special subjects
Symptom Relief for the Dying Patient
Nausea and Vomiting
Many seriously ill patients experience nausea, frequently without vomiting. Nausea may arise with gastrointestinal problems (eg, constipation, gastritis), metabolic abnormalities (eg, hypercalcemia, uremia), drug adverse effects, increased intracranial pressure secondary to cerebral cancer, and psychosocial stress. When possible, treatment should match the likely cause—eg, stopping NSAIDs, treating gastritis with proton pump inhibitors, and trying corticosteroids for patients with known or suspected brain metastases. If nausea is due to gastric distention and reflux,metoclopramide(eg, 10 to 20 mg orally or subcutaneously 4 times a day as needed or given on a scheduled basis) is useful because it increases gastric tone and contractions while relaxing the pyloric sphincter. The 5-hydroxytryptamine (5-HT)3 antagonistsondansetronandgranisetronoften dramatically relieve nausea. Patients with no specific cause of nausea may benefit from treatment with a phenothiazine (eg,promethazine25 mg orally 4 times a day;prochlorperazine10 mg orally before meals or, for patients who cannot take oral drugs, 25 mg rectally 2 times a day). Anticholinergic drugs such asscopolamineand the antihistaminesmeclizineanddiphenhydramineprevent recurrent nausea in many patients. Combining lower doses of the previously mentioned drugs often improves efficacy. Second-line drugs for intractable nausea includehaloperidol(started at 1 mg orally or subcutaneously every 6 to 8 hours, then titrated to as much as 15 mg/day). Nausea and pain due to intestinal obstruction are common among patients with widespread abdominal cancer. Generally, IV fluids and nasogastric suction are more burdensome than useful. Symptoms of nausea, pain, and intestinal spasm respond tohyoscyamine(0.125 to 0.25 mg every 4 hours sublingually or subcutaneously),scopolamine(1.5 mg topically),morphine(given sc or rectally), or any of the other previously mentioned antiemetics.Octreotide150 mcg subcutaneously or IV every 12 hours inhibits gastrointestinal secretions and dramatically reduces nausea and painful distention. Given with antiemetics,octreotideusually eliminates the need for nasogastric suctioning. Corticosteroids (eg,dexamethasone4 to 6 mg IV, IM, or rectally 3 times a day) may decrease obstructive inflammation at the tumor site and temporarily relieve the obstruction. IV fluids may exacerbate obstructive edema. 