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Primary care for the declining cancer survivor

The Journal of Family Practice. 2019 October;68(8):448-450,452-455
October 7, 2019|Journal of Clinical Outcomes Management
Michael J. Arnold, MD, FAAFP;Stella Hayes, MD;John F. Sullivan, DO
Author and Disclosure Information

Uniformed Services University of the Health Sciences (Dr. Arnold); Naval Hospital Jacksonville, Fla (Drs. Hayes and Sullivan)
michael.arnold@usuhs.edu

The authors reported no potential conflicts of interest relevant to this article.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States government.

Asking yourself 1 question can help you to estimate an advanced cancer patient’s prognosis and determine how best to help in setting end-of-life priorities.

PRACTICE RECOMMENDATIONS

› Implement palliative/ supportive care shortly after the diagnosis of an incurable cancer. A

› Candidly communicate prognoses to patients and help them adjust their goals of care. B

› Recommend hospice care for patients who likely have less than 6 months to live, especially with treatmentrelated complications or significant caregiver stress. B

› Delay opioid therapy— if possible—to better control symptoms near the end of life. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Delirium can be treated with antipsychotics; haloperidol has been most frequently studied.54 Antipsychotics are effective at reducing agitation but not at restoring cognition.55 Case reports suggest that use of atypical antipsychotics can be beneficial if adverse effects limit haloperidol dosing.56 Agitated delirium is the most frequent indication for palliative sedation.57

Dyspnea. In the last weeks, days, or hours of life, dyspnea is common and often distressing. Dyspnea appears to be multifactorial, worsened by poor control of secretions, airway hyperactivity, and lung pathologies.58 Intravenous hydration may unintentionally exacerbate dyspnea. Hospice providers generally discourage intravenous hydration because relative dehydration reduces terminal respiratory secretions (“death rattle”) and increases patient comfort.59

Honest conversations, with best- and worst-case scenarios, are important to patients and families and should occur while the patient is well enough to participate and set goals.

Some simple nonpharmacologic interventions have benefit. Oxygen is commonly employed, although multiple studies show no benefit over room air.59 Directing a handheld fan at the face does reduce dyspnea, likely by activation of the maxillary branch of the trigeminal nerve.60

 

Opioids effectively treat dyspnea near the end of life with oral and parenteral dosing, but the evidence does not support nebulized opioids.61 Opioid doses required to treat dyspnea are less than those for pain and do not cause significant respiratory depression.62 If a patient taking opioids experiences dyspnea, a 25% dose increase is recommended.63

Reversible causes of delirium include uncontrolled pain, medication adverse effects, and urinary and fecal retention.

Anticholinergic medications can improve excessive airway secretions associated with dyspnea. Glycopyrrolate causes less delirium because it does not cross the blood-brain barrier, while scopolamine patches have reduced anticholinergic adverse effects, but effects are delayed until 12 hours after patch placement.64 Atropine eye drops given sublingually were effective in a small study.65

Continue to: Palliative sedation

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