Some thoughts on HIV
PALLIATIVE MANAGEMENT OF
OTHER SYMPTOMS IN HIV
PATIENTS
Page 6
ORAL PROBLEMS
Oral Candida
Oral Ulcers:
Herpes simplex and Aphthous ulcers
Oral Malignancies:
Kaposi’s sarcoma and lymphoma
Xerostomia (Dry mouth)
Page 7
ORAL KAPOSI’S SARCOMA AND
LYMPHOMA
Management:
• Surgery
• Radiotherapy
• Chemotherapy
• Analgesia
• Oral hygiene
Page 8
XEROSTOMIA
Management
Attend to any reversible causes:
drug side effects
dehydration
mouth breathing
• Good oral hygiene improves comfort
• Chewing stimulates production of saliva
• Increase fluid intake where possible
• Frequent sips of water and sucking ice chips
• Saliva substitutes
Page 9
OESOPHAGEAL SYMPTOMS
Oesophageal candida
Ulcers:
Aphthous, herpes simplex and cytomegalovirus
Malignancies:
Kaposi’s sarcoma and lymphoma
Management
Treat specific infections (If painful swallowing + oral candida, treat
empirically for oesophageal candidia)
Antacids (used after meals)
mucosal coating agents such as sucralfate
Page 10
Often result of opioid medication.
Management
Diet
Medication
CONSTIPATION
Page 11
Medication- constipation
Stimulant laxatives frequently combined with stool softeners
Stimulant Laxatives
Sennosides
Stool softeners
Osmotic laxatives most appropriate in opioid induced constipation
Lactulose (Duphulac®)- least side effects
Liquid Paraffin
Magnesium hydroxide (Milk of Magnesia®)
Rectal agents
when constipation does not respond to oral agents
Glycerine suppositories
Large volume sodium phosphate
enemas
Warm olive oil enema
Digital removal of stools
Page 12
CHRONIC DIARRHOEA
Causes
idiopathic HIV enteropathy
infective causes (cryptosporidium, giardia )
overflow diarrhoea secondary to faecal impaction
Management
Infective causes - seek and treat, three stool specimens for
MC&S and special coccidial stains
Diet
Oral rehydration
Medication:
– Codeine phosphate 30-60mg 4 x daily
– Loperamide (Imodium®) 4-16mg daily
– Morphine
(If simultaneous analgesia required)
Start with 30mg daily
Page 13
NAUSEA AND VOMITING
Causes
•Drugs (e.g. opioids)
•Biochemical disturbances (renal and liver failure)
•Gastric stasis
•Intestinal infection
•Subacute intestinal obstruction (mass lesions)
•Pharyngeal irritation (tenacious sputum or candida infection)
•Raised intra cranial pressure
Management
•Diet
•Other non-drug measures
•Maintain hydration
•Determine cause where possible
•Use a suitable route of administration
Page 14
NAUSEA AND VOMITING MEDICATION
Metoclopramide (Maxolon®)
• 10-20mg 6 hourly PO, SC or IV
• 40-100mg/24h can be used in a syringe driver
• useful agent in most patients with nausea and vomiting
• gastric stasis or ileus
Haloperidol (Serenace®)
•1,5mg-5mg daily or twice daily in divided doses PO or SC
• drug induced nausea or biochemical disturbances
Prochlorperazine (Stemetil®)
•5-10mg 8 hourly PO, 12,5mg 8 hourly IM, 25mg rectal suppository
Page 15
NAUSEA AND VOMITING MEDICATION
CONTINUED
Cyclizine (Valoid®)
50mg 8 hourly PO, SC or PR
raised intracranial pressure, vestibular causes, peritoneal and
intestinal irritation
Odansetron (Zofran®) and Granisetron (Kytril®)
chemotherapy induced nausea, also other settings
Dexamethasone (Decadron®)
4-16mg daily PO or SC
non-specific nausea and vomiting
space occupying brain lesions
Page 16
CHRONIC COUGH
•
Specific treatment of infections
• Cough syrups (expectorants, mucolytic agents and
bronchodilators)
• Codeine phosphate, 10mg 6 hourly increasing to 60mg
6 hourly
• Other opium derivatives dextromorphan, noscapine or
pholcodine
Page 17
DYSPNOEA
• Support and reassurance – medication can alleviate symptoms
• Reversible causes: seek and treat
•
• Allow patient to choose most comfortable position
• Facial cooling - fan or open window
• Distraction and massage
• Intermittent oxygen using nasal catheters
•
Medication
Page 18
MEDICATION FOR DYSPNOEA
Morphine solution 5-10mg 4 hourly
If already using morphine for pain,
increase dose by 25-50%
Benzodiazepines - lorazepam (Ativan®) or
diazepam (Valium®)
Page 19
SKIN ULCERS
Infective, malignant and pressure ulcers
• regular turning, positioning and sheepskin
• adequate analgesia
• cleaned daily
• basic dressings:
• Gauze soaked with 50% liquid paraffin and 50%
bactericidal solution
• Crushed metronidazole tablets in aqueous cream -
offensive ulcers and cavities.
Page 20
GENITAL ULCERS
Herpes simplex can cause extensive ulceration
• Disease specific treatment
• Analgesia
• Sucralfate suspension-topical application
Page 21
DELIRIUM, CONFUSION AND
RESTLESSNESS
•More than 50% of pre-terminal AIDS patients
•Distinguish
delirium
from
emotional anguish,
psychiatric illness and dementia
•Sudden
onset
and
fluctuating
level
of
consciousness
•Look for and treat reversible cause
Page 22
COMMON TREATABLE CAUSES OF
DELIRIUM
• Infection (cystitis or pneumonia)
• Urinary retention or faecal impaction
• Drugs (high doses of corticosteroids or
accumulation of morphine metabolites)
• Alcohol withdrawal
.
Page 23
DELIRIUM, CONFUSION AND
RESTLESSNESS
Management
•Ensure the safety of the patient
•Uncluttered environment
•A familiar person should present
Medication:
• Haloperidol 1,5mg – 20mg daily PO or SC
• Phenothiazines (Chlorpromazine)
• Benzodiazepines may be added, e.g. lorazepam
(Ativan®) 1mg PO or SC as necessary
•Do not sedate delirious patients with benzodiazepines alone
Page 24
THE IMMINENTLY DYING PATIENT
•Review medication regularly – stop unnecessary drugs
•Route of drug administration may need to be changed
• continuous subcutaneous infusion via a syringe driver
• buccal, sublingual and rectal routes
Page 25
PATIENTS CLOSE TO DEATH
• Loss of appetite
• Decreased thirst and oral fluid intake
• Decreased urine output
• Increasing weakness
• Neurological dysfunction which could include confusion,
hallucinations, myoclonic jerks and coma
• Decreased circulatory perfusion causing peripheral cyanosis
and cool extremities
• Noisy breathing.
• Explanation to the family alleviate anxiety
Page 26
PATIENT CLOSE TO DEATH
Death rattle:
•
Hyoscine butylbromide (Buscopan) 10-20mg 4 hourly SC or
atropine 1mg 4 hourly SC
Page 27
PATIENTS CLOSE TO DEATH
Food and fluids in patients who can no longer eat or drink:
Family frequently request IV or NG hydration
Artificial hydration includes the use of nasogastric tubes, intravenous
infusions or subcutaneous infusions.
The body has mechanisms to adapt to fasting
Artificial hydration does not seem to influence survival or
symptom control
May cause physical discomfort to the patient
Ethically, use of artificial fluids and nutrition is regarded as a
medical treatment or intervention
Page 28
DEATH AND BEREAVEMENT
Bereavement: Situation where a person has
lost someone to whom he/she was attached.
Mourning: process of grieving that loss.
Page 29
Phases of mourning
• Numbness and disbelief
• Phase of intense sadness, longing, guilt or anger
• Depression and despair
• Resolution and recovery
Page 30
Risk factors for complicated grief
• Untimely death (person in prime of life)
• Death linked to stigma
• Multiple losses
• Prolonged period of caring
• Precarious social and/or financial situation
Page 31
Assisting families of dying HIV patients
• Establish caring and supportive relationship
• Counselling and informing the family
• Families often need to see their doctor or health care worker
within a day of the death to settle questions and issues
surrounding the illness and death
• Health care worker visit within one to two weeks – assess
physical and emotional well-being
• Ongoing support during the first months following a death
Page 32
Adequate palliative care is not only
essential for patients with advanced HIV
infection, but it is also a rewarding
experience for care givers and one which
advances much personal growth.
OTHER SYMPTOMS IN HIV
PATIENTS
Page 6
ORAL PROBLEMS
Oral Candida
Oral Ulcers:
Herpes simplex and Aphthous ulcers
Oral Malignancies:
Kaposi’s sarcoma and lymphoma
Xerostomia (Dry mouth)
Page 7
ORAL KAPOSI’S SARCOMA AND
LYMPHOMA
Management:
• Surgery
• Radiotherapy
• Chemotherapy
• Analgesia
• Oral hygiene
Page 8
XEROSTOMIA
Management
Attend to any reversible causes:
drug side effects
dehydration
mouth breathing
• Good oral hygiene improves comfort
• Chewing stimulates production of saliva
• Increase fluid intake where possible
• Frequent sips of water and sucking ice chips
• Saliva substitutes
Page 9
OESOPHAGEAL SYMPTOMS
Oesophageal candida
Ulcers:
Aphthous, herpes simplex and cytomegalovirus
Malignancies:
Kaposi’s sarcoma and lymphoma
Management
Treat specific infections (If painful swallowing + oral candida, treat
empirically for oesophageal candidia)
Antacids (used after meals)
mucosal coating agents such as sucralfate
Page 10
Often result of opioid medication.
Management
Diet
Medication
CONSTIPATION
Page 11
Medication- constipation
Stimulant laxatives frequently combined with stool softeners
Stimulant Laxatives
Sennosides
Stool softeners
Osmotic laxatives most appropriate in opioid induced constipation
Lactulose (Duphulac®)- least side effects
Liquid Paraffin
Magnesium hydroxide (Milk of Magnesia®)
Rectal agents
when constipation does not respond to oral agents
Glycerine suppositories
Large volume sodium phosphate
enemas
Warm olive oil enema
Digital removal of stools
Page 12
CHRONIC DIARRHOEA
Causes
idiopathic HIV enteropathy
infective causes (cryptosporidium, giardia )
overflow diarrhoea secondary to faecal impaction
Management
Infective causes - seek and treat, three stool specimens for
MC&S and special coccidial stains
Diet
Oral rehydration
Medication:
– Codeine phosphate 30-60mg 4 x daily
– Loperamide (Imodium®) 4-16mg daily
– Morphine
(If simultaneous analgesia required)
Start with 30mg daily
Page 13
NAUSEA AND VOMITING
Causes
•Drugs (e.g. opioids)
•Biochemical disturbances (renal and liver failure)
•Gastric stasis
•Intestinal infection
•Subacute intestinal obstruction (mass lesions)
•Pharyngeal irritation (tenacious sputum or candida infection)
•Raised intra cranial pressure
Management
•Diet
•Other non-drug measures
•Maintain hydration
•Determine cause where possible
•Use a suitable route of administration
Page 14
NAUSEA AND VOMITING MEDICATION
Metoclopramide (Maxolon®)
• 10-20mg 6 hourly PO, SC or IV
• 40-100mg/24h can be used in a syringe driver
• useful agent in most patients with nausea and vomiting
• gastric stasis or ileus
Haloperidol (Serenace®)
•1,5mg-5mg daily or twice daily in divided doses PO or SC
• drug induced nausea or biochemical disturbances
Prochlorperazine (Stemetil®)
•5-10mg 8 hourly PO, 12,5mg 8 hourly IM, 25mg rectal suppository
Page 15
NAUSEA AND VOMITING MEDICATION
CONTINUED
Cyclizine (Valoid®)
50mg 8 hourly PO, SC or PR
raised intracranial pressure, vestibular causes, peritoneal and
intestinal irritation
Odansetron (Zofran®) and Granisetron (Kytril®)
chemotherapy induced nausea, also other settings
Dexamethasone (Decadron®)
4-16mg daily PO or SC
non-specific nausea and vomiting
space occupying brain lesions
Page 16
CHRONIC COUGH
•
Specific treatment of infections
• Cough syrups (expectorants, mucolytic agents and
bronchodilators)
• Codeine phosphate, 10mg 6 hourly increasing to 60mg
6 hourly
• Other opium derivatives dextromorphan, noscapine or
pholcodine
Page 17
DYSPNOEA
• Support and reassurance – medication can alleviate symptoms
• Reversible causes: seek and treat
•
• Allow patient to choose most comfortable position
• Facial cooling - fan or open window
• Distraction and massage
• Intermittent oxygen using nasal catheters
•
Medication
Page 18
MEDICATION FOR DYSPNOEA
Morphine solution 5-10mg 4 hourly
If already using morphine for pain,
increase dose by 25-50%
Benzodiazepines - lorazepam (Ativan®) or
diazepam (Valium®)
Page 19
SKIN ULCERS
Infective, malignant and pressure ulcers
• regular turning, positioning and sheepskin
• adequate analgesia
• cleaned daily
• basic dressings:
• Gauze soaked with 50% liquid paraffin and 50%
bactericidal solution
• Crushed metronidazole tablets in aqueous cream -
offensive ulcers and cavities.
Page 20
GENITAL ULCERS
Herpes simplex can cause extensive ulceration
• Disease specific treatment
• Analgesia
• Sucralfate suspension-topical application
Page 21
DELIRIUM, CONFUSION AND
RESTLESSNESS
•More than 50% of pre-terminal AIDS patients
•Distinguish
delirium
from
emotional anguish,
psychiatric illness and dementia
•Sudden
onset
and
fluctuating
level
of
consciousness
•Look for and treat reversible cause
Page 22
COMMON TREATABLE CAUSES OF
DELIRIUM
• Infection (cystitis or pneumonia)
• Urinary retention or faecal impaction
• Drugs (high doses of corticosteroids or
accumulation of morphine metabolites)
• Alcohol withdrawal
.
Page 23
DELIRIUM, CONFUSION AND
RESTLESSNESS
Management
•Ensure the safety of the patient
•Uncluttered environment
•A familiar person should present
Medication:
• Haloperidol 1,5mg – 20mg daily PO or SC
• Phenothiazines (Chlorpromazine)
• Benzodiazepines may be added, e.g. lorazepam
(Ativan®) 1mg PO or SC as necessary
•Do not sedate delirious patients with benzodiazepines alone
Page 24
THE IMMINENTLY DYING PATIENT
•Review medication regularly – stop unnecessary drugs
•Route of drug administration may need to be changed
• continuous subcutaneous infusion via a syringe driver
• buccal, sublingual and rectal routes
Page 25
PATIENTS CLOSE TO DEATH
• Loss of appetite
• Decreased thirst and oral fluid intake
• Decreased urine output
• Increasing weakness
• Neurological dysfunction which could include confusion,
hallucinations, myoclonic jerks and coma
• Decreased circulatory perfusion causing peripheral cyanosis
and cool extremities
• Noisy breathing.
• Explanation to the family alleviate anxiety
Page 26
PATIENT CLOSE TO DEATH
Death rattle:
•
Hyoscine butylbromide (Buscopan) 10-20mg 4 hourly SC or
atropine 1mg 4 hourly SC
Page 27
PATIENTS CLOSE TO DEATH
Food and fluids in patients who can no longer eat or drink:
Family frequently request IV or NG hydration
Artificial hydration includes the use of nasogastric tubes, intravenous
infusions or subcutaneous infusions.
The body has mechanisms to adapt to fasting
Artificial hydration does not seem to influence survival or
symptom control
May cause physical discomfort to the patient
Ethically, use of artificial fluids and nutrition is regarded as a
medical treatment or intervention
Page 28
DEATH AND BEREAVEMENT
Bereavement: Situation where a person has
lost someone to whom he/she was attached.
Mourning: process of grieving that loss.
Page 29
Phases of mourning
• Numbness and disbelief
• Phase of intense sadness, longing, guilt or anger
• Depression and despair
• Resolution and recovery
Page 30
Risk factors for complicated grief
• Untimely death (person in prime of life)
• Death linked to stigma
• Multiple losses
• Prolonged period of caring
• Precarious social and/or financial situation
Page 31
Assisting families of dying HIV patients
• Establish caring and supportive relationship
• Counselling and informing the family
• Families often need to see their doctor or health care worker
within a day of the death to settle questions and issues
surrounding the illness and death
• Health care worker visit within one to two weeks – assess
physical and emotional well-being
• Ongoing support during the first months following a death
Page 32
Adequate palliative care is not only
essential for patients with advanced HIV
infection, but it is also a rewarding
experience for care givers and one which
advances much personal growth.
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