End of life care/symptoms of terminal illness

Specialties > Mental health

Differential Diagnosis Schema 🧠

Pain

Cancer-related pain: Often due to tumor infiltration, bone metastases, or nerve compression
Non-cancer pain: May include conditions like chronic arthritis, ischemic pain, or neuropathy
Treatment-related pain: Side effects from radiotherapy, chemotherapy, or surgical interventions
Psychosomatic pain: Exacerbated by anxiety, depression, or existential distress

Dyspnea

Respiratory causes: Includes conditions such as lung cancer, COPD, or pulmonary fibrosis
Cardiac causes: Congestive heart failure, cardiomyopathy, or pericardial effusion
Anemia: Common in terminal illness due to bone marrow infiltration, chronic disease, or bleeding
Anxiety: Can exacerbate the sensation of breathlessness
Pleural effusion: Often seen in advanced cancer, leading to compression of the lung

Nausea and Vomiting

Gastrointestinal causes: Bowel obstruction, constipation, or gastroparesis, often related to malignancy
Chemotherapy-induced: Common side effect of many chemotherapy agents
Increased intracranial pressure: From brain metastases or primary brain tumors
Metabolic causes: Hypercalcemia, uremia, or liver failure leading to toxin accumulation
Medication side effects: Opioids, antibiotics, or other medications used in palliative care
Psychological causes: Anxiety or anticipatory nausea in response to treatment

Fatigue

Cancer-related fatigue: Due to the cancer itself, often exacerbated by treatments like chemotherapy or radiotherapy
Anemia: Common in terminally ill patients, contributing to profound fatigue
Metabolic disturbances: Electrolyte imbalances, renal failure, or liver dysfunction
Chronic disease: Fatigue associated with chronic conditions like heart failure, COPD, or renal failure
Psychological factors: Depression, anxiety, or sleep disturbances

Constipation

Opioid-induced: Common in patients receiving opioid analgesia for pain management
Dehydration: Reduced fluid intake leading to hard stools and constipation
Hypercalcemia: Can cause decreased bowel motility
Immobility: Reduced physical activity contributing to decreased gastrointestinal motility
Gastrointestinal obstruction: May be partial or complete, often due to tumor burden
Dietary factors: Low dietary fiber intake, often due to reduced appetite or intake

Key Points in History 🥼

Symptom Onset and Duration

Rapid vs gradual onset: Rapid onset may suggest acute complications like bowel obstruction or infection, while gradual onset may be more indicative of disease progression
Duration: Chronic symptoms may indicate ongoing management issues, while acute changes may necessitate immediate intervention
Triggers: Identifying factors that exacerbate symptoms can help tailor palliative interventions
Impact on quality of life: Understanding how symptoms affect daily living can guide holistic care planning

Background

Past medical history: Includes the primary diagnosis (e.g., cancer, COPD, heart failure) and comorbidities
Medication history: Review current and previous treatments, focusing on those that may contribute to symptom burden
Family history: Consider hereditary factors in diseases like cancer or neurodegenerative disorders
Social history: Living situation, availability of carers, and support systems are crucial in planning end-of-life care
Psychosocial factors: Assess for anxiety, depression, and existential distress that may worsen symptoms

Possible Investigations 🌡️

Laboratory Tests

Full blood count: To assess for anemia, infection, or bone marrow suppression
Electrolytes: Monitor for imbalances like hypercalcemia, hyponatremia, or renal dysfunction
Liver function tests: Important in patients with hepatic metastases or liver failure
Renal function tests: To assess for renal impairment, especially in patients with dehydration or on nephrotoxic drugs
Calcium levels: Hypercalcemia is a common issue in patients with bone metastases or certain cancers
CRP/ESR: May help assess the presence of infection or inflammation, though often less useful in terminal stages
Blood cultures: If infection is suspected, particularly in febrile patients
Glucose levels: Particularly important in diabetic patients or those on corticosteroids

Imaging and Specialist Tests

Chest X-ray: To assess for pneumonia, pleural effusion, or lung metastases if symptomatic
Abdominal ultrasound/CT: May be indicated in cases of suspected bowel obstruction or liver metastases
CT/MRI brain: To evaluate for brain metastases or increased intracranial pressure if neurological symptoms are present
ECG: To assess for arrhythmias or ischemia, particularly in patients with chest pain or dyspnea
Echocardiography: Useful in assessing cardiac function if heart failure is a concern
Bone scan: May be indicated if bone metastases are suspected and causing significant pain
Paracentesis: Diagnostic and therapeutic for patients with symptomatic ascites
Endoscopy: Consider in patients with intractable nausea/vomiting where obstruction or malignancy is suspected

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