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Palliative Treatment

Essentials

  • Cancer can cause symptoms at any stage of the course of the disease. Effective symptom management improves patients' quality of life and reduces emergency room visits and human suffering.
  • Symptom management is an essential part of cancer care, and the aim is to start palliative care proactively and early. The guidelines mentioned in this article may be used in the curative and suppressive phases of the disease, as appropriate.
  • After the end of suppressive care, good symptomatic care will safeguard the quality of life of patients in their last days, months, even years, and allow them to focus on what is important to them with as little distress as possible.
  • Terminal care takes place in the last weeks or days of life, with a focus on good pain management and care.
  • Quality of life means different things to different patients and health care personnel: find out what the patient wants and choose palliative treatment that itself does more good than harm. The treatment options mentioned in this article should be considered from this perspective.
  • Identify, record and monitor the symptoms of cancer and the overall situation using symptom questionnaires.
  • Discuss treatment alternatives with the patient. Explain the probable aetiology of the symptoms, engage family members in the treatment, and consult with specialists.
  • In cooperation with the patient and relatives, make a treatment plan that anticipates symptoms and the course of the disease.
  • In case of severe symptoms, consult a palliative medicine unit.
  • Notice that in this article drug doses are indicated using the format A-B mg × X-Y, where A-B indicates the strength of a dose and X-Y the number of doses per day. Examples:
    • 10-20 mg × 1-3 = 10-20 mg 1-3 times daily (i.e. daily total dose 10-60 mg)
    • 10 mg × 1 = 10 mg once daily (i.e. daily total dose 10 mg).

Respiratory symptoms

Cough: causes and treatments

  • Heart failure Chronic Heart Failure, asthma Long-Term Management of Asthma, COPD Chronic Obstructive Pulmonary Disease (COPD), pulmonary fibrosis Idiopathic Pulmonary Fibrosis, gastro-oesophageal reflux disease Gastro-Oesophageal Reflux Disease, adverse effect of a drug (ACE inhibitor): treatment according to the primary disease, discontinuation of medication
  • Infection: antimicrobials, antipyretics
  • Pulmonary embolism Pulmonary Embolism
  • Lung metastases, pleural tumour, tumour-induced irritation of the pharynx and airways
    • Prednisolone 40-60 mg × 1 p.o. or dexamethasone 4-10 mg × 1 p.o. with dose tapering according to response
    • Antitussive medication, see below.
    • Radiotherapy
  • Pleural effusion: see Dyspnoea (below)
  • Pneumonitis caused by cytotoxic medication or radiotherapy: see Dyspnoea (below)
  • Swallowing "the wrong way", Pulmonary aspiration (pharyngeal palsy, obstructing tumour, gastro-oesophageal reflux Gastro-Oesophageal Reflux Disease)
    • Pharyngeal palsy: eating sitting up with chin pointed downwards
    • Fluid is made thicker (e.g. starch thickener)
    • Radiation of the obstructive tumour, laser therapy or bypassing using a stent
    • Gastrostoma (PEG tube)
  • Haemoptysis
    • Infection: antimicrobials
    • Tranexamic acid 1000-1500 mg × 3 orally, 500-1 000 mg × 3 intravenously
    • Prednisolone 40-60 mg × 1 p.o. or dexamethasone 4-10 mg × 1 p.o., with tapering doses according to the response
    • Radiotherapy if there is a clear local radiotreatable focus.
  • Dry cough
    • Dry air itself can cause and aggravate dry cough.
      • Humidification of dry air: sodium chloride 0.9% 5 ml with an inhaler
  • Mucus secretion
    • Infection: antimicrobials
    • Pain prevents the patient from coughing productively, coughing is difficult when the patient is lying down
      • Management of pain
      • Position therapy
      • Breathing into a bottle (using a thin hose and a bottle containing 10-20 cm of water)
    • Dry, sticky mucus
      • Humidification of the air
      • Mucolytes (e.g. erdostein 300 mg × 2 p.o.)
    • Profuse thin mucus
    • If the patient is too weak to cough
      • Antitussives, see below
      • Aspiration of mucus from the airways is seldom necessary and it is unpleasant for a conscious patient.
      • Anticholinergics, e.g. glycopyrronium bromide 0.2 mg × 1-6 s.c. or 0.6-1.2 mg daily continuous s.c./i.v. infusion decreases mucus production in the airways but also dries the mouth.
  • Antitussive medication

Dyspnoea

  • Identify treatable causes, and in all cases alleviate symptoms.
    • Coronary heart disease Chronic Coronary Syndrome (Coronary Heart Disease),heart failure, asthma, COPD: treatment based on the underlying disease
    • Pulmonary embolism Pulmonary Embolism: anticoagulant therapy
    • Pneumonia, septicaemia: antimicrobials, antipyretics
    • Pneumonitis induced by a drug (bleomycin, methotrexate, immuno-oncologic drugs, tyrosine kinase inhibitors):
      • If you suspect a drug-induced pneumonitis (dry cough, increasing dyspnoea, atypical pneumonia / pneumonitis on x-ray during or immediately after the administration of a drug), contact the unit treating the cancer and outside normal working hours consult an on-call oncologist.
      • A CT scan of the lungs is usually necessary for the diagnosis.
      • Treatment is started, depending on the symptom profile, as necessary, with a glucocorticoid, prednisolone 40-60 mg × 1 p.o. with tapering doses.
      • In severe immuno-oncological pneumonitis, large-dose parenteral glucocorticoid: methylprednisolone 1-2 mg/kg × 1 i.v.
      • Medication causing symptoms is usually discontinued temporarily.
    • Radiation-induced pneumonitis may appear (1-)3(-6) months after pulmonary radiotherapy and manifest itself as cough, dyspnoea and sometimes as increased CRP and fever. In a CT scan or x-ray of the lungs, fibrosis is detected in the radiotherapy area.
      • Rest
      • Prednisolone 40-60 mg × 1 p.o. or dexamethasone 4-10 mg × 1 with tapering dose according to response
      • Antitussives (see above); antimicrobials if an infection co-exists
    • Anaemia: red cell transfusion; in iron deficiency anaemia intravenous iron, i.e. ferric carboxymaltose; in some cases epoetin may be indicated
    • Fever: antipyretics.
    • Partial pulmectomy, lung fibrosis: symptomatic therapy
  • Tumour-induced causes of dyspnoea in the neck and thorax
    • Compression of the trachea, bronchi or the vena cava superior, atelectasis, lung metastases, lymphangitis carcinomatosa
      • Dexamethasone 4-10 mg × 1-3 p.o. with dose tapering according to response
      • Anticoagulation therapy in obstruction of superior vena cava if not contraindicated
      • Radiotherapy
      • In compression, consider stenting or laser therapy.
    • Pleural effusion
      • Pleural aspiration (not more than 1 500 ml at a time)
      • Prednisolone 40-60 mg × 1 p.o. or dexamethasone 4-10 mg × 1 p.o. with dose tapering according to response
      • Pleural effusion requiring repeated aspiration: consider consultation of a thorax surgeon (long-term drainage [e.g. Denver], chemical pleurodesis with talc, pleurectomy).
    • Pericardial tamponade
      • Aspiration ± drainage
  • Ascites
    • Puncture
      • A patient whose ascites derives from carcinosis, i.e. spread of cancer cells on the peritoneum, tolerates ascites punctures usually well from the viewpoint of haemodynamics, even if 3-6 litres of liquid is removed within 24 hours, and albumin compensation is not necessary in these patients.
      • An elevation in portal pressure due to extensive liver metastases may cause hepatorenal syndrome. Treatment comprises ascites removal and in the same way as patients with liver cirrhosis, compensation of albumin 20 g per 3-4 litres of ascites fluid.
    • In frequent ascites puncures, consider a tunnelled catheter.
    • Prednisolone 40-60 mg × 1 p.o. or dexamethasone 4-10 mg × 1 p.o. with dose tapering according to response
    • Diuretics although the response is usually slight and electrolyte imbalances are more pronounced.
  • Enlarged liver or large abdominal tumour: elevation of the upper body, half-sitting position
  • Constipation Obstipation in the Adult: induced bowel movement, see below.
  • Anxiety, hyperventilation
  • Non-pharmacological management of dyspnoea
    • Dyspnoea is often accompanied by anxiety and panic, which can make the situation worse (like a vicious cycle). Discuss the course of the illness with the patient, relatives and health care personnel in advance. Review and record the medications and interventions to be used in the event of an attack, i.e. the plan for dyspnoea attacks.
      • Keep the planned medicines easily accessible e.g. in the pocket, on the bedside table.
      • (Half-)sitting resting position, calm breathing, window open etc.
      • Agree how to alert help; e.g. bell, phone (number must be readily at hand, written down clearly or programmed into a mobile phone).
    • Consider whether you should discuss the fear of suffocation. Patients with a lung tumour or pulmonary metastases may fear suffocation even when no such risk is expected. Suffocation caused by cancer is very rare and possible only in case of bronchial obstruction or bleeding caused by a tumour in the head and neck region.
    • If dyspnoea is severe despite treatment, you can agree with the patient and his/her family to keep the level of consciousness so low that the patient need not suffer from the feeling of suffocation; instructions on medication are given below.
    • Physiotherapy, breathing and relaxation exercises, physical exercise, respiratory aids
    • Instructions, how physical strain is adjusted depending on functional capacity
    • Oxygen if the patient has hypoxaemia and he/she subjectively benefits from oxygen (oxygen concentrator to be provided at home, requires non-smoking: see Chronic Obstructive Pulmonary Disease (COPD))
    • Flow of air, a blowing fan: in a non-hypoxaemic patient, blowing of air at the patient relieves dyspnoea as effectively as oxygen. Some patients find that the airflow on the face relieves the feeling of dyspnoea and is soothing.
  • Pharmacotherapy for dyspnoea
    • Often the combination of an opioid, glucocorticoid and benzodiazepine works best.
    • Opioids are effective in the treatment of dyspnoea.
      • Starting dose with a morphine solution 10-20 mg × 4-6 p.o. and short-acting oxycodone (capsule, solution) 5-10 mg × 4-6 p.o.
      • Starting dose with a long-acting oxycodone 10-20 mg × 2 p.o.. In a small, drug-sensitive elderly patient, 5 mg × 2 p.o. can be started.
      • Starting dose with parenteral morphine and oxycodone 5-10 mg × 4-6 s.c./i.v. or continuous infusion 10-20 mg/24 h s.c./i.v.
      • Dose is increased by 20-30% adjusted to the response
    • Benzodiazepines
      • Lorazepam 0.5-2 mg × 1-3 p.o., i.v. or 2-4 mg/day s.c./i.v. infusion
      • Midazolam 2.5 mg × 1-6 s.c. or 5-10 mg/day s.c./i.v. infusion
      • Diazepam (5-)10-20 mg at night, 5-10 mg × 1-3 p.o./p.r.; 5-20 mg/day i.v. infusion
    • Glucocorticoids and other drugs affecting the airways
    • If necessary, start mood-altering medication.
    • Ask about smoking, encourage cessation, with the support of nicotine replacement products, as necessary.
    • Give the patient (written) instructions on medication for acute attacks of dyspnoea: the patient should always have 1-2 doses of opioid and 1-2 doses of benzodiazepine available, e.g. in the pocket, in the purse or on the bedside table.
    • If effective sedation is required
      • continue the symptomatic medication
      • titrate effective opioid medication
      • add a benzodiazepine, e.g. midazolam 2.5-5 mg i.v. or 5-10 mg s.c. every 10 minutes until the patient is calm; plan continuous medication on the basis of the dose needed to calm the patient.
      • haloperidol often enhances sedation, e.g.2.5-5 mg i.m./i.v. once every hour until the patient is calm; plan continuous medication on the basis of the dose needed to calm the patient
      • add glycopyrronium 0.2-0.4 mg s.c./i.v up to 1.4 mg/day if patient is mucusy.
    • Agree upon emergency medication if a catastrophe, e.g. tracheal bleeding/compression, is to be expected.
      • The patient must not be left alone. The health care personnel must remain calm.
      • A tranquillizer combined with a potent opioid: for example, diazepam 5-20 mg i.v. or 10-20 mg per rectum or lorazepam 1-2 mg i.v./s.c. or midazolam 2.5-5 mg i.v./s.c. together with morphine or oxycodone 10-20 mg i.v./s.c. (starting doses)
      • If necessary, repeat the dose until the patient gets better. In very severe cases, the medication must be repeated, until the patient becomes unconscious.

Dry mouth and stomatitis

Oral hygiene

  • Essential for patient's well-being and protection of oral infections
  • Advice and care provided by a dentist and dental hygienist are important.
  • Soft toothbrush
  • No strong mouth rinses or toothpastes
  • Well-fitted prostheses that are cleaned twice daily and not worn at nights.
  • Frequent mouth rinsing and gargling
    • Water
    • Saline solution (1 tsp of salt in 2 dl of water)
    • Salt-sodium bicarbonate solution (1 tsp of salt + 1 tsp of sodium bicarbonate in 2 dl of water
    • Chlorhexidine diluted

Dry mouth

  • Discontinuation of medications that dry up the mouth, if possible
  • Saliva substitutes, moisturizing gels, protective sprays (various products are available in regular and hospital pharmacies)
  • Xylitol products in different forms, may increase salivary secretion
  • Crushed ice, crushed pineapple, ice lollies, lemon sticks, cooking oil

Eating

  • Lukewarm, mildly spiced soft foods.
  • Nothing very cold or hot.

Treatment of candida and herpes infections

  • Candida is the most common cause of oral infection.
  • Local therapy in addition to oral hygiene including dental prosthesis
  • In candida stomatitis refractory to local therapy, give fluconazole systemically, 100 mg × 1 p.o. for a period of 5-7 days. If the patient has dry mouth with no saliva, the concentration of a systemic antimicrobial drug on the oral mucosa may remain inadequate, and hence also local antifungal therapy is required.
  • Herpes infection
    • For herpes infections in the oral mucosa: valaciclovir 500 mg × 2 p.o. for 5 days, acyclovir 200 mg × 5 p.o. for 5 days

Treatment of pain

  • Local therapy:
    • Lidocaine mouth rinse 5 mg/ml 15 ml for gargling + 15 ml swallowed × 1-8 (note allergy and danger of aspiration)
    • Lidocaine solution (20 mg/ml) 5-10 ml first gargled and then swallowed slowly × 1-6 (note allergy and danger of aspiration)
    • Sucralfate first gargled and then swallowed 200 mg/ml 5 ml x 4-6 (if this induces vomiting, the patient should not swallow the dose) may reduce the need for analgesics.
    • Morphine solution 2 mg/ml 15ml for gargling 2-3 minutes × 6-8, may not be swallowed
    • Systemic pain medication: see Pharmacological Treatment of Cancer Pain. In severe damage of the mucous membranes, parenteral opioids may be required.

Anorexia Medically Assisted Hydration for Adults Receiving Palliative Care

  • Offering food is a natural way to show caring, but for a person with no appetite, pushing food and focusing attention on eating only makes the situation more difficult.
    • Discussing the mechanisms of cancer-related loss of appetite with the patient and relatives helps to understand the situation.
    • The analogy of a lack of appetite during a cold is often instructive.
  • There is no clear evidence of the correlation of fluid status and the feeling of thirst.
  • Causes of anorexia
    • Medication, such as antineoplastic agents, analgesics.
    • Oral Candida infection (common, see above)
    • Sore or dry mouth: see above for the treatment of stomatitis and dry mouth; see also article Dryness of the Mouth.
    • Nausea: see section on the treatment of nausea below.
    • Early feeling of satiety, which may be caused by
      • constipation (see section below on management)
      • abdominal tumour or large liver (glucocorticoids may reduce swelling: prednisolone 20-40 mg × 1 p.o. or dexamethasone 4-10 mg × 1 p.o.)
      • ascites (treatment: see above here).
      • Treatment: (half-)sitting position, small portions, metoclopramide 10 mg × 3 p.o. given 20 minutes before a meal.
    • Metabolic causes, e.g. hypercalcaemia Hypercalcaemia and Hyperparathyroidism, uraemia Treatment of Chronic Renal Failure
    • Swallowing "the wrong way", pulmonary aspiration (pharyngeal palsy, obstructing tumour): see above
    • Pain: take care of pain medication Pharmacological Treatment of Cancer Pain
    • Depression: comforting, medication (among the antidepressant drugs, mirtazapine increases appetite)
  • Cold food (ice cream, milkshake etc.)
  • The eating environment and situation must be made as comfortable as possible for the patient.
  • Small portions on small plates. Pleasantly set meals at short intervals when the patient wishes. A smell-free place for eating.
  • Shared unhurried meals by the table dressed up instead of eating in the bed wearing nightwear
  • An aperitif may improve the patient's appetite; any alcoholic drink is suitable (NB antabus interaction with metronidazole).
  • Glucocorticoids can improve appetite and other aspects of the patient's condition. They can be used as a 1-2-week course or as long as there is response and there are no side effects that prevent their use (swelling, loss of sleep at night).

Nausea and vomiting Haloperidol for the Treatment of Nausea and Vomiting in Palliative Care Patients, 5-HT3 Receptor Antagonists in Chemotherapy-Induced Nausea and Vomiting

Causes and treatment alternatives

  • Chemotherapy, also other medicines used to treat cancer, such as protein kinase inhibitors
    • Acute chemotherapy-induced emesis: antiemetic medication is given as premedication at home and during treatment at the treating unit.
    • Treatment of delayed chemotherapy-induced emesis
      • Dexamethasone 2-4 mg × 1-2 p.o. for 2-4 days ± metoclopramide 10 mg × 3 p.o. and, as necessary, 5-HT3-receptor blockers (see dosage below).
      • Lorazepam at the dose of 0.5-1 mg × 1-3 p.o. enhances the effect of other antinauseatic agents.
      • Haloperidol 0.5-1 mg × 1-3 p.o. also a possible additional drug for nausea (dopamine receptor antagonist)
      • NB: some cancer drugs, e.g. capecitabine, are administered as tablets at home either continuously or as a course lasting several weeks; check the medication list.
    • Other drugs, for example, opioids (nausea caused by opioids seldom lasts more than a week), antihypertensive and mood-altering drugs
      • Stop unnecessary drugs, change the drug, and check dosage. Add antinausea medication as necessary.
    • Irradiation of the abdomen or large pelvic field
  • Total brain radiation
    • May increase or cause swelling around metastases: dexamethasone 4-6 mg × 1-3 p.o., 5-HT3-receptor blocker (see dosage below). If already on glucocorticoid medication, increase the dose to 2-3-fold.
    • During the weeks following the radiation therapy of the brain, the symptoms of nausea may again become worse due to either radiation-induced brain oedema or progression of the disease: as first aid, raise the glucocorticoid dosage to 2-3-fold; if a glucocorticoid is not already used, start dexamethasone 2-6 mg × 1-3 p.o/s.c./i.v.
  • Hypercalcaemia: rehydration, bisphosphonates, glucocorticoids; see treatment of hypercalcaemia Hypercalcaemia and Hyperparathyroidism
  • Increased intracranial pressure (brain tumour, brain metastases): dexamethasone 4-10 mg × 1-3 p.o./s.c./i.v. with dose tapering according to response. Consult a neurosurgeon about the possibility of surgery, a radiotherapist about radiotherapy.
  • Enlarged liver, ascites: see above for treatment here
  • Uraemia Treatment of Chronic Renal Failure, liver failure Cirrhosis of the Liver: symptomatic treatment
  • Oesophagitis, gastritis, peptic ulcer Peptic Ulcer Disease, Helicobacter Pylori Infection and Chronic Gastritis: remember the possibility and treatment of candida stomatitis and oesophagitis.
  • Constipation is a common and curable cause of nausea; see below and separate article for treatment Obstipation in the Adult.
  • Bowel obstruction: see below
  • Anxiety, fear, depression: appropriate treatment of nausea, psychological support and anxiolytic and/or antidepressive medication, when necessary
  • Cough resulting in vomiting: see section on treatment of cough above.
  • Symptomatic medication at suggestive doses
    • Metoclopramide 10 mg × 1-3 p.o./s.c./i.v., 20-30 mg/day as a continuous s.c./i.v. infusion
    • Haloperidol 0.5-1 mg × 1-3 p.o./s.c./i.v., 5-10 mg daily s.c./i.v. infusion
    • Lorazepam 0.5-1 mg × 1-3 p.o./s.c./ i.v., 2-4 mg/day as a s.c./i.v. infusion
    • Dexamethasone 2-8 mg × 1 p.o.(sometimes administration in the morning and afternoon may also alleviate nausea), 4-10 mg × 1-2 s.c., i.v., prednisolone 20-60 mg × 1
    • Prochlorperazine 5-10 mg × 1-3 p.o.
    • Scopolamine patch 1 mg every 3 days
    • Levomepromazine 2.5-10 mg × 1 p.o. at night
    • Hydroxyzine 25 mg × 1 p.o. at night, cyclizine 25-50 mg × 1-3
    • 5-HT3-receptor blockers are effective in the prevention of acute nausea induced by cytoxic agents that cause moderate or severe nausea as well as in the treatment of nausea induced by radiation therapy of the brain and upper abdomen.
    • 5-HT3-receptor blockers may be beneficial in the prevention of delayed nausea caused by cytotoxic agents and of chronic nausea in cancer patients as well as in relief of opioid-induced nausea in some patients, if other drugs do not provide sufficient response; disadvantages include constipation and headache, can prolong the QT interval.
      • Granisetron 1 mg × 1-2 / 2 mg × 1 p.o., 1-3 mg × 1-3 i.v.
      • Ondansetron 4-8 mg × 1-2 p.o. (also an orally resorbable preparation), 16 mg × 1 p.r., 8 mg × 1-3 i.v.
    • Above drugs in combinations

Constipation Laxatives for the Management of Constipation in Palliative Care Patients, Muopioid Antagonists for Opioidinduced Bowel Dysfunction in Cancer and in Palliative Care

  • Constipation is a very common symptom in a patient with advanced cancer. It is associated with the disease itself, changes in diet, reduction of exercise, drugs, lack of privacy in the hospital or a combination of these factors. Rule out intestinal obstruction (vomiting, cramp-like pain, visible peristaltic activity, swelling of the stomach), see below section on intestinal obstruction and acute abdomen Acute Abdomen in the Adult.
  • In the beginning of treatment, auscultate abdominal sounds palpate the stomach and perform touch per rectum.
  • Causes
    • Cancer: obstruction caused by a tumour, peritoneal carcinosis, ascites (see above here), spinal cord damage: causal treatment if possible
    • Drugs: opioids, anticholinergics (e.g. antipsychotics, antidepressants), vinka-alkaloids, 5-HT3 receptor blockers; reduce if possible
    • Changes in nutrition, lack of appetite, sore mouth, dehydration: recommend ample amounts of fluids, higher fibre diet (if possible), analgesics; treatment of the mouth and anorexia: see above
    • Reduction in physical activity: encourage physical activity and treat pain that prevents it
    • Painful anal fissure Anal Fissure, irritated haemorrhoids Haemorrhoids
    • Hypercalcaemia Hypercalcaemia and Hyperparathyroidism
    • Hypothyroidism Hypothyroidism
    • Lack of privacy in the hospital: ensure sufficient privacy
  • Constipation is a private complaint: ask about bowel function regularly and directly, encourage a debilitated patient to ask for extra help to go to the toilet.
  • Start prophylactic medication for constipation when opioids are initiated, e.g. macrogol 12 g × 1 p.o. to be taken regularly!
  • Medication is given preferably orally. Suppositories are used when necessary as extra help in a difficult situation or bowel movement is induced by giving an enema.
    • Bulk laxatives require ample amounts of fluids and are not suitable for a patient in poor condition.
    • Osmotic laxatives (e.g. lactulose 10-30 ml × 1-2 p.o., macrogol 12 g × 1-6 p.o. according to the response) are used alone or with stimulant laxatives
    • A stimulant laxative (senna 5-10 g × 1 p.o., sodium picosulphate 5-10 mg × 1 p.o., bisacodyl 5-10 mg × 1 p.o.) alone or combined with osmotic laxatives
    • Prokinetic agents: metoclopramide 10 mg × 1-3 p.o.
    • Opioid antagonists
      • Combination of an opioid with naloxone: maximum daily dose is 160 mg oxycodone hydrochloride and 80 mg of naloxone hydrochloride. Titration of the opioid amount is more difficult when using a combination product.
      • Methylnaltrexone bromide may be beneficial in opioid-induced constipation refractory to other laxative therapy; administer 12 mg s.c. once daily at most. The patient must not have mechanical bowel obstruction.
      • Oral naloxegol may be beneficial in opioid-induced constipation refractory to other laxative therapy; 25 mg × 1 p.o. The patient must not have mechanical bowel obstruction.

Diarrhoea

  • Treatment-related causes
    • Drug treatment for cancer is the most common cause of diarrhoea in a cancer patient (e.g. cytostatics like 5-fluorouracil, capecitabine [oral preparation administered at home], irinotecan, topotecan, tyrosine kinase inhibitors, immuno-oncologic therapies)
    • Irradiation of the pelvic region
    • Postoperative causes: resection of the intestine or pancreas, blind-loop syndrome
    • Antimicrobial treatment: Clostridioides difficile
  • Cancer-related causes
    • Carcinoid syndrome in neuroendocrine tumour: causative and symptomatic treatment, including telotristat, octreotide and lanreotide
    • Pancreas cancer: osmotic diarrhoea, pancreatic enzyme substitution, consultation with a therapeutic dietitian
    • Disturbance in the absorption of bile acids: cholestyramine
    • Postoperative conditions after surgery for intestinal cancer: consultation with a therapeutic dietitian
  • Constipation may cause "overflow" diarrhoea; digital rectal examination. Treatment of constipation: see above.
  • Some nutrients may aggravate diarrhoea: spicy, greasy, fibre-rich foods, lactose-containing dairy products. Sometimes during chemotherapy lactose tolerance becomes impaired. Some patients benefit from a FODMAP diet, with guidance from a dietician, as necessary.
  • Oral or parenteral fluid therapy is indicated when it is beneficial in the overall situation.
  • Symptomatic treatment (note: in diarrhoeas and infectious conditions caused by drugs or radiotherapy, do not hesitate to refer the patient to a hospital and consult the treating unit. Bowel inflammation caused by cytostatic and immuno-oncologic therapy involves even a risk of bowel perforation.
    • Patient with no pain: loperamide 4 mg starting dose and 2 mg after each diarrhoeic voiding, up to 16 mg/day p.o.
    • Opioids
    • Octreotide 50-100 µg × 1-3 i.v./s.c. (up to 900 mg/24 h) in diarrhoea with large volumes

Intestinal obstruction

  • If the patient's condition and prognosis allow surgical intervention consult a surgeon (see Intestinal Obstruction, Paralytic Ileus and Pseudo-Obstruction).
    • Correction of dehydration and fluid balance as well as decompression by a nasogastric tube prepare the patient for operation or stent placement.
  • Inoperable obstruction
    • In a distal obstruction food intake and medication may be successful also orally.
    • The need for parenteral nutrition must be considered individually. When the intestine is permanently obstructed the cancer is usually so advanced that parenteral nutrition is not beneficial.
    • If no response to medication is detected, parenteral hydration and the use of nasogastric tube are discontinued.
    • Medication aims to alleviate nausea, vomiting, bowel secretion and pains. In a distal obstruction pharmacotherapy may make oral food intake possible. In a proximal obstruction vomiting often follows soon after food or drug intake and, depending on the location of the obstruction, PEG tube placement or jejunostomy should be considered. If the prognosis is short and the patient vomits constantly despite medication, discuss with him/her the pros and cons of a nasogastric tube. The aim is to provide drug therapy by subcutaneous infusion, which allows discharge with the support of hospital at home (if applicable in the local setting). Once the vomiting has subsided, some drugs can be administered orally, although absorption is uncertain.
      • Glycopyrronium bromide 0.4-1.2 mg/day continuous s.c./i.v. infusion, 0.2 mg × 1-6 s.c. Anticholinergic drug that is beneficial against vomiting and nausea, reduces peristaltic activity and increases the absorption of fluid and salts.
      • Butyliscopamine 40-100 mg/day continuous s.c. infusion as an alternative to glycopyrronium bromide
      • Octreotide may be beneficial in the treatment of nausea and vomiting and may reduce the profuse secretion of fluid in the intestinal canal; dosage 100 µg × 1-3 s.c., 100-150 µg s.c. infusion up to 600-900 µg. According to the response, increase the dose and continue the drug; if no response occurs, discontinue.
      • Haloperidol 2.5-10 mg daily s.c./i.v. infusion or 0.5-1 mg × 1-3 orally
      • Morphine 30 mg/day s.c./i.v. infusion, oxycodone 20 mg/day s.c./iv. infusion or 10-30 mg × 2 p.o., starting doses
      • Usually the medication is a combination of haloperidol, opioid and glycopyrronium or octreotide, and to add effectiveness, as necessary, glucocorticoid, 5-HT3-receptor blocker and metoclopramide (if no complete blockage or colic pain).
      • Dexamethasone 4-5 mg × 1-2 s.c. enhances anti-nausea effect and a therapeutic trial of 5-6 days may reduce swelling around the tumour

Hiccups

  • Causes Hiccup
    • Several nerves and factors affecting these nerves may cause hiccups. In cancer the most common causes are primary tumours and metastases in the central nervous system, thoracic cavity and gastrointestinal tract.
    • Oesophagitis or gastritis caused by drugs (cytostatic drugs, glucocorticoids) or radiation therapy
    • Pneumonia, purulent pleurisy
    • Uraemia, hyponatraemia, hypokalaemia or hypocalcaemia
  • Treatment of the cause when possible
  • Non-pharmacological treatments, e.g.: the patient should try sitting up, breathing into a paper bag, drinking two glasses of water or swallowing two tsps of sugar.
  • Pharmacotherapy

Itching

  • In an advanced cancer, several concomitant mechanisms may cause itching. Skin care is essential regardless of the aetiology of itching.
  • The most common cause of pruritus in cancer patients is dryness of the skin. Choose the emollient cream that the patient is most comfortable with. Greasier ointments have a longer lasting effect. Soap should be avoided, and emollient cream or oil is applied to the skin before a bath/shower or oil is added to the bath water. Dry the skin patting lightly. Daily washing with water dries the skin and is not necessary.
    • Moderately strong and strong glucocorticoid creams in periods of 1-3 weeks
    • Cooling menthol ointments can be used as skin cream.
      • Menthol-alcohol solutions are available at pharmacies.
    • Cotton gloves for the night, short nails, light cotton clothing
    • Heat, anxiety, boredom and lack of activity make pruritus worse.
  • Skin infections
    • Topical treatment and possibly systemic antimicrobial drug
    • Shingles: valaciclovir 1 000 mg × 3 p.o. for 7 days or aciclovir 800 mg × 5 p.o. for 7 days and effective pain management right from the start (see also Shingles (Herpes Zoster))
  • Drug-induced pruritus
    • Discontinue the drug or change it to another one, treat allergic reaction.
    • Some biological drugs cause even strong skin reactions, often exactly to patients that benefit from the drug the most. The patients usually have instructions from the treating unit and an instruction booklet by the drug manufacturer; if necessary, consult the treating unit. The most common adverse effects of immuno-oncologic drugs are skin reactions, which are treated with glucocorticoids in ointment form, tablet form or, in case of a severe reaction, intravenously; consult.
    • Opioids can cause itching which is rarely mediated through histamine, but e.g. atopic patients may benefit from changing the drug to fentanyl (does not release histamine). Change between two opioid preparations , and some patients may benefit from a combination of oxycodone and naloxone.
  • Cancer-induced pruritus
    • Skin cancers, skin metastases
      • Wound therapy; consult a wound care nurse, as necessary
      • Irradiation therapy (see below)
      • Plastic surgeon consultation
    • Cancers particularly associated with itching are lymphomas, melanoma, and in situ carcinoma of the vulva and rectum; treatment of cancer if possible.
    • Therapeutic trial with glucocorticoids (see below)
    • Cholestasis
      • In extrahepatic cholestatis drainage of the biliary ducts endoscopically or percutaneously
      • Cholestyramine 4 g × 4 p.o. in fruit juice, not suitable for patients with low food intake and drinking or with difficulties in taking drugs.
      • Glucocorticoids, antihistamines, opioid antagonists, gabapentin (see below)
    • Uraemia

Drugs potentially beneficial against itching Pharmacological Interventions for Pruritus in Adult Palliative Care Patients

  • Glucocorticoids: prednisolone 20-80 mg × 1 p.o. or dexamethasone 2-10 mg × 1-2 p.o., tapering the dose down according to treatment response
  • Primarily sedative drugs: sedating antihistamine hydroxyzine 25 mg ½-1 tablet × 1-3 p.o., non-drowsy antihistamines may also be tried, e.g. cetirizine 10 mg × 1 p.o.; lorazepam 0.5-2 mg × 1-3 p.o., 2-4 mg/24 h s.c./i.v. infusion; diazepam 5-10 mg × 1-3 p.o./p.r., 5-10 mg/24 h i.v. infusion; haloperidol 0.5-2 mg × 1-3 p.o., 2.5 mg × 1-3 i.v., 5-10 mg/24 h s.c./i.v. infusion
  • Opioids: e.g. oxycodone 10-20 mg × 2 p.o., as a starting dose
  • Opioid antagonists:
  • Gabapentin up to 300 mg × 1-3 p.o.: tumour-induced pruritus, opioid-induced pruritus, cholestasis, uraemia
  • SSRI drugs, e.g. sertraline 50-100 mg × 1

Palliative radiotherapy

  • Indications
    • Bone pain that does not respond to pain medication (including opioids): at least partial palliation is achieved in about two thirds of patients and total relief on pain in about half. The onset of pain relief varies from a few days to four weeks and palliation lasts on average 3-6 months. If there was a response to palliative radiotherapy, it can be repeated in the future if necessary as symptoms return when the focus has grown. Single radiation is as effective as fractionated multiple radiation in alleviation of pain, and it is easier for the patient and the treating unit to implement. Initially, the pain in the area to be treated may temporarily increase with radiotherapy: adequate analgesic medication, as necessary.
    • Prevention of fractures of the weight-bearing bones. Radiotherapy is often carried out in several fractions. Also consult a surgeon conserning the possibility of prophylactic stabilization.
    • Prevention and treatment of spinal cord compression. NB: if the patient is developing paraparesis, tetraparesis, or the cauda equina syndrome, i.e. he/she has progressive neurological symptoms, start glucocorticoid therapy without delay (see below) and consult a neurosurgeon and an oncologist. On working days radiotherapy can be started on the same day as an emergency treatment. The neurological status of the patient at the time the therapy is started influences the outcome. Lost mobility is rarely regained.
    • Managing pressure symptoms: e.g. brain metastases, brain tumour, nerve compression
    • Haemorrhage: haemoptysis, haematuria, skin metastases
    • Treatment of skin tumours and metastases
    • Reducing obstructions (bronchus, vena cava superior, ureter)
  • If neurological, pressure or obstruction symptoms occur in the beginning of the treatment, or if they are to be expected as an adverse effect due to swelling caused by radiotherapy, a glucocorticoid is used, e.g. dexamethasone 4-10 mg × 1-3 p.o. or parenterally. Anticoagulation therapy is started in obstruction of superior vena cava if not contraindicated.
  • The aim of palliative radiotherapy is to relieve symptoms quickly, to the precise target with as few adverse effects as possible. Irritation of the organs surrounding the target to be irradiated causes adverse effects of radiotherapy, which are usually rather minor at palliative doses.
  • The most common adverse effects of radiotherapy include fatigue, redness of the skin, irritation and pain in the area being treated and, in the case of the gastrointestinal tract, nausea.
  • On the average, palliative radiotherapy is administered in 1-10 fractions.
  • Before starting radiotherapy, a dose-planning CT scan is performed, after which a radiotherapist determines the area to be treated and a physicist makes a radiotherapy plan. The dose-planning scan and the start of radiotherapy may take place on different days. The patient may go to radiotherapy from another unit.
  • Radiotherapy is not a treatment for a patient who is dying, confused or in very poor general condition. Although radiotherapy itself does not cause pain, the patient must be able to lie still on a hard surface for about 15 minutes. Additionally, the patient has to stay alone in the therapy room on a high treatment table. Prophylactic breakthrough pain medication is administered before the radiotherapy session.

References

  • Palliative and end-of-life care. Current care guideline. Working group set up by the Finnish Medical Society Duodecim and Finnish Association for Palliative Medicine. Helsinki: Finnish Medical Society Duodecim, 2019 (accessed 24 Oct 2022). Available in Finnish http://www.kaypahoito.fi/hoi50063.
  • Kaasa S, Loge JH, Aapro M, et al. Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018;19(11):e588-e653. [PubMed]

Evidence Summaries ⬆