Non-Pain Symptom Assessment and Management
Dyspnea
Opioids are first-line for refractory dyspnea regardless of oxygen saturation; oxygen helps only documented hypoxemia. Simple airflow (fan, open window) and treating anxiety also help. Traps: benzodiazepines alone are not indicated for dyspnea, and oxygen for a non-hypoxemic patient does not relieve breathlessness in trials.
Nausea and vomiting
Match the drug to the mechanism. Chemoreceptor trigger zone or metabolic cause: haloperidol or prochlorperazine. Vestibular: scopolamine or meclizine. Gastroparesis or gastric compression: metoclopramide. Serotonergic causes such as chemotherapy or obstruction: ondansetron. Anticipatory or cortical nausea: benzodiazepine or olanzapine (broad-spectrum). In complete bowel obstruction, avoid prokinetics if colic is present; use octreotide and dexamethasone.
Other core symptoms
Constipation: prophylactic stimulant plus osmotic agent; methylnaltrexone for refractory opioid-induced cases. Delirium: screen with the CAM, search for causes (pain, retention, impaction, drugs, infection, hypoxia, withdrawal), use nonpharmacologic measures first, and reserve antipsychotics for distress; avoid benzodiazepines except in alcohol or benzodiazepine withdrawal. Terminal secretions: anticholinergics such as glycopyrrolate plus repositioning, recognizing the evidence is weak and the patient is usually not distressed. Anorexia-cachexia: a short steroid course or megestrol (weigh thrombosis and adrenal suppression); food carries symbolic weight. Hiccups: baclofen or gabapentin. Depression at end of life: psychostimulants give rapid benefit.
Rule of thumb: one drug per receptor mechanism, and reassess within 24–48 hours before adding another agent.