Nausea and Vomiting:

Causes:

1. Medications: Opioids, digoxin, anti-convulsants, antibiotics.

2. Toxins: Infections, radiotherapy, chemotherapy.

3. Metabolic Imbalances: High calcium levels, ketoacidosis, kidney failure.

4. Brain Related: Tumors in the brain, brain infections, cancer spreading to the brain’s lining, increased pressure inside the skull, meningitis, cerebral malaria, ear infections.

5. Gastrointestinal Issues: Slowed stomach emptying, intestinal blockage, constipation, fungal infection in the mouth or esophagus, tumors in the abdomen or pelvis, partial or complete obstruction of the bowel.

Assessment:

1. Take a history, noting the amount of vomit, its contents, and any odor.

2. Distinguish between actual vomiting, coughing up secretions, or bringing up undigested food.

   • Determine how long the problem has been occurring, including how often it happens, what triggers it, the type of vomit, and its consistency.

   • Review the patient’s medication list, including antibiotics, ARVs, and NSAIDs.

   • Consider the possibility of increased pressure within the skull.

   • Examine the abdomen to rule out inflammation of the pancreas or stomach, and peptic ulcers.

Pharmacological Management:

1. Choose anti-sickness medications based on understanding how different classes of drugs work.

2. Treat the underlying cause if possible (e.g., constipation with a stimulant laxative at night, reviewing and possibly changing other medications).

3. Select appropriate anti-sickness medications based on the cause:

   • To calm the vomiting center in the brain: hyoscine, cyclizine 50mg every 6 hours.

   • To calm the chemoreceptor trigger zone in the brain: prochlorperazine 5-10mg three times a day, haloperidol 0.5-1mg twice a day.

   • To help the upper bowel function normally: metoclopramide 5-10mg three times a day.

   • For delayed stomach emptying: metoclopramide 5-10mg three times a day (not used if there’s a blockage).

   • For disturbances of balance: prochlorperazine 5-10mg three times a day, cyclizine 50mg every 6 hours, for kidney problems – haloperidol 0.5-1mg.

Non-Pharmacological Management:

1. Provide emotional support, especially for symptoms related to anxiety or anticipation.

2. Suggest relaxation techniques.

3. Recommend changes to diet, such as drinking more fluids and eating small, regular meals.

4. Create a peaceful environment away from food smells that might trigger nausea.

Diarrhea:

Causes:

1. Imbalance in the use of laxatives.

2. Medications like antibiotics, NSAIDs, and ARVs.

3. Fecal impaction – liquid stool leaking around a hard stool or tumor.

4. Radiation therapy to the abdomen or pelvis.

5. Problems with nutrient absorption.

6. Tumors in the colon or rectum.

7. Other illnesses occurring at the same time.

8. Unusual eating habits.

9. HIV infection.

10. Stress.

Assessment:

1. Identify the cause of the diarrhea.

2. Distinguish between true diarrhea and overflow around a blockage.

3. Gather information about how long it has been occurring, the characteristics of the stool (volume, frequency, presence of blood), and any related symptoms (abdominal pain, fever).

4. Review the patient’s medications.

5. Perform stool tests to check for infection.

Pharmacological Management:

1. Advise drinking more fluids with oral rehydration solution after each episode of diarrhea.

2. If symptoms continue, give anti-diarrheal medication such as loperamide 2-4 capsules initially, then 2 capsules after each bowel movement, codeine 30mg three times a day, or liquid morphine 5mg/5ml every 4 hours, or 10ml at night.

3. Administer antibiotics for infections, for example, septrin 480mg twice a day if needed.

4. Consider IV fluids for severe dehydration.

5. Review and adjust medications if necessary.

6. Apply barrier cream to protect the skin when needed.

Non-Pharmacological Management:

1. Provide advice on nutrition.

2. Encourage drinking plenty of fluids.

3. Offer skin care to prevent breakdown.

4. Provide appropriate advice for incontinence, including using waterproof sheets and regular changing/cleaning to prevent pressure sores.

Constipation:

Causes:

• Direct effects of disease:

  1. Blockage in the intestines from tumors or pressure from masses in the abdomen.

  2. Damage to the lower spinal cord.

• Secondary effects of disease:
  3. Reduced food intake and a diet lacking in fiber.
  4. Dehydration.
  5. General body weakness.
  6. Metabolic problems – low potassium, high calcium.

• Medications:
  7. Opioids like codeine or morphine.
  8. Anticholinergic drugs like tricyclic antidepressants.
  9. Diuretics.

• Concurrent disease:
  10. Diabetes, underactive thyroid.
  11. Hemorrhoids, anal fissures. (Note: The most common causes are side effects from opioids and the effects of the illness itself.)

Assessment:

1. Take a history to determine the cause of the constipation.

2. Establish the patient’s usual bowel habits and their current pattern.

3. Perform abdominal and rectal examinations.

Pharmacological Management:

1. Prescribe suitable laxatives, such as bisacodyl 5-15mg at night.

2. Consider using pawpaw seeds, chewed or crushed in a drink.

3. Reduce or stop the dose of constipating medications.

Non–Pharmacological Management:

1. Use rectal interventions if needed, such as enemas.

2. Advise increasing fiber intake and fluid consumption.

3. Ensure privacy and accessible toilet facilities.

Management in Children:

For children, a laxative that draws water into the bowel (e.g., lactulose) is better than a stimulant laxative (bisacodyl) as stimulants can cause severe stomach pain in children. When starting opioids, prevent constipation by adding laxatives (e.g., bisacodyl).

Remember to adjust the dosage based on the child’s age:

• 6-12 years: Bisacodyl 5-10mg once daily by mouth.

• Step 1: Try lactulose, gradually increasing the dose over one week:

  • <1 year: 2.5ml twice daily.

  • 1-5 years: 5mls twice daily.

  • 6-12 years: 10mls twice daily.

• Step 2: If no improvement, add Senna.

  • 2-6 years: 1 tablet twice daily by mouth.

  • 6-12 years: 1-2 tablets twice daily by mouth.

• Step 3: If already on opioids, use step 2 drugs immediately.

Additional Notes:

If a rectal exam reveals hard stool, try a glycerine suppository. If the stool is soft but not moving, try a bisacodyl or senna suppository. If the rectum is empty, consider a bisacodyl suppository to bring the stool down or a high-phosphate enema.

For severe constipation, consider a phosphate enema or a bowel preparation product if available.

Mouth Sores and Difficulty Swallowing (Dysphagia)

These sores are often caused by fungal infections in the mouth and esophagus. Preventing mouth problems involves good oral hygiene, keeping the mouth moist, and promptly treating any infections.

Causes of mouth sores and difficulty swallowing:

1. Infections like fungal infections or herpes.

2. Inflammation of the mucous membranes from radiotherapy or chemotherapy.

3. Ulcers.

4. Poor dental hygiene.

5. Dry mouth from medications, salivary gland damage due to radiation or tumors, or breathing through the mouth.

6. Tumor erosion of the cheek lining, possibly leading to a fistula.

7. Iron deficiency.

8. Vitamin C deficiency.

Non-pharmacological management:

1. Prevention through regular mouth cleaning, keeping the mouth moist, and treating infections promptly.

2. Regularly check the mouth, teeth, tongue, palate, and gums for dryness, inflammation, ulcers, or infection.

3. Educate the patient and family on proper mouth care using available resources.

4. Use a soft brush or cloth for gentle cleaning, avoiding harsh brushing.

5. Rinse the mouth with a simple mouthwash of sodium bicarbonate or saline (a pinch in a glass of water).

6. Relieve dry mouth by sucking on ice or fruit pieces.

7. Apply petroleum jelly to the lips after cleaning.

Assessment and pharmacological management:

• Treat pain according to the WHO pain relief ladder.

• Consider oral morphine for severe pain from mucositis.

• Treat oral fungal infections even without visible white patches if there is inflammation:

  • Nystatin oral drops (1–2mls) every 6 hours after eating and at night, holding in the mouth for local effect.

  • Fluconazole (50mg daily for five days), increasing to higher doses (200mg daily for two weeks) if swallowing is difficult and esophageal candidiasis is suspected. Ketoconazole (200mg daily) is an alternative, but be aware of potential drug interactions.

• Treat other infections:

  • Apply Gentian Violet three times daily, effective for various sores.

  • Use metronidazole mouthwash (crushed tablets or liquid for injection mixed with fruit juice) for foul-smelling mouth sores, especially in oral cancer cases. Consider acyclovir (200mg by mouth for five days) for herpes infections. Severe infections may require oral or intravenous medications.

• Treat inflammation:

  • Consider steroids like oral dexamethasone (4–8mg) or prednisolone powder or solution for ulcers and inflammation. Ensure any infection is well-treated first, as steroids can worsen infections.

Hiccup

Hiccups are common in patients who are dying and can be distressing and exhausting, especially if they persist.

Cause:

1. Hiccups are usually caused by irritation of the phrenic nerve in the neck or chest, or irritation of the diaphragm.

2. Conditions linked to hiccups include tumors causing stomach distension, lung tumors, esophageal cancer, kidney failure, and enlarged liver.

3. Hiccups can also originate in the brain.

Management of hiccups:

Immediate measures:

1. Pharyngeal stimulation: Have the patient swallow dry bread or two spoons of sugar.

2. Correct uremia if possible.

3. Simple re-breathing from a paper bag to increase carbon dioxide levels.

4. Help the patient sit upright.

5. Medications like Metoclopramide (10-20 mg every 8 hours), haloperidol (3 mg at night), or chlorpromazine (25-50 mg at night) may be prescribed.

Gastro-esophageal reflux

Gastro-esophageal reflux often happens when there is pressure on the diaphragm from an abdominal tumor or fluid buildup, or with neurological disorders.

Management:

1. Position the patient upright, sitting.

2. Give medications after meals.

3. Consider giving milk.

4. If the patient is taking NSAIDs, they may need to stop.

5. Simple antacids like Magnesium trisilicate (10 ml every 8 hours) may be prescribed. If it continues, cimetidine (200 mg every 12 hours), ranitidine (300 mg every 12 hours), or omeprazole (20-40 mg once daily) may be prescribed.

Dehydration

Dehydration is common, and there is a strong desire to ensure patients are well-hydrated.

Diagnosis:

The diagnosis and how it affects the patient can depend on:

1. Whether dehydration occurs with an illness expected to get better, like diarrhea in a lung cancer patient with a longer prognosis, or severe diarrhea in an HIV/AIDS patient.

2. Presence of other symptoms:

   • Dehydration can worsen drug side effects, especially for medications like morphine, by affecting how the body gets rid of them. Stopping unnecessary medications or lowering doses while managing symptoms is advisable.

   • Fluids may be given briefly to ease distressing symptoms like hallucinations or muscle twitching.

3. Presence of a dry mouth rather than thirst:

   • Patients might say they are thirsty but appear well-hydrated; their symptom could be dry mouth.

   • If the patient is very thirsty and keeping their mouth moist doesn’t help, giving extra fluids might be appropriate.

4. Assess the patient’s proximity to death:

   • Patients near death often struggle with drinking and may cough when swallowing.

Assessment and management of dehydration:

1. A dilemma arises when a patient is very ill and nearing the end of life. For most dying patients, a decrease in fluid intake is natural and appropriate. Explaining this to the family can ease worries and reduce requests for more fluids.

2. Keeping the mouth and lips clean and moist is crucial, as a dry mouth can be more distressing than thirst.

3. In some situations, artificial hydration might be considered. Oral hydration should be tried first if possible, but IV or subcutaneous infusions can be considered if needed. Subcutaneous infusions are less invasive and can be done at home.

4. Too much hydration can lead to fluid overload, requiring IV access, which can become painful and difficult. Several factors should be considered when deciding to give extra fluids.

5. Offering more than sips of fluid can risk aspiration and pneumonia.

6. Families often worry about discomfort without hydration. However, loss of appetite and severe weight loss are common in advanced cancer, HIV/AIDS, and end-stage organ failure, and forced feeding or hydration won’t improve these conditions.

Cachexia and Anorexia

Cachexia refers to weakness, significant weight loss, and poor appetite common in advanced cancer, HIV/AIDS, and end-stage organ failure.

Cachexia is not the same as hunger or thirst and won’t improve with forced feeding or hydration. The causes differ between diseases but involve inflammatory substances and metabolic changes that cause the body to break down muscle and fat.

General measures for managing cachexia:

Ensure reversible causes of anorexia or malnutrition are addressed, such as:

• Lack of available or easily digestible food.

• Difficulty swallowing.

• Sore mouth or altered taste.

• Indigestion, nausea, vomiting, or constipation.

• Pain.

Management in Children:

Corticosteroids should generally not be used in children if lack of appetite and weight loss are the only symptoms.

A short course of corticosteroids may be considered for children with additional symptoms like nausea, pain, weakness, or low mood. Dexamethasone is the most appropriate corticosteroid for children. Alternatively, prednisone can be used at a dosage of 0.05-2mg/kg divided 1-4 times daily.

Faecal Incontinence

Faecal incontinence is upsetting for the patient and challenging for family to manage at home. Causes include:

1. Faecal impaction: Blockage leading to leakage.

2. Excessive laxatives: Causing loose stools.

3. Frequent, severe diarrhea in weak patients.

4. Paralysis affecting bowel control.

5. Weakened anal muscles, especially in the elderly.

6. Tumors in the anal or rectal area.

Management strategies for faecal incontinence:

1. Thorough rectal examination to identify the cause.

2. For relaxed anal muscles, constipating agents like loperamide or codeine phosphate may help.

3. For paralyzed or constipated patients, regular rectal emptying and stool softeners can help.

4. For ano-rectal carcinoma:

   • Radiotherapy may be recommended.

   • Rectal steroids like prednisolone suppositories twice daily or betamethasone foam twice daily can provide relief.

   • Metronidazole can be used rectally for offensive discharge.

5. Practical measures at home:

   • Use waterproof sheets and diapers, promptly changing and cleaning the patient after each episode.

   • Apply barrier cream to protect the skin.

   • Regularly turn immobile patients to prevent pressure sores.

Fatigue:

Chronic fatigue is common in advanced disease, often caused by multiple factors.

Causes of fatigue:

1. Anemia

2. Pain

3. Emotional distress

4. Sleep problems

5. Poor nutrition

General care for managing fatigue:

• Adjusting daily activities around periods of higher and lower energy.

• Treating the underlying cause if possible, e.g., blood transfusion for anemia.

• Low doses of stimulants like methylphenidate or antidepressants can be considered.

• Non-drug interventions include conserving energy, physical exercise, and stress reduction through relaxation and meditation.

Insomnia:

Insomnia is difficulty falling asleep, staying asleep, waking up too early, or non-restful sleep. It’s common in advanced disease and can be temporary or ongoing.

The causes of insomnia:

1. Temporary: Often due to stressful life events, bereavement, or illness.

2. Chronic: Linked to medical or psychiatric conditions, medication use, or unhelpful sleep habits. In advanced disease, it can be a psychological or physical side effect of diagnosis or treatment.

General care for managing insomnia:

• Reduce intake of nicotine, caffeine, and other stimulants, and avoid alcohol close to bedtime.

• Regular exercise earlier in the day can be helpful.

• Benzodiazepines are common sleep medications, providing quick relief by reducing the time to fall asleep, improving sleep quality, and promoting restful sleep.

• Long-acting benzodiazepines like lorazepam and diazepam can be considered but are not recommended for long-term use due to the risk of tolerance, dependence, and other side effects.

Confusion:

Confusion is a distressing symptom and can be challenging to manage.

Causes:

1. Uncontrolled pain

2. Urinary retention or severe constipation

3. Changes in environment or ward transfers

4. Metabolic disturbances (e.g., high or low sodium, high calcium, kidney problems)

5. Infections (e.g., urinary tract infection, fungal meningitis, other opportunistic infections)

6. Low oxygen levels

7. Increased pressure in the skull, strokes

8. Medication side effects (e.g., opioids, anticholinergics, corticosteroids)

9. Withdrawal from substances (e.g., alcohol, benzodiazepines, opioids)

10. Dementia, delirium, brain damage from HIV

11. Sudden loss of sight or hearing

General care for managing confusion

Create a calm, familiar, and reassuring environment. Regularly remind the patient of their surroundings and the time. Avoid physical restraints unless essential for safety. Support family involvement and allow them to express concerns.

Management:

• Address underlying causes (pain, urinary retention, constipation, infections, organ failure).

• Use medications cautiously to avoid over-sedation.

  • Mild agitation: diazepam or lorazepam.

  • Severe delirium: haloperidol or chlorpromazine with diazepam (not diazepam alone for severe delirium).

Depression:

Often misunderstood, under-diagnosed, and under-treated. Assess for persistent low mood (>50% of the day), loss of enjoyment/interest, inappropriate guilt, suicidal thoughts.

• Ongoing support and counseling.

• Consider antidepressants (e.g., amitriptyline, imipramine) if counseling is insufficient.

Anxiety:

May be part of depression or independent. Assess for panic, irritability, tremor, sweating, sleep disturbance, poor concentration.

• Encourage discussing fears and anxieties.

• Non-pharmacological: massage, relaxation, counseling.

• Consider benzodiazepines (e.g., diazepam) for persistent, impacting symptoms.