Palliative care in cancer patients

GI symptoms:

The most frequent symptoms are:

• Anorexia
• Malaise
• Weakness

Current research suggests that endogenously produced cytokines (e.g. TNF and ILs) are mediators of the anorexia/cachexia syndrome

Nausea and vomiting:

• Occurs in up to 2/3 of cancer patients in the last 6 weeks of life
• In order to ensure adequate absorption of the antiemetic, parenteral administration (preferably SC) may be helpful for the first 24-48 hours

Antiemetics are classified according to their affinities for NT receptor sites:

• A prokinetic DA antagonist (e.g. metoclopramide 10mg tds) would be helpful in vomiting due to upper GI stasis or liver metastases
• Prokinetics should be avoided in cases of intestinal obstruction, as they increase peristalsis in the upper bowel
• Centrally acting anticholinergics (e.g. cyclizine 50mg tds) or centrally acting DA antagonists (e.g. haloperidol 1.5mg tds) are the drugs of choice in vomiting caused by drugs or metabolic disturbance
• As with the prescription of analgesics, antiemetics will be most effective if prescribed on a regular, rather than ‘as required’ basis

Bowel obstruction:

• May present acutely or in a more chronic manner
• The cause is often multifactorial
• A small number of patients may benefit from surgical intervention
• Most patients will not be suitable for surgery and can be managed medically
• The active medical management of malignant bowel obstruction includes:
• The relief of intestinal colic using an antispasmodic (e.g. hyoscine butylbromide 60-80mg daily)
• Treating continuous pain with adequate analgesia (e.g. diamorphine)
• Treating vomiting if nausea is a problem with a centrally acting antiemetic (e.g. cyclizine 150mg daily or haloperidol 5-10mg daily)

It will be necessary to administer all of the above medications parenterally (the SC route is most appropriate)

Patients may be allowed to drink and eat low-residue diets which are mostly absorbed in the proximal GI tract

Respiratory symptoms:

• In particular, dyspnoea
• Management is based on accurate diagnosis of the cause and active treatment of all potentially reversible situations:
• Treat infections
• Drain pleural/pericardial effusions
• Transfuse symptomatic anaemia patients
• The sensation of dyspnoea and a cycle of respiratory panic may be partially relieved by the prescription of regular benzodiazepines. Regular doses of short-acting opioids (5-20mg qqh) are also helpful