Symptom Management in Palliative Medicine

Abstract

Palliative care is an interdisciplinary specialty focused on providing comfort, communication, and support for patients, families, and professional caregivers throughout the course of a life-limiting illness. This chapter discusses assessment and treatment of symptoms and disorders that commonly contribute to patient distress during these illnesses: pain, disorders of the respiratory and gastrointestinal systems, skin disorders, hot flashes, fatigue, pruritis, insomnia, and delirium. This chapter reviews care of the imminently dying patient, discusses methods for assessing patients' symptoms, and provides two examples of valid and reliable symptom measurement systems: the Edmonton Symptom Assessment Scale and the Memorial Symptom Assessment Scale. Achieving symptom control requires the physician to assess patient suffering in all dimensions: physical, psychological, social, and spiritual. The extent of the assessment may be modified, however, based on patients’ prognosis as well as their goals and the burden and benefit of the diagnostic intervention. A 10-step protocol for terminal wean is presented. Signs that patients are entering their final days and symptom management in the last hours of a patient's life are discussed. Tables list the modified Edmonton Symptom Assessment Scale; the Memorial Symptom Assessment Scale; the DOLOPLUS-2 scale (behavioral pain assessment in the elderly); relative potencies of commonly used opioids; conversions between the transdermal fentanyl patch and morphine; symptomatic treatment for dyspnea, cough, and hiccups; pharmacologic treatment of nausea and vomiting; a progressive bowel regimen for patients receiving opioid therapy; treatments for constipation; etiology-based treatment for oral problems; risk factors for pressure ulcers; and applicable medications for physical and psychological sources of distress near the end of life. This chapter contains 12 tables, 120 references, 5 MCQs.