Palliative care: Other symptoms
Constipation
This is a common symptom in patients with terminal illness due to loss of appetite, dehydration, immobility, drugs, and disease involving the gastrointestinal tract. Patients on morphine and other constipating drugs should be prescribed regular prophylactic laxatives. Regular administration of a faecal softener and a peristaltic stimulant is often recommended. The dose should be titrated to enable patients to pass a stool easily every one to three days.Diarrhoea
Diarrhoea is less common than constipation in patients with terminal illness . The diagnosis must be made carefully to exclude ‘overflow diarrhoea’ which is liquid faecal matter seeping past impacted faeces. Common causes of diarrhoea include excessive laxative use, side effects of drug therapy (e.g. chemotherapy, antibiotics), infections (e.g. C. difficile) and initiation of enteral feeds. Agents such as loperamide and codeine may provide symptomatic relief. Treatment for specific conditions include octreotide in patients with a carcinoid tumour which acts by increasing water and electrolyte absorption in the gut and slowing intestinal motility.
Dyspnoea
Dyspnoea is an unpleasant sensation of being unable to breathe easily. It is common in patients with advanced disease. It is important to ensure that any underlying co-morbidities, such as COPD or heart failure, are optimally managed. Opioids can help to relieve the sensation of breathlessness and tend to be more beneficial in patients who are breathless at rest. Often lower doses are required compared with pain, for example starting with immediate-release morphine 1-2mg every four hours and titrating according to response. Benzodiazepines can be used in the management of breathlessness associated with anxiety.Confusion
This may be managed by treating the underlying cause e.g. hypercalcaemia. If this fails, consider antipsychotics such as haloperidol or olanzapine. In terminal restlessness midazolam, levomepromazine and haloperidol may be administered as continuous subcutaneous infusions via syringe drivers.Excessive respiratory secretions
These can be reduced by subcutaneous injection of hyoscine hydrobromide, hyoscine butylbromide or glycopyrronium bromide. However, hyoscine hydrobromide crosses the blood-brain barrier and is often not used as a first-line antisecretory unless sedation is desirable.Intestinal obstruction
Intestinal obstruction occurs when there is a partial or complete obstruction of the gut lumen and/or peristaltic failure. The patient may suffer a range of symptoms depending upon the severity and location of the obstruction, but they may include vomiting, constipation, constant abdominal pain and colic.Choosing appropriate medicines to manage these problems is sometimes difficult due to their effects on gut motility. For example, as a prokinetic, metoclopramide may be helpful in a patient with nausea and vomiting who has gastric stasis, but it couldn’t be used if the patient also has colic because it might make it worse. Morphine may be helpful for constant abdominal pain, but if the patient also has peristaltic failure then an agent with a lower risk of constipation such as fentanyl should be considered. Erratic or poor oral absorption of medicines may also present a problem in patients with intestinal obstruction, and the use of non-oral options may be necessary such as patches or syringe drivers.