Symptoms Control

Symptom control aims at the primary goal of providing comfort and improving the quality of life for individuals facing serious illness and end-of-life stages.

Symptom control and management play a crucial role in achieving this aim/goal. Palliative care focuses on addressing the physical, emotional, social, and spiritual needs of patients, with a particular emphasis on relieving distressing symptoms.

Common symptoms in Palliative Care

System	Symptoms
GIT	Dry mouth, painful mouth, nausea and vomiting, dysphagia, indigestion, constipation, diarrhea, intestinal obstruction, ascites
Respiratory	Shortness of breath (SOB), cough, death rattle, hemoptysis
Genito-Urinary	Dysuria, prostatism, spasms, urinary retention, urinary incontinence, hematuria
Skin	Fungating wound, pruritus, pressure sores
Neurological	Weakness, seizures, headache
Psychiatric	Adjustment disorders, depression, anxiety, delirium
Other	Anorexia, sleep disturbance

Principles of Symptom Assessment

Accept the patient’s description: It is important to accept the patient’s description of their symptoms, considering the type and severity, as true and valid.
Assess each symptom separately: Since most patients experience multiple symptoms, it is necessary to evaluate and analyze each symptom individually.
Diagnose the possible cause: Determine the potential underlying cause of the symptom or problem through a comprehensive diagnostic process.
Take a detailed history and examination, including:
a. Onset of symptom: Gather information about when the symptom started, its severity, character, periodicity, precipitating and relieving factors, impact on sleep, mobility, quality of life, and its significance to the patient, particularly in the case of pain.
b. Medication history: Explore the patient’s past medication usage, including the effectiveness of previous drugs and any failures, as well as the current medications and any complementary or alternative treatments being used for symptom management.
Evaluate associated symptoms: Identify and assess any additional symptoms that may be related to the main symptom, such as constipation and abdominal distension in cases of intestinal obstruction.
Perform a mandatory physical examination: Conduct a focused, thorough, and detailed physical examination that specifically targets the system associated with the presenting symptom.
Proactively ask and observe: Don’t wait for the patient to complain; instead, actively inquire about their symptoms and carefully observe any visible signs or changes.
Use appropriate investigations: Employ suitable investigations to guide clinical decision-making, ensuring that they are not performed unnecessarily or solely for the sake of doing them.
Avoid delaying treatment: Initiate practical management and treatment without undue delay, even if investigation results are pending.
Explain possible causes of symptoms: Provide explanations to the patient and their family regarding the potential reasons behind the symptoms, fostering open and regular communication that is essential for their understanding and involvement in the care process.

Principles of Symptom Management (Woodworth, 2004)

Evaluation: Before initiating treatment, it is important to diagnose each symptom accurately.
Explanation: Prior to treatment, provide clear explanations to the patient about the intended approach and set realistic goals for symptom management.
Management: Tailor the treatment plan to each individual, considering their specific needs and preferences.
Monitoring: Continuously assess and review the impact of the treatment on symptom control, making necessary adjustments as needed.
Attention to details: Avoid making assumptions and ensure that all relevant details are taken into account when managing symptoms.
Utilize both drug and non-drug measures: Incorporate a combination of pharmaceutical and non-pharmaceutical interventions to effectively control and manage symptoms.
Allow sufficient time for interventions: Give interventions an appropriate amount of time to take effect before determining their success or failure.
Adopt a multidisciplinary team approach: Collaborate with a diverse team of healthcare professionals to provide comprehensive symptom management.
Seek consultation: When necessary, consult with a senior or more experienced clinician to gain insights and guidance in complex cases.
Consider referral: In situations where specialized management is required, consider referring the patient to appropriate specialists or healthcare facilities.
Implications of inaccurate assessment: Recognize that inaccurate assessment of the patient’s symptoms can have various implications on the overall management plan.
Treat the underlying cause: Whenever possible, focus on treating the root cause of the symptoms to achieve optimal symptom control and management.

In Summary, Principles of Symptom Control are;

	Holistic assessment
1	Careful and detailed history
2	Relevant clinical examination
3	Appropriate investigations
4	Establish diagnosis
5	Explain everything to the patient.
1	Detailed history: First step in effective management of a patient’s symptoms is undertaking a detailed history. This enables us to diagnose the possible cause of the symptoms. We must remember the concept of “Total Care” and resist the temptation to focus on physical aspects of history.
2	Physical examination: It should be focused, thorough, and detailed. Direct examination towards the system of the presenting symptom.
3	Investigations: Appropriate investigations to guide clinical decision making. May not be a realistic option in terms of financial, location, and resources. Do not delay starting treatment pending investigation results.
4	Establish Diagnosis: Cause of symptoms may be due to the disease itself, the treatment for the disease, disease-related debility, or concurrent disorders. What is the underlying mechanism? E.g., hypercalcemia, raised ICP.
16	Explanation to patient: Explain the possible causes of symptoms to the patient and family. A simple explanation of the cause and nature of the symptoms to the patient may help to reduce fears or anxieties. Open and regular communication is essential.

Gastrointestinal Tract Symptoms

Nausea and Vomiting:

Causes:

Pharmaceutical: opioids, digoxin, anti-convulsants, antibiotics.
Toxic: infection, radiotherapy, chemotherapy.
Metabolic: hypercalcemia, ketoacidosis, renal failure.
Intracranial: cerebral tumors, cerebral infections, meningeal metastases, raised ICP, meningitis, cerebral malaria, ear infections.
Gastrointestinal: gastric stasis, intestinal obstruction, constipation, candidiasis, abdominal and pelvic tumors, partial or complete bowel obstruction.

Assessment:

Take a history, including the amount, content, and odor of vomit.
Differentiate between vomiting, expectoration, or regurgitation.
a. Determine the duration of the problem, including frequency, precipitating factors, type, and consistency.
b. Review medication history, including antibiotics, ARVs, NSAIDs.
c. Consider raised intracranial pressure.
d. Examine the abdomen to rule out pancreatitis, gastritis, and peptic ulcers.

Pharmacological Management:

Choose anti-emetics based on understanding different classes of medications and their mechanisms of action.
Treat the underlying cause, if possible (e.g., constipation with bisacodyl – 5mg nocte, review and possibly change medication).
Select appropriate anti-emetics based on the cause:
- Depress vomiting center: hyoscine, cyclizine 50mg 6-hourly.
- Depress chemoreceptors: prochlorperazine (Stemetil) 5-10mg tds, haloperidol 0.5-1mg bd.
- Normalize upper bowel function: metoclopramide 5-10mg tds.
- Delayed gastric emptying: metoclopramide 5-10mg tds (contraindicated in obstruction).
- Vestibular disturbances: prochlorperazine 5-10mg tds, cyclizine 50mg 6-hourly, uraemia – haloperidol 0.5-1mg.

Non-Pharmacological Management:

Provide psychological support, especially for anxiety-related or anticipatory symptoms.
Recommend relaxation techniques.
Suggest dietary modifications, such as increased fluid intake and small, regular meals.
Create a calm environment away from food odors that may induce nausea.

Diarrhea:

Causes:

Imbalance of laxative therapy.
Drugs such as antibiotics, NSAIDs, ARVs.
Fecal impaction – fluid stool leaks past a fecal plug or tumor mass.
Abdominal or pelvic radiotherapy.
Malabsorption.
Colonic or rectal tumors.
Concurrent disease.
Odd dietary habits.
HIV.
Stress.

Assessment:

Identify the cause of diarrhea.
Differentiate between diarrhea and overflow.
Gather history regarding duration, characteristics (volume, frequency, presence of blood), and associated symptoms (abdominal pain, fever).
Review medications.
Perform stool tests for culture and sensitivity.

Pharmacological Management:

Advise increased fluid intake with oral rehydration solution after each episode of diarrhea.
If symptoms persist, administer anti-diarrheal medication such as loperamide 2-4 capsules stat, then 2 capsules after every motion, codeine 30mg tds, or liquid morphine 5mg/5ml 4 hourly, 10ml at night.
Administer antibiotics for infections, e.g., septrin 480mg bd if needed.
Consider IV fluids for severe dehydration.
Review and modify medications if necessary.
Apply barrier cream (e.g., aqueous cream) to protect the skin when necessary.

Non-Pharmacological Management:

Provide nutrition advice.
Encourage plenty of oral fluids.
Offer skin care to prevent breakdown.
Provide appropriate advice for incontinence, including the use of a mackintosh/plastic under-sheet and regular changing/cleaning to prevent bedsores, etc.

Constipation:

Causes: Direct effects of disease:

Intestinal obstruction from tumors in the bowel wall or external compression from abdominal masses.
Damage to the lumbosacral spinal cord. Secondary effects of disease:
Decreased food intake and low-fiber diet.
Dehydration.
General body weakness.
Metabolic abnormalities – hypokalemia, hypercalcemia. Medications:
Opioids such as codeine or morphine.
Anticholinergic drugs such as tricyclic antidepressants.
Diuretics. Concurrent disease:
Diabetes mellitus, hypothyroidism.
Hemorrhoids, anal fissures. (Note: The most common causes are related to the side effects of opioids and the effects of progressive disease.)

Assessment:

Take a history to ascertain the cause of constipation.
Establish the previous and present bowel pattern.
Perform abdominal and rectal examinations.

Pharmacological Management:

Prescribe appropriate laxatives, such as bisacodyl 5-15mg nocte.
Consider the use of pawpaw seeds chewed or crushed in a fruit drink.
Reduce or stop the dose of constipating drugs.

Non–Pharmacological Management:

Use rectal interventions if required, such as enemas.
Advise on increasing a high-fiber diet and fluid intake.
Ensure privacy and adequate toilet facilities.

Management in Children:

For children, an osmotically active laxative (e.g., lactulose) is preferable to a stimulant laxative (bisacodyl) as stimulants may cause severe abdominal 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 orally.
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 orally.
- 6-12 years: 1-2 tablets twice daily orally.
Step 3: If already on opioids, use step 2 drugs right away.

Additional Notes:

If rectal examination 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 using a bisacodyl suppository to bring the stool down or a high-phosphate enema.
For severe constipation, consider using a phosphate enema or a bowel prep product (e.g., Movicol) if available.

Mouth Sores and Difficulty Swallowing (Dysphagia)

These sores are commonly caused by oral and esophageal candidiasis. It’s important to note that many mouth-related problems can be prevented by practicing good mouth care, keeping the mouth moist, and promptly treating any infections.

Causes of mouth sores and difficulty swallowing :

Infections such as candidiasis or herpes.
Mucositis resulting from radiotherapy or chemotherapy.
Ulceration.
Poor dental hygiene.
Dry mouth caused by medications, salivary gland damage due to radiotherapy or tumors, or mouth breathing.
Erosion of the buccal mucosa by tumors, possibly leading to fistula formation.
Iron deficiency.
Vitamin C deficiency.

Non-pharmacological management:

Prevention through regular mouth cleaning, maintaining moisture, and promptly treating infections.
Regularly checking the mouth, teeth, tongue, palate, and gums for dryness, inflammation, ulcers, or infection.
Educating the patient and family on proper mouth care using available resources.
Using a soft brush or soft cotton cloth for gentle brushing, avoiding harsh brushing.
Rinsing the mouth with a simple mouthwash made from sodium bicarbonate or saline (a pinch in a glass of water is sufficient) can be effective.
Relieving dry mouth by sucking on ice or pieces of fruit.
Applying petroleum jelly on the lips after cleaning.

Assessment and pharmacological management:

Treating pain following the WHO analgesic ladder.
Considering oral morphine for severe pain caused by mucositis.
Treating oral candidiasis even in the absence of white patches but with inflammation:
- Nystatin oral drops (1–2mls) every 6 hours after food and at night, holding the dose in the mouth for topical action.
- Fluconazole (50mg daily for five days), increasing to higher doses (200mg daily for two weeks) if there is difficulty swallowing and suspicion of esophageal candidiasis. Ketoconazole (200mg daily) is an alternative, but caution must be exercised regarding drug interactions.
Treating other infections:
- Applying Gentian Violet three times daily, which is useful for many types of sores.
- Using metronidazole mouthwash, prepared by mixing crushed oral tablets or liquid for injection with fruit juice, to alleviate discomfort from foul-smelling mouth sores, especially in oral cancer cases. Consider acyclovir (200mg po for five days) for herpes infections. Severe infections may require oral or parenteral medications.
Treating inflammation:
- Considering the use of steroids, such as oral dexamethasone (4–8mg) or prednisolone powder or solution, for ulceration and inflammation. However, it’s important to ensure that any infection is well treated, as steroids can exacerbate them.

Hiccup

Hiccups are a common occurrence among many patients who are in the dying process. These hiccups can be quite distressing and exhausting for the patient, especially if they persist and do not resolve quickly.

Cause:

The underlying cause of hiccups is typically irritation of the phrenic nerve in the neck of the mediastinum or irritation of the diaphragm from above.
Commonly associated with hiccups are conditions such as tumors that cause stomach distension, lung tumors, esophageal cancer, renal failure, and hepatomegaly.
Additionally, hiccups can also be of central origin, originating from the brain.

Management of hiccups:

Immediate measures:

Pharyngeal stimulation: This can be achieved by having the patient swallow a piece of dry bread or two spoons of sugar.
Correcting uremia if possible.
Simple re-breathing from a paper bag to elevate the level of carbon dioxide (PCO2).
Assisting the patient in a sitting up position.
Medications such as 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 commonly occurs when there is pressure on the diaphragm caused by an abdominal tumor or ascites, or in the presence of a neurological disorder.

Management:

It is helpful to position the patient in an upright, sitting position.
Administer medications after meals.
Consider giving the patient milk.
If the patient is currently taking NSAIDs, they may need to discontinue their use.
Simple antacids such as Magnesium trisilicate (10 ml every 8 hours) may be prescribed. If the condition persists, 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 a common symptom often observed in patients, and there is a strong desire among both relatives and the medical or nursing team to ensure proper hydration for the patients.

Diagnosis:

The diagnosis and prognosis of dehydration can be influenced by several factors:

Dehydration may occur when a patient experiences an intercurrent illness that is expected to resolve, such as an episode of diarrhea in a patient with lung cancer who has a prognosis of several months or severe diarrhea in an HIV/AIDS patient.
Presence of other symptoms:

a. Dehydration can significantly impair drug excretion, leading to increased side effects, particularly for medications like morphine. It is advisable to discontinue unnecessary medications or reduce the dosage while maintaining symptom control.

b. Supplementary fluids may be administered for a short period to alleviate distressing symptoms like hallucinations or myoclonic jerks.
Presence of a dry mouth rather than thirst:

a. Patients may report feeling thirsty, but they may appear well hydrated, and their symptom could be a dry mouth.

b. If the patient is excessively thirsty, and measures to keep their mouth moist are ineffective, considering supplementary fluids may be appropriate.

c. Assess the patient’s proximity to death:
- Patients nearing death often struggle with managing oral fluids and may even experience coughing during swallowing.

Assessment and management of dehydration:

A dilemma arises when a patient is critically ill and entering the terminal phase. In most patients approaching death, a reduction in fluid intake is natural and appropriate as they no longer require significant fluid intake. Explaining this to the family can help alleviate concerns and reduce requests for supplementary fluids.
It is crucial to keep the mouth and lips clean and moist, as dry oral mucosa can be more distressing than thirst.
In certain situations, considering artificial hydration may be appropriate. Whenever possible, oral hydration should be attempted, but if necessary, intravenous (IV) or subcutaneous (SC) infusions can be considered. SC infusions are the least invasive and can even be administered in a home setting.
Excessive hydration can lead to fluid overload, requiring venous cannulation, which may become painful and challenging. When deciding to administer supplementary fluids, several factors should be taken into account.
Offering more than sips of oral fluids in this situation risks the complication of aspiration and pneumonia.
Families often worry that the patient will be uncomfortable without hydration. However, it’s important to note that anorexia and cachexia (severe weight loss) are common in advanced cancer, HIV/AIDS, and end-stage organ failure, and forced feeding or hydration will not improve these conditions.

Cachexia and Anorexia

Cachexia refers to weakness, profound weight loss, and poor appetite commonly observed in advanced stages of cancer, HIV/AIDS, and end-stage organ failure.

It is important to understand that cachexia is not associated with hunger or thirst and cannot be improved by forced feeding or hydration. The underlying mechanisms of cachexia differ among different diseases but involve the release of inflammatory mediators and metabolic alterations that induce a catabolic state, resulting in significant weight loss affecting both fat and skeletal muscle.

General measures for managing cachexia:

Ensuring that reversible causes of anorexia or malnutrition are addressed, such as:
- Lack of available or digestible food.
- Dysphagia.
- Sore mouth or altered taste.
- Dyspepsia, nausea and vomiting, or constipation.
- Pain.

Management in Children:

Corticosteroids should not be used in children if anorexia/cachexia is the sole symptom that may benefit from treatment.
A short trial of corticosteroids may be considered in children with associated symptoms like nausea, pain, asthenia, or depressed mood. Dexamethasone is the most appropriate corticosteroid dose in children. Alternatively, prednisone can be used at a dosage of 0.05-2mg/kg divided 1-4 times a day.

Faecal Incontinence

Faecal incontinence is a distressing symptom for the patient and presents a challenging problem for their relatives to manage at home. The causes of faecal incontinence can vary and may include:

Faecal impaction: A blockage in the rectum can lead to involuntary leakage of stool.
Excessive use of laxatives: Overuse of laxatives can cause loose stools and contribute to incontinence.
Frequent and severe diarrhoea in debilitated patients.
Paraplegic patients: Those with paralysis or impaired control of the lower body may experience difficulties in controlling bowel movements.
Relaxed anal sphincters, especially in the elderly: Weakening of the muscles that control bowel movements can result in incontinence.
Ano-rectal tumors: Tumors in the anal or rectal region can disrupt normal bowel function and contribute to incontinence.

Management strategies for faecal incontinence:

Thorough rectal examination: A comprehensive examination should be performed to identify the underlying cause of the incontinence.
Patients with relaxed anal sphincters may benefit from the use of constipating agents such as loperamide or codeine phosphate.
Paraplegic or constipated patients can benefit from regular rectal evacuation and the use of faecal softeners to maintain regular bowel movements.
Patients with ano-rectal carcinoma may find relief through the following measures:
- Radiotherapy (RT) may be recommended.
- Rectal steroids, such as prednisolone suppositories twice daily or betamethasone foam twice daily, can provide relief.
- Metronidazole can be used rectally if there is an offensive discharge.
Practical measures to manage faecal incontinence at home include:
- Using plastic under sheets, diapers, and promptly changing and washing/drying the patient after each episode.
- Applying barrier cream to protect the skin.
- Regularly turning immobile patients to prevent pressure sores.

Neurological Symptoms

Fatigue:

Chronic fatigue is a common symptom in people with advanced disease. It can have multiple causes that are often overshadowed by coexisting disease processes.

Causes of fatigue:

Anaemia
Pain
Emotional distress
Sleep disturbances
Poor nutrition

General care for managing fatigue:

Adapting lifestyle around periods of greater energy or fatigue.
To address fatigue, it is important to treat the underlying cause if possible. For example, if anaemia is contributing to fatigue, a blood transfusion may be appropriate.
Low doses of psycho-stimulants such as methylphenidate (Ritalin) or antidepressants can also be considered.
Non-pharmacological interventions include energy conservation, physical exercise, stress reduction through relaxation techniques, and meditation.

Insomnia:

Insomnia refers to difficulty initiating or maintaining sleep, early-morning awakening, non-restful sleep, or a combination of these symptoms. It is common in individuals with advanced disease and can be transient or chronic.

The causes of insomnia:

Transient: Often related to life crises, bereavement, or illness.
Chronic: Associated with medical or psychiatric disorders, drug intake, or maladaptive behavioral patterns. In advanced disease, it can emerge as a psychological or physiological side effect of diagnosis or treatment.

General care for managing insomnia

Reducing intake of nicotine, caffeine, and other stimulants, as well as avoiding alcohol near bedtime.
Regular exercise earlier in the day can also be helpful.
Benzodiazepines are commonly used hypnotic medications for sleep, offering prompt relief by decreasing time to sleep onset, improving sleep efficiency, and promoting a sense of restful sleep.
Long-acting benzodiazepines like lorazepam and diazepam can be considered, but they are not recommended for long-term treatment due to the risk of tolerance, dependency, and other side effects.

Confusion:

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

Causes:

Uncontrolled pain
Urinary retention or severe constipation
Changes in environment or transfer from one ward to another
Metabolic disturbances (e.g., uraemia, hypercalcaemia, hyponatraemia)
Infections (e.g., urinary tract infection, cryptococcal meningitis, other opportunistic infections)
Hypoxia
Raised intracranial pressure, strokes
Medication-induced (e.g., opioids, antimuscarinics, corticosteroids)
Withdrawal states (e.g., alcohol, benzodiazepines, opioids)
Dementia, delirium, HIV encephalopathy
Sudden sensory deprivation (blindness, deafness)

General care for managing confusion

Creating a calm and reassuring environment that is as familiar as possible.
Reminding the patient of their surroundings and orientation in time can be helpful.
Physical restraint should be avoided unless necessary for the patient’s safety.
Supporting family members to stay with the patient and express their concerns is important.

The management of confusion

Addressing underlying causes such as pain, urinary retention, constipation, infections, and organ failure.
Medications can be used to relieve symptoms, but caution should be exercised to avoid excessive sedation.
For mild agitation, diazepam or lorazepam can be given. For severe delirium, haloperidol or chlorpromazine can be considered along with diazepam, but not as a sole treatment for severe delirium as it may worsen confusion.

Depression:

Depression is often misunderstood, under-diagnosed, and under-treated. Assessing and managing depression involves considering key factors such as low mood for more than 50% of each day, loss of enjoyment or interest, excessive or inappropriate guilt, and thoughts of suicide.

Ongoing support and counseling may be necessary, and antidepressant medications can be considered if depression does not respond to counseling. Amitriptyline and imipramine are examples of antidepressants that may be prescribed.

Anxiety:

Anxiety may be a symptom of depression or can occur independently. Assessment and management of anxiety involve recognizing symptoms such as feelings of panic, irritability, tremor, sweating, sleep disturbances, and lack of concentration. Providing opportunities for the patient to talk about their fears and anxieties can be beneficial. Non-pharmacological interventions like massage, relaxation techniques, and counseling may help. If persistent symptoms significantly affect the patient’s quality of life, medication with benzodiazepines such as diazepam can be considered.

Respiratory Symptoms

Breathlessness:

Difficulty in breathing can be a frightening experience for patients. They often use words such as “suffocating,” “choking,” “could not get enough air,” or “it felt like I was about to die” to describe their experience.

Causes of breathlessness:

Respiratory causes: Primary or secondary lung cancers, pleural effusion, pulmonary embolism, tracheal tumors, airway collapse, infections, lymphangitis carcinomatosa, and chronic obstructive pulmonary disease (COPD), weak respiratory muscles.
Cardiac causes: Superior vena cava obstruction, anemia, cardiac failure, cardiomyopathy, pericardial effusion.
Other causes: Ascites, and breathlessness secondary to treatments like radiotherapy, chemotherapy, or pneumonectomy.

General care for managing breathlessness:

Adjusting the patient’s position: It is usually best for the patient to sit up. However, in patients with pleural effusion, lying on the affected side with the good lung upwards can help maximize ventilation.
Ensuring good ventilation: This can be achieved by opening windows, using a fan, or even fanning with a newspaper.
Assisting with slow, deep breathing and adjusting activity accordingly.
Gently suctioning any excessive secretions.

Assessment and management of breathlessness:

Taking a careful history: Inquire about the severity, duration, and associated features such as breathlessness worsening when lying down or on exertion, pleuritic chest pain, or hemoptysis.
Treating reversible conditions if possible: This may include addressing anemia, heart failure, infection, pulmonary embolism, or pleural effusion.
Addressing underlying anxiety and panic.
Using medications to relieve symptoms:

a. Morphine: 2.5-5mg orally every four hours. If the patient is already taking oral morphine for pain, adjust the dose and advise on taking extra doses as required.
b. Diazepam: 2-5mg at night, especially for anxiety and panic.
c. Dexamethasone: 8-12mg daily for specific causes such as superior vena cava obstruction or lymphangitis carcinomatosa.
d. Consider other medications such as bronchodilators, diuretics, or oxygen, depending on their availability and the cause of breathlessness.

Cough

The incidence of cough in all cancer patients is around 30%, while in patients with lung or bronchus cancer, it is as high as 80%. In patients living with HIV/AIDS, any duration of cough should raise a high suspicion of tuberculosis (TB), and the patient should be referred for investigations such as Gene X-pert.

Causes of cough:

Bronchial obstruction from a primary tumor or enlarged medial sternal glands, which is the most common cause.
TB or pneumonia in immunosuppressed patients.
Left ventricular failure, characterized by dyspnea and cough that wakes the patient.
Vocal cord paralysis due to hilar tumor or lymphadenopathy.
Unrelated causes to cancer, such as smoking, common colds, asthma, or congestive heart failure.

During the assessment, consider the following:

Type of cough: Determine if the cough is productive (with phlegm) or dry, and whether the patient is able to cough effectively.
Identify factors that precipitate, worsen, or relieve the cough.

Perform a physical examination of the mouth, throat, lungs, and heart.

Management of cough:

Productive cough: Perform gentle postural drainage to aid expectoration and drainage if the patient’s condition allows. Steam inhalations can be helpful if the sputum is thick. Antibiotics are often prescribed to clear infections and facilitate easier expectoration. Bronchodilators, such as salbutamol, can be included in cough mixtures if bronchospasms are present.
Non-productive cough: Sedation at night can be achieved with codeine linctus (1mg/ml, 10mls every 4 hours) or morphine (2.5mg, with an increase in the usual dose by 2.5mg every 4 hours).

Nursing management:

Positioning the patient in bed, propped up with 2 or 3 pillows in the most comfortable position.
If there is a pleural effusion, the patient should lie on the side of the effusion in a semi-recumbent position.

Urinary Symptoms

Urinary Retention

Urinary retention in terminally ill patients can have various causes, including:

Drug-induced retention, particularly from anti-cholinergic medications, tricyclic antidepressants, and opioids. This is usually temporary and initially only.
Neurological causes, especially spinal cord compression.
Faecal impaction of the rectum, which can be resolved by evacuating the rectum.
Prostatic carcinoma obstructing the bladder neck, which requires managing the underlying cause.

In all of the above causes, catheterization of the patient should be performed while managing the underlying cause.

Dysuria

Causes:

Urinary tract infections (UTIs).
Bladder or prostatic carcinoma, particularly affecting the bladder neck.
Calculi (stones) or retained blood clots in the urinary system.
Infiltration of the bladder by a tumor from adjacent organs such as the rectum, vagina, or cervix.

Management:

Except for UTIs, catheterization is crucial to perform bladder washouts and address incontinence or partial retention.

Generalized bladder pain from bladder carcinoma may be relieved by prostaglandin inhibitors such as Ibuprofen (400mg four times a day), but strong analgesics like opioids are usually necessary and should not be withheld.
If the above measures fail, permanent catheterization may be considered as an option.

Urinary catheterization is very useful for ill patients to prevent dribbling incontinence or recurring retention. When performing catheter care, the following tips are helpful:

Use Foley catheters.
Avoid inflating/deflating the bulb or inserting different sizes of catheters repeatedly.
Bladder washouts are beneficial. Use Chlorhexidine 0.05% daily for infection prevention and weekly for maintenance, and saline for removing debris, deposits, and clots. Carers should be trained to perform bladder washouts using boiled, cooled water at home to remove debris.
To minimize discomfort during catheterization for anxious patients, administer oral or rectal diazepam (2-5mg) or morphine (5mg) 30 minutes before the procedure.
In about 10% of patients nearing the end of life, hematuria (blood in urine) may occur. In severe cases, a bladder washout using a silver nitrate solution can help reduce bleeding.
Reassurance and explanation to family members are crucial.

Skin Related Conditions

Skin disorders can cause significant discomfort and distress to patients, especially as end-of-life approaches. Lack of activity and excessive weight loss can contribute to the development of skin breakdown. Recognizing the potential causes of skin and mucous membrane disorders is crucial because terminally ill patients cannot afford to wait for diagnostic test results before initiating therapy. Treatment planning is based on clinical identification of the most likely diagnosis, and therapy should be started as soon as possible to alleviate discomfort.

Pruritus (Itching)

Near the end of life, the cause of pruritus may be related to the patient’s primary illness, co-morbid conditions, allergies, and infections.

The causes of pruritus;

HIV/AIDS
Pre-existing skin diseases (such as eczema, psoriasis, or infestations)
Dry skin, particularly senile pruritus
Obstructive jaundice
Anxiety
Allergic reactions

Management:

For HIV/AIDS-related pruritus due to drug eruptions, apply 1% hydrocortisone cream.
In cases of multiple opportunistic skin infections, rinse the skin after bathing with a 0.05% Chlorhexidine solution. This usually provides results within 10 days.
In cases of obstructive jaundice where biliary stenting is unavailable, the following measures can be taken:
- Administer steroids such as Dexamethasone (2mg twice daily, reducing to 1mg/day) or Prednisolone (15mg reducing to 10mg daily in the morning).
- Use an antihistamine, such as Chlorpheniramine (4mg three times daily).

Other measures to alleviate pruritus include:

Advising the patient to keep their nails short and to gently rub itching skin to prevent damage.
Using a cold fan on exposed skin.

Hyperhidrosis (Excessive Sweating)

Hyperhidrosis, or excessive sweating, can cause discomfort and anxiety in patients.

Caused by various factors, including:

Intercurrent infections, including tuberculosis (TB)
Toxemia associated with liver metastases
Lymphomas
High doses of morphine

Management:

Identify and treat the underlying cause.
If fever is present, administer antipyretics such as Paracetamol, Ibuprofen, or Diclofenac, which may initially increase sweating but eventually bring down the temperature and provide cooling effects.
Steroids like Dexamethasone (2-4mg/day) can also be given.
Frequent sponging and appropriate advice regarding clothing and bedding can help alleviate discomfort.

Oedema and Swelling

Kaposi’s Sarcoma is a common cause of swelling in various parts of the body, particularly the legs and face. The woody hard infiltration of the skin by the tumor leads to areas of distension, blockage of small vessels and lymphatics, and fluid retention.

Management:

Considering starting antiretroviral therapy (ART) to improve the condition.
Chemotherapy, if available.
Pain relief with analgesics.
Managing the underlying cause, if identified.

Bilateral Upper Limb Oedema

Bilateral upper limb edema is mainly caused by superior vena cava obstruction, resulting in venous distension in the area drained by the superior vena cava. Management involves:

Prompt radiotherapy (RT)
Chemotherapy
High-dose Dexamethasone

Unilateral Lower Limb Oedema

The three principal causes of unilateral lower limb edema in terminal care are:

Venous and/or lymphatic obstruction caused by a pelvic tumor. Consider radiotherapy (RT) and chemotherapy to shrink the tumor.
Deep venous obstruction. Avoid anticoagulants due to the bleeding tendency in terminal diseases.
Infection, which can manifest as cellulitis, lymphangitis, or deep tissue infection from a nearby tumor.

Management:

Use appropriate antibiotics, specifically broad-spectrum or according to culture and sensitivity results.
Advise bed rest.
Administer analgesics to control pain.

Bilateral Lower Limb Oedema

The three principal causes of bilateral lower limb edema in terminal care are:

Lymphatic and venous obstruction caused by a pelvic tumor. Management:

High-dose Dexamethasone
Diuretics, preferably Spironolactone (75-400mg daily) together with Frusemide (40-200mg daily)

Cardiac failure, which should be treated using routine methods.

Lypoalbuminemia resulting from dietary deficiency or loss in ascitic fluids. Prolonged periods of sitting with dependent feet can also cause lower limb edema, but it is not an indication for diuretics. Management:

Elevate the feet
Encourage leg movement through walking or passive movements
Treat the contributing factor
Provide reassurance to the patient and family members

Ascites

Ascites is the accumulation of excessive fluid in the peritoneal cavity, which is the space within the abdomen. Malignancy, or cancer, accounts for around 10% of all adult cases of ascites.

Clinical features of ascites :

Increasing distension of the abdomen
Abdominal pain
Early satiety (feeling full quickly after eating)
Nausea and vomiting
Shortness of breath
Leg edema (swelling)

Pathogenesis

The pathogenesis of ascites involves an imbalance between fluid influx and efflux in the peritoneal cavity. Increased fluid influx is associated with peritoneal metastasis (spread of cancer to the peritoneum) and increased peritoneal permeability. Reduced efflux is associated with lymphatic vessels blocked by tumor infiltration and liver metastasis causing low albumin levels.

Causes of ascites can include

ovarian carcinoma,
colorectal carcinoma,
pancreatic carcinoma,
gastric carcinoma,
cardiac failure,
renal failure, and liver failure.

Management

Correcting the underlying cause if possible, as successful treatment of the underlying condition can often control ascites.
Non-drug treatment options include paracentesis, which involves the removal of fluid from the peritoneal cavity. However, ascites is likely to reaccumulate after paracentesis.
Drug treatment options for ascites include the use of spironolactone, which is a diuretic that helps reduce fluid accumulation, and frusemide may be added if necessary.

Fungating Tumors and Odors

Fungating tumors can cause distress to patients due to embarrassment and isolation from relatives and friends.

Management:

Regular cleaning of the fungating tumor with saline.
Radiotherapy (RT) may be a good option.
Crushed Metronidazole tablets applied to the fungating area can remove odor and dry up the discharge.
Metronidazole tablets can be inserted into sinuses or orifices leading to smelly growth, particularly in rectal or cervical cancers. It helps with pain relief, hemostasis, and clearing infections caused by anaerobic organisms.

Wound Care

Causes of wounds:

Fungating skin cancers (primary or secondary), such as breast, sarcoma, squamous tumors, or melanoma.
Poor wound healing due to debility, poor nutrition, and illness.
Pressure sores due to debility and immobility.

General Care:

Cleaning wounds:

Use a simple saline solution made by boiling water and adding salt (a pinch for a glass or one teaspoon for 500mls).
Use saltwater baths for perineal wounds.
Avoid caustic cleaning agents like hydrogen peroxide.
Consider leaving a wound exposed to air (while monitoring for maggots).
If necessary, apply clean dressings daily or more frequently if there is discharge.
Consider using locally available materials, such as old cotton cloths washed and cut to size, for simple dressings.
Educate the patient’s family on how to perform daily dressing changes.
Prevent pressure sores by regularly changing the patient’s position.
Keep the skin dry and clean.
Consider using a water-filled surgical glove for pressure relief in critical areas.

Assessment and Management:

Is there pain?

Use non-adherent dressings and soak them off before changing.
Administer analgesia 30 minutes before changing the dressing.

Is there an unpleasant smell?

Sprinkle crushed metronidazole tablets directly onto the wound (avoid enteric-coated tablets) or use metronidazole gel if affordable.
Consider using locally available remedies such as natural yogurt, papaya, or tried-and-tested local herbs.
Honey or sugar can be temporarily used on a dressing for de-sloughing necrotic wounds. Dressings should be changed twice a day as they become moist, but within a few days, you can revert to dry dressings or metronidazole.

Is there discharge?

Use absorbent dressings and change them frequently.

Is there bleeding?

In cases of severe bleeding, consider radiotherapy or surgery. Use dark cloths to soak up the blood.
Clean the wound carefully to avoid trauma during dressing changes.
Consider using crushed topical tranexamic acid (500mg).

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