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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
    Management of Common Physical Symptoms

    General Management Guidelines
    Specific Symptoms
    Closing Comments

    General Management Guidelines

      Case Example
      Ms S is a 67-year-old woman with progressive pulmonary fibrosis. She has been having progressive shortness of breath and nausea for several months. Her physician visits her at home
    • History and physical examination
      • Identical to the standard approach used to manage any illness
        • Thorough history
        • Physical examination
        • Appropriate investigations (laboratory or radiological) appropriate for the patient’s situation

      • Best possible understanding of each symptom’s etiology and underlying pathophysiology, before appropriate therapy is chosen
    • Conceptualize likely causes
      • As symptoms are often interrelated with multiple concurrent medical problems, management can be challenging

      • Not acceptable to have an unthinking approach to symptom management, as causes and appropriate therapies can vary widely
    • Discuss treatment options and assist with decision-making
      • Once the cause(s) and pathophysiology are known, intervention ideally includes therapy to relieve the symptom(s) as well as treat underlying causes

      • When goals for care preclude disease management, symptom relief may be all that is required

      • When symptoms are debilitating or the patient is too weak, physicians will not be able to wait for the results of investigations before initiating therapy

      • Initial therapeutic trials based on history, examination, and inference about the pathophysiology may provide both symptom relief and/or additional information as to the etiology and pathophysiology

      • As with pain management (see Module 4: Pain Management), if a symptom is present continuously, medication should be prescribed on a continuous or "around-the-clock" basis

      • Breakthrough doses may also be required
    • Provide ongoing patient and family education and support
      • Key to successful management

      • Encourage patient and family to keep a diary when symptoms are out of control or adverse effects occur
    • Involve members of the entire interdisciplinary team
      • When individual patient management becomes complex, physicians are encouraged to consult with local palliative medicine experts, and other members of the interdisciplinary team

      • Optimize therapies and minimize the risk of adverse events and drug interactions
    • Reassess frequently
      • Etiologies and pathophysiology may change

      • Frequent reassessment is critical, particularly when symptoms recur

      • As changes in the patient’s condition can occur rapidly, caregivers should be prepared to respond quickly

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

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    Closing Comments

    Symptom control requires the physician to combine scientific knowledge of pathophysiology, pharmacotherapeutics, and human behavior with communication skills and clinical judgment. It is challenging and rewarding to help patients feel better in spite of progressive disease.

    Careful attention to symptom control may lead to better tolerance of disease-modifying therapies, and may even help prolong life.

    Continued symptom control as patients approach the end of their lives will give them the opportunity to realize the final goals they are striving for.

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