PAIN

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/Vomiting

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

Dyspnea

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

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 laxative. Generally, bulk-type laxatives should not be used as they may lead to impaction.

Diarrhea

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

 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.

 Anorexia

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.

Cachexia

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 nutrition.

Anxiety

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.

Confusion

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.

Asthenia

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.

Oral Hygiene

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 teeth/gums. 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.

Decubitus Ulcers

 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.