PALLIATIVE MEDICINE NAUSEA, VOMITING, BOWEL OBSTRUCTION in Thirty Minutes T.F. Benton St. Columba’s Hospice

SYMPTOM CONTROL : a consistent approach Cause(s) Disease Treatment - past - present Associated frailty Unrelated

SYMPTOM CONTROL : a consistent approach Management Explanation/Expectation active palliative/symptomatic

TREATMENT ACTIVE SYMPTOMATIC patient - wishes disease - extent - tempo - availability of treatment [relatives - wishes]

NAUSEA, VOMITING, RETCHING Cancer bowel obstruction metabolic raised intra-cranial pressure cough induced Treatment drugs Associated poor oral hygiene constipation fungating tumour/odour anxiety infection Unrelated peptic ulcer

Unrelated peptic ulcer Associated poor oral hygiene constipation fungating tumour/odour anxiety infection Unrelated peptic ulcer

NAUSEA and VOMITING radiotherapy drugs - opioids gastric irritants TREATMENT chemotherapy radiotherapy drugs - opioids gastric irritants antibiotics

NAUSEA & VOMITING Associated poor oral hygiene constipation fungating tumour/odour anxiety infection

NAUSEA and VOMITING UNRELATED PROBLEMS peptic ulcer

NAUSEA & VOMITING CTZ VC GI TRACT cyclizine pressure dexamethasone anxiety HC anxiolytic metabolic obstruction gastric irritants CTZ VC GI TRACT cyclizine haloperidol metoclopramide lansoprazole levomepromazine octreotide

BOWEL OBSTRUCTION localized disease new primary adhesions late radiation scarring

BOWEL OBSTRUCTION - surgery? - age - poor g.c. - palpable tumour - previous RT/CT - small bowel obstruction

- IV fluids, NG aspiration - surgery - stent - symptom management: BOWEL OBSTRUCTION - IV fluids, NG aspiration - surgery - stent - symptom management: pain, nausea, vomiting constipation, diarrhoea

BOWEL OBSTRUCTION pain - morphine, diamorphine, Buscopan nausea - levomepromazine - cyclizine, ondansetron vomiting - NG tube secretions - Buscopan, octreotide dexamethasone - parenteral fluids - nutrition

• “Doctor, he’s not drinking.” • fluids? • essential drugs • parenteral drugs • “Doctor, he’s not drinking.” • fluids? • feeding?

SUBCUTANEOUS FLUIDS - DEHYDRATION - thirst - dry mouth - confusion - constipation - weakness - renal failure

Subcutaneous Fluids NOT routine NO evidence it prolongs life May be unnecessarily burdensome However, may relieve family tension Ethical debate ongoing

Sub-acute bowel obstruction a spectrum physical obstruction peristaltic failure _________________________ high-pitched bowel sounds diminished bowel sounds colic no colic buscopan metroclopramide faecal softener stimulant laxative

DECISION-MAKING I could have another operation…but they left it to me to decide I was too well for treatment yet I wasn’t well enough for treatment yet

... dying differently … … natural history changing … … living with disease …