Nausea and vomiting in end-of-life care: managing this debilitating symptom in the community
Nausea and vomiting (N&V) are common, debilitating and distressing symptoms for patients with advanced cancer, precipitating admission to hospital for intravenous antiemetic and re-hydration (Glare et al, 2011). The causes of N&V in end-of-life care (EOLC) are multifaceted, with appropriate therapy guided by thorough assessment (Walsh et al, 2017; Watson et al, 2019). Cyclizine and levomepromazine can, depending on aetiology, be cited as effective antiemetic agents for patients with advanced cancer (Ingleton and Larkin, 2015; Watson et al, 2019). Conversely, careful consideration of the use of dexamethasone for the management of N&V in EOLC should be taken, due to known side effects (Ferrel and Paice, 2019). This case study will use a systematic approach to critically appraise the management of N&V, experienced by a community patient receiving EOLC from the district nurses.
Nausea, an unpleasant sensation in the stomach, accompanied by a feeling of the need to vomit, and vomiting, the dynamic explosion of gastric contents through the mouth, are different physiologic processes, activating the same neural pathways (Wickham, 2020). Nausea and vomiting (N&V) is often multicausal for patients with advanced cancer receiving palliative care, often as a consequence of their primary disease, treatments including anti-cancer therapies, impaired gastric emptying, opioid use, or cranial causes (Leach, 2019). Collis and Mather (2015) and Glare et al (2011) highlight the importance of a comprehensive assessment in determining the cause and likely reversibility of N&V, thereby providing accurate information related to the antiemetic strategy. The antiemetic strategy is based on sound knowledge of the mechanism of N&V, the pathophysiology of this mechanism and the pharmacology of the drugs available, ensuring effective prescription and administration of medication to ameliorate the identified mechanism causing the N&V (Glare et al, 2008). There is recognition that a specific palliative care assessment tool, such as the Pepsi-Cola mnemonic (Gold Standards Framework Centre, 2014) (see Tables 1a and 1b), can complement clinical experience and assessment, directing the assessor to obtain an in-depth history and to identify the palliative care needs and support required of the person receiving care (Faull and Blankley, 2015).
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