5.4 Symptom Management
Symptom management in palliative care requires an astute care team that is aligned to the status of the child, as well as the goals of care of the child and family. The first step to best symptom management comes from appropriate identification of the etiology of the symptom. Then, it is important to have an armamentarium of management strategies in the hope of aligning the choice of intervention with the goals of care.
Discussion with your local tertiary care centre and/or palliative care provider(s) may be essential to determining which strategies listed below could be helpful.
| Symptom | Management Strategies | Medications & Suggested Initial Doses |
| Agitation/
Delirium |
Consider looking for reversible cause (e.g. low sodium; high calcium). Attempt to help orient the child. Comforting social interactions may be helpful with familiar visitors. Minimize noise and avoid unnecessary stimulation. |
|
| Bleeding – mucosal | Have dark towels on hand.
If bleeding does not respond to medication/transfusion, and is excessive, consider palliative sedation to decrease associated anxiety. |
|
| Constipation | Manage proactively when administering opioids. Most adolescents will not disclose so must be asked specifically about bowel habits. |
|
| Diarrhea | Consider: new illness, diet, medications and treatment, hydration. |
|
| Dyspnea/
Respiratory |
Try deep breathing and distraction. Oxygen may be beneficial for relief of dyspnea, regardless of O2 saturations. A fan blowing on the face and/or an open window may be effective for decreasing the sensation of breathlessness.
Opioids are used for the relief of dyspnea. Benzodiazepines may be used as adjunct if dyspnea also due to anxiety. |
|
| Nausea & Vomiting | Determination of etiology should guide treatment and medication modalities.
Strategies to help approach anorexia and aversion to foods might include: small blended meals, sips of fizzy drinks, restricted intake and avoiding lying flat after eating. Control smells and noise in the home, good oral hygiene. Visualization, distraction and relaxation have also proved effective. |
Select agent(s) based on most responsible mechanism for nausea/ vomiting:
|
| Pain | A full pain assessment is imperative to effective pain management. Consider whether there is a neuropathic component.
Consider integrative therapies such as massage, imagery, music therapy, acupressure, acupuncture, TENS, etc.
Consider radiotherapy for local bone pain due to solid tumours/metastases
It has been shown that appropriate opioid use does not hasten death, but improves QOL and may actually prolong life. There is no opioid dose limit.
Pain from advanced cancer is unlikely to be transient or improve – so imperative to provide REGULAR DOSING, and supplement with PRN for breakthrough pain.
If pain is refractory, or side effects are unmanageable (constipation, nausea, urinary retention, pruritus), consider opioid rotation. Refer to an opioid conversion table or a PPC specialist. |
Adjuvants:
|
| Pruritus | Can be a side effect of opioids due to their histamine releasing properties: usually resolves within a few days of treatment initiation or increased dosage. Some opioids result in less pruritus than others; may respond to opioid rotation (hydromorphone, fentanyl). |
|
| Secretion Control | If child is too weak to clear own secretions, reposition on side for postural drainage. Â Give frequent mouth care.
Suctioning can cause irritation and increased secretions, and should be avoided if possible. Most effective treatment, with fewest side effects, is to reduce total fluid intake (via enteral tube, IV). Titrate to comfort and urine output. |
*Consider side effects: thickened, difficult to clear secretions, dry mouth and drowsiness |
| Seizures | Seizures at end-of-life can be very distressing, and aggressive management is most often appropriate. | Management strategy: benzoà benzo à phenobarbital (if intractable)
|
| Urinary Retention | Consider looking for reversible causes (high dose opiods; spinal metastases/primary amenable to radiation).
Having a warm bath and encouraging the child to pass urine in the water is often the most effective treatment for opioid induced retention. Consider opioid rotation. Catheterization may be necessary to relieve the discomfort of a full bladder. |
It is recommended with the use of drugs at end of life that may cause urinary retention to have catheterization supplies in the event the child is unable to void and cause is not reversible. |
References
- Chen, J. and Lau, E. (Ed). Sick Kids Drug Handbook and Formulary. The Hospital for Sick Children: Toronto, ON. 2013 & 2014
- Dipchand, A. and Friedman, J. (Ed.). The Hospital of Sick Children Handbook of Pediatrics. 11th 2009.
- Goldman, Hann, Liben. Oxford Textbook of Palliative Care for Children, 2nd Oxford University Press, 2012.
- Hain, R. and Jassal, S. Paediatric Palliative Medicine, Oxford Specialist Handbooks in Paediatrics.
- Levine, D., Lam, C., et al. Best Practices for Pediatric Palliaitve Cancer Care: A Primer for clinical Providers. Journal of Supportive Oncology 2013; 11: 114-125.
- POGO/PCMCH Provincial Pediatric Palliative Care Steering Committee. Symptom Management Guide for Children Near/End-of-Life.
- Rainbow Children’s Hospice Basic Symptom Control in Paediatric Palliative Care – 11th Edition Accessed June 3, 2014. [Available online]
- Shaw, T. Pediatric Palliative Pain and Symptom Management. Pediatric Annals, 2012. 41(8): 329-334
- Waterloo Wellington Symptom Response Kit Clinical Guidelines and Order Form. Revised 2014.
Primary authors Dr. Stacey Marjerrison, McMaster Children’s Hospital, Hamilton Health Sciences, Hamilton and Patti Bambury, Grand River Hospital, Kitchener. Reviewed by the POGO Satellite Manual Palliative Care Working Group, 2016.