Palliative Care and Pain Management at the End of Life ___________________________________________
Prevalence The prevalence of diarrhea among adults with life-limiting disease varies widely, ranging from 3% to 90%, with the highest rates reported among people with HIV infection or AIDS [211]. Etiology The most frequent cause of diarrhea in patients receiving pal- liative care is overuse of laxatives and leakage around a fecal impaction [360]. Other common causes include infectious enteritis if acute onset or fever, and impact of underlying disease in people with HIV/AIDS or metastatic colorectal cancer. Diarrhea is also a side effect of many drugs, includ- ing antihypertensives, antacids containing magnesium, some NSAIDs, potassium supplements, quinidine, thiazide diuret- ics, retroviral agents, prokinetic agents (metoclopramide), and antibiotics [310; 360]. Prevention No appropriate measures to prevent diarrhea are available. Assessment A detailed history is the cornerstone of assessing patients for diarrhea. The condition is distressful, yet embarrassing, and direct questions should be asked because the patient may not be forthcoming about the symptom. The clinician should ask the patient about the onset of diarrhea, dietary habits, food intolerances, timing of diarrhea in relation to eating, and medications [360; 361]. The patient should also describe bowel movements in terms of frequency, color, and consistency. If possible, a stool specimen should be evaluated. If infectious diarrhea is suspected, a stool sample for culture and toxin assay should be evaluated to identify the causative organism [361; 362]. Screening (stool antigen assay) for Clos- tridioides difficile enterocolitis should always be considered if diarrhea is indolent, unremitting, or recurrent, even if a history of recent antibiotic use is not obvious, as the screening test is simple and the treatment definitive. Management The American Gastroenterological Association developed guidelines for the treatment of chronic disease in the general clinical setting, but no specific guidelines are available for the management of diarrhea in palliative care [362]. Treatment of an underlying condition is the optimal approach to managing diarrhea. The clinician should review the medica- tion list and discontinue or reduce the dose of any medication that may be the cause [360; 361]. Nonpharmacologic approaches to managing diarrhea include avoiding gas-forming and bulky foods, hot spices, fats, alcohol, and milk until diarrhea is controlled. The patient should be encouraged to drink plenty of fluids to avoid dehydration; beverages with added electrolytes, such as sports drinks, can help maintain proper electrolyte balance.
Pharmacologic management includes the use of bulk-forming agents, adsorbents, and opioids [361]. Kaolin and pectin (Kaopectate), available over the counter, is a combination of adsorbent and bulk-forming agents. However, it provides modest relief and it may take up to 48 hours to be effective [361]. Loperamide (Imodium) is the drug of choice for diarrhea because its side effect profile is better than that for codeine or diphenoxylate (Lomotil) [361]. The initial dose of loperamide is 4 mg, with an additional 2 mg after each loose stool [361]. The package insert for loperamide notes that the maximum daily dose in a 24-hour period is 16 mg, but doses of up to 54 mg a day have been used as part of palliative care with few adverse events [361]. Octreotide has been effective for profuse secretory diarrhea associated with HIV infection and can be used to treat refractory diarrhea [361]. The use of octreotide for diarrhea in the palliative setting is usually off-label, as the drug is FDA approved for the treatment of diarrhea and flushing associated with metastatic carcinoid tumors [247]. Octreotide is administered as a continuous subcutaneous infusion at a rate of 10–80 mcg/hr until improvement of symptoms [361]. Infectious diarrhea should be treated with an appropriate antibiotic. A systematic review found probiotic agents to be of benefit in the management of acute infectious diarrhea [363]. An update to that review could not confirm whether probiotic agents reduce the duration of diarrhea [364]. INSOMNIA As defined, insomnia refers to a variety of sleep disturbances, including difficulty falling asleep and difficulty staying asleep (insufficient amount of sleep or frequent awakenings), that results in impaired function during the day [365]. The most frequent type of insomnia among people at the end of life is difficulty staying asleep, primarily because of pain [366]. A lack of sufficient sleep affects the quality of life by contribut- ing to daytime fatigue and weakness, exacerbating pain, and increasing the potential for depression. Family members also become distressed when the patient is unable to sleep, which, in turn, may increase the burden on caregivers. Prevalence Insomnia is common among the general population, and rates reported for adults with life-limiting disease are even higher, ranging from 9% to 83% [201; 207; 211; 367]. The highest rates have been found among patients with end-stage renal disease [211]. Etiology The primary difference between insomnia in the general popu- lation and in people with life-limiting diseases is that insomnia in the latter group is usually secondary to the life-limiting disease or its symptoms [366]. Overall, uncontrolled pain is the most common contributor to the inability to sleep well [366; 367]. Other common physical symptoms such as dyspnea, nocturnal hypoxia, nausea and vomiting, pruritus, and hot flashes are also causes of insomnia. Restless legs syndrome may be a substantial contributor to the disruption of sleep among persons with end-stage renal disease [210; 310; 368; 369].
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MDCA1525
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