Palliation of Urologic Symptoms Important for Terminal Patients

        Urologic problems are common in elderly patients with terminal illnesses and for them, researchers from the University of Kansas recommended palliation plans that balance life expectancy with the time it will take to get benefit from proposed therapies. Taking into consideration an individual's goals and looking at a wide range of options, they said, are important for lowering the burden of care while managing symptoms.
        Writing in Clinics in Geriatric Medicine, the authors of a new review noted that although 10.1% of all cancer deaths annually are from urologic cancers, urologic symptoms are also associated with the terminal stage of illnesses such as multiple sclerosis, Alzheimer's disease, and stroke (Clin Geriatr Med 2015;31:667–78).
        Organ failure (recurrent, sudden episodes of decline) and frailty (low levels of functional independence for long periods of time) are the trajectories in about 60% of deaths in the United States. Approximately 30% of deaths are from cancer, which involves a more predictable, steady loss of function. The remainder dies from sudden illness.
        Open, honest communication with patients and their families and an understanding of these typical disease trajectories are key when providing comfort care, the authors said. “Urologic problems have a significant impact on quality of life, which is made more difficult because of the privacy around the issues,” lead author Christian T. Sinclair, MD, told Caring for the Ages. “People can have a significant amount of embarrassment even bringing up the issue with clinicians.”
        For severe anxiety related to the condition, anxiolytics may be necessary.
        Integrating palliative care into the overall treatment plan for patients with advanced disease, studies show, not only can improve symptoms and quality of life but also may improve survival. Clinicians should keep in mind, the authors said, that what is appropriate to treat a particular symptom may be different for a person with days to live compared with someone with weeks or months of life expectancy.
        To palliate bone pain over the short term, NSAIDs and steroids are the mainstay because they work quickly. Oral dexamethasone (4–12 mg daily) can be added to improve functional status and quality of life but its effects may last only a few weeks. Bisphosphonates are an option for longer-term therapy. One or two fractions of external beam radiation may improve quality of life and work more quickly than bisphosphonates. Secondary options for bone pain include surgery, transcutaneous electrical nerve stimulation, and physical and occupational therapy.
        NSAIDs, steroids, and opioids are options for patients with pelvic pain, but clinicians also should look for a potentially reversible cause of this end-of-life symptom. A straight catheter can be used to rule out urinary retention as the underlying reason for delirium, which can also be triggered by medications such as anxiolytics and anticholinergics that are used to treat urinary incontinence.
        A urinary catheter — or a suprapubic one if a urinary catheter can't be inserted — also is first-line treatment for a suspected lower urinary tract obstruction. Placement of a ureteral stent or percutaneous nephrostomy tube may be an option for a patient with an upper tract obstruction who is expected to live for weeks or months.
        Hematuria can occur with administration of cyclophosphamide or ifosfamide and be hemorrhagic. For severe anxiety related to the condition, anxiolytics may be necessary. Consultation with a urologist and a palliative care physician about a treatment plan is recommended.
        In individuals who are dying, bladder outlet obstruction is common because of natural changes in the body and also as a side effect of anticholinergic medications. Patients with acute obstruction typically have severe lower abdominal pain whereas chronic obstruction may be painless. Use of a urinary catheter or a change in medications are the first-line treatments.
        The authors noted that risk of bacterial infection is increased in patients with indwelling or suprapubic catheters, 50% of whom will have bacteria in their urine within 10 to 14 days of catheter insertion. If a patient develops a catheter-associated urinary tract infection, consideration should be given to removing the device.
        Regardless of the urinary tract symptoms seen in a patient with a terminal condition, a good history and physical examination are essential. “Often at the end of life, it is even more important to explore the risks and benefits in light of the prognosis and goals of care, and it takes time to sit down and discuss that with patients and their families,” Dr. Sinclair said. The information gathered, however, may have benefits such as eliminating the need for urologic imaging that would be challenging to provide in an LTC setting.
        —Judith M. Orvos, ELS