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

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

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

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

5. 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

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

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

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

9. NAUSEA and VOMITING
UNRELATED PROBLEMS peptic ulcer

10. 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

11. BOWEL OBSTRUCTION
localized disease
new primary
adhesions
late radiation scarring

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

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

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

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

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

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

18. 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

19. 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

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