PRINCIPLES OF SYMPTOM CONTROL

The important principles of symptom control are:

• Medical expertise

• High quality nursing care

• Full assessment

• Attention to detail

• Regular review

• Ability (and energy) to listen

• Communication skills

Many patients with advanced cancer continue to suffer unnecessary physical distress because many doctors and nurses remain unaware of what can be achieved.

«  “Surely the most important principle of symptom control must be to get on and do it.” (Mary Baines)

Too often expressions like “We’re waiting for the drugs to work” really mean “We don't know what else to do and can’t be bothered to find out.”

It is possible to significantly control the symptoms of pain, nausea, vomiting, dyspnea and dysphagia in ALL patients, and to abolish these unpleasant symptoms altogether in the great majority. It is almost always possible to control symptoms effectively in the patient’s home, if there are willing carers and a competent home care team. It demands skillful medical care, skillful prescribing of drugs, and also skillful use of the doctor “as a drug” – using the skills of listening, reassurance and explanation to boost patient confidence and morale, and to reduce fear and insecurity. It demands high quality care from nurses who are committed to total care of patient and family, who are educated to identify and assess pain, who understand the use of analgesics, and who are willing, if necessary, to act as advocates for their patients. Visit regularly – at least daily if there are uncontrolled symptoms. Severe pain is a medical emergency. (see Home Care)

«  Symptom control often enables rehabilitation.

Once symptoms are controlled, the next step is to ask “Can this patient be helped to become more independent?” (see Rehabilitation)

Controlling physical symptoms is usually simple and straightforward (and often very rewarding for all concerned). It demands proper assessment of each problem, including history and examination. Occasionally special tests such as x-rays, bone scans or blood tests are appropriate. It can seem more difficult to be methodical when a patient is very ill or very anxious, but it is still possible.

History – It is important first of all to listen. This builds trust, which improves compliance. The order in which problems are conveyed is in itself an important message.

Having listened, it is then important to elicit symptoms. (We usually talk of eliciting signs in general medicine.) There seems to be an unwritten rule in medicine that a patient is “allowed” only one problem at a time. The patient can be embarrassed to discuss more than two or three problems, when in fact there can be many more than this. It is possible to tackle a long list of problems at a first assessment only by knowing that there is a full team of people capable of absorbing some of the problems, and dealing with them.

Discover the significance of symptoms. Patients with cancer (and their families) often assume that new symptoms are due to the spread of the disease. Explanation reduces anxiety. (see Explanation)

Examination – Examination of the patient is an essential step in symptom control. It is in itself a powerful, non-verbal message saying, “I am interested in you, and this is how I am going to care for you.” It is important to look for obvious physical signs of oral thrush, pressure areas, hepatomegaly, bony tenderness, impacted feces, ankle edema, etc.

It is also an important opportunity for the nurse or doctor to make a positive comment such as “You have lovely skin”, or “Your lungs sound completely healthy.” These comments obviously need to be true, but it is usually possible to find something to be positive about. This can be a great boost to morale in the face of progressing disease.

Special tests – It is often unnecessary to subject people with advanced disease to special investigations, but occasionally it is essential.

For example:

• Chest x-ray, in the assessment of dyspnea

• X-rays or scans, in the assessment of metastases or possible pathological fractures

• Blood, to diagnose uremia or hypercalcemia (as causes of nausea, thirst, drowsiness, confusion)

«  Routine measurements of temperature, pulse, respiration and blood pressure are not necessary in terminal illness.

The symptoms listed below are those commonly seen on admission to St. Christopher’s Hospice. The percentages are based on routine questioning of 6,677 patients admitted between 1975 and 1984. They give a useful overview of the frequency of particular problems, but they give no indication of the severity of symptoms or of the changing nature of symptoms.

For example, mild dyspnea on exertion is a non-specific symptom at some stage in almost all patients with far advanced cancer. Severe dyspnea at rest is surprisingly rare even with lung cancer patients. Similarly, towards the end of life almost all patients will complain of weakness.

Most patients have several different physical symptoms at the same time.

Some very important problems are not included on this list. About 70% of patients complain of soreness or dryness of the mouth. Some less common physical symptoms are also missing: hiccups, pruritis, sweating, thirst. Psychological and spiritual problems (confusion, anxiety, depression) are also not included. Nevertheless, this list provides a useful over-view of common problems.

Since patients tend to have several symptoms, polypharmacy is unavoidable. Skillful prescribing is essential and often makes the difference between poor and excellent symptom control. (see Prescribing)

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.