• Anorexia is common in patients with widespread cancer; prednisolone 15-30 mg daily and/or alcohol (in the patient's preferred form) before meals, many help.
• Confusion may not need treatment unless it is accompanied by restlessness. Useful in an emergency is haloperidol, or thioridazine (less sedating) or chlorpromazine (if sedation is desired).
• Constipation is usual in dying patients, whether due to opioid analgesic or to inadequate intake of food and fluid,24 and physical inactivity. It can be exceedingly troublesome and management should begin early to forestall the need for the major unpleasantness and humiliations of manual removal of faeces and the lesser ones of enemas. Dietary measures should be used where practicable. A stimulant laxative and faecal softener (danthron plus poloxamer: co-danthramer) is commonly effective. Suppositories, e.g. glycerol or bisacodyl, should be used if the bowels have not been opened for three days and the rectum is found to be loaded.
• Convulsions. Sodium valproate orally is preferred as it is effective for a wide range of seizure disorders (for status epilepticus see p. 417).
• Dyspnoea. Chronic dyspnoea (not due to respiratory failure) may be relieved by an opioid (causing respiratory centre depression and reducing its sensitivity to chemical stimuli) but, when there is respiratory failure due to pulmonary disease, any sedation may be life-threatening. Oxygen is used as appropriate; a benzodiazepine reduces the anxiety of dyspnoea; dexamethasone reduces inflammation around obstructive tumours that cause dyspnoea. Accumulations of mucus that the patient is too weak to expel cause 'death rattle'; this terminal event, often more distressing to others than to the patient, may be eliminated by drying up secretions with an antimuscarinic drug (hyoscine or atropine 4- to 8-hourly).
• Emergencies such as major haemorrhage, pulmonary embolus, severe choking, fracture of large bone: give morphine 10 mg plus hyoscine 0.4 mg i.m.; this combination provides acute relief and some desirable short-term retrograde amnesia which may extend to the whole unpleasant episode.
24 It is normal and comfortable to die slightly dehydrated; full hydration leads to full urinary bladder (with discomfort, restlessness, incontinence), salivary drooling and death rattle; it also increases heart failure (with dyspnoea which enhances death rattle); intravenous tubes make final embraces almost impossible (Lamerton R1991 Lancet 337: 981).
• Hiccup (due to diaphragmatic spasm). Where this is intractable and exhausting, chlorpromazine (or other phenothiazine) or metoclopramide may help; also baclofen, nifedipine or sodium valproate.
• Insomnia. Use temazepam or zopiclone (which may be less prone to cause confusion in the elderly).
• Lymphoedema, e.g. due to pelvic cancer, that causes pain may be helped by prednisolone (15-30 mg/day).
• Mental distress may be helped by an antidepressant or tranquilliser, according to circumstances. Patients may too easily be drugged into uncomplaining silence, but it does not follow that they are not still in deep distress:
.. .the grief that does not speak
Whispers the o'er-fraught heart, and bids it break.25
And this unpleasant way of ending life can be avoided by discerning choice and, particularly, careful dosage of drugs.
• A mouth that is dry and painful may be due to candidiasis (treat with nystatin), to dehydration (rehydrate the patient judiciously where this can be done orally); the symptom can be managed by frequent small drinks or crushed ice to suck (plus assiduous mouth hygiene to prevent unpleasant infection); if due to antimuscarinic drugs, including some antidepressants, withdraw the drug or adjust its dose.
• Nausea and vomiting, whether due to disease or to opioid drug, cause great distress and can be more difficult to manage than pain; two drugs acting by different mechanisms may be needed when a single agent fails, e.g. metoclopramide (dopamine D2-receptor antagonist) or ondansetron (5-HT3-receptor antagonist) or hyoscine (antimuscarinic). For vomiting of hypercalcaemia: use an antiemetic and treat the cause (p. 740).
• Night sweats can be distressing and cause insomnia: indomethacin helps.
• Restlessness in terminal illness that has no obvious cause, e.g. pain, full bladder, may be treated with methotrimeprazine
25 William Shakespeare (1564-1616). Macbeth, Act 4, Scene 3.
(levromepromazine; a phenothiazine tranquilliser with analgesic effect) by injection. It may be combined with morphine (or diamorphine), which are tranquillisers as well as being analgesics; diazepam is useful for muscle twitching.
• Swallowing of solid-dose forms may be difficult and these may stick in the oesophagus in weak recumbent patients, especially if inadequate fluid is taken with the dose (at least two big gulps or 100 ml with the patient's trunk vertical).
• Urinary frequency, urgency and incontinence: flavoxate, tolterodine, oxybutynin (antimuscarinics) may be useful; they may cause retention of urine if there is anatomical obstruction. The pain (with reflex muscle spasm) of an indwelling catheter may be alleviated by diazepam.
• Raised intracranial pressure (see p. 328): dexamethasone may be used indefinitely; reduce dose to 5 mg/d if practicable.
• Fungating tumours and ulcers may smell distressingly due to anaerobic bacterial growth. Benefit may be gained by topical providone-iodine or metronidazole gel.
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