Palliative: Symptoms

Question 1

What symptoms can occur at the end of life?

Answer 1

Nausea and vomiting
Constipation
Breathlessness
Oral problems
Insomnia
Pruritis
Repeated venepuncture
Agitation and confusion
Hiccups
Respiratory tract secretions

Question 2

What are causes of N/V at end of life?

Answer 2

Chemotherapy
Constipation
Hypercalcaemia
Oral candidiasis
GI obstruction
Drugs
Severe pain
Infection 
Renal failure

Question 3

What is management of N/V

Answer 3

Treat reversible causes: laxatives, analgesia, hydration for hypercalcaemia, fluconazole for oral candida

Anti-emetic

Question 4

What should you base antiemetic choice on? Give 6 different anti-emetics

Answer 4

Mechanism or nausea
Site of action

Cyclizine
Metoclopramide
Domperidone
Haloperidol
Ondansetron
Levomepromazine

Question 5

What class is cyclizine? What is it used for?

Answer 5

Antihistamine, anticholinergic

Central action so good for intracranial disorders

Question 6

What class is metoclopramide? What is it used for? SE?

Answer 6

Dopamine antagonist
Blocks celtral chemoreceptor trigger zone
Peripheral prokinetic effects

Good in gastroparesis

Extra-pyramidal side effects PADT

Question 7

What class is domperidone? What is it used for?

Answer 7

Peripheral dopamine antagonist - does not cross BBB

Question 8

What class is haloperidol? What is it used for?

Answer 8

Dopmaine antagonist

Effective in drug or metabolically induced nausea
Use lower doses IV/SC as more potent

Question 9

What class is ondansetron? What is it used for? SE?

Answer 9

5HT3 serotonin antagonist

Good for chemo/radiotherapy related nausea
May cause constipation

Question 10

What class is levomepromazine? What is it used for?

Answer 10

Broad spectrum
May be very effective if feat/anxiety contributing
Can sedate

Question 11

What are causes of constipation at EOL?

Answer 11

Opioid side effect
Hypercalcaemia
Dehydration
Drugs
Intra-abdominal disease

Question 12

Mx of constipation?

Answer 12

Treat reversible causes
Good fluid intake
Privacy and toilet access

Stimulant Senna at night ± softener (sodium docusate)
Osmotic laxative (macrogol)
Rectal treatments (glycerol suppository, phosphate enema)

Question 13

What are causes of breathlessness at EOL?

Answer 13

Infection
Effusion
Anaemia
Arrhythmia
Thromboembolism

SVCO

Question 14

Mx of breathlessness

Answer 14

Treat reversible causes
Consider thoracocentesis ± pleurodesis for effusion
Radiologically placed permanent drain if recurrent effusions

Low dose opioids to reduce respiratory drive

Benzodiazepine if associated anxiety e.g. lorazepam SC

Question 15

What are causes of oral problems?

Answer 15

Poor oral hygiene
radiation
Drugs - anticholinergics, chemotherapy, diuretics
Infection - candidiasis, herpes simplex

Question 16

Mx for oral problems?

Answer 16

Oral candida - oral fluconazole
Herpes simplex - aciclovir

Good mouth care
Maintain fluid intake with frequent smalld rinkes
Sugar free chewing gum
Normal saline mouth washes
Soft toothbrush

Salivary stimulants - e.g. pilocarpine eye drops in mouth

Question 17

Mx for insomnia?

Answer 17

Appropriate room temperature
Darkness
Quiet during the night (side room)
Prescribed glucocorticoids in morning - can cause insomnia if given later
Discuss and address psychological issues

Zopiclone
Benzodiazepines

Question 18

What are causes of pruritis?

Answer 18

Systemic disease (hepatitis, renal failure, polycythaemia)
Cancer related (cholestasis, lymphoma, leukaemia, hepatoma, myeloma, paraneoplastic)
Drug reaction (opioids, SSRA, chemotherapy)
Primary skin disease

Question 19

What is Mx of pruritis?

Answer 19

Treat underlying cause where possible
Cholestasis: biliary stenting, sertraline
Opioid induced - antihistamine, opioid switch
Paraneoplastic - paroxetine

Regular topical emollients as soap substitute

Avoid topical antihistamines - may cause contact dermtitis

Question 20

Mx for repeated venepuncture

Answer 20

Risk of painful extravasation and phlebitis may be avoided by use of a central catheter - Hickman or PIC)

Flush with saline or dilute heparin every week