Symptoms and End of Life Care

This article briefly discusses some of the goals and objectives that entail end of life care with cancer.  These are difficult things to discuss but are actually a very important part of cancer care both for you and your family.  Having an idea about what to expect and being able to express your wishes while you are able to is both comforting for you and your family.  There are few things as painful as having an unconscious relative that is very sick and being asked to make major life-altering decisions about their care.  In this situation, if their wishes are not crystal clear or written out it often creates feelings of guilt and conflict among family members.  One of the biggest fears someone with cancer often has is that of dying with pain.  The fear of the unknown and what to expect as symptoms become severe can also cause depression.  A competent cancer physician can address all of these needs and anticipate them before they become a problem.

Care of cancer at the end of life entails several facets that include:

  • Pain Control: Pain control is an important and achievable goal with cancer care.  The world health organization (WHO) strongly endorses a step-wise approach to relief of cancer pain that is termed the Pain Relief Ladder.

The basic strategy is to gradually escalate both the potency and dosage of non-narcotic and narcotic anti-pain medications.  The early addition of continuous delivery systems such as scheduled doses, pain patches that deliver  narcotics trans-dermally, or even continuous intravenous infusions of narcotics help achieve this goal.  An eventual concern is that the level of pain medicine given may have dramatic side effects with the most serious ones being slowing of the breathing and possible death.  The ethical principle involved with this is termed the double-effect.  The double effect principle basically says that as long as the intention of the treatment plan is to relieve pain and not to end life than the unintended potential consequence of death from narcotic treatment is ethically and morally justifiable.  None of us want pain or to die with pain.  Non-pharmacologic techniques such as guided imagery and acupuncture are very effective in these situations.

  • Anxiety and Depression: After diagnosis with a serious cancer but before the severe symptoms set it there is a waiting period.  This time period is often filled with many strong emotions and it is quite normal to feel both anxiety and depression at times.  Even with a terminal prognosis of “6 months to live” it is still common to see people live as short as 3-4 months or as long as 3-6 years with a supposedly terminal cancer.  The uncertainty of the course also provokes anxiety.  Even with terminal cancer, 3 or 5 years is a long time and give plenty of valuable time to spend with family or time to achieve life unsettled life goals.  Treatment of depression allows this time to be optimal and is a worthwhile effort.  It may be easy to say “what’s the use, I’m going to die?” but in a sense we could extend that logic to all of us in a sense of futility.  This type of fatalism not only robs the joy of life but deprives your family of valuable time with you.  Fortunately, there are very effective treatments for both anxiety and depression that are not sedating and allow good function.
  • Shortness of Breath: This is also called dyspnea and sometimes also described as an air hunger.  Dyspnea is a common symptom with advanced cancer, particularly those that either spread to the lungs or start in the lungs.  The sensation of difficulty breathing is very uncomfortable, almost more so than pain, and very difficult psychologically.  In addition to obvious measures such as oxygen therapy there may be other palliative measures such as drawing fluid from around the lung which provide relief of this symptom.  More commonly, dyspnea from end stage cancer is treated effectively with narcotics.  Strong narcotics are very effective in removing the sensation of dyspnea.
  • Nausea and Vomiting: This is a common symptom both from cancer and from common cancer treatments such as chemotherapy.  We all get nauseas from time to time but the severe nausea and vomiting with end stage cancer can be unrelenting and very uncomfortable.  In the last few years there have been newer types of medications such as ondansetron and granisetron that are very effective in relieving nausea with end stage cancer.
  • Hospice Care: This strategy of treatment is appropriate for this with a prognosis of less than 6 months to live.  A good hospice program provides around the clock support and allows the person with cancer to stay at home until the end and avoid stress provoking and costly trips to the hospital that do nothing to prolong life.
  • Living Will and Advance Directive: These are basically documents that express what you want done in dire circumstances when you may be unable to make decisions.  It is most important that you fill these forms out and discuss your wishes with your family.  Sometimes these documents leave room for interpretation such as “if things seem irreversible.”  When faced with a situation, grief and anxiety cloud judgment and a family member may feel guilt if they follow your wishes especially if they wonder if it truly is irreversible.  It is helpful to relieve them of that guilt and anxiety and tell them bluntly to follow your wishes knowing that is what you want done.  This paperwork should address things such as artificial feeding, being placed on a breathing apparatus or ventilator, and whether CPR is wanted or not.  In the vast majority of end of life cancer care, these dramatic measures are not appropriate, are uncomfortable and do nothing to prolong life or improve the quality of life.  Sometimes these measures are added to a patient’s care to provide benefit for the family so they believe “something is being done”.  This is not fair to them or the patient and an honest open discussion is best.

REFERENCES:

  1. Rakel RE; Rakel DP. (2011)  Rakel: Textbook of Family Medicine, 8th ed.  Chapter 5. Philadelphia, PA: Elsevier-Saunders.
  2. Abeloff, M.D. (2008). Abeloff: Abeloff’sClinical  Oncology, 4th ed. Chapter 44. Philadelphia, PA: Churchill Livingstone – Elsevier
  3. www.nlm.nih.gov/medlineplus/hospicecare.html
  4. www.who.int/cancer/palliative/painladder/en/
  5. This article was originally published on September 3, 2012 and last revision and update was 9/4/2015.