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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 10: Common Physical Symptoms
    Specific Symptoms

     
    Breathlessness (Dyspnea)
    Nausea and Vomiting
    Constipation
    Diarrhea
    Anorexia/Cachexia Fatigue/Weakness
    Fluid Balance/Edema
    Skin
    Odors
    Insomnia

    Anorexia/Cachexia

    Case Example

    MC is a 53-year-old obstetrician with widely metastatic breast cancer to bone, liver, and lung. Her disease is slowly progressive despite chemotherapy and hormonal therapy. She has lost 60 pounds in the past 4 months, and complains of a poor appetite.

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    Definition/Description

    • Anorexia (loss of appetite)
    • Cachexia (loss of weight)
    • Frequently accompanied by generalized fatigue (asthenia)
    • Occur in many illnesses, particularly in advanced disease process
    • Wasting syndromes often seen with malignancies, heart and pulmonary disease, renal, and hepatic failure, and chronic infections, including AIDS

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    Causes

    • Specific etiology of these symptoms is not well understood
    • Significant cause of distress to patients and, even more so, to families and caregivers
      • Often construed as evidence of "failure" to provide adequate care

      • Alternately, attentive families may believe that they are doing something wrong

      • Many patients and families conclude that, if only the patient would eat more, he/she would resume his/her former weight and vigor


      • These symptoms typically represent progression of disease and are not reversible

    • Loss of appetite, weight, and energy are not strictly the result of malnutrition
    • Providing nutrition, even parenterally, does not change the course of the disease
    • Helping patients and families understand these distinctions often diminishes guilt, hostility, or conflict
    • The physician and members of the health care team can then help the patient and family focus on things that may be useful

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    Assessment

    • Assessing for dysphagia, odynophagia, medication effects, or infections that may be causing or exacerbating the problem may be worthwhile
    • There are therapies that may improve appetite and add weight, although none affect longevity
    • The resumption of eating for enjoyment, and the sense of normalcy that it promotes, may be worth the attempt and expense if it improves the patient’s and family’s sense of well-being

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    General Management of Anorexia/Cachexia

    • Assess, manage comorbid conditions
      • Anxiety
      • Nausea
      • Dehydration
      • Constipation
      • Oral or systemic infections
    • Educate, support family and caregivers
      • Help them distinguish between the normal progression of the disease (over which they have no control) and things they can do to help the patient feel better

      • Explore the emotional components and the meaning of the patient not eating, losing weight, or not having energy

      • Assess how much the patient (as opposed to family) is bothered by symptoms

      • Frequently the patient is comfortable with these symptoms, but the family is distressed
    • Favorite foods/nutritional supplements
      • Offer the patient favorite foods and nutritional supplements (if the patient enjoys them)

      • Eliminate dietary restrictions

      • Reduce portion sizes and make food look appetizing

      • Avoid odors that the patient finds disagreeable

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    Specific Management of Anorexia/Cachexia

    • Alcohol
      • Frequently forgotten are the appetite-stimulating properties of alcohol

      • Particularly if the patient has enjoyed alcohol previously, it may be quite salutary to encourage an aperitif, cocktail, or other drink
    • Corticosteroids have an appetite-stimulating effect, in addition to their effects on mood and energy
      • dexamethasone in doses of 2–20 mg/day is recommended because of its long half-life, permitting once-daily dosing, and relative lack of mineralocorticoid effects, though any corticosteroid will work

      • megestrol acetate has been shown to stimulate appetite and promote weight gain in patients with AIDS and advanced cancer. The best dose is unclear and there appears to be large individual variation. Begin with 200 mg po q 6–8h and titrate up or down to maintain effect

      • the cannabinoids (e.g., tetrahydrocannabinol [THC]), have been shown to promote weight gain in patients with AIDS and cancer. Begin with a small dose and titrate to effect and tolerability
    • Androgens
      • The androgens (e.g., oxandrolone, nandrolone, etc) are currently under investigation for their effects on appetite and weight

      • A therapeutic trial may be appropriate, especially in patients with HIV/AIDS

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    Comments on the Last Hours of Life

    • As patients approach the last hours of their lives, almost everyone will cease oral intake
    • As the patient’s gag reflex and swallowing may become compromised, there may be a significant increased risk of aspiration
    • Patients, family members, and caregivers often find these changes distressing, and need a lot of support
    • See:
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