Symptom Control

Clinical Focus: Symptom Control in Serious Illness

Symptom control in hospice and palliative care focuses on relieving suffering and improving quality of life for patients with serious, life-limiting illnesses. Unlike curative care, the goal is aggressive symptom management while aligning interventions with patient goals. This topic is high-yield on certification exams (e.g., CEN, FNP, Hospice & Palliative Care Nursing) and critical for clinical practice, as unrelieved symptoms lead to distress, poor outcomes, and caregiver burnout^[1].

Recognizing Total Pain and Other Critical Symptom States

• Total Pain: A concept by Dame Cicely Saunders describing pain as physical, psychological, social, and spiritual^[2].
• Breakthrough Pain: Transient exacerbation of pain despite well-controlled baseline pain; often requires rapid-onset analgesics^[3].
• Dyspnea at End of Life: Subjective sensation of breathlessness; managed with opioids, oxygen, and non-pharmacologic measures^[4].
• Delirium: Acute fluctuating disturbance in attention and cognition; often multifactorial in terminally ill patients^[5].
• Terminal Secretions (“Death Rattle”): Gurgling sound due to saliva pooling in the oropharynx; managed with anticholinergics (e.g., glycopyrrolate) and repositioning^[6].

Structured Approach to Pain and Symptom Management

WHO Analgesic Ladder

The World Health Organization (WHO) three-step approach remains the foundation for cancer pain management^[7]:

1. Step 1 (Mild pain): Non-opioids ± adjuvants (e.g., acetaminophen, NSAIDs).
2. Step 2 (Moderate pain): Weak opioids ± non-opioids ± adjuvants (e.g., codeine, tramadol).
3. Step 3 (Severe pain): Strong opioids ± non-opioids ± adjuvants (e.g., morphine, hydromorphone, fentanyl).

Adjuvants include anticonvulsants for neuropathic pain, corticosteroids for inflammation or bone pain, and antidepressants^[8].

Total Symptom Management Approach

• Assess and document symptoms using validated tools (e.g., ESAS, MSAS, Pain Scale).
• Address physical, emotional, social, and spiritual domains.
• Use non-pharmacologic interventions (e.g., massage, music therapy, guided imagery).
• Involve interdisciplinary team (chaplain, social worker, pharmacist).

Frequently Encountered Symptoms and Their Indicators

• Pain: Often underreported in cognitively impaired patients; look for grimacing, guarding, or agitation^[9].
• Nausea & Vomiting: May be due to opioids, constipation, or metabolic changes; treat with antiemetics (metoclopramide, haloperidol, ondansetron).
• Constipation: Nearly universal with opioids; prevent with bowel regimen (senna, docusate, osmotic laxatives)^[10].
• Fatigue: Most common symptom in advanced illness; consider energy conservation, treat anemia, and address reversible causes.
• Anorexia/Cachexia: Consider appetite stimulants (megestrol acetate, corticosteroids) after discussing goals.
• Dyspnea: Opioids are first-line; oxygen only if hypoxic; consider fans, positioning, and benzodiazepines for anxiety.

Systematic Symptom Assessment Using Validated Tools

• Pain Assessment: Use “PQRST” mnemonic: Provoking/Palliating, Quality, Region/Radiation, Severity, Timing.
• Dyspnea Assessment: Rate severity (0–10); assess triggers, oxygenation, and patient distress.
• Delirium Assessment: Use Confusion Assessment Method (CAM) or CAM-ICU; rule out reversible causes (infection, opioids, dehydration).
• Functional Assessment: Palliative Performance Scale (PPS) or Karnofsky score helps predict prognosis and guide care.
• Psychosocial/Spiritual: Assess for existential distress, meaning-making, and grief; use open-ended questions.

Therapeutic Strategies: Pharmacologic and Non-Pharmacologic Approaches

Pharmacologic Management

All medications should be prescribed according to patient-specific goals of care and monitored for adverse effects.

Non-Pharmacologic Interventions

• Positioning (elevate head of bed for dyspnea, left lateral for nausea).
• Relaxation techniques, breathing exercises, guided imagery.
• Manual therapies (massage, gentle touch).
• Environmental modifications (soft lighting, calm music, family presence).

Mitigating Clinical Risks and Preventing Adverse Events

• Opioid-induced respiratory depression: Rare when titrated properly in opioid-tolerant patients; monitor respiratory rate and sedation level; have naloxone available but use only with extreme caution in hospice (may precipitate withdrawal and pain crisis)^[11].
• Falls risk: Sedation and weakness increase falls; use bed alarms, assistive devices, and non-pharmacologic aids.
• Skin breakdown: Immobility and poor nutrition cause pressure injuries; reposition every 2 hours, use specialty mattresses.
• Medication errors: Use one pharmacy, clear labeling, and avoid multiple opioid formulations; educate caregivers.

Essential Reminders for Certification Exams

• Remember the WHO ladder: Step 2 includes weak opioids; Step 3 includes strong opioids.
• Constipation prophylaxis: Always start bowel regimen when beginning opioids (except in days to hours before death).
• Dyspnea treatment: Morphine is first-line; oxygen only if hypoxic.
• Terminal secretions: Glycopyrrolate or scopolamine; avoid deep suctioning (causes trauma and distress).
• Delirium: Often reversible; haloperidol is preferred for agitation (but avoid in dysrhythmias).
• Hospice philosophy: Never initiate interventions that increase suffering; focus on comfort and dignity.
• Common exam scenario: Patient with end-stage COPD reports dyspnea 8/10; first action is to give low-dose morphine (not oxygen unless hypoxemic).

References

1. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 4th ed. 2018. https://www.nationalcoalitionhpc.org/ncp
2. Saunders CM. The philosophy of terminal care. In: Saunders CM, ed. The Management of Terminal Malignant Disease. 2nd ed. London: Edward Arnold; 1984:232–241. https://doi.org/10.1207/s15427587pco0101_3
3. Mercadante S, Portenoy RK. Breakthrough cancer pain: twenty-five years of study. Pain. 2016;157(2):288–296. https://doi.org/10.1097/j.pain.0000000000000421
4. Walsh D, Caraceni A, Fainsinger R, et al. Palliative Medicine. Philadelphia: Saunders; 2009. https://doi.org/10.1016/B978-1-4160-6095-4.00001-3
5. Breitbart W, Alici Y. Agitation and delirium at the end of life: “We can’t forget the truth.” J Clin Oncol. 2008;26(31):5018–5021. https://doi.org/10.1200/JCO.2008.18.0942
6. Bennett M, Maher K. Glycopyrrolate for the management of death rattle in the imminently dying: a systematic review. J Pain Symptom Manage. 2013;45(3):563–568. https://doi.org/10.1016/j.jpainsymman.2012.03.004
7. World Health Organization. WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents. Geneva: WHO; 2018. https://www.who.int/publications/i/item/9789241550390
8. Jordan KE, Hanson LC, Hickman SE, et al. Oxford Textbook of Palliative Medicine. 5th ed. Oxford: Oxford University Press; 2015. https://doi.org/10.1093/med/9780199656097.001.0001
9. Herr K, Coyne PJ, McCaffery M, et al. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Pain Manag Nurs. 2011;12(4):230–250. https://doi.org/10.1016/j.pmn.2011.10.002
10. Nee J, Zakari M, Sugarman MA, et al. Opioid-induced constipation: a review of current guidelines and a practical approach. Am J Med. 2018;131(11):1286–1295. https://doi.org/10.1016/j.amjmed.2018.06.027
11. Twycross R, Wilcock A, Howard P. Palliative Care Formulary. 6th ed. Nottingham: Palliativedrugs.com; 2018. https://www.palliativedrugs.com