Innovations in Hospice and Palliative Care

The 2nd Joint Clinical Conference and Exposition on Hospice and Palliative Care, Orlando, Florida -- March 23-26, 2001

David Introcaso, PhD


April 25, 2001

In This Article

Nonpain Symptom Management

A constellation of nonpain symptoms is typically associated with pain management in patients with serious, chronic, and eventually fatal illnesses. Michael Frederich, MD, Medical Director of the San Diego Palliative Home Healthcare, San Diego, California, discussed some of the common symptoms and suggested approaches to mitigation.[5]

Family members, caregivers and volunteers should receive education concerning the disease process (eg, a decrease in appetite in dying patients is common). The patient should be moved to another room, if possible, and encouraged to sit up during meals. Use of a stimulant (eg, caffeine) and supplements can be effective. Attention to food selection (patient preference with no limits) is important. Professional providers should be attentive to mouth problems and adequately trained in the use of enteral (tube) feedings and total parenteral nutrition when appropriate.

Families and caregivers should be instructed that any feeding should be administered only in small portions. The diet is typically liquid or low residue. Feeding is best done early in the day, and only if the patient wants to eat. In cases of complete obstruction, fluid administration is not appropriate because it will cause pain. Medications can include docusate sodium; antispasmodics (eg, a transdermal scopolamine patch); antiemetics (frequently effective in combinations); somatostatin (octreotide); and continuous subcutaneous infusion of medications, such as morphine, scopolamine, or haloperidol.

First establish what constitutes a "normal" bowel pattern for the patient. It is important to recognize that this symptom can occur with use of every opioid. Decreased fluid intake and decreased activity/mobility also may contribute to constipation. Tolerance for this side effect should not be accepted. Dietary interventions alone are not sufficient to correct the problem. Treatment should be guided by rectal examination. Specific measures for relieving constipation can include stimulant softener combinations, osmotic laxatives, combination agents (eg, casanthranol and docusate sodium), and enemas.

Caregivers can remove irritants and combat dryness with fluids and provide humidification through use of a steam vaporizer. Professional staff should address postnasal drainage with antihistamines and infection with the use of appropriate antibiotics. For cardiac patients, angiotensin-converting enzyme (ACE) inhibitors and diuretics may be appropriate. Use of bronchodilators (eg, albuterol or ipratropium inhalers) may also prove helpful for some patients.

The only reliable measure of this symptom is patient self-report of shortness of breath, a smothering feeling, and/or an inability to get enough air. It is crucial to recognize that respiratory rate and blood gas results often do not correlate with the feeling of breathlessness experienced by patients. Common causes of dyspnea include anxiety, bronchospasm, hypoxemia, pleural effusion, pneumonia, anemia, pulmonary edema and embolism. Treatment should attempt to address underlying pathology. Interventions may include use of oxygen, opioids, anxiolytics, and nonpharmacologic interventions, such as environmental modifications (eg, use of circulating fans and humidifiers), repositioning the patient, and managing anxiety with relaxation techniques and breathing exercises.

This condition should be suspected in patients with breast or lung cancer and patients with multiple myeloma. Symptoms include confusion, nausea, vomiting, constipation, and profound weakness. Treatment includes ambulation, hydration, and pharmacologic remedies, such as dexamethasone, furosemide, pamidronate, calcitonin, or etidronate.

During this session it was recommended that patients not be automatically medicated for symptoms of anxiety, restlessness, confusion, or acute psychosis. First priorities are to maintain a safe environment, provide reality reinforcement, and maintain physical touch. If possible, avoid use of physical restraints. Medications recommended for anxiety include lorazepam, diazepam, and pentobarbital. Haloperidol and chlorpromazine are most commonly used for confusion. Haloperidol is recommended for acute psychosis and midazolam and phenobarbitol for sedation (aggressive palliation).

Causes of nausea are numerous and may include metastases, meningeal irritation, mental anxiety, mucosal irritation, medications, and altered motility. Treatment should be specific to underlying causes, if known. Treatments include antacids, antiemetics, dopamine antagonists, antihistamines, anticholinergics, serotonin antagonists, prokinetic agents, and cytoprotective and cerebral cortical agents.


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