Non-Pain Symptom Assessment and Management
Dyspnea
Low-dose opioids are first-line for refractory dyspnea regardless of oxygen saturation. Supplemental oxygen helps only the hypoxemic patient; a fan, open window, positioning, and paced activity help the rest. Benzodiazepines treat the anxiety that accompanies dyspnea but are not first-line for the breathlessness itself.
Nausea and vomiting
Match the antiemetic to the pathway: gastric stasis and obstruction - metoclopramide (avoid in complete obstruction); chemoreceptor trigger zone - haloperidol, prochlorperazine, ondansetron; vestibular - scopolamine, meclizine; broad or refractory - olanzapine. Always look for constipation, hypercalcemia, uremia, opioids, and raised intracranial pressure as causes.
Delirium and agitation
Screen with the CAM. Non-pharmacologic measures first; haloperidol or an atypical antipsychotic for distressing symptoms. Reserve benzodiazepines for alcohol or benzodiazepine withdrawal and catatonia - they worsen most delirium.
Other symptoms
Bowel obstruction: octreotide, dexamethasone, antisecretory agents, and consideration of a venting gastrostomy. Anorexia-cachexia: treat reversible causes, discuss goals; megestrol and corticosteroids have limited benefit and real harms. Terminal secretions: reposition and use an anticholinergic; explain to families that suctioning and deep airways do not help and cause distress.
Traps
Giving oxygen to a non-hypoxemic dying patient; treating terminal restlessness with escalating sedation before ruling out a full bladder, impaction, or pain; assuming 'death rattle' means the patient is drowning.
Rule of thumb. Any new symptom in advanced illness gets a quick reversible-cause check - constipation, urinary retention, medication effect, electrolyte - before adding a drug.