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Nausea: Assessment and Management
Medical Resident/Oncology Fellow Competency Assessment Tool Palliative Care Domain: Pain and Symptom Management Table of Contents
Introduction for the Learner (Resident/Oncology Fellow) . . . . . . . . . . . . . . . . . . . . . . . 2 Nausea: Assessment and Management
Introduction for the Learner (Resident/Fellow)
Introduction for the Clinical Faculty Evaluator
Prior to your evaluation of competency:
How to perform this competency assessment:
• Complete the web-based palliative care training program A Medical Resident or Oncology Fellow has requested that you "Medical Resident Training in End-of-Life and Palliative assess their competency in a selected palliative care domain dur- Care" before you undergo this competency assessment . The ing the time you are the attending physician on this service . To training program is available on the UMMS Intranet, click on assist you with this evaluation, please do the following .
Physicians . The course is listed under "Helpful Links ." It is Preparing for field evaluation of competency:
also available via the internet at http://134 .192 .120 .12/canRes/ • Review this Competency Assessment Tool thoroughly includ- htdocs/login .asp ing the Learning Objectives (Part 1), Teaching Outline (Part - Review Unit II-Management of Symptoms other than Pain 2) and Evaluation Checklist (Part 3) prior to pre-discussion (Nausea, Vomiting, Constipation) of the web based palliative counseling with Resident (required) .
care training program .
• Review Unit Unit 2 Module 3 (Nausea, Vomiting, Constipa- - Review Part 1 (Learning Objectives), Part 2 (Teaching Out- tion) of the Web-based palliative care training program, "Med- line) and Part 3 (Evaluation Checklist) THOROUGHLY so ical Resident Training in End-of-Life and Palliative Care ." The that you are aware of what is required of you . training program is available on the UMMS Intranet, click on • When you think you are suitably prepared for testing your Physicians . The course is listed under "Helpful Links ." It is competency in this area, ask the attending physician on your also available via the internet at http://134 .192 .120 .12/canRes/ inpatient clinical rotation to evaluate the selected competency htdocs/login .asp (optional) .
when the appropriate clinical situation arises .
Format of competency evaluation:
• Ascertain that the attending/faculty member is certified to During the clinical rotation
conduct the Palliative Care Competency Evaluation . • Based on the Learning Objectives (Part 1), Teaching Outline Field evaluation of competency:
(Part 2), and Evaluation Checklist (Part 3) of this document • During the course of a clinical rotation, it is anticipated that and the content in Unit II, Module 5 of the palliative care you will have opportunities to demonstrate your competency training website, assess whether the Resident or Fellow meets in Nausea: Assessment and Management with regard to pal- the Learning Objectives during the course of this clinical rota- liative and end-of-life care during morning work rounds with your attending, and also throughout the day or during times of night call or cross-coverage . • Review strengths and weaknesses of competency evaluation • Identify a faculty member to evaluate your competency – with Resident/Fellow .
current service attending recommended, if s/he is certified to • Provide constructive feedback to improve Residents/Fellows' conduct evaluation . ASK FACULTY MEMBER TO REVIEW performance and patient outcomes .
THIS COMPETENCY ASSESSMENT TOOL PRIOR TO YOUR PERFORMING THIS TASK SO THAT THEIR Complete Evaluation Checklist (Part 3 of this document)
MEMORY WILL BE REFRESHED AS TO THE DESIRED • Share with learner; allow learner to make his/her own self- CHARACTERISTICS OF PERFORMANCE THEY WILL assessment of performance .
BE EVALUATING during the course of the rotation . • Faculty and Resident/Fellow must sign this Evaluation Check- • At the end of the rotation, the Clinical Faculty Evaluator com- list (Part 3) .
pletes the Evaluation Checklist (Part 3) of this document, and • Learner is responsible for returning Evaluation Checklist to shares it with you . Dr . Wolfsthal (Residents) or Dr . Mannuel (Fellows) .
• You will also complete the self-evaluation portion of the checklist as a measure of competency in practice based learn-ing . • Evaluation Checklist must be signed by faculty and Resident .
• Return Evaluation Checklist to Dr . Susan Wolfsthal, Internal Medicine Residency Director or Dr . Heather Mannuel, Hema-tology/Oncology Fellowship Director .
Medical Resident/Oncology Fellow Competency Assessment Tool Palliative Care Domain: Pain and Symptom Management Nausea: Assessment and Management
Part 1: Learning Objectives
Note to learner and Clinical Faculty Evaluator: The Learning Objectives are listed in terms of fulfilling the six ACGME core compe-tencies, listed below; these are reflected in Evaluation Checklist in Part 3 of this document .
LEGEND to ACGME core competencies: http://www .acgme .org/Outcome OBJECTIVES –
A competent Medical Resident or Oncology Fellow will be able to: Describe how nausea has a significant negative impact on quality of life.
Interpret the role of the cerebral chemoreceptor trigger zone and vomiting center in the mediation of nausea and vomiting.
Describe three anatomical sites that send afferent input to the medullary vomiting center.
List at least two causes of nausea and vomiting for each of the following categories: gastrointestinal, CNS, drugs, metabolic, psychological.
Describe the mechanism of action and relative cost of at least one drug from each of the following classes: 1) dopamine antagonists; 2) serotonin antagonists; 3) glucocorticoid; 4) benzodiazepine; 5) cannabinoid; 6) anti-histamine.
Discuss the role of behavioral treatments for nausea.
Take a thorough history from a patient with nausea.
Construct a differential diagnosis for at least three patients with nausea.
Develop an initial treatment plan for at least three patients with nausea.
Effectively treat nausea that is refractory to an initial treatment approach.
List resources for managing nausea refractory to standard pharmacological manage- Prescribe anti-emetics in a cost-effective manner.
PC – Patient Care MK – Medical Knowledge PBL&I – Practice-Based Learning and Improvement IPCS – Interpersonal and Communication Skills P – Professionalism SBP – Systems-Based Practice (Adapted from Weissman, DE, Ambuel, B, Hallenbeck, JL . Improving end-of-life care: A resource guide for physician education. 4th ed. Milwaukee: Medical College of Wisconsin, 2007 and Emanuel LL, von Gunten CF, Ferris FD . The Education in Palliative and End-of-life Care [EPEC] Curriculum . Chicago: American Medical Association; 1999) . Medical Resident/Oncology Fellow Competency Assessment Tool Palliative Care Domain: Pain and Symptom Management Nausea: Assessment and Management
Part 2: Teaching Outline for Learner and Clinical Faculty
Evaluator (From Weissman, et al .1)
• Also, recommend reviewing Unit 2, Module 3 (Nausea, Vomit- • Psychological ing, Constipation) of the Web-based palliative care training program, "Medical Resident Training in End-of-Life and Pal- liative Care ." The training program is available on the UMMS Intranet, click on Physicians . The course is listed under "Help- - Conditioned response (e .g . anticipatory nausea/vomiting) ful Links ." It is also available via the internet at * May lead to nausea either via stimulation of CTZ and/or http://134 .192 .120 .12/canRes/htdocs/login .asp vestibular system .
Mechanism Of Vomiting
** May lead to nausea via stimulation of CTZ and/or vagal af- Vomiting Center--control center in medulla for coordinating the
efferent output of vomiting motor sequence (vomiting reflex) .
Sources of afferent input to the Vomiting Center • chemoreceptor trigger zone (CTZ) - entry point for emeto- • Behavioral treatments genic blood or CSF–borne • substances - located in the area postrema outside the Blood Brain Barrier (morphine, hypercalcemia, uremia) • cerebral cortex - limbic system (e .g . anxiety--anticipatory • visceral afferent - (vagal) stimulation--pharynx, GI tract (gas- • Nasogastric drainage or percutaneous gastrotomy - indicated mainly for gastric stasis/obstruction or bowel obstruction • midbrain ICP receptors - (e .g . raised intracranial pressure) refractory to conservative management .
• vestibular system - (e .g . drugs: morphine, infections) • Fluid management - patients with GI obstruction may benefit from restricting oral fluids and/or discontinuing IV fluids to decrease GI fluid output and vagal stimulation .
• Gastrointestinal Drug Therapy
There are many anti-emetics to choose from . Although often used in a trial and error fashion, certain disorders will respond best to a drug from a specific drug class . These include: • Movement-related nausea - Squashed stomach syndrome • Tumor-related elevated intracranial press . Glucocorticoid • Gastric stasis - Abdominal carcinomatosis • Stimulation of CTZ (drugs, uremia) Dopamine antago- - Extensive liver metastases nist or Serotonin - Acute effect of abdominal radiation or chemotherapy • Constipation Specific drugs - Posterior fossa tumors/bleed • Dopamine Antagonists - Infectious or neoplastic meningitis - prochlorperazine (Compazine) PO, IV, IM 10 mg q6; 25 mg supp pr q12 - chlorpromazine (Thorazine) PO, IV, IM 25-50 mg q6; 25 mg supp pr q6 - Chemotherapy ** - haloperidol (Haldol) PO, SC, IV, IM 0 .5-2 mg q6 - droperidol (Inapsine) IV, IM 0 .5-2 .5 mg q6 - thiethylperazine (Torecan) - promethazine (Phenergan) IV, PO 25 mg q6; pr 12 .5-50 mg supp pr q6; Medical Resident/Oncology Fellow Competency Assessment Tool Palliative Care Domain: Pain and Symptom Management Nausea: Assessment and Management
• Serotonin Antagonists - most expensive class - ondansetron (Zofran) IV 10 mg q8; PO 4-8 mg Q8h Berger AM, Shuster JL, VonRoenn JH (Eds .) . Principles and Practices of Palliative Care and Supportive Oncology. Lippin- - granisetron (Kytril) IV 10 mcg/kg qd, PO 1 mg qd cott-Wiliams-Wilkins, 2006 .
Hallenbeck, J . Fast Facts and Concepts #005 Treatment of Nau- - dolasetron (Anzemet) IV or PO dose is 100 mg qd sea and vomiting (VOMIT) . End-of-Life/Palliative Education • Glucocorticoids Resource Center, August 2005, 2nd . Ed . www .eperc .mcw .edu - Dexamethasone - dose and schedule are empiric: 4-10 mg Jancin B . Nausea at end-of-life: Think mechanistically . Internal Medicine News. August 1, 2007 . www .findarticles .com • Benzodiazepines King C . Nausea and vomiting . In Textbook of Palliative Nursing - lorazepam (Ativan PO or IV .5-2 mg q6 (helps to (2nd ed.). Ferrell BG, Coyle N . Oxford University Press, 2006 .
prevent anticipatory N/V) Mannix KA . Palliation of nausea and vomiting . In Hanks G, Cherny NI, Christakis NA, Fallon M, Kaasa S, Portenoy RK - dronabinol (Marinol) PO 2 .5-10 mg q6 (poorly tolerated (Eds) . Oxford Textbook of Palliative Medicine (4th Ed.). New York: Oxford University Press . 2010 . pp . 801-811 .
Regnard C . Dysphagia, dyspepsia and hiccup . In Hanks G, - diphenhydramine (Benadryl) PO or IV 25-50 mg q6 Cherny NI, Christakis NA, Fallon M, Kaasa S, Portenoy RK - hydroxyzine (Vistaril) PO or IM 25-50 mg q6 (Eds) . Oxford Textbook of Palliative Medicine (4th Ed.). New York: Oxford University Press . 2010 . pp . 812-832 .
- metoclopramide (Reglan) Wood GJ, Shega, JW, Lynch B, VonRoenn, JH . Management of · standard oral dose of 10 mg is ineffective against most intractable nausea and vomiting in patients at end-of-life . JAMA · is useful for treating gastroparesis · high-dose IV 1-3 mg/kg is effective against chemothera- py-induced nausea .
• Drugs for continuous infusion - chlorpromazine--start at 1 .0 mg /hr; IV; titrate up in 1 mg in- crements, typical response at 1- 3 mg/hr but can go higher—upper dose defined by unacceptable side effects - metoclopramide-start at 1 .0 mg/hr; IV or SQ Medical Resident/Oncology Fellow Competency Assessment Tool Palliative Care Domain: Pain and Symptom Management Nausea: Assessment and Management
Part 3: Evaluation Checklist
Learner name: _ Evaluator/Attending: _ o Resident PGY Level: [ ] 1 o Fellowship Year: Rotation Site: [ ] Inpatient Cancer Center [ ] Inpatient GIM [ ] Oncology Clinic [ ] Continuity GIM clinic [ ] Other Please rate the trainee's competency/skills/knowledge/attitude using the following scales: For competency/skills
For knowledge and attitudes (e.g. Medical Knowledge)
4 = Competent to perform independently 3 = Competent to perform with minimal supervision 3 = Satisfactory 2 = Competent to perform with close supervision / coaching 2 = Below average 1 = Needs further basic instruction 1 = Insufficient – needs further learning n/o = not observed n/o = not observed 4o 3o 2o 1o n/oo Developed an initial treatment plan for at least three patients with nausea.
4o 3o 2o 1o n/oo Effectively treated nausea that is refractory to an initial treatment approach.
4o 3o 2o 1o n/oo Prescribed anti-emetics in a cost-effective manner.
Overall Performance:
4o 3o 2o 1o n/oo Described how nausea has a significant negative impact on quality of life.
4o 3o 2o 1o n/oo Understood the role of the cerebral chemoreceptor trigger zone and vomiting center in the mediation of nausea and vomiting.
4o 3o 2o 1o n/oo Described three anatomical sites that send afferent input to the medullary vomiting center.
4o 3o 2o 1o n/oo Listed at least two causes of nausea and vomiting fro each of the following categories: gastrointestinal, CNS, drugs, metabolic, psychological. 4o 3o 2o 1o n/oo Described the mechanism of action and relative cost of at least one drug from each of the following classes: 1) dopamine antagonists; 2) serotonin antagonists; 3) glucocorticoid; 4) benzodiazepine; 5) can-nabinoid; 6) anti-histamine.
4o 3o 2o 1o n/oo Discussed the role of behavioral treatments for nausea. 4o 3o 2o 1o n/oo Constructed a differential diagnosis for at least three patients with nausea.
Overall Performance:
Interpersonal and Communication Skills
4o 3o 2o 1o n/oo Took a thorough history from a patient with nausea.
Overall Performance:
Systems Based Practice
4o 3o 2o 1o n/oo Listed resources for managing nausea refractory to standard pharmacological management.
Overall Performance:
Medical Resident/Oncology Fellow Competency Assessment Tool Palliative Care Domain: Pain and Symptom Management Nausea: Assessment and Management
Part 3: Evaluation Checklist (Continued)
Systems Based Practice
4o 3o 2o 1o n/oo Listed resources for managing nausea refractory to standard pharmacological management.
Overall Performance:
4o 3o 2o 1o n/oo Recognized nausea as a common end-of-life symptom.
Overall Performance:
Resident/Fellow areas for improvement:
Overall impression: Did the Resident/Fellow demonstrate competency in a manner so as to do no harm?
Resident/Fellow self-evaluation of performance: May comment on any of the above checklist items or other reflections on perfor-
mance; perceived strengths, and need for improvement and learning.
Clinical Faculty Evaluator/Attending Clinical Faculty Evaluator/Attending – PRINTED NAME/DATE Resident/Fellow – PRINTED NAME/DATE Medical Resident/Oncology Fellow Competency Assessment Tool Palliative Care Domain: Pain and Symptom Management

Source: http://palliativecaretraining.org/PDFs/CAT02D.pdf