Non-Pain Symptom Management
Dyspnea
Opioids are first-line for refractory dyspnea in cancer and advanced COPD; titrate to symptom relief, not to oxygen saturation. Oxygen helps only hypoxemic patients; a handheld fan and cool airflow help normoxemic patients. Benzodiazepines are adjuncts for anxiety-driven dyspnea but not first-line. Reassure families that appropriately titrated opioids do not hasten death.
Nausea and vomiting
Choose by mechanism: serotonin antagonists for chemotherapy or radiation; metoclopramide for gastric stasis and dysmotility; haloperidol for metabolic and chemical causes; scopolamine or glycopyrrolate for vestibular causes and obstruction-related secretions; dexamethasone for raised intracranial pressure and obstruction; olanzapine as a broad-spectrum agent. In complete bowel obstruction, avoid prokinetics and use haloperidol plus dexamethasone, adding octreotide to reduce secretions.
Constipation
Opioid-induced constipation is expected. Prescribe a stimulant plus an osmotic laxative prophylactically; bulk-forming agents are often poorly tolerated with low oral intake. For refractory cases consider methylnaltrexone, naloxegol, or lubiprostone, and always rule out impaction.
Delirium, fatigue, and anorexia–cachexia
Delirium is a medical emergency: search for opioids, anticholinergics, infection, constipation, urinary retention, hypercalcemia, and hypoxia. Haloperidol is first-line for agitated delirium at end of life; avoid benzodiazepines except in alcohol or benzodiazepine withdrawal. Fatigue warrants screening for anemia, hypothyroidism, depression, poor sleep, and deconditioning; methylphenidate or modafinil may help selected patients. In cancer anorexia–cachexia, megestrol and dexamethasone modestly stimulate appetite; artificial nutrition does not reverse cachexia and may add burden.
Rule of thumb
In malignant bowel obstruction: stop the pump (haloperidol), dry the secretions (octreotide, glycopyrrolate), and damp the inflammation (dexamethasone).