Pain
Treatment depends on the cause and nature of the pain:
- Somatic pain from superficial structures is well localised: follow regular Pain Management with paracetamol or NSAIDs and add an opiate analgesic when required
- Visceral pain is poorly localised: opioids are frequently necessary but consider steroids such as dexamethasone or prednisolone
- Neurogenic pain from damage, pressure or stretching of a peripheral nerve is controlled often with multiple agents: opioids, ketamine, antidepressants, anticonvulsants or nerve blocks
Dyspnoea and cough
Address underlying cause (see Dyspnoea)
Symptomatic management by:
- Position the patient to provide maximum comfort (usually sitting up)
- Provide oxygen if hypoxic or cool air from a fan
- Prescribe morphine 5-10 mg or lignocaine 50-100 mg via a nebuliser for persistent cough
- Prescribe benzodiazepine to relieve anxiety from worsening dyspnoea
- Give dexamethasone 4 mg PO or IV to treat dyspnoea associated with lymphangitis carcinomatosis
’Death Rattle’
Gurgling respirations from a dying patient unable to clear oropharyngeal secretions
- Consider repeated suctioning (but this is often unpleasant and traumatic for the family)
- Reassure family, position patient on their side and administer an anticholinergic agent such as:
- Glycopyrrolate 200-400 micrograms SC
- Atropine 600 micrograms SC
Nausea
Treat according to aetiology:
- Metoclopramide 10 mg PO or IV or IM
- Ondansetron 4-8 mg SL or IV
- Domperidone 10-20 mg PO
- Prochlorperazine 5-10 mg PO or 12.5 mg IM or slowly IV
- Haloperidol 1 mg PO or IM or IV
- Droperidol 0.5 mg or IM or IV
- Lorazepam 1 mg PO or SL
- Dexamethasone 4 mg PO or IM or IV; also acts an appetite stimulant
Dry Mouth
Administer frequent mouthwashes, offer sips of water or give ice chips to suck
Agitation
Consider:
- Medication side effects
- Intractable pain
- Full bladder
- Loaded rectum
- Anxiety and fear Consider benzodiazepines:
- Lorazepam 1 mg PO or SL
- Midazolam 10-20 mg/24 h or clonazepam 0.5-2 mg/24 h as a continuous subcutaneous infusion