Neurological Symptoms in Palliative Care
INTRODUCTION
Neurological symptoms in palliative care are often invisible — unlike a wound or a tumour, fatigue, confusion, or depression cannot be seen. Yet they cause immense suffering and are frequently under-recognised and under-treated.
💡 Key Message: In palliative care, the patient's mind and nervous system deserve the same careful attention as their body. A patient with well-controlled pain but untreated depression is not receiving good palliative care. (Physiological context: The somatosensory cortex processes physical pain, while the limbic system processes emotional pain. Both pathways activate the same stress cascades—cortisol and sympathetic overload—meaning emotional suffering physically deteriorates the body).
FATIGUE
What Is Fatigue?
Fatigue in palliative care is not ordinary tiredness. It is a persistent, overwhelming sense of exhaustion that is not relieved by rest or sleep. It affects physical, mental, and emotional function.
The patient's words: "I feel like I've run a marathon, but I've only walked to the toilet."
Causes of Fatigue
| Cause | Explanation & Pathophysiological Expansion |
|---|---|
| Anaemia | Reduced oxygen-carrying capacity → tissues are starved of oxygen. (Without O2, the electron transport chain in the mitochondria halts, forcing cells into anaerobic glycolysis, which produces lactic acid and yields only 2 ATP instead of 36 ATP, leading to profound cellular exhaustion). |
| Pain | Constant pain is exhausting; the body uses massive amounts of ATP and sympathetic nervous system energy to cope with it. |
| Emotional distress | Anxiety, depression, and grief drain mental and physical energy via chronic HPA-axis (Hypothalamic-Pituitary-Adrenal) activation. |
| Sleep disturbances | Poor-quality or insufficient sleep prevents central nervous system restoration and clearance of metabolic waste from the brain (glymphatic system). |
| Poor nutrition | Cachexia, anorexia, malabsorption → absolute lack of glucose and lipid fuel for the body. |
| Medications | Opioids, sedatives, some antiemetics cause direct CNS depression and drowsiness. |
| Tumour-related factors | Release of inflammatory cytokines (like TNF-alpha and Interleukin-6) creates a hypermetabolic, catabolic, energy-draining state where the body literally breaks down its own muscle for fuel. |
| Organ failure | Heart, liver, kidney failure → reduced metabolic efficiency and buildup of toxic metabolites (like urea) that depress the brain. |
🧠 Mnemonic for Causes of Fatigue
"A-P-E-S-P-M-T-O"
- Anaemia
- Pain
- Emotional distress
- Sleep disturbance
- Poor nutrition
- Medications
- Tumour factors
- Organ failure
Assessment of Fatigue
| Question to Ask | Why It Matters |
|---|---|
| "When did the fatigue start?" | Sudden onset suggests an acute, potentially reversible cause (e.g., GI bleeding, new infection). |
| "Is it worse at certain times?" | Morning fatigue may heavily suggest depression; post-activity fatigue suggests cardiac deconditioning or anaemia. |
| "Does rest help?" | If rest does NOT help, this is pathological fatigue (driven by cytokines/disease, not just exertion). |
| "How does it affect your daily life?" | Guides intervention priority and establishes a baseline for Activities of Daily Living (ADLs). |
| "Are you sleeping well?" | Identifies sleep disturbance as a primary contributing factor. |
| "What medications are you taking?" | Identifies drug-induced fatigue (e.g., accumulating metabolites of long-acting opioids). |
Management of Fatigue
A. Treat the Underlying Cause
- Anaemia: Blood transfusion if appropriate and beneficial (e.g., Hb < 7 g/dL with severe symptoms).
- Pain: Optimise analgesia.
- Depression / anxiety: Counselling, antidepressants, anxiolytics.
- Sleep disturbance: Treat insomnia (see Insomnia section).
- Malnutrition: Nutritional support, treat oral problems (e.g., oral thrush).
B. Pharmacological Management
| Drug | Dose | Notes |
|---|---|---|
| Methylphenidate (Ritalin) | Low dose | Psychostimulant — increases alertness and energy by blocking dopamine and norepinephrine reuptake in the brain; use with extreme caution in cardiac patients (can cause tachycardia/arrhythmias). |
| Antidepressants | As prescribed | If depression is contributing to fatigue. |
Uganda : Methylphenidate may not be readily available. Focus aggressively on treating reversible causes (anaemia, pain, sleep) and utilizing non-pharmacological strategies.
C. Non-Pharmacological Management
| Strategy | How It Helps |
|---|---|
| Energy conservation | Plan activities for when energy is highest (peak circadian rhythms); rest before and after. |
| Prioritise tasks | Do only what is essential; delegate or eliminate non-essential activities. |
| Physical exercise | Gentle walking or stretching maintains muscle tone (preventing severe atrophy) and improves mood via endorphin release. |
| Relaxation and meditation | Reduces sympathetic emotional drain; improves sleep quality. |
| Scheduled rest periods | Short, planned rests prevent severe exhaustion from overexertion. |
| Family education | Teach family that fatigue is a physiological disease state, not laziness — they should support, not push the patient. |
👩⚕️ Nursing Tip: Help the patient create an "energy budget" — like a financial budget, but for energy. Decide what activities are "essential," "helpful," and "can wait," and allocate energy accordingly.
INSOMNIA
What Is Insomnia?
Insomnia is a subjective complaint of inadequate sleep, which may manifest as:
- Difficulty falling asleep (sleep onset insomnia)
- Difficulty staying asleep (sleep maintenance insomnia)
- Early morning awakening with inability to return to sleep
- Non-restful sleep — waking feeling unrefreshed
💡 Key Point: Insomnia is what the patient says it is. If they feel they are not sleeping enough or well, they have insomnia — even if they appear to sleep to an observer.
Types of Insomnia
| Type | Duration | Causes |
|---|---|---|
| Transient | Days to weeks | Life crisis, bereavement, acute illness, hospital admission (loss of familiar environment). |
| Chronic | Months or longer | Medical disorders, psychiatric disorders, maladaptive habits, long-term medications. |
Causes of Insomnia in Palliative Care
| Category | Examples |
|---|---|
| Physical | Pain, dyspnoea, nausea, pruritus (severe itching), urinary frequency, cough. |
| Psychological | Anxiety, depression, fear of death (thanatophobia), anticipatory grief. |
| Environmental | Unfamiliar hospital ward, noise, bright lights, uncomfortable bed. |
| Medications | Steroids (especially if given late in the day - mimics morning cortisol spike), stimulants, some antidepressants. |
| Lifestyle | Daytime napping, irregular sleep schedule, caffeine, nicotine (a stimulant). |
| Disease-related | Hyperthyroidism, delirium, restless legs syndrome. |
Assessment of Insomnia
| Question | Purpose |
|---|---|
| "What time do you go to bed?" | Identifies irregular schedule disrupting circadian rhythms. |
| "How long does it take to fall asleep?" | Identifies sleep onset problems (often anxiety-driven). |
| "Do you wake during the night? How often?" | Identifies sleep maintenance problems (often pain or urinary frequency). |
| "What time do you wake in the morning?" | Early morning awakening is a classic hallmark of clinical depression. |
| "Do you nap during the day?" | Daytime napping depletes "sleep drive" (adenosine buildup) needed for night sleep. |
| "Do you drink tea, coffee, or alcohol?" | Caffeine blocks adenosine receptors. Alcohol suppresses REM (Rapid Eye Movement) sleep, causing fragmented, non-restful architecture. |
| "What medications do you take and when?" | Steroids after 4 PM commonly cause insomnia. |
| "What are you thinking about when you can't sleep?" | Reveals anxiety, fear, or rumination. |
Non-Pharmacological Management
- Reduce stimulants: Cut down nicotine, caffeine (tea, coffee, cola), especially after midday.
- Avoid alcohol near bedtime: Alcohol may help you fall asleep initially (via GABA), but it causes fragmented, non-restful sleep due to REM rebound later in the night.
- Exercise regularly: But do it in the morning or early afternoon, not near bedtime.
- Establish a sleep routine: Same bedtime and wake time every day.
- Create a sleep-friendly environment: Dark, quiet, cool room; comfortable bedding.
- Relaxation before bed: Warm bath, gentle music, reading, prayer, meditation.
- Avoid daytime napping: Or limit to 20–30 minutes early afternoon.
- Address underlying symptoms: Treat pain, dyspnoea, nausea — these are common physiological causes of insomnia.
👩⚕️ Nursing Tip: In hospital, minimise nighttime disruptions — cluster care (do observations, medications, and turns all together at once), dim lights, and reduce noise. Protect the patient's sleep as you would protect their medication.
Pharmacological Management
| Drug | Dose | Half-Life | Notes & Pharmacokinetics |
|---|---|---|---|
| Lorazepam | 0.5–2 mg | 10–22 hours | Long-acting; undergoes direct glucuronidation in the liver (no active metabolites). Safest to use longer in the elderly without cumulative daytime drowsiness. |
| Diazepam | 2.5–10 mg | 20–50 hours | Very long-acting; metabolized into desmethyldiazepam (an active metabolite with a half-life of up to 100 hours!). High risk of accumulation, daytime sedation, and falls in the elderly. |
⚠️ IMPORTANT WARNING: Benzodiazepines are NOT for long-term chronic insomnia due to the risk of:
- Tolerance: Receptors downregulate, needing higher doses for the same effect.
- Dependence: Severe withdrawal symptoms (seizures, rebound insomnia) if stopped abruptly.
- Falls and confusion: Especially in the elderly due to muscle relaxation and ataxia.
- Respiratory depression: Lethal if combined with opioids!
📝 Nursing Exam Tip: Lorazepam is preferred over diazepam for insomnia in palliative care because it has fewer active metabolites and less risk of daytime sedation — this is especially important in elderly or frail patients whose livers cannot efficiently clear long-acting drugs.
CONFUSION (DELIRIUM)
What Is Confusion?
Confusion (delirium) is an acute, fluctuating disturbance of consciousness and attention with altered perception and cognition. It is distressing for patients, frightening for families, and highly challenging for nurses.
💡 Key Distinction (High-Yield for Exams):
- Delirium: Acute onset (hours to days), fluctuating course, reversible (often) — common in palliative care. Driven by acute neurotransmitter imbalance (Excess Dopamine, Deficient Acetylcholine).
- Dementia: Chronic, progressive, usually irreversible structural brain disease — may coexist with delirium!
Causes of Confusion in Palliative Care
| Category | Causes |
|---|---|
| Pain | Uncontrolled pain causes sympathetic overdrive, agitation, and confusion. |
| Urinary retention | Full bladder → severe discomfort, agitation, and reflex confusion (highly common in the elderly). |
| Constipation | Faecal impaction → toxicity, discomfort, vagal nerve irritation. |
| Metabolic disturbances | Uraemia (renal failure), hypercalcaemia (bone mets), hyponatraemia, hypoglycaemia, hepatic encephalopathy (ammonia buildup crossing the blood-brain barrier). |
| Infections | UTI, pneumonia, cryptococcal meningitis (HIV), other opportunistic infections. |
| Hypoxia | Low oxygen → immediate cerebral dysfunction. |
| Raised intracranial pressure | Brain metastases, cerebral oedema, stroke. |
| Medications | Opioids (toxicity), antimuscarinics (hyoscine, atropine - block acetylcholine), corticosteroids (steroid psychosis), benzodiazepines. |
| Withdrawal states | Sudden cessation of Alcohol, benzodiazepines, or opioids. |
| Neurological conditions | Dementia, HIV encephalopathy, previous stroke. |
| Sensory deprivation | Sudden blindness or deafness (e.g., losing glasses/hearing aids) → profound disorientation. |
🧠 Mnemonic for Causes: "P-U-C-M-I-H-R-M-W-D-S"
(Or use the famous DELIRIUM mnemonic below in Section 9)
- Pain
- Urinary retention
- Constipation
- Metabolic (uraemia, calcium, sodium)
- Infection
- Hypoxia
- Raised ICP
- Medications
- Withdrawal
- Dementia / HIV encephalopathy
- Sensory deprivation
Types of Delirium
| Type | Features | Common Causes |
|---|---|---|
| Hyperactive delirium | Agitated, restless, hallucinations, picking at sheets, trying to climb out of bed. | Alcohol withdrawal, steroid psychosis, untreated pain. |
| Hypoactive delirium | Lethargic, withdrawn, reduced responsiveness, quiet, staring into space. | Opioid toxicity, uraemia, hepatic failure, hypoxia. |
| Mixed delirium | Alternates between hyperactive and hypoactive states. | Most common presentation in advanced terminal disease. |
👩⚕️ Nursing Tip: Hypoactive delirium is often missed because the patient is quiet and not disruptive to the ward. Always explicitly assess the level of consciousness and orientation — never assume the patient is "just tired."
Assessment of Confusion
- Orientation: Time, place, person.
- Attention: Can they follow a conversation? Count backwards from 20? (Inattention is the hallmark of delirium).
- Memory: Recent events, why they are in hospital.
- Perception: Hallucinations? (Visual hallucinations are most common in delirium; auditory are more common in schizophrenia).
- Physical examination: Full body check for retention (palpate bladder), constipation, infection, dehydration.
- Vital signs: Fever (infection), low SpO2 (hypoxia), low BP (dehydration/shock).
- Medication review: Recent changes? New opioids? Steroids?
Non-Pharmacological Management
| Intervention | Rationale |
|---|---|
| Calm, familiar environment | Reduces sensory overload; familiar objects (photos, religious items) help ground their orientation. |
| Re-orientation | Gently tell the patient where they are, what day it is, who you are. |
| Avoid physical restraints | Restraints massively increase agitation, cause physical injury, and are degrading — use only as an absolute last resort for imminent safety. |
| Family presence | Familiar faces reduce fear; encourage family to talk calmly and hold hands. |
| Good lighting during the day | Helps maintain circadian rhythm and prevents "sundowning". |
| Minimise nighttime disruptions | Protect sleep to prevent worsening delirium. |
| Address sensory deficits | Return glasses and hearing aids immediately if available. |
Pharmacological Management
| Drug | Dose | Indication | Caution / Mechanism |
|---|---|---|---|
| Diazepam | 2–5 mg | Mild agitation / Alcohol withdrawal | Can paradoxically worsen confusion in the elderly; highly sedating. |
| Lorazepam | 0.5–2 mg | Mild agitation | Shorter-acting alternative to diazepam. |
| Haloperidol | 1.5–5 mg | Severe delirium — agitation, hallucinations | First-line for severe delirium. (Mechanism: It is a potent Dopamine (D2) receptor antagonist, calming the hyperactive dopamine pathways causing the hallucinations). Monitor for extrapyramidal side effects (stiffness, tremors). |
| Chlorpromazine | 25–50 mg | Severe delirium (alternative to haloperidol) | More sedating; use if haloperidol is ineffective. |
⚠️ CRITICAL WARNING: Do NOT use benzodiazepines as the sole treatment for severe delirium (unless it is explicitly caused by alcohol/benzo withdrawal). They frequently worsen confusion, depress respiration, and cause paradoxical rage/agitation. Always use haloperidol (± benzodiazepine if needed) for severe delirium.
📝 Nursing Exam Tip: The exam question will often describe an elderly patient with severe agitation, visual hallucinations, and confusion. The correct answer is Haloperidol — not diazepam alone.
DEPRESSION
Depression is frequently misunderstood, under-diagnosed, and under-treated in palliative care. It is not the same as sadness or grief — it is a clinical condition that severely impacts quality of life by altering brain chemistry (depleting Serotonin and Norepinephrine).
- Sadness = A normal emotional response to loss — comes and goes in waves, responds to support and comfort.
- Depression = A persistent, pervasive low mood that does not lift, regardless of circumstances — requires clinical treatment.
Diagnostic Features of Depression
- Low mood: Present for more than 50% of each day, most days.
- Loss of enjoyment / interest: Anhedonia — absolutely nothing brings pleasure anymore.
- Excessive or inappropriate guilt: Feeling they are a burden, irrationally blaming themselves for their illness.
- Thoughts of suicide: Passive ("I wish I wouldn't wake up") or active ("I want to end it").
- Hopelessness: Total belief that things will never improve.
- Physical symptoms: Poor sleep, poor appetite, fatigue, psychomotor slowing (moving and talking very slowly).
Assessment of Depression
| Question | Significance |
|---|---|
| "How is your mood most days?" | Persistent low mood is the key diagnostic criteria. |
| "Do you still enjoy things you used to?" | Identifies loss of interest = anhedonia. |
| "Do you feel like a burden to your family?" | Guilt is a core, highly destructive feature. |
| "Have you had thoughts of hurting yourself?" | Suicidal ideation — always ask directly and clearly. |
| "Do you see any future for yourself?" | Hopelessness strongly predicts severity and suicide risk. |
👩⚕️ Nursing Tip: It is a dangerous myth that asking about suicide "puts the idea in their head." Direct, compassionate questioning is safe and essential. Ask: "Sometimes when people are in this situation, they think about ending their life. Have you had thoughts like that?"
Management of Depression
A. Non-Pharmacological
- Ongoing support and counselling: Allows expression of fears, grief, and anger.
- Spiritual support: Chaplain, imam, pastor — addresses existential distress and loss of meaning.
- Family involvement: Reduces isolation; family can monitor mood changes.
- Meaningful activities: Even small tasks (prayer, music, conversation) restore purpose.
B. Pharmacological
| Drug | Class | Notes & Mechanisms |
|---|---|---|
| Amitriptyline | Tricyclic antidepressant (TCA) | Blocks serotonin/norepinephrine reuptake. Also helps neuropathic pain and sleep. Has strong anticholinergic side effects (dry mouth, constipation, urinary retention). |
| Imipramine | Tricyclic antidepressant | Similar to amitriptyline. |
💡 Important Pharmacological Consideration: Standard Antidepressants (TCAs, SSRIs) take 2–4 weeks to start working because they require physical downregulation of receptors in the brain. In palliative care with a very limited prognosis (e.g., days to weeks to live), this is not practical! Consider faster alternatives:
- Psychostimulants (methylphenidate) — work within days for mood and energy.
- Corticosteroids (dexamethasone) — can artificially improve mood (euphoria) and appetite short-term.
ANXIETY
Anxiety is a normal response to life-threatening illness. However, when it becomes persistent, overwhelming, and interferes with daily life, it requires intervention. Anxiety triggers a massive sympathetic "fight or flight" overload (tachycardia, tachypnea, cortisol surge). It may occur as a symptom of depression, or independently (fear of death, pain, leaving loved ones).
Manifestations of Anxiety
- Psychological: Feeling of panic, dread, irritability, poor concentration, rumination.
- Physical: Tremor, sweating, tachycardia, palpitations, dyspnoea, severe muscle tension.
- Behavioural: Restlessness, pacing, avoidance, clinging to family, refusal of care.
- Sleep: Difficulty falling asleep, early waking, nightmares.
Management of Anxiety
A. Non-Pharmacological
- Opportunity to talk: Listening without judgment reduces isolation.
- Massage: Physical touch reduces cortisol and promotes oxytocin/relaxation.
- Relaxation techniques: Deep breathing (stimulates the Vagus nerve to slow the heart), progressive muscle relaxation, guided imagery.
- Counselling & Spiritual support: Addresses catastrophic thinking and existential fears.
- Family presence: Reduces fear of abandonment.
B. Pharmacological
- Diazepam (2–5 mg): For persistent, severe anxiety affecting quality of life; also helps muscle spasm and insomnia.
- Lorazepam (0.5–2 mg): Shorter-acting; excellent for acute panic/anxiety episodes.
👩⚕️ Nursing Tip: Benzodiazepines are effective for anxiety but should NOT replace psychological support. Use them when non-pharmacological measures are insufficient and the sympathetic overload is severely impacting the patient's quality of life.
BREATHLESSNESS (DYSPNOEA)
Breathlessness is a frightening, subjective experience of difficult or uncomfortable breathing. It is one of the most distressing symptoms in palliative care. (Pathophysiologically, it occurs due to an "afferent mismatch" — the brain's respiratory center demands a certain tidal volume, but the stretch receptors in the lungs report back that the lungs are not expanding enough, triggering a panic response).
The patient's words: "I felt like I was suffocating," "I couldn't get enough air," "It felt like I was about to die."
Causes of Breathlessness
- Respiratory: Lung cancer, pleural effusion, pulmonary embolus, tracheal tumour, airway collapse, infection, COPD, weak respiratory muscles.
- Cardiac: SVCO (Superior Vena Cava Obstruction), anaemia, cardiac failure, cardiomyopathy, pericardial effusion.
- Other: Ascites (pushes up on the diaphragm), radiotherapy/chemo side effects, pneumonectomy, extreme anxiety.
Non-Pharmacological Management
- Positioning: Usually sitting upright; if pleural effusion, lie on the affected side with the good lung upwards to maximise ventilation/perfusion matching.
- Ventilation (THE FAN): Open windows, use a fan, or even fan with newspaper.
- Activity adjustment & Breathing techniques: Pace activities; slow, deep, pursed-lip breathing (creates positive end-expiratory pressure to keep airways open).
- Suction secretions: Gently suction if present.
- Reassurance: Stay with the patient; hold their hand; speak calmly to break the anxiety-breathlessness cycle.
💡 Why a Fan Helps (Crucial Physiology): Cool air blown across the face stimulates the sensory branches of the Trigeminal Nerve (Cranial Nerve V). This nerve sends inhibitory signals directly to the respiratory center in the brain, fundamentally reducing the perception of breathlessness. It is a simple, free, and highly effective intervention even if oxygen saturations are totally normal!
Pharmacological Management
| Drug | Dose | Indication & Mechanism |
|---|---|---|
| Morphine | 2.5–5 mg PO every 4 hrs | Reduces the central perception of breathlessness (blunts the medulla's sensitivity to CO2 buildup). If already on morphine for pain, titrate dose upwards. |
| Diazepam | 2–5 mg at night | For anxiety and panic associated with breathlessness. |
| Dexamethasone | 8–12 mg daily | Steroid to reduce inflammation for specific causes (e.g., SVCO, lymphangitis carcinomatosis, airway compression). |
| Bronchodilators / Diuretics | As prescribed | For reversible airway obstruction (COPD, asthma) or fluid overload (cardiac failure, ascites). |
| Oxygen | 2–4 L/min | Only if hypoxic (SpO2 < 90%) and available; oxygen will not relieve the sensation of breathlessness if SpO2 is already normal. |
📝 Nursing Exam Tip: Many nurses are terrified to give Morphine to a breathless patient, fearing it will stop their breathing. Morphine relieves breathlessness not by suppressing respiration dangerously, but by reducing the brain's panic perception of breathlessness. At low, careful doses (2.5–5 mg), it is completely safe and does NOT cause dangerous respiratory depression.
| Symptom | Key Feature | Most Common Cause | First-Line Drug | Key Non-Drug | Red Flag |
|---|---|---|---|---|---|
| Fatigue | Not relieved by rest | Anaemia, pain, depression | Treat cause; methylphenidate if available | Energy conservation, scheduled rest | Sudden onset = acute cause (bleed) |
| Insomnia | Subjective poor sleep | Pain, anxiety, steroids | Lorazepam 0.5–2 mg (short-term) | Sleep hygiene, reduce caffeine | Chronic use of benzodiazepines |
| Confusion | Acute, fluctuating, altered consciousness | Uraemia, infection, medications, hypoxia | Haloperidol 1.5–5 mg (severe) | Calm environment, re-orientation, family | Hypoactive delirium = easily missed |
| Depression | Persistent low mood, anhedonia, guilt | Disease burden, uncontrolled symptoms | Amitriptyline, imipramine; methylphenidate if rapid effect needed | Counselling, spiritual support | Suicidal ideation — always ask |
| Anxiety | Panic, dread, physical symptoms | Fear of death, pain, loss | Diazepam 2–5 mg if severe | Talking, massage, relaxation | Avoid benzodiazepines as sole long-term treatment |
| Breathlessness | Frightening sensation of suffocation | Lung cancer, effusion, COPD, anxiety | Morphine 2.5–5 mg; diazepam for panic | Fan, upright position, reassurance | Stridor = upper airway emergency |
MNEMONICS AND EXAM TIPS
🧠 Mnemonic for Confusion Causes: "DELIRIUM"
- Drugs: Opioids, steroids, anticholinergics
- Electrolytes / Environment: Sodium, calcium; unfamiliar ward
- Lack of drugs: Withdrawal from alcohol, benzodiazepines
- Infection: UTI, pneumonia, meningitis
- Retained: Urinary retention, constipation
- Intracranial: Raised ICP, stroke, metastases
- Under-oxygenated: Hypoxia
- Myocardial / Metabolic: Heart failure, uraemia, hepatic failure
🧠 Mnemonic for Insomnia Management: "S-L-E-E-P"
- Schedule: Regular sleep-wake times
- Limit stimulants: No caffeine, nicotine after midday
- Environment: Dark, quiet, cool room
- Exercise: Earlier in the day, not near bedtime
- Pharmacology: Short-term benzodiazepines only if needed
Exam-Style Questions
Q1: A patient with advanced cancer becomes acutely confused 3 days after starting morphine. What are your first three actions?
Answer: 1. Check for opioid toxicity (reduce or hold next dose). 2. Rule out other causes: check urinary retention (bladder scan/palpate), constipation, infection (fever), dehydration. 3. Review other meds. If severely agitated, administer haloperidol 1.5–5 mg.
Q2: A dying patient has not slept for 3 nights due to anxiety and fear of death. They refuse counselling. What medication would you consider?
Answer: Diazepam 2–5 mg at night or lorazepam 0.5–2 mg. These reduce anxiety and promote sleep. However, continue offering psychological support—medication is not a substitute.
Q3: Why is a fan effective for breathlessness even when oxygen saturation is normal?
Answer: A fan stimulates the trigeminal nerve with cool air, sending signals to the brain that override and reduce the perception of breathlessness. It changes how the brain interprets the sensation.
Q4: A patient says they feel tired all the time but sleep 10 hours a night. What is the most likely diagnosis, and what should you assess?
Answer: This is pathological fatigue (rest does not relieve it). Assess for anaemia (check Hb), pain control, depression, malnutrition, and medication side effects.
Q5: A patient with HIV and cryptococcal meningitis becomes confused. What is the likely cause of the confusion?
Answer: The infection itself (cryptococcal meningitis causing brain inflammation) is the primary cause. Also consider other opportunistic infections, med side effects, metabolic disturbances, and raised intracranial pressure.
- Fatigue is not ordinary tiredness — assess for reversible causes (anaemia, pain, depression, sleep).
- Insomnia is what the patient says it is — treat underlying physical symptoms first, then consider short-term benzodiazepines.
- Lorazepam is preferred over diazepam for insomnia in elderly/frail patients due to fewer active metabolites.
- Confusion is often reversible — always check for urinary retention, constipation, infection, hypoxia, and medications.
- Hypoactive delirium is easily missed — assess level of consciousness in all patients, not just the agitated ones.
- Haloperidol is first-line for severe delirium — do NOT use benzodiazepines alone.
- Depression is under-diagnosed — ask directly about low mood, anhedonia, guilt, and suicidal thoughts.
- Anxiety responds to talking and listening first — use benzodiazepines only when non-pharmacological measures fail.
- Breathlessness is frightening — stay with the patient, use a fan, position upright, and give morphine for the sensation.
- A fan for breathlessness is free, safe, and effective — never forget this simple nursing intervention.
💎 Final Clinical Pearl: In palliative care, neurological symptoms are profoundly interconnected. A patient with uncontrolled pain cannot sleep; poor sleep worsens fatigue and depression; depression reduces appetite and energy; and the cycle continues. Your role as a nurse is to break this cycle by assessing and treating each symptom systematically — and never forgetting the healing power of your presence, your listening, and your compassion.
REFERENCES
- World Health Organization (WHO) Guidelines for Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents.
- Oxford Textbook of Palliative Nursing.
- National Institute for Health and Care Excellence (NICE) Guidelines on Palliative Care for Adults.
- Local Clinical Guidelines and Formularies (e.g., Uganda Clinical Guidelines for Palliative Care).
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