Comprehensive Symptom Assessment and Management Course Summary

Volume 23, Number 12: December 2022
IAHPC’s comprehensive assessment and management course for symptoms other than pain is taught by: Dr. Eduardo Bruera, Dr. David Hui, Dr. Aimee Christie, Dr. Donna Zhukovsky, and Dr. Chitra Venkateswaran. Photos used with permission.

Common Symptoms in Palliative Care & How to Treat Them

The IAHPC Comprehensive Symptom Assessment and Management Course concluded in November, but members can access any or all of the modules, which were recorded, at any time. It is a follow-up to the 2022 Comprehensive Pain Assessment and Management Course, which was very highly rated by participants.

The teachers of each module have provided the following summaries.

Module 1: Introduction: Palliative care integration around the globe. Approach to symptom assessment

Dr. Eduardo Bruera: Palliative care has evolved over time from end-of-life care delivered in the community, to interdisciplinary teams that integrate person-centered care, to disease management many months earlier. Structures and processes have needed major adaptation, and the teams do not always receive the increased resources needed to deliver these evidence-based services. This puts some teams at risk of burnout. This talk addresses the existing evidence and proposes ways to manage growth and team support. 

Dr. Donna Zukovsky: In this introductory module, we discuss the rationale for systematically screening patients for symptoms that commonly occur in advanced illness. We then look at what types of validated tools are available and how to select the tool that best fits your needs. Next, we take a high-level look at causes of mortality globally and in low-income countries, followed by an overview of symptom prevalence in different populations. We then focus on a multidimensional approach to symptom assessment. We conclude by looking at how to use this information in order to target a whole-person approach directed at the underlying causes, as befits the individual’s goals of care. We use patient examples to stimulate an interactive case-based approach with session participants. 

Tara Devi Laabar, of Perth, Australia, conducts an in-depth interview with an elderly Bhutanese woman diagnosed with chronic lung disease to explore her palliative care needs. Used with permission.
Module 2: Fatigue

Dr. Donna Zukovsky: In this session, we provide a definition of fatigue, discuss how it impairs quality of life, and look at different words that patients use to describe fatigue. After reviewing the prevalence of fatigue in different medical conditions, we focus on understanding the primary and secondary causes of fatigue, a major component of its evaluation. Primary causes relate to the primary underlying disorder and the underlying pathophysiologic mechanisms, which are often not well understood. Secondary causes are myriad and may relate to comorbidities, disease-specific treatments, mood, electrolyte and sleep disorders, and/or unrelieved symptoms. Using the approach to symptom assessment and management discussed in module 1, we then look at mainstays of management for your patient. We use patient examples to stimulate an interactive case-based approach with session participants. 

Module 3: Delirium

Dr. David Hui: Delirium is one of the most common and distressing neuropsychiatric syndromes in patients with advanced illnesses. The evidence is still developing and there is much confusion regarding the role of non-pharmacologic and pharmacologic approaches in the management of delirium in the palliative care setting. In this session, an up-to-date review of the literature is provided, and some practical strategies for clinicians are shared.

Module 4: Gastrointestinal Intestinal Symptoms I: Anorexia-Cachexia Syndrome, Constipation & Diarrhea

Dr. Donna Zukovsky: This module starts with an in-depth discussion of the anorexia-cachexia syndrome, the stages of cachexia, and its negative impact of the syndrome on multiple health care outcomes. Domains of symptom assessment include muscle strength and mass, caloric intake and nutritional impact symptoms, underlying catabolic drivers, functional alterations, and associated psychosocial distress. Using the approach to symptom assessment and management discussed in module 1, we pay special attention to treating nutritional impact symptoms and underlying reversible metabolic derangements, together with a focus on non-pharmacologic modalities of care. For pharmacotherapy, the role of appetite stimulants and associated limitations are reviewed. In the second part of the module, we discuss constipation, a highly prevalent symptom that is often overlooked and can be misdiagnosed as diarrhea. We will also discuss true diarrhea, a symptom more common in low-income countries where infectious causes of mortality often prevail. We use patient examples to stimulate an interactive case-based approach with session participants.

Module 5: Gastrointestinal Intestinal Symptoms II: Nausea and Vomiting, Malignant Bowel Obstruction & Oral Symptoms

Dr. Donna Zukovsky: In this second module about gastrointestinal symptoms, we take a close look at the pathophysiology of nausea and vomiting, and the multiple potential contributing etiologies. After reviewing an approach to symptom assessment, we take a careful look at pharmacotherapy, given the multiple receptors often involved in the genesis of nausea and vomiting. We also discuss general supportive and integrative modalities for the management of nausea and vomiting. Next, we discuss the clinical features of different types of malignant bowel obstruction, a common cause of nausea and vomiting in the cancer population. Medical management is the mainstay when patients are not surgical candidates or if surgery is not consistent with the person’s goals of care. We review general supportive measures, choice of pharmacotherapy, and additional considerations. We conclude with a brief discussion of oral symptoms—distressing but often overlooked—and the limited options available that we can use for their amelioration.  

Module 6: Respiratory Symptoms: Dyspnea, Cough, Secretions

Dr. David Hui: Patients with advanced diseases suffer from respiratory symptoms, such as dyspnea, cough, and death rattle. There is a growing body of literature to support clinical practice, although many unanswered questions remain. In this session, an evidence-based synopsis on the assessment is provided, as well as non-pharmacologic measures and pharmacologic treatment of dyspnea, cough, and death rattle. 

Module 7: Insomnia

Dr. Aimee Christie: Insomnia is a highly prevalent symptom in advanced medical illness, associated with both physical and mental health comorbidities. Careful assessment is recommended to clarify contributing factors. Patients should be encouraged to make behavioral changes to their sleep routine, sleep habits, and sleep environment prior to pharmacological interventions. In this session, Cognitive Behavioral Therapy for Insomnia (CBT-I) is described, including the components of sleep restriction, stimulus control, and relaxation. The CBT-I intervention has been successfully adapted using surface-level changes (e.g., linguistic, telehealth, reduced treatment dose) and deep-level changes (e.g., addressing disease-specific fears, incorporating yoga, involvement of family). CBT-I is the first-line treatment for sleep disturbance, can be adapted successfully for various populations, and can be used in conjunction with medications.  

Dr. Donna Zukovsky: Sleep disturbance in common in the population at large. In this module, we provide an objective definition of insomnia and look at its prevalence in different types of advanced medical illness and in different care settings. Using the approach to symptom assessment and management discussed in module 1, we focus on evaluating the many potential etiologies that may be contributing to sleep disturbance, and an approach to their management. The latter focuses on treating reversible factors whenever possible and non-pharmacologic approaches, such as sleep hygiene, environmental and lifestyle modifications, and exercise. For more difficult to treat insomnia, cognitive behavioral therapy for insomnia is at least as effective as pharmacotherapy. There are limited data to support the use of traditional sleep aids. We review some of these agents, along with the complications and side effects that are associated with many. We use patient examples to stimulate an interactive case-based approach with session participants.

Module 8: Psychological distress in palliative care

Dr. Chitra Venkateswaran: Around 60% of palliative care patients experience emotional distress. From 30% to 40% of patients with cancer report emotional distress symptoms as a consequence of the disease and treatment, many of whom meet the criteria for psychiatric diagnosis, such as adjustment, anxiety, and depressive disorders. This impairs the quality of life of the patient and their family, leading to increased burden to family as well as treating teams, poor control of physical symptoms, and poor treatment compliance. Screening for distress has been recommended routinely across palliative care settings to identify patients in need of clinical attention and intervention. In this session, an overview of methods to understand, screen and measure distress, and a range of interventions to manage psychological distress, are given.

Eduardo Bruera, MD, FACP, FAAHPM, is chair of the Department of Palliative, Rehabilitation and Integrative Medicine, Division of Cancer Medicine, at The University of Texas MD Anderson Cancer Center, USA.

Aimee Christie, MS, PhD, is an assistant professor in the Department of Rehabilitation & Integrative MedicineDivision of Cancer Medicine, at The University of Texas MD Anderson Cancer Center, USA.

David Hui, MD, MSc, is an associate professor of medicine in the Department of Palliative, Rehabilitation and Integrative Medicine, Division of Cancer Medicine, at The University of Texas MD Anderson Cancer Center, USA.

Chitra Venkateswaran, MD is a professor in the Department of Psychiatry, and senior consultant in palliative care at Believers Church Medical College, Kerala, India.

Donna S. Zhukovsky, MD, FACP, FAAHPM, is a professor in the Department of Palliative, Rehabilitation and Integrative Medicine Division of Cancer Medicine, at The University of Texas MD Anderson Cancer Center, USA.

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