Otolaryngology Training Short on End-of-Life Care Advice

One presenter offers guidance on what otolaryngologists can do to offer comfort to their dying head and neck cancer patients

TORONTO-Otolaryngologists are generally not trained in end-of-life issues, even though they are certainly not strangers to having to work with dying patients.

In a presentation at the recent Annual Meeting of the Eastern Section of the Triological Society here, Matthew Russell, a medical student at Boston University School of Medicine (Mass.), described details ranging from predicting when end of life will occur in certain types of head and neck cancer patients to managing pain and talking to family members.

Caring for patients at the end of life is one of the most intimate interactions a physician can have. But little training is provided on these issues in subspecialty training, he said. Head and neck cancer is not always 100% curable, and is a cause of death the otolaryngologist-head and neck surgeon is close to. While physicians have little training in the realm of helping the dying patient, it’s not something to be shunned, he said. It is an important time to offer comfort and reassurances to patients, find ways to help reduce their pain, and make their transition to end of life easier.

Understanding mechanisms of death, reasonably prognosticating residual time of life, and understanding cultural context for patients can relieve much of the anxiety experienced in these difficult times, Russell said.

For nociceptive pain resulting from bone metastases, opioids aren’t enough and the patient needs to be treated with radiation therapy.

Issues to Consider

Terminal otolaryngic patients can suffer from hunger, pain, dyspnea, nausea, vomiting, diarrhea, and delirium. Appropriate management can help patients and families feel less distress through the terminal events, he said.

Much is known about the behavior and patterns of head and neck malignancy. As a consequence, the pattern of metastatic spread of the major head and neck tumors is relatively predictive of symptoms that each cancer type can produce-meaning when the end of life will come and which symptoms are likely to be present are fairly predictable. The information can be used by the physician to guide treatment, as well as to counsel patients.

Caring for patients at the end of life is one of the most intimate interactions a physician can have. But little training is provided on these issues in subspecialty training. – -Matthew Russell

Predictive markers for end of life occurring within two weeks include Cheyne Stokes respiration (changes in respiration patterns, including episodes of apnea), along with the patient being in bed greater than 90% of the time.

Hypercalcemia in the setting of cancer, dyspnea, and being in bed greater than 50% of the time would suggest a prognosis of three months remaining.

A prognosis of six months or less can be predicted in patients with brain metastases treated with palliative radiation and metastatic solid tumors without effective treatments, as well as other signs and symptoms of [central nervous system] atrophies, Russell said.

Treating Pain at End of Life

Patients who enter palliative care have a number of major symptoms that can all be addressed to increase comfort. The first key area is pain, much of which can be treated with opioid therapy.

Once patients are no longer treated with just short-acting opioids, one can institute a regimen of long-acting opioids every 12 hours as well as short-acting opioids given every four hours as needed, Russell said.

For nociceptive pain resulting from bone metastases, opioids aren’t enough and the patient needs to be treated with radiation therapy. Neuropathic pain, generally caused by nerve compression or central nervous system metastases, can be treated with gabapentin given every eight hours. In addition, patients can be given medications at night to help them sleep.

Breathing, Mental Status, and Hydration

Terminal patients commonly suffer from dyspnea, which can be due to obstruction or other causes. Simple measures should first be instituted here, including nasal oxygen, as well as a bedside fan for air movement which helps with the symptoms, he said. Also, morphine at a dose of 1 to 5 mg IV as needed can be effective.

Anxiety in terminal patients can be treated with lorazepam. Other changes in mental status can be treated with haloperidol, giving increased doses as needed. Low doses of stimulants can be used to treat depression in terminal patients.

Another factor many doctors don’t consider is the use of hospital chaplains on their end-of-life care team.

As for patients who have intractable pain, agitation, and other uncontrollable and distressful symptoms, the treatment of last recourse can be palliative sedation, given through continuous infusion of sedatives out of recognition that this will induce unconsciousness from which the patient may never recover, he said. The primary beneficial effect to the dying patient needs to be considered carefully with this approach.

Another issue with palliative sedation is hydration in the patient. Reducing the use of diuretics can help with water loss, plus appropriate levels of fluids can be administered.

On the other hand, not all patients will be institutionalized at end of life since many will prefer to spend their last days at home. Finding ways to help patients be at home can help reduce some of their stresses.

For home care, we don’t have the capability to sustain life with high technical medical equipment for long periods of time. But in the palliative setting, there are many benefits provided, in this case by Medicare, that patients can use, he said. These are worth investigating.

Another factor many doctors don’t consider is the use of hospital chaplains on their end-of-life care team. They are very important members of the palliative care team and often help answer the more personal and philosophical questions about dying. They really support the role of the physician and help with family grief management, Russell said.

An Important Reminder

Gady El-Har, MD, who attended the conference, told ENToday he found the presentation of interest. He is Professor of Otolaryngology and Neurosurgery at SUNY Health Science Center in Brooklyn, NY.

It’s a very important issue for us, for people who treat head and neck cancer. We’re very well trained at taking care of people, but I’m not sure we’re very well trained in giving up-that is, in deciding when to give up-and what we do with the patient. We have nothing to offer to them, he said.

Talks such as this one are key in helping remind doctors that more things can be done to help patients before they die. Hopefully we will know what to do with these patients. How to help them to end their life in a dignified, reasonable way, Dr. El-Har said.

©2006 The Triological Society