Management of Other Symptoms Seen in Palliative Care

Introduction

As you have seen throughout previous chapters of this module, the management of the symptoms associated with the condition for which a patient is receiving palliative care is an essential consideration for nurses working in palliative care settings. In previous chapters of this module, you studied in detail the management of two of the most common symptoms which occur in the palliative care setting - dyspnoea and pain; you should revise these chapters now, if required. In this chapter, you will study the types, causes and management of other common problems in the palliative care setting - including gastrointestinal symptoms, anxiety / depression / delirium, fatigue / weakness and skin problems. In completing this chapter, you will be further equipped with the skills and knowledge necessary to provide high-quality palliative care to patients with a variety of life-limiting conditions.

Important note

This chapter assumes a basic knowledge of human anatomy and physiology. If you feel you need to revise these concepts, you are encouraged to consult a quality nursing textbook.

Management of gastrointestinal symptoms in the palliative care setting

As you have seen throughout previous chapters of this module, people receiving palliative care can experience a range of significant gastrointestinal symptoms. These may be related directly to the person's condition, or underpinned by the medications they are receiving. Consider the following case study:

As highlighted above, people receiving palliative care can experience a range of significant gastrointestinal symptoms. These symptoms, and their management in the palliative care setting, are described in detail following:

• Nausea and vomiting: these are particularly unpleasant gastrointestinal symptoms, and are often described by patients in the palliative care setting as more disabling even than pain. They may have a range of uncomfortable associated effects, including excessive salivation, perspiration, tachycardia, epigastric pain, early satiety, flatulence, acid reflux and hiccup. Research suggests that up to 70% of patients in general palliative care settings may experience nausea and / or vomiting; these symptoms are typically associated with the administration of chemotherapeutic and other medications (e.g. opioids, some non-steroidal anti-inflammatory medications [NSAIDS], some antibiotics, some corticosteroids, etc.), patients with organ failure (particularly of the liver and / or kidney/s), patients with disruption to the vestibular centre in the brain (e.g. due to brain tumours, or other conditions resulting in increased intracranial pressure), patients with HIV/AIDS, and patients experiencing high levels of anxiety. The management of nausea and vomiting in the palliative care setting depends on the cause of these conditions.

Pharmacological interventions are particularly effective in managing and relieving nausea and / or vomiting; review the information in the following table:

Anti-emetic Medication	Use
Haloperidol	For nausea and vomiting induced by opioids and other chemicals, and when anxiety aggravates gastrointestinal symptoms.
Metoclopramide	For nausea and vomiting caused by gastric stasis, ileus and chemotherapy; use with caution in patients with cardiac problems.
Phenothiazines (e.g. chlorpromazine)	For nausea and vomiting caused by intestinal obstruction, peritoneal irritation, vestibular problems, raised intracranial pressure, and where the aetiology of gastrointestinal symptoms are unknown.
Scopolamine	For nausea and vomiting caused by intestinal obstruction, peritoneal irritation and raised intracranial pressure.
5-HT3 receptor antagonists	For nausea and vomiting caused by chemotherapy, radiation and post-operatively; is often combined with dexamethasone.
Antihistamines	For use in nausea and vomiting caused by intestinal obstruction, peritoneal irritation, vestibular problems and raised intracranial pressure; may have a mild sedative effect.

There are also a range of non-pharmacological and complementary therapies which may be used in the management of nausea and vomiting in the palliative care setting. These include self-care strategies such as dietary changes (e.g. drinking clear liquids and eating bland foods, etc.) and environmental changes. Maintaining a log of symptoms, interventions and responses can help patients in palliative care settings be proactive in managing their nausea, vomiting and associated symptoms.

• Dysphagia (difficulty swallowing): this is particularly common in patients with head and neck cancer, and conditions affecting muscular function (e.g. late-stage multiple sclerosis, amyotrophic lateral sclerosis, Parkinson's disease, etc.). A patient with dysphagia is at significant risk of aspiration, which can result in complicated respiratory conditions such as pneumonia, and it may predispose the person to other distressing problems such as choking. The management of dysphagia depends on each individual patient's prognosis. If the patient has a short prognosis (i.e. days), nutrition and hydration may be withheld if this is consistent with the wishes of the patient and their family / carers / significant others (as relevant). For patients with a longer diagnosis, behavioural interventions (e.g. taking time to chew food, avoiding 'pocketing' food in the cheeks, sitting upright with the head tilted forward when eating, etc.) and nutrition interventions (e.g. serving of pureed foods, thickened fluids, etc.) may be used. A nasogastric tube or percutaneous endoscopic gastronomy (PEG) may be used to facilitate administration of nutrition and hydration. The involvement of allied health professionals, including dieticians and speech pathologists, is recommended.
• Constipation: this is often due to bowel obstruction, adverse medication side-effects, hypercalcaemia, dehydration and inadequate dietary intake. Constipation must be prevented, wherever possible, by managing these factors. However, if it does occur, oral aperients (usually a combination of a stimulant laxative with a stool softener) are usually very effective in resolving the problem. There are a number of different types of oral aperients which may be used in the palliative care setting:

Aperient Medication	Action
Lubricant softeners (e.g. mineral oil)	Prevents the absorption of water from the stool into the bowel.
Bulk-forming laxatives (e.g. methylcellulose, psyllium, etc.)	Resists the breakdown of stool by bacteria; increases the bulk of the stool and shortens transit time through the bowel.
Emollient softeners (e.g. docusate sodium, etc.)	Increases the penetration of water into the stool.
Osmotic laxatives (e.g. lactulose, sorbitol, etc.)	Creates and osmotic gradient in the intestine.
Saline laxatives (e.g. magnesium citrate, sodium bisphosphate, etc.)	Creates and osmotic gradient in the intestine.
Stimulant laxatives (e.g. senna, bisacodyl, etc.)	Stimulates the submucosal nerve plexus to increase gastrointestinal motility.

• Diarrhoea: diarrhoea may be a result of a hypermotile gastrointestinal system, a secondary complication of problems such as bowel obstruction or gastrointestinal infection, or medication side-effects (particularly with chemotherapy). Pharmacological interventions, including antidiarrhoeals such as loperamide, are often effective. The management of diarrhoea also involves nutrition interventions (e.g. drinking clear liquids, eating bland foods, and omitting foods that are lactose-containing, spicy and / or rich in fat). Managing dehydration and electrolyte imbalances in a patient with diarrhoea is an important consideration for nurses working in palliative care settings.
• Xerostomia (dry mouth): this is usually due to a reduction in salivary production, often because of radiotherapy, oral surgery, gland obstruction and / or neurological problems. It may also be a side-effect of some medications (e.g. anticholinergics, anticonvulsants, antidepressants, antihistamines, corticosteroids, opioid analgesics, NSAIDS, calcium channel blockers, beta [β] blockers, diuretics, etc.). Xerostomia is usually managed by addressing the cause, where possible, including by reviewing and altering medications. Other interventions, including maintaining frequent oral hygiene, humidifying air, and using products such as peppermint water, sugarless gum or mild citric acids, can all be effective in reducing xerostomia.

Management of anxiety, depression and delirium in the palliative care setting

Patients receiving palliative care are at significant risk of a variety of complex psychiatric and neurological problems - including, but not limited to, anxiety, depression and delirium. Occasionally, these are a result of the patient's disease process; more often, however, they develop due to the difficult social and emotional situation in which patients receiving palliative care often find themselves. Consider the following case study:

The management of anxiety, depression and delirium are described in detail in the following section of the chapter:

• Anxiety: this is defined as feelings of distress or tension, disproportionate to the situation or without a clear cause. Anxiety may also be triggered by poorly-managed pain, endocrine disorders, cardiovascular and respiratory conditions (particularly those resulting in hypoxia), and / or neurological conditions. It results in a variety of physical, affective, behavioural and cognitive responses:

Physical Symptoms	Affective Symptoms
Tachycardia, tachypnoea. Diaphoresis, tremors. Light-headedness.	Nervous or restless behaviours (e.g. picking, pacing, frequent movement, etc.).
Behavioural Symptoms	Cognitive Symptoms
Avoidance of situations. Compulsions.	Edginess, worry, panic. Thoughts of self-injury, etc.

Anxiety is generally managed using pharmacological interventions - specifically, anti-anxiolytics such as benzodiazepines, tricyclic agents, selective serotonin reuptake inhibitors (SSRIs), etc. Nurses working in palliative care settings can have a significant positive impact on a person's anxiety by helping them to acknowledge their fears, learn and make decisions about their management options, and maintain control and autonomy to the degree they choose, etc. Avoidance of caffeine, maintaining healthy activity / rest cycles, and stress management techniques (e.g. breathing exercises, relaxation strategies, music therapy, guided imagery, distraction etc.) can also be useful in managing anxiety. Psychotherapy, including counselling, may also be beneficial.

• Depression: this is the experience of prolonged, unrelieved melancholy, often accompanied by physical symptoms (e.g. changes in sleep patterns and appetite, fatigue, cognitive dysfunction, etc.). Patients receiving palliative care who are at particular risk of depression include those who have experienced previous psychiatric illness, those with a family history of psychiatric illness, those with distressing symptoms such as pain, delirium, fatigue, those with poor social support, and those with advanced illness. Management of depression focuses on the use of antidepressant medications, including psychostimulants, tricyclic antidepressants and SSRIs. Non-pharmacological interventions such as psychotherapy, music and pet therapy, and group activities can also be useful for patients experiencing depression in the palliative care setting.
• Delirium: this is an acute disturbance of consciousness affecting a person's cognition, arousal and attention, and often causing confusion and / or agitation. It is very common in the last weeks of life in particular; indeed, up to 90% of all terminally ill patients may experience some degree of delirium. Patients with diseases that affect their neurological processes, who are receiving chemotherapy and / or radiotherapy, who have uncontrolled pain, who take multiple medications and / or who are withdrawing from medications, who experience metabolic fluctuations, organ failure, infection, nutritional deficiencies, and who have a history of psychiatric illness are at particular risk of delirium in palliative care settings.

Delirium often occurs progressively, beginning with non-specific symptoms such as withdrawal, irritability, new forgetfulness and incontinence, and developing into outbursts of anger, agitation, restlessness and psychosis. Patients are alternately hypoactive and hyperactive, with the hyperactive form being the most severe. The pathophysiology of delirium is poorly-understood; therefore, its management is complex. The causes of delirium, where identified, should be eliminated to the greatest extent possible. Various medications, alone and in combination - including neuroleptics (e.g. haloperidol, chlorpromazine, etc.), benzodiazepines (e.g. lorazepam, midazolam, etc.), and anaesthetics (e.g. propofol) - may all be used in the management of delirium. Activity pacing and maintaining healthy activity / rest cycles can also be useful in the management of delirium in some people.

Management of fatigue and weakness in the palliative care setting

Fatigue is a very common experience for people receiving palliative care. It is particularly common in people with conditions such as cancer, chronic pain, multiple sclerosis and primary biliary cirrhosis, and it is also associated with infection, fever, tissue injury, anaemia, hypoxia, malnutrition and depression - but it may ultimately occur in patients with any terminal illness. Fatigue affects a patient's interactions with others, their self-perception, their sense of hopefulness and their ability to function. Consider the following case study:

It is important for nurses working in palliative care settings to realise that fatigue does not occur in a 'vacuum'; rather, it is usually associated with other conditions and complications. In particular, fatigue is associated with a decrease in both physical and cognitive performance and capacity. Most patients experience fatigue and weakness concurrently, however fatigued patients in palliative care settings generally experience a number of other associated symptoms. Like pain, fatigue is a highly subjective experience - essentially, it is what the patient experiencing it says it is. Also, as with pain, fatigue is an unpleasant experience.

It is also important for palliative care nurses to make a distinction between 'normal' fatigue (i.e. that which is experienced by healthy people), and that which is experienced by patients receiving palliative care. Healthy people regularly experience some degree of fatigue; however, these people usually recover from fatigue after a period of rest. Patients receiving palliative care may not readily recover from fatigue; furthermore, this fatigue has a more significant severity, duration and impact than 'normal' fatigue.

Fatigue may be classified into one of three different types:

• Acute (physiologic) fatigue: this is fatigue which generally occurs in healthy individuals, and is usually linked to a single cause (e.g. exercise, exertion, lack of sleep, etc.). Acute fatigue has a rapid onset and a short duration; it is typically alleviated by rest, healthy diet, gentle exercise and stress management, etc.
• Chronic fatigue: this is pathological fatigue which lasts longer than 6 months and has no known physiologic purpose (i.e. it generally occurs without a correlation to exertion or activity). It is not relieved by any of the strategies listed above, and may have a significant negative impact on a person's capacity to perform activities of daily living and their quality of life. Where this type of fatigue is accompanied by comorbidities such as impaired cognitive dysfunction and psychological problems (e.g. depression, irritability, mood swings, anxiety, panic attacks, etc.), the person may be diagnosed with chronic fatigue syndrome.
• Secondary fatigue: this is fatigue which occurs when the body's reserves of energy become depleted due to the presence of chronic disease (often cancer). Secondary fatigue occurs following many of the different treatments for cancer (e.g. surgery, radiation therapy, chemotherapy, etc.). It is also often associated with conditions such as severe weakness, malnutrition, anaemia and cachexia.

In the palliative care setting, the goal of fatigue management is to relieve the fatigue to the greatest extent possible, and in doing so improve the patient's quality of life. However, fatigue can rarely be completely relieved; therefore, nurses working in palliative care settings must assist patients to learn to cope with their fatigue. This may involve:

• Teaching energy conservation strategies (e.g. activity pacing, taking extra rest periods, seeking assistance for key activities, etc.). Nurses may help patients to think about energy using a 'bank account' analogy, which may be depleted by activity and must be replenished by rest.
• Keeping a daily journal, to identify factors associated with energy depletion and restoration. This can assist people to better manage their experience of fatigue.
• Gentle exercise, within the patient's capacity and tolerance (provided the patient is not exhausted). Often, a gentle walk outdoors is beneficial. Rather than depleting a patient's energy reserves, this type of exercise often reduces fatigue; it may also promote feelings of increased physical and psychological wellbeing. The involvement of allied health professionals, including physiotherapists and occupational therapists, is recommended.
• Managing a patient's nutritional status. Eating frequent, small meals comprised of high-glycaemic index foods can provide a person with a regular, steady supply of energy. A patient's nutritional needs, particularly in relation to protein and fat, should be assessed and managed. Sugars, which often provide a person with a short 'boost' of energy, are ultimately detrimental and should be avoided. A patient with fatigue should be assessed for nutritional deficiencies, particularly for iron, folate and Vitamin B₁₂.

There are also a variety of medications which may be prescribed to a patient experiencing fatigue. For example, a patient experiencing fatigue may be prescribed medications to treat the underlying problems causing the fatigue (if known), medications to treat proinflammatory cytokines (e.g. tumour necrosis factor), corticosteroids (which can improve appetite and elevate mood), psychostimulants and / or antidepressants. However, it is important for nurses working in palliative care settings to remember that fatigue is often underpinned by the use of medications; therefore, the administration of additional medications to manage fatigue should be done with caution.

Management of skin problems in the palliative care setting

Patients receiving palliative care may experience one or more of a number of common skin problems - including, but not limited to:

• Pressure ulcers: these occur when there is unrelieved pressure on an area of the body, resulting in progressive tissue ischaemia and necrosis. They typically appear on the skin overlying the bony prominences of the body, including the sacrum. They are staged (from Stage I to State IV, in ascending severity) according to their size, depth and level of tissue involvement.

It is important for nurses working in palliative care settings to realise that pressure ulcers are a completely preventable condition. A person's risk of developing one (or more) may be limited by strategies such as:

• Regular bathing in warm (not hot) water, using only mild soaps.
• Using gentle moisturisers to treat dry skin.
• Avoiding low-humidity environments (e.g. harsh air-conditioning).
• Proactively managing incontinence.
• Regular turning and repositioning (at least every 2 hours).
• Use of positioning devices, including pillows where required.
• Using lifting devices (e.g. hoists) when assisting a patient to mobilise.
• Assisting a patient to do range-of-motion exercises.

If a patient receiving palliative care does develop a pressure ulcer, it must be proactively managed to promote its healing, where possible, and at least prevent its worsening. This involves using a variety of dressings - including one or more of film, hydrogel, hydrocolloid, calcium alginate, foam, negative pressure and antimicrobial dressings. Management of the acute pain associated with a pressure ulcer is also an important consideration; this may be achieved using pharmacological interventions, as well as pressure-relieving devices (e.g. special cushions, mattresses, beds, etc.).

• Skin tears: these are acute wounds which occur when a patient's fragile skin 'tears' when shearing pressures are applied. The majority of skin tears occur in the upper extremities, particularly on the hands and forearms. As with pressure ulcers, skin tears can be prevented using a variety of techniques:
  • The use of soaps which help to maintain the skin's natural pH.
  • Patting, rather than rubbing, the patient's skin dry.
  • The use of proper positioning, turning, lifting and transferring techniques.
  • Encouraging the patient to wear long sleeves for protection.
  • Padding bed rails, wheelchair arms and leg supports, etc.
  • Using non-adherent tapes and dressings on frail skin.
  • Using gauze around drains, catheters, etc.

If a patient receiving palliative care does receive a skin tear, it must be proactively managed to promote its healing, where possible. The wound should be protected using non-adherent tapes and dressings; an arrow should be placed on the dressing to indicate the direction of the skin tear, and to minimise any further skin injury when the dressing is removed. Pain relief is an important consideration.

• Ostomy-related skin injury: this occurs when the skin around an ostomy site breaks down, often due to an 'incontinent ostomy' (i.e. one which leaks fluid). Common signs include erythema, maceration, ulceration and denudation in the region of an ostomy. Once again, ostomy-related skin injury can be prevented by techniques to maintain peristomal skin integrity, including using a correct ostomy system for the patient (e.g. well-fitting pouches, etc.), gently removing adhesive ostomy barriers, using barrier creams / powders and skin sealants, and avoiding unnecessary touching of the stoma site. If an ostomy-related skin injury does occur, it should be managed using the standard nursing skin-care strategies described in this chapter.
• Fistulas: these are abnormal openings in the tissue between two organs, or between an organ and the skin; they are typically associated with malignancies and obstructions, radiation, Crohn's disease, and postoperative adhesions. Fistulas are often chronically infected, and can be very difficult to prevent and manage. Often, complex pouching and drainage systems, usually involving negative pressure, are used. Promoting the comfort of the patient, both in terms of pain relief and exudate, is a key consideration for nurses.
• Malignant wounds: these are wounds which occur when cancerous cells, often metastases from a primary cancer, infiltrate and erode through the skin. They are particularly common in patients with primary cancers of the breast, head and neck and genital region, however they may also occur as a primary cancer (e.g. due to a melanoma). It is estimated that around 5% of patients with metastatic cancer will develop a malignant skin wound.

There are five key strategies in the management of malignant wounds:

1. Controlling the growth of the cancer - this is achieved using typical therapies such as radiotherapy, surgery, chemotherapy, topical laser therapy and hormone treatment, depending on the type of cancer a person has been diagnosed with.
2. Controlling malodour associated with the wound - malignant wounds are typically necrotic, fungating and very malodorous. Occlusive dressings and charcoal pads can be used to control the odour associated with the wounds. The interdisciplinary team should also consider antibiotic therapy and de-sloughing the wound. Using air-freshening and aromatherapy products may also be beneficial.
3. Controlling pain associated with the wound - as you saw in a previous chapter of this module, pain may be controlled through a combination of pharmacological and non-pharmacological interventions.
4. Controlling exudate associated with the wound - this involves using highly-absorbent dressings and pads which occlude the wound, where possible. Heavily-exudating wounds may require negative pressure wound drainage systems and / or radiotherapy. Protection of the skin surrounding a heavily-exudating wound to prevent its maceration, and the subsequent spread of the wound, is an important consideration for nurses working in palliative care settings.
5. Controlling the bleeding associated with the wound - it is important to note that malignant wounds are often comprised of very friable tissue, which bleeds easily and significantly. Padded dressings which allow the application of pressure to the wound, and haemostatic dressings, are important considerations. Special gauze soaked in adrenaline (which promotes vasoconstriction), silver sulphadiazine / sucralfate paste and radiotherapy may be considered for wounds which bleed heavily. It is important for nurses working in palliative care settings to note that if a cancer infiltrates a major vessel, a patient may haemorrhage rapidly and uncontrollably, causing their sudden death; the patient, their family / carers / significant others, and those involved in their care should be warned of this possibility, where appropriate.

Other skin injuries, including an incontinence-related skin injury: these are common skin injuries which, although originating from different causes, typically result in regional skin maceration. These conditions should be managed using the standard nursing skin-care strategies described in this chapter. Controlling bleeding in friable areas of the wound, odour management and the management of exudate are particularly important considerations.

It is important for nurses working in palliative care settings to realise that skin problems - particularly those which are large, have high levels of exudate and / or odour, and / or are painful - can have significant psychological impacts on patients. Patients may be fearful of or repulsed by their wounds. Consider the following case study:

Psychological support strategies, as described throughout this chapter of the module, are key considerations for patients with skin problems.

Conclusion

Remember: the management of the symptoms associated with the condition for which a patient is receiving palliative care is an essential consideration for nurses working in palliative care settings. In previous chapters of this module, you studied in detail the management of two of the most common symptoms which occur in the palliative care setting - dyspnoea and pain. In this chapter, you have studied the types, causes and management of other common problems in the palliative care setting - including gastrointestinal symptoms, anxiety / depression / delirium, fatigue / weakness and skin problems. In completing this chapter, you are now further equipped with the skills and knowledge necessary to provide high-quality palliative care to patients with a variety of life-limiting conditions.

Reference list

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Radbruch, L, Strasser, F, Elsner, F, Ferraz Goncalves, J, Loge, J, Kaasa, S, Nauck, F & Stone, P (2008) Fatigue in palliative care patients: An EAPC approach, Palliative Medicine, vol. 22, no. 1, pp. 13-32.