Managing Nausea and Vomiting in Palliative Care Patients

Nausea and vomiting are common and distressing symptoms in many palliative care patients. Identifying the cause or causes and treating the symptoms promptly can increase comfort and quality of life.

Nausea is an unpleasant feeling in the stomach that may or may not be followed by vomiting. Vomiting is the sudden, forceful expulsion of the stomach contents which may or may not be preceded by nausea. They very often occur together but can also occur independently of each other.

Nausea is very common as a patient moves toward the end of life. It is most common in patients with terminal cancer with more than half reporting this symptom. It is also common in patients with other diagnoses. It almost goes without saying that nausea and vomiting are distressing symptoms but, more importantly, they can prevent a patient from taking in adequate hydration and nutrition as well as important medications.

There are several causes of nausea and vomiting. Noxious odors, tastes, or sights can sometimes trigger this response. Certain medications such as opioid analgesics (narcotic pain medications), NSAID’s, antibiotics, and chemotherapeutic agents can cause nausea as well. Physical changes in the gastrointestinal tract such as constipation or a bowel obstruction are yet other examples of causes. Because treatment of nausea and vomiting can largely depend on what's causing it, your health care provider will do a thorough assessment to try to determine the cause.

Treatment will begin with identifying the cause, and reversing it if possible. This may include removing or avoiding noxious stimuli, discontinuing unnecessary medications, and treating constipation. Medications to treat nausea and vomiting may be used when the cause is irreversible or the symptoms persist despite treatment. Medications may include:

• Anti-emetics like Phenergan and Compazine
• Anti-anxiety drugs like lorazepam
• Metoclopramide(Reglan)
• Haloperidol (Haldol)
• Diphenhydramine (Benadryl)

There are many different ways to administer most of the common medications to treat nausea and vomiting, which is especially important if pills are regurgitated before digestion. Some patients may be given a liquid form of the medicine if they can keep it down. Sometimes medication will be given as a suppository (in the rectum) or even as a topical gel on the skin.

There are other treatments that can be given along with medication or used while you're waiting for a medication to arrive. Some things you can try include:

• Provide fresh air and loosen the patients clothing.
• Apply a cool compress to the patient's forehead, neck, and wrists.
• Avoid odors that can trigger an episode; avoid cooking heavily-odored food and don’t wear perfume or after-shave when you will be close to the patient.
• Offer small meals and limit drinks served with each one. Offer liquids at other times during the day but drinking too much liquid with food can cause vomiting.
• Serve food cold, which can limit odors that can make a patient nauseated.
• As with any symptom, be sure to contact your healthcare provider immediately. Prompt treatment will help ensure that the patient gets comfortable as soon as possible.

_Sources:

_{Kinzbrunner, BM; Weinreb, NJ; Policzer, JS; 20 Common Problems: End of Life Care, McGraw-Hill Publishing, 2002.}

_{Ferrell, BR and Coyle, N; Textbook of Palliative Nursing, Oxford University Press, 2006.}