Common symptoms can be controlled as follows:1
metoclopramide 10 mg (o) tds
corticosteroids (e.g. dexamethasone 2–8 mg tds) high-energy drink supplements
If opioids need to be maintained, the laxatives need to be peristaltic stimulants, not bulk-forming agents. Treat as for any patient in the GP setting. Aim for firm faeces with bowels open about every third day.
e.g. lactulose 20 mL bd
Movicol, one to two sachets, in 125 mL water, 1–3 times daily
Rectal suppositories, microenemas or enemas may be required (e.g. Microlax).
Shaw's (or PCU) cocktail is useful for severe constipation. With a small quantity of water melt one tablespoon of Senokot granules in a microwave oven. Add 20 mL Agarol and constitute to 100 ml with cold or warm milk or ice-cream.
Tip: Tilt the pelvis for defecation by sitting upright with books under feet for elevation.
Noisy breathing and secretions7,11
Conservative: repositioning to one side, reduced parenteral fluids and nasogastric suction.
hyoscine butylbromide (Buscopan) 20 mg SC, 4 hourly or 60–80 mg daily by SC infusion
glycopyrrolate 0.2 mg SC as a single dose followed by 0.6–1.2 mg/24 hrs by continuous SC infusion
For unconscious patient, as above, also consider:
hyoscine hydrobromide 0.4 mg SC, 4 hourly or 0.8–2.4 mg/24 hrs by continuous SC infusion
atropine 0.4–0.6 mg SC 4–6 hourly (be cautious of delirium)
These agents dry secretions and stop the ‘death rattle’.
Identify the cause, such as a pleural effusion, and treat as appropriate. Pleural taps can be performed readily in the home (consider the PleurX® catheter). Adjust the patient's posture. Corticosteroids can be given for lung metastases. Oxygen may be necessary to help respiratory distress in the terminal stages and bedside oxygen can be readily obtained. Morphine can be used for intractable dyspnoea e.g. 2.5–5 mg (o) 4 hourly, together with haloperidol or a phenothiazine for nausea. Use a short-acting benzodiazepine (e.g. lorazepam 0.25–5 mg) sublingually if anxiety is a component.
(Exclude reversal causes, e.g. drugs, fear, faecal impaction, urinary retention.)
0.5 mg SC bolus or 0.25–0.5 mg (o) 12 hourly (drops SL) (3 drops = 0.3 mg) or tabs7
1–4 mg over 24 hours in SC syringe driver
midazolam 2.5–5 mg SC 1–3 hourly prn or 2.5–10 mg sublingual or intranasal or 10 mg 4 hourly by SC infusion
add (with care because of fitting) haloperidol
haloperidol 1.5–5mg (o) daily or 0.5–1 mg (SC) 4 hourly prn (can be reduced after 10 days) or 1–2.5 mg over 24 hours via SC infusion
metoclopramide 10–20 mg (o) or SC 8 hourly prn
Alternatives: promethazine, cyclizine
If due to poor gastric emptying, use a prokinetic agent: metoclopramide, cisapride or domperidone.
Consider ondansetron or tropisetron for nausea and vomiting induced by cytotoxic chemotherapy and radiotherapy (see CHAPTER 60).
To reduce pain, apply a mixture of 10 mg/mL topical morphine with 8 g/mL Intrasite hydrogel.
Common symptoms are headache and nausea. Consider corticosteroid therapy (e.g. dexamethasone 4–16 mg daily). Analgesics and antiemetics such as haloperidol are effective.
Paraplegia is especially prone to occur with carcinoma of the prostate, even when treated with LHRH analogues. The warning signs are the development of new back pain, paraesthesia in limbs or the recent development of urinary retention.1 The objective is to prevent paraplegia developing. High-dose corticosteroids are given while arranging urgent hospital admission.
clonazepam 0.25–1 mg (o) bd (consider oral liquid drops)
haloperidol 1–2.5 mg (o) bd
Swallowing granulated sugar with or without vinegar does not appear to be effective. Other drugs reported to be beneficial include baclofen, midazolam, chlorpromazine, nifedipine and metoclopramide.
mirtazapine 30 mg (o) daily, helpful for night-time sedation and appetite
consider methylphenidate (psychostimulant) 5 mg (o) bd since evidence indicates an improvement in symptoms13
This problem may be assisted by a high-calorie and high-protein diet. Otherwise consider total parenteral nutrition. A list of high-energy drink supplements is provided in Palliative Care: The Nitty Gritty Handbook.1
Determine the cause, including adverse opioid effect. Investigations include FBE, MCU, CXR, pulse oximetry. Consider treatment with olanzapine and haloperidol (refer to CHAPTER 45).
Consider hypercalcaemia in the presence of drowsiness, confusion, twitching and abdominal pain. It may be a paraneoplastic effect of myeloma and cancers (particularly lung and breast). It carries a poor prognosis—monitor serum calcium >3 mmol/L. Treat with rehydration, reduction of tissue mass and bisphosphonates.