Key notes on symptom control issues in Palliative Care

Investigations

The diagnosis is based on the clinical picture. Investigations may help but are not needed for appropriate management to be initiated.

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  Plain abdominal films may show the classic fluid levels of obstruction.
  

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  CT of abdomen and pelvis may be helpful in detecting tumour recurrence.
  

Management

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  If a single level of obstruction is possible, as in colorectal cancer, then a surgical opinion should be sought, if the patient’s general performance status is good.
  
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  Vomiting will rarely be abolished whatever the level of obstruction, but can be reduced to a tolerable frequency in most cases.
  
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  It is rare for a patient with malignant bowel obstruction to need nasogastric tube insertion and parenteral fluids. The nausea and vomiting can usually be controlled (although not completely eliminated) using appropriate medication in a syringe driver. This often needs specialist input to establish the correct drug combination
  

In high level obstruction consider metocolpamide 60mg subcutaneously over 24 hours in a syringe driver.

If colic is a significant feature use hyoscine butylbromide 60mg subcutaneously over 24 hours in a syringe driver.

If nausea is a significant symptom use haloperidol 5mg subcutaneously over 24 hours.

With frequent large volume vomits, consider using octreotide 600-900 micrograms subcutaneously over 24 hours in syringe driver, titrating the dose up or down depending on response.

Patients may eat and drink what they wish: sufficient absorption across the GI tract can take place to prevent absolute dehydration. Patients will tolerate some degree of dehydration provided careful attention is paid to mouth care.

Breathlessness

Breathlessness
Step one	Diagnose the cause and treat if possible	Small doses of oral short acting opioids
Step two	Nebulised saline	Anxiolytics
Step three	Trial of steroids	Ask for help

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  The impact of dyspnoea on patients will vary. Patients with a history of chronic obstructive pulmonary disease whose respiratory capacity is already limited may be less affected than someone with no such history.
  
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  Identify and where possible treat reversible factors such as anaemia, bronchospasm and pleural effusion.
  
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  Identify and address patient’s and family’s concerns and expectations about breathlessness. Patients and families are frequently fearful that the patient will choke to death (unlikely) or literally run out of breath (unlikely).
  
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  Teach self help measures such as use of fans, open windows and relaxation/breathing techniques. Modify lifestyle to minimise physical exertion e.g., moving the bed downstairs, sitting down to wash and shave, etc.