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Essentials of Palliative Care pp 107–135Cite as

Symptom Management

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Abstract

Advanced disease is associated with much suffering. Emotional, spiritual, and social pains are a significant component of this distress. Alleviation of physical discomforts allows patients to cope with other aspects of suffering. The common symptoms of pain, nausea, and vomiting, respiratory distress, cachexia, delirium, and insomnia readily respond to systematic treatment. The use of pharmacologic and nonpharmacologic tools is described in this chapter.

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Author information

Authors and Affiliations

  1. Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Angèle Ryan M.D.

Authors
  1. Angèle Ryan M.D.
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Corresponding author

Correspondence to Angèle Ryan M.D. .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, Yale University, New Haven, 06520, Connecticut, USA

    Nalini Vadivelu

  2. Citrus Road 278, River Ridge, 70123, Louisiana, USA

    Alan David Kaye

  3. Keck School of Medicine, Department of Anesthesiology, Pain Medic, of the University of Southern California, Los Angeles, 90035, California, USA

    Jack M. Berger

Appendices

Review Questions

  1. 1.

    Tolerance develops rapidly to all the following opioid side effects except:

    1. (a)

      Respiratory depression

    2. (b)

      Sedation

    3. (c)

      Dysphoria

    4. (d)

      Constipation

    5. (e)

      Nausea

  2. 2.

    All the following drugs provide antineuropathic benefit in the treatment of pain, with the exception of:

    1. (a)

      Tricyclic antidepressants

    2. (b)

      Nonsteroidal anti-inflammatory drugs (NSAIDs)

    3. (c)

      Serotonin norepinephrine reuptake inhibitors (SNRIs)

    4. (d)

      Anticonvulsants

    5. (e)

      Ketamine

  3. 3.

    Which of the following statements about dyspnea is true:

    1. (a)

      Nebulized opioids are an established treatment for this symptom

    2. (b)

      Emotional factors contribute to the severity of dyspnea

    3. (c)

      The extent of dyspnea is reliably measured by respiratory rate and arterial oxygenation

    4. (d)

      Anxiolytics may result in respiratory depression and should be avoided

    5. (e)

      Disease-modifying therapies are rarely beneficial in treating dyspnea

  4. 4.

    For the management of delirium in advanced disease, which of the following statements is false:

    1. (a)

      Aggressive use of benzodiazepines is required to treat the agitation typically associated with delirium

    2. (b)

      Review of medications is essential to assess for reversible causes

    3. (c)

      Periods of lucidity do not rule out the presence of delirium

    4. (d)

      Depression and pain behaviors may mimic the signs of delirium

    5. (e)

      The provision of supportive familiar surroundings is an effective treatment

  5. 5.

    Beneficial interventions for the treatment of symptoms associated with inoperable bowel obstruction include all the following except:

    1. (a)

      Somatostatin analog

    2. (b)

      Percutaneous gastric venting

    3. (c)

      Haloperidol

    4. (d)

      Corticosteroids

    5. (e)

      Parenteral nutrition

Answers

  1. 1.

    (d). This symptom remains throughout the treatment course, tolerance developing very slowly, if at all, thus requiring vigilance and treatment. The other side effects dissipate within several days.

  2. 2.

    (b). Although anti-inflammatory drugs provide significant co-analgesia in many pain states, the most commonly used agents for neuropathic pain include the antidepressants, N-methyl-d-aspartate (NMDA) antagonists such as ketamine, and anticonvulsants.

  3. 3.

    (b). Similar to the pain symptom, dyspnea is accompanied by fear and apprehension regarding physical discomfort as well as the prognostic implications. Anxiolytics are an important tool for alleviating the distress. Although nebulized drugs are used in limited circumstances, the mainstay of pharmacological treatment is systemic opioids. Since this is a subjective symptom, external measures are of little value in assessing dyspnea. Correction of any underlying pathology is beneficial in alleviating the symptom burden.

  4. 4.

    (a). Although agitation is a component of the hyperactive category of delirium, benzodiazepines, when used alone, may aggravate delirium. Review of medications is important as drugs are a reversible etiology of this symptom. The variable course of delirium which includes periods of lucidity and signs that mimic other disease states (e.g., depression, pain) should be considered when making the diagnosis of delirium. Nonpharmacologic modalities are an important component of therapy.

  5. 5.

    (e). The goal of treatment in this condition is to reduce the symptoms caused by increased secretions and motility in the gut. Artificial nutrition adds to the metabolic and fluid load and worsens symptoms. The other choices are all valid for treatment of the associated nausea.

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Ryan, A. (2013). Symptom Management. In: Vadivelu, N., Kaye, A., Berger, J. (eds) Essentials of Palliative Care. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-5164-8_7

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