can be tough to manage. But it’s a common symptom, with 70% of patients experiencing shortness of breath in the last six weeks of life.
Dr. Chittenden also notes that dyspnea is distressing to patients and their families. That’s why she advises treating it as aggressively as possible, within acceptable parameters.
Start with non-pharmacologic interventions. “Opening windows and using fans can help a lot,” she explains.
She also recommends identifying treatable factors, such as a persistent cough or secretions that might be exacerbating the dyspnea. In such cases, nebulizers, expectorants and cough suppressants can alleviate shortness of breath.
An anticholinergic can help reduce phlegm and make patients more comfortable, but there’s a tradeoff in terms of side effects: Some patients may be bothered by dry mouth, sleepiness or confusion. Dr. Chittenden often uses glycopyrrolate, which is less likely than other anticholinergics to cross the blood-brain barrier.
In certain late-stage chronic diseases such as COPD and CHF, oxygen and opioids are appropriate first-line remedies. Depending on the cause of the dyspnea, however, oxygen is not always needed.
“We tend to plunk everybody on oxygen,” she points out, adding that there’s a psychological component at play, with some people saying they feel better even when the nasal cannula are pointing at their cheek. “People may be short of breath even if the oxygen level in their bloodstream is OK.”
Goals of care
With intractable shortness of breath, it’s probably time to introduce morphine or another opioid for symptom relief. Give 1 to 2 mg of IV morphine every three to four hours if treating around the clock, Dr. Chittenden says, or every 20 to 30 minutes PRN. Titrate the dose upwards to achieve the desired level of comfort and relief.
But keep in mind that the best way to manage symptoms includes discussing care goals. Patients may feel very differently about certain symptoms, depending on their understanding of their illness and their values and goals.
Also plan to work through psychological issues that symptoms may trigger. When patients with nausea or dyspnea fear that they are dying and they haven’t been able to express these anxieties, addressing them may improve the symptoms themselves.
“There is a whole mind-body connection that we are only beginning to understand,” says Dr. Chittenden. Non-pharmacologic interventions, including guided imagery, meditation and acupuncture, can be very powerful tools. And if patients have accepted the fact that they’re dying and want to focus on comfort and quality of life, “you should be more aggressive about using opioids and other medications.”
But for patients who have CHF and possibly many years to live, hospitalists should use opioids more judiciously. “Start low and go slow,” she says, to avoid over-sedation and to allow patients to develop tolerance to side effects. When titrating opiates correctly, physicians shouldn’t be afraid of respiratory depression or addiction, two issues that haunt clinicians unnecessarily.
Finally, Dr. Chittenden says, hospitalists should discuss these issues with the primary care physician, whether or not there is an important change in treatment plan. “That,” she points out, “is just good practice.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Chadds Ford, Pa.