What is the approach to symptom management in Palliative and End-of-Life (PEM) care?

Comprehensive Approach to Symptom Management in Palliative and End-of-Life Care

The most effective approach to symptom management in palliative and end-of-life care requires a structured, medication-based protocol focused on addressing common refractory symptoms, with midazolam for sedation, levomepromazine for delirium, and opioids for pain and dyspnea as first-line agents, while providing comprehensive family support. 1

Core Principles of Symptom Management

Assessment and Monitoring

• Regular and systematic assessment of pain, dyspnea, and depression is essential for all patients with serious illness at the end of life 2
• Use validated symptom assessment scales when possible, with consideration for cognitive impairment that may limit patient self-reporting
• For non-communicative patients with weeks to days to live, assess using physical signs of distress 2
• Family members' assessments of symptoms, especially pain and anxiety, are generally helpful when patient self-reporting is limited 2

Pain Management

• First-line medications:
  • Opioids (particularly morphine) for moderate to severe pain
  • NSAIDs for mild to moderate pain
  • Bisphosphonates for bone pain in cancer patients 2
• For cancer-related pain, opioids can be titrated aggressively for adequate management 2
• Continue pre-existing pain medications unless adverse effects occur; do not reduce solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for symptom control 2

Dyspnea Management

• First identify and treat underlying causes when possible and appropriate (pleural effusion, cardiac fluid, etc.) 2
• Pharmacologic interventions:
  • Opioids are first-line for unrelieved dyspnea 2
  • Benzodiazepines (like midazolam) when dyspnea is associated with anxiety 2
  • Oxygen therapy for short-term relief of hypoxemia 2
• Non-pharmacologic interventions:
  • Positioning, airflow (fans), relaxation techniques
  • Therapeutic procedures for fluid management when appropriate 2

Delirium Management

• First-line: Antipsychotics (levomepromazine 12.5-25mg every 8h) 1
• Common pitfall: Mismanaging delirium with opioids or benzodiazepines as initial treatment, which can worsen symptoms 1
• Address reversible causes (medications, infection, dehydration, hypoxia)

Palliative Sedation for Refractory Symptoms

• Indicated for intolerable suffering from refractory symptoms despite optimal management
• Medication protocol:
  • Initial sedation with midazolam (starting dose 0.5-1 mg/h or 1-5 mg PRN) 1
  • If inadequate response, consider adding levomepromazine, phenobarbital, or propofol 1
  • Titrate to the least level necessary for adequate symptom relief 2
• Medications for symptom palliation used before sedation should be continued unless ineffective or causing distress 2

Special Considerations Based on Disease Trajectory

Patients with Months to Weeks to Live

• Focus shifts from prolonging life toward maintaining quality of life 2
• Consider discontinuation of anticancer treatment and offer best supportive care 2
• Provide guidance regarding anticipated course of disease 2
• Prepare for potential discontinuation of life-prolonging interventions 2

Patients with Weeks to Days to Live (Actively Dying)

• Should not receive anticancer therapy but intensive palliative care focusing on symptom control 2
• Route of administration changes: 94% of patients require subcutaneous route near death 1
• Opioid dose should not be reduced solely for decreased vital signs when necessary for symptom management 2
• For refractory symptoms, palliative sedation can be considered after consultation with specialists 2

Family Support and Communication

• Critical elements include:
  • Encouraging family presence with the patient 2
  • Providing reassurance about treatment decisions 2
  • Regular updates about the patient's condition 2
  • Offering post-death meeting to address grief and concerns 2
• Family should be informed that medications for symptom relief are unlikely to shorten the patient's life 2
• Periodic screening of caregivers for practical and emotional needs 2

Common Pitfalls and How to Avoid Them

1. Inadequate symptom assessment: Use systematic assessment tools and involve family observations when patient self-reporting is limited 2

2. Inappropriate opioid reduction: Do not reduce opioids solely for decreased vital signs when necessary for symptom control 2

3. Abrupt discontinuation of pain medications: When tapering opioids is necessary, reduce by no more than 10-25% of total daily dose to avoid withdrawal symptoms 3

4. Mismanaging delirium: Use antipsychotics first rather than opioids or benzodiazepines, which can worsen delirium 1

5. Inadequate family communication: Provide regular updates and reassurance about the care plan to reduce family distress 2

6. Describing palliative care as "giving up": Reframe as "fighting" for better quality of life 2

7. Failing to continue baseline pain medications: Pre-sedation symptom medications should be continued unless ineffective or causing distress 2

By implementing this structured approach to symptom management in palliative and end-of-life care, clinicians can significantly improve quality of life and reduce suffering for patients with advanced illness.