Symptom Management
Symptom Management
Symptom management starts with mechanism and reversible causes. For dyspnea, use low-dose opioids, a fan, positioning, energy conservation, and oxygen only for documented hypoxemia; routine oxygen does not help nonhypoxemic dyspnea. Nausea and vomiting require matching the antiemetic to the pathway: metoclopramide for gastric stasis but avoid in obstruction, haloperidol or prochlorperazine for chemical or metabolic causes, ondansetron for serotonin-mediated nausea, dexamethasone for increased intracranial pressure or bowel obstruction, and scopolamine or glycopyrrolate for secretions. Constipation needs a proactive bowel regimen, especially with opioids. Delirium is a medical emergency: identify and treat causes, use nonpharmacologic measures first, and reserve antipsychotics for distressing symptoms; avoid benzodiazepines except in alcohol or benzodiazepine withdrawal. Terminal secretions are often not distressing to the patient; anticholinergics and repositioning may help, but deep suctioning is usually not indicated. Anorexia and cachexia are not reversed by forced feeding.
Traps: giving oxygen routinely, using one antiemetic for all mechanisms, ignoring constipation, sedating delirium without a workup, and treating terminal secretions as if they always cause suffering. Do not assume depression is inevitable or fatigue is untreatable.
Worked example/rule of thumb: a dying patient with noisy respirations and no signs of distress needs family education that the sound reflects airflow over secretions and is not choking; reposition, consider glycopyrrolate, and avoid aggressive suction. Rule: match drug to mechanism, treat reversible causes, and reassess distress rather than the sound alone.