Generally, the first symptom to relieve distress is associated
with pain. Pain is what the patient says is pain. It is subjective,
multidimensional and can include psychological, social and
spiritual aspects. Pain can be either chronic or acute; generally
the pain becomes chronic in nature.
Proper control of pain requires an assessment of the type of pain
that the patient experiences. There are many different pharmacological
agents that can be used to treat different types of pain;
somatic, visceral and deafferentiation pain.
Pain medication must generally be given around the clock. It is
generally given in anticipation of pain, not necessarily in
response to pain. The patient must have flexibility in dosing so
that a baseline level of pain relief is obtained with the opportunity
of immediately addressing “breakthrough” pain. In many
cases, long-acting products are used where the proper dosage is
determined by titrating the patient and allowing the patient to
use immediate acting products for “breakthrough” pain. If the
use of the immediate release products becomes more frequent,
the dose of the long acting products is usually increased. Also,
one must learn that there is usually no such thing as an “overdose”.
The dose of the analgesics used should relieve the pain
and not cause sedation and side effects.
Generally, the patient is asked to rate their pain on a scale of 0
through 10, where 0 is being free of pain and 10 is the worst
imaginable pain. Although most patients would prefer to be free
of pain, many are quite content with maintaining the pain at
about 3 or below on this scale.
Nausea and vomiting occur in a reported 60% of terminal cancer
patients, but these symptoms tend to be intermittent. Nausea
can be due to drug side effects, oral thrush, brain metastases,
anxiety, gastric irritation, intestinal obstruction, constipation,
small stomach syndrome, hypercalcemia, uremia and a lowgrade
urinary tract or pulmonary infection. It usually has more
than one cause. Appropriate routes of administration of antinauseants
include parenteral, rectal and transdermal.
Drug therapy has included neuroleptics (haloperidol, prochlorperazine),
antihistamines (cyclizine, hydroxyzine,
dimenhydrinate), anticholinergics (hyoscine), prokinetics (metoclopramide,
domperidone, cisapride), 5HT3 antagonists
(ondansetron, granisetron), corticosteroids (dexamethasone) and benzodiazepine
The incidence of dyspnea in advanced malignancies can range
from 48-79% in patients. It is a frequent part of the dying
process and can be due to multiple causes, including anemia,
ascites, bronchospasm, cardiac failure, lung collapse, lung infection,
pericardial effusion, pleural effusion, pneumothorax,
pulmonary emboli and superior vena cava obstruction. The
treatment varies depending upon the etiology and the condition
of the patient, but can include bronchodilators, corticosteroids,
sedatives and oxygen.
Constipation is a frequent complaint and may be related to the
use of narcotics for pain management. In addition to drug use
(narcotics, diuretics, anticholinergics, aluminum-containing
antacids), other causes of constipation include a low-fiber diet,
failure to heed the urge (due to lack of privacy or incorrect positioning)
or reduced defecation (possibly due to anal fissure or
hemorrhoids), dehydration, depression and hypercalcemia. Generally, patients
should go no more than three
days without a bowel
movement. Laxative treatment
should include both a fecal
softener and a stimulant
bulk-type laxatives should
not be used as they may lead
Causes of diarrhea may include steatorrhea (due to malabsorption
of fat), malignant intestinal obstruction, laxative imbalance,
rectal tumor, fecal incontinence due to lack of sphincter control
and a carcinoid tumor.
Hiccups are a reflex that results from irritation of the vagus
nerve or by stimuli from other parts of the central nervous system.
The reflex is processed in the brain stem and is inhibited
by increased carbon dioxide in the blood and by stimuli from
the pharynx. It can be caused by irritation of the vagus nerve,
irritation of the phrenic nerve and by the central nervous system.
Drug therapy can be implemented with an antacid
preparation with dimethicone; every 4-6 hours. If not effective,
metoclopramide (10-20 mg every 4-6 hours) or cisapride (20 mg
every 12 hours) can be added. If it persists, baclofen (5-10 mg
every 6-12 hours) can be substituted for the metoclopramide.
The rationale is that the antiflatulent drugs facilitate belching,
reducing gastric distension; metoclopramide hastens gastric
emptying, and baclofen relaxes the diaphragm. Other drugs
that have been used include chlorpromazine, haloperidol,
phenytoin, sodium valproate, carbamazepine and nifedipine.
The majority of hospice patients experience a loss of appetite
(anorexia) as their illness progresses. Taste abnormalities are
relatively common in seriously ill patients and the body needs
less intake when it is inactive. Some causes are reversible, but
progressive anorexia is a natural part of dying. Other factors
that may contribute include chemotherapy, radiation therapy,
oral thrush, constipation, nausea, hyponatremia, hypercalcemia,
chemotherapy and depression.
The extent of muscle wasting and weight loss during cachexia
is much greater than would be expected simply from reduced
food intake alone. Also, cachexia is not reversed by increased
food intake. Causes of cachexia include vomiting, diarrhea,
malabsorption, reduced food intake, hemorrhage, ulceration,
increased metabolic rate, abnormal metabolism, surgery,
chemotherapy, radiation therapy, starvation and diabetes mellitus.
Therapy has included corticosteroids, progestogens,
prokinetic drugs (metoclopramide) and parenteral and enteral
Anxiety is a normal reaction in most patients; however, some
patients have a severe and prolonged reaction to the physical
effects of the illness and its potential implications for the future.
The realization that death is approaching may cause feelings of
regret, missed opportunities and guilt and fear of suffering of
what happens after death. Causes can be fear of the illness/
treatment, thoughts about the past/future, worries about family/
finances, incomplete or conflicting information from healthcare
workers/family, loss of independence, pain, dyspnea, nausea,
weakness, drugs (neuroleptics, stimulants, corticosteroids),
drug withdrawal (alcohol, benzodiazepines), depression, delirium
and paranoia. Drug therapy has included antidepressants,
benzodiazepines, antipsychotics and propranolol.
About 30% of cancer patients will experience confusion at some
point during their illness which may be a result of drugs, full
bladder, pain, impaction, brain metastases, infection, metabolic
imbalance, anxiety, withdrawal from alcohol or benzodiazepines
and delirium. Many drugs, including psychoactive
drugs, diuretics, beta blockers, anti-Parkinsonism drugs and
sulfonamides can also cause confusion.
The loss of energy, generalized weakness and rapid tiring during
exercise are common symptoms of terminal illness and may be a
part of the anorexia-cachexia syndrome. It may result from illness
(anorexia, inactivity, anemia, hyponatremia, hypoadrenalism,
renal/liver failure), be cancer-related, treatment related (surgery,
chemotherapy, radiation therapy, drugs-diuretics, antihypertensives
or oral hypoglycemics), or result from infection, dehydration,
malnutrition and starvation. Drug therapy for asthenia is limited
but has included corticosteroids and progestogens.
Routine oral hygiene can prevent discomfort, facilitate
eating/drinking, prevent halitosis, minimize social isolation and
psychological distress; ensure that the oral mucosa and lips are
moist, clean and healthy, and remove debris and plaque from the
Toothbrushes and dental floss (if practical) should be used at least
twice daily. A mouthwash can be used every two to four hours.
Petroleum jelly will help prevent dry, cracked lips and should be
applied regularly in a thin layer at least twice daily.
Dry mouth can be relieved by drinking fluids, chewing gum, taking pilocarpine, using artificial saliva and using non-alcoholic mouthwashes.
Candidiasis can be treated using a nystatin mouthwash or
by taking oral ketoconazole or fluconazole.
Aphthous ulcers are painful and can be treated using tetracycline
suspension mouthwash (250 mg in 10-20 mL of water in mouth for
three minutes then expectorated; repeat every eight hours for three
days), chlorhexidine gluconate mouthwash (0.2%; rinse with 10 mL
every eight hours) and hydrocortisone lozenges (2.5 mg every eight
hours). Local analgesic agents can be provided as needed.
Pressure on the skin and tissues in contact with a chair, bed or
other surface can result in decubitus ulcers. When healthy, we minimize
the pressure by changing position; in the immobile patient
however, damage can develop in a matter of a few hours. The earliest
sign is redness (blanching erythema), followed by
non-blanching erythema, partial-thickness skin loss, and then an
established ulcer (a deep crater with full-thickness skin loss and
damage to subcutaneous tissue).
A number of different compounded medications are commonly
used for treating decubitus ulcers including such drugs as topical
protectants, phenytoin and misoprostol.