Non-Pain Symptom Assessment and Management
Dyspnea
Dyspnea is subjective. Opioids are first-line for refractory dyspnea in palliative care, titrated similarly to pain. Oxygen helps only patients with documented hypoxemia; a fan and cool air can help others. Benzodiazepines are not first-line unless anxiety is prominent. A trap is ordering oxygen routinely for a dying patient with normal saturation.
Nausea and vomiting
Identify the likely mechanism. Haloperidol is useful for metabolic or gastric causes; metoclopramide for gastroparesis; ondansetron for chemotherapy-related nausea; olanzapine for mixed or refractory nausea; dexamethasone for raised intracranial pressure or bowel obstruction. In malignant bowel obstruction, octreotide plus dexamethasone can reduce secretions and edema. A trap is using one antiemetic for every cause.
Constipation and delirium
Constipation is common with opioids; start senna with or without docusate prophylactically. Methylnaltrexone can help refractory opioid-induced constipation. Delirium requires identifying reversible causes such as infection, constipation, urinary retention, medications, hypercalcemia, or hypoxia. Nonpharmacologic measures come first; antipsychotics may be used for distressing agitation but are not curative. Benzodiazepines can worsen delirium unless withdrawal or seizures are present.
Other symptoms
Terminal secretions are usually not distressing to the patient; reposition and use glycopyrrolate or scopolamine rather than deep suctioning. Anorexia and cachexia do not routinely require appetite stimulants; short-term megestrol or dexamethasone may be considered but have harms. Treat depression and anxiety appropriately. Recognize emergencies such as spinal cord compression, hypercalcemia, and seizures.
Rule of thumb
Match the antiemetic to the mechanism, and always look for reversible causes of delirium before sedating.