Question

Case Study Scenario:

Location: Oncology Unit

History/Information: The patient is a 56 year old female with a history of ovarian cancer diagnosed 4 years ago and treated with surgery and chemotherapy. The patient was found to be BRCA1 positive at the time of her surgery – her tumor was graded as IIIB. Eighteen months ago, the patient found a lump in her right breast which was biopsied and found to be malignant. She underwent a lumpectomy, followed by chemotherapy and radiation. Two months ago the patient started to experience pain in her hips, back and shoulders, a feeling of loosing her balance at times and RUQ abdominal discomfort. A medical workup revealed extensive metastatic disease in her bones, brain and liver. The medical team determined that further treatment would be futile. The patient is married with two children who live out of state. Her daughter is single and frequently travels for business. Her son is married with two small children. The daughter and son have visited three times since the patient’s symptoms began two months ago – the daughter is currently at the bedside. Advance directives have been signed by the patient who has chosen to be a DNR and who has named her spouse as her healthcare surrogate decision maker. It has been fi ve days since the patient was admitted to the Oncology Unit – on admission she presented with signifi cant dyspnea and malignant ascites. An abdominal paracentesis was performed with 3000 mL of fl uid removed. Over the past fi ve days, the patient’s abdomen has again become distended and tight and a fl uid wave is evident on assessment. Because of the patient’s dyspnea and general discomfort, she has decided to stay in the acute care setting and is refusing admission to Hospice. She is using oxygen at 2 LPM per nasal cannula and has a Foley catheter and an IV in place. She has been on a regular diet since admission but is unable to eat due to nausea and vomiting. Healthcare Provider’s Orders: Foley catheter as needed for urinary retention or patient comfort Oxygen at 2 LPM per cannula then titrated as needed for dyspnea IV D5/0.45% NaCl at 50 mL/hour Morphine Sulfate 10 mg IV every 4 hours around the clock Morphine Sulfate 1 to 6 mg IV every 1 hour as needed for break through pain/dyspnea Lorazepam 0.5 to 1 mg IV every 4 hours as needed for anxiety/nausea/seizures Haloperadol 0.5 to 1 mg SC every 4 hours as needed for agitation/nausea Acetaminophen 650 mg rectal suppository every 4 hours for pain/fever Hyoscyamine tablet 0.125 to 0.25 mg sublingual every 4 hours as needed to control excess secretions Docusate 50 mg/Senna 8.6 mg (Senokot-S®) one capsule orally twice a day. Hold if diarrhea Laxative, suppository or enema of choice as needed for constipation Activity as tolerated with assistance Mouth care every 2 hours when awake – soft foam, lemon or glycerin swabs

Discuss how pain, agitation, anxiety, and dyspnea are identified and manged in the increasingly less responsive patient at end-of-life

Answer 1

Health care professionals should be proficient in managing the symptoms of end of life care. As the disease progresses, opiates medication is increased to relieve pain and provide comfort. Various measures should be taken to manage end-of-life care.

Pain:

Pain is one of the important symptoms faced by the patient at the end of life care. Health care professionals should recognize the patient's pain and its impact on physical and psychological distress. opiates are the best choice in treating of aggravating pain. Pain should be rated using a behavioral scale. The analgesic technique should be followed based on the protocol by the palliative care physician to keep pain under control.

Agitation:

Agitation is common at the end of life. It is essential to find the exact cause for agitation and to assess the adverse effects of drugs, sedation, delirium. Assess the patient's risk associated with agitation and minimize complications and injury. Avoid dehydration, nutritional deficiencies, hypoxia, renal failure, to minimize agitation. Use physical restraints if needed. benzodiazepines are effective for agitation than lorazepam.

Anxiety:

Anxiety increases with the progress of the disease. Provide adequate psychological support to reduce stress on the patient. Make spiritual distress and support on the patient to cope up with the disease. Make family members to be involved in the daily care of the patient.

Dyspnea:

Dyspnea caused due to poor lung and cardiac function at the end of life. Patient breathing patterns and types should be included in the clinical assessment. Administer opiates to reduce respiratory complications. Make the patient at an awake state. Avoid pleural effusion and buildup of fluid mass. Treating adequately the shortness of breath help to improve the quality of life.