What are the non-pharmacological and pharmacological management strategies for patients requiring palliative care?

Palliative Care: Non-Pharmacological and Pharmacological Management Strategies

The most effective palliative care approach combines targeted non-pharmacological interventions with appropriate pharmacological management, tailored to the patient's estimated life expectancy and specific symptoms. 1

Assessment and General Approach

Based on Life Expectancy

• Years to live: Focus on disease-modifying treatments alongside symptom management
• Months to weeks: Transition to primarily symptom-focused care, consider discontinuing disease-modifying treatments
• Weeks to days: Intensify palliative interventions, discontinue non-essential medications, focus exclusively on comfort 1

Non-Pharmacological Management Strategies

Physical Symptom Management

• Dyspnea management:

  • Sitting upright
  • Hand-held fans directed at the face
  • Relaxation techniques and breathing exercises 1
  • Environmental modifications (cooler temperatures)
  • Stress management techniques 1

• Pain management:

  • Acupuncture
  • Physical therapy
  • Mindfulness-based stress reduction
  • Music therapy 1

• Edema/Fluid management:

  • Support stockings/leg elevation
  • Long-term in-dwelling drains for chronic pleural effusions and ascites 1

Environmental Interventions

• Create a safe, aesthetic, and pleasing environment 2
• Reduce excessive stimuli (noise, light)
• Ensure comfortable room temperature
• Provide familiar objects for comfort and orientation 1

Psychosocial and Spiritual Support

• Emotional support for patients and caregivers
• Educational interventions about disease progression and expected symptoms
• Spiritual care aligned with patient's beliefs
• Counseling for anticipatory grief 1
• Cognitive behavioral therapy for anxiety and depression 3

Communication and Advance Care Planning

• Discuss goals of care and treatment preferences early
• Complete advance directives and ensure availability across all care settings 1
• Determine preferred place of death 1
• Address family conflicts regarding goals of care 4

Pharmacological Management by Symptom

Dyspnea

• First-line: Morphine 2.5-10 mg PO q2h PRN or 1-3 mg IV q2h PRN 1
• For anxiety-associated dyspnea: Add benzodiazepines (lorazepam 0.5-1 mg PO q4h PRN) 1
• For excessive secretions: Scopolamine 0.4 mg subcutaneous q4h PRN or 1.5 mg patches 4
• Note: Oxygen therapy only beneficial for symptomatic hypoxia 1

Pain

• Mild pain: Acetaminophen/paracetamol 4
• Moderate-severe pain: Opioids (morphine as first-line) 1, 4
• Neuropathic pain: Add anticonvulsants or antidepressants 4
• Bone pain in cancer: Consider bisphosphonates 1

Depression

• Pharmacological: Tricyclic antidepressants, selective serotonin reuptake inhibitors 1
• Non-pharmacological: Psychosocial interventions 1
• For anorexia/depression: Consider mirtazapine 4

Delirium

• First reduce/eliminate delirium-inducing medications (steroids, anticholinergics)
• Moderate delirium: Oral haloperidol, risperidone, olanzapine, or quetiapine 1
• Severe delirium/agitation: Haloperidol, olanzapine, or chlorpromazine 1
• Refractory agitation: Add lorazepam to neuroleptics 1

Constipation

• Preventive: Increase fluids, dietary fiber (if appropriate)
• Treatment: Laxatives, stool softeners, methylnaltrexone (for opioid-induced constipation) 1

Nausea/Vomiting

• Metoclopramide (caution with QT prolongation)
• 5-HT3 antagonists (setrons)
• Promethazine, prochlorperazine 1, 4

Special Considerations for End-of-Life Care (Days to Hours)

Medication Management

• Route of administration: Transition from oral to subcutaneous route (94% of patients near death) 5
• Discontinue non-essential medications 4
• Increase doses of symptom-control medications as needed 1
• Consider opioid rotation if delirium is believed to be caused by neurotoxicity 1, 4

Nutrition and Hydration

• Focus on comfort rather than nutritional goals
• Educate family that absence of hunger/thirst is normal in dying patients 4

Family Support

• Provide emotional and spiritual support
• Educate about the dying process
• Address caregiver burden and grief 1

Common Pitfalls to Avoid

1. Delaying palliative care integration until the final days of life rather than introducing it early in disease trajectory
2. Focusing solely on pharmacological interventions without implementing non-pharmacological strategies
3. Avoiding opioids due to addiction concerns when they are essential for symptom control 4
4. Continuing medications that no longer benefit the patient or may cause harm
5. Neglecting psychosocial and spiritual needs of both patient and family
6. Failing to complete advance care planning early in the disease course 1

By implementing both non-pharmacological and pharmacological approaches based on the patient's specific symptoms and estimated life expectancy, palliative care can significantly improve quality of life and provide comfort during the end-of-life journey.