Palliative Care

Palliative Care

  • Nausea and Vomiting in Palliative Care
  • Pain in Palliative Care
  • Shortness of Breath in Palliative Care 

 

 

Nausea and Vomiting in Palliative Care 

Nausea = sensation of the desire to vomit
Vomiting = action of expelling GI contents via mouth (usually an involuntary reflex)

Causes of nausea ?and vomiting in palliative patients

  • Cancer e.g. brain metastasis or bowel obstruction
  • Disease complications e.g. Hypercalcaemia
  • Debility e.g. infection, constipation
  • Treatment e.g. chemotherapy
  • Concurrent e.g. Gastroenteritis

Manag?ement of vomiting

  • Treat underlying cause if possible e.g. infection
  • Determine which neurotransmitter receptors are involved
  • Chose and antiemetic for the specific neuroreceptor
  • Choose the relevant route of administration
  • Reassess to identify any additional triggers

Decide whether any of triggers can be reversed

When the cause of symptoms is known, the antiemetic should be chosen depending on its receptor affinity.  E.g. metoclopramide for treatment of drug side effects. 
 
 

  Dopamine D-2 antagonist Histaminee H-1 antagonist Acetylcholine
(muscarinic) antagonist
5HT2 antagonist 5HT3 antagonist 5HT4 agonist
metoclopramide ++       (+) ++
domperidone ++          
cisapride           +++
ondansetron         +++  
cyclizine   ++ ++      
haloperidol +++ +        
levomepromazine ++ +++ ++ +++    

 
Antiemetic drugs work by binding to specific receptor sites in the chemoreceptor trigger zone (CTZ) or vomiting centre (VC) in the brainstem.  At each site, there are several receptors; the more strongly the drug binds to the receptor, the more potent its antiemetic activity.
Levomepromazine is generally the second line medication used in nausea in palliative care.  It has a broad mechanism of action has good symptomatic relief but many side effects including its action as a sedative.  It can be given by the oral and subcutaneous route.
 

Non-pharmacological treatments

  • Relaxation techniques
  • Calm treatment
  • Hypnotherapy
  • Small meals/snacks
  • Cover odorous wounds
  • Avoid strong smells e.g. cooking
  • Sea bands/acupressure

- See more at: http://almostadoctor.co.uk/content/systems/palliative-care/nausea-and-vomiting-palliative-care#sthash.GyKIiev9.dpuf

 

Pain in Palliative Care 

Pain = unpleasant sensory and emotional experience with physical, psychological, spiritual and social aspects.  

Assessment of pain

It is important to remember that pain is a symptom and not a diagnosis.  The key to successful treatment is accurate diagnosis.  This can be achieved by good history taking. 
 
S                Site
O               Onset
C               Character
R               Radiation
A               Associated features
T                Timing
E                Exacerbating and relieving factors
S                Severity

Causes of pain in palliative care

  • Effect of underlying pathology e.g. lung cancer
  • Result of treatment e.g. neuropathy from chemotherapy
  • Unrelated e.g. DVT/pressure sores

Treatment of pain in palliative care

The principles of pain relief in palliative care are:

  • By the clock (regular)
  • By the mouth
  • By the ladder (use the analgesia ladder)

WHO pain ladder

  1. Non-opioid e.g. paracetamol
  2. Mild opioid e.g. Codeine and adjuvant e.g. ibuprofen
  3. Strong opioid e.g morphine

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