Page 1673 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 92 Palliative Care 1491

“talk things over” with puppets or stuffed animals rather than real isolation from loved ones, sepsis, hypoxia, metabolic abnormalities,
people. Importantly, euphemistic expressions about death can be withdrawal from alcohol, opioids or benzodiazepines, drug reactions
confusing or even frightening (for instance, equating death with sleep (e.g., akathisia from metoclopramide, phenothiazines, and butyro-
may result in the child’s being afraid of going to bed) and should be phenones; paradoxical agitation from benzodiazepines and olanza-
avoided. pine), and uncontrolled pain. Nonpharmacologic treatments, such as
Needless to say, parents of children with hematologic malignancies relaxation training, hypnosis, supportive psychotherapy, and counsel-
also experience distressing symptoms such as anxiety, depression, and ing, are very effective. Pharmacologic treatments usually include
spiritual and psychosocial concerns. Recognition of these by the benzodiazepines (e.g., the short-acting lorazepam, starting dose
pediatric clinician may serve families well while the child is alive and 0.5–2 mg every 8 hours as needed; or long-acting clonazepam, start-
during bereavement. ing dose 0.25–0.5 mg orally (PO) two-times daily), selective serotonin
reuptake inhibitors (SSRIs; see later), and, when there is evidence of
delirium, neuroleptics (see later).
Symptom Management in Adults It is estimated that 5–26% of patients with advanced cancer meet
criteria for a major depressive disorder, and patients with high
Patients with hematologic malignancies experience a high physical symptom burden such as patients facing bone marrow transplanta-
25
and psychologic symptom burden, similar to patients with metastatic tion are at higher risk. It can be difficult to discern which patients
solid tumors, especially during periods of treatment, when hospital- with advanced disease are depressed or grieving. The usual somatic
22
ized, or with advanced disease. Pain and antiemetic therapy for signs of depression or grief (e.g., anorexia, sleep disturbances, fatigue,
adults is reviewed elsewhere in this volume (see Chapter 91). Anxiety, or weight loss) are common in this population. Depressed patients,
depression, delirium, and control of symptoms occurring in the last however, will be anhedonic and feel worthless, guilty, hopeless, or
days of life are reviewed subsequently. helpless. Grieving patients, in contrast, are very sad, but they are able
25
Among social sources of distress are financial concerns and, with to find happiness in some circumstances and can plan for the future.
increasing debility, loss of independence and sense of contribution Pain, a past or family history of substance abuse, depression, or
and efficacy. Worries about burdening the family or that the family bipolar illness are major risk factors for depression. Terminally ill
will fail them when they really need them may lead patients to request patients responding “Yes” to the screening question “Are you
physician-assisted suicide. Social workers are the key team members depressed?” are very likely to be confirmed as depressed in a more
who can help alleviate or at least ameliorate these sources of distress, comprehensive evaluation. Useful follow-up questions include “How
and can help the caregivers cope. do you see your future?” “What do you imagine is ahead for yourself
Physicians should also explore religious and spiritual concerns, with this illness?” “What aspects of your life do you feel most proud
and understand what rituals will be important at the end of life. of? Most troubled by?”
Spiritual and existential distress occur when individuals are unable to As part of the treatment of depression, pain must be brought under
find sources of meaning, hope, love, peace, comfort, strength, and control. Counseling can explore patient fears, provide emotional
connection in life, or when there is dissonance between their beliefs support, and help patients review their lives and find the meaning and
and what is happening to them. Patients who use “positive” religious areas of accomplishment in them. A variety of models of therapy are
coping (e.g., prayer, feeling a sense of connectedness to a religious used, and none has been shown to be superior over the others. The psy-
community, having a positive relationship with God) have been chostimulants dextroamphetamine and methylphenidate (2.5–5 mg,
found to have better mental health status, growth in the spiritual 8 AM and noon; maximum dose 60 mg daily) often act within a few
dimension with stress, and a better overall quality of life. Patients days. The SSRIs are the first choice when immediate onset is not
who use “negative” religious coping (e.g., ascribe their illness to a needed because they usually take several weeks to show effect. Useful
punishing God or one who has abandoned them) have a poorer agents include citalopram (Celexa) and paroxetine (Paxil; 10 mg PO
23
quality of life. Clinicians should therefore include either a formal daily initially; maximum 40 mg PO daily); escitalopram (Lexapro;
or informal spiritual assessment for all patients diagnosed with serious 10 mg PO daily initially; maximum 20 mg PO daily); sertraline
illness. (Zoloft; 50 mg PO daily initially, maximum 200 mg PO daily);
fluoxetine (5–10 mg PO daily initially; maximum 60 mg PO daily);
and the serotonin–norepinephrine reuptake inhibitor venlafaxine
PSYCHOLOGIC CONCERNS (Effexor; 37.5 mg PO twice daily initially; maximum 225 mg PO
daily). Venlafaxine inhibits norepinephrine, serotonin, and dopamine
Clinicians must assess and attend to patients’ and families’ psychoso- reuptake. Major side effects of the SSRIs include hyponatremia,
cial distress, including developmental issues, meaning and impact of sexual dysfunction or loss of libido, and gastrointestinal complaints
illness, coping style, impact on sense of self, relationships, stressors, (e.g., nausea, diarrhea, and foul-smelling flatus). Modafinil may also
spiritual resources, economic circumstances, and physician–patient be an effective adjuvant agent to reduce SSRI-related sedation. The
relationship; they must be able to distinguish normal human reac- exact mechanism of action of mirtazapine (Remeron; 15 mg PO at
tions of grief, sadness, despair, fear, anxiety, loss, and loneliness in bedtime initially; maximum 45 mg PO at bedtime) is unknown.
patients facing the end of their lives, from clinical anxiety and depres- If the patient is expected to live longer than weeks to a few
24
sion. Up to 50% (or more) of patients with advanced cancer meet months, a stimulant and an SSRI should be started simultaneously,
criteria for a psychiatric disorder when the diagnosis of adjustment and the stimulant can be titrated off several weeks later. Tricyclic
disorder is included. 25 antidepressants are less useful in these patients because of their side-
effect profile.
If the patient does not respond to first-line agents, a psychiatrist
Anxiety and Depression should be consulted. Referral to a psychiatrist is also necessary when
the physician is unsure of the diagnosis; the patient is psychotic,
It is noteworthy that depression and anxiety are often not recognized confused, or delirious; the patient previously had a major psychiatric
as symptoms in children, and in many instances are inadequately disorder; the patient is suicidal or requesting assisted suicide; or there
addressed. Significant anxiety is found in approximately 25% of adult are dysfunctional family dynamics.
25
patients with cancer, and anxiety symptoms can interfere with their
ability to receive care. Patients with panic disorders, agitated depres-
sion, phobias, obsessive-compulsive disorder, delirium, posttraumatic Delirium
stress disorder, or adjustment disorders can all present with anxiety.
Anxiety in dying patients may arise from worries about the future Delirium occurs in up to 80% of patients dying from advanced
12
(uncontrolled symptoms, family concerns, or concerns about death), cancer and can cause distress and anxiety in caregivers. Delirious