QUICK REFERENCE GUIDE FOR SYMPTOM MANAGEMENT
The most prevalent of symptoms reported in advanced disease
Rule out possible causative factors and evaluate which might be treatable given goals of care: anemia, iron deficiency, electrolyte imbalances, hypothyroidism, hypoxia, nutrition deficiencies, medications, anxiety/depression, sleep abnormalities
Exercise, physical therapy, occupational therapy
Assistive devices, caregiving support (hygiene, cleaning, meals)
Stimulants such as methylphenidate (Ritalin®) 2.5-5 mg PO QD or BID to start, then titrate prn
Dexamethasone (Decadron®) 2-8 mg PO QD, do not give in the evening
Mirtazapine (Remeron®) 15 mg PO QHS to enhance sleep, also improves appetite and mood
Evaluate sleep patterns current and prior to diagnosis
Suggest sleep hygiene measures: reduce caffeine in afternoon/evening, do not watch TV/computer/cellphone/tablets in bed, limit alcohol intake, cool room, warm bath before bed
Relaxation therapy such as mindfulness exercises, meditation, guided imagery
For some, pharmacologic therapies ineffective if used daily
Zolpidem (Ambien®) 5-10 mg PO QHS; lower doses for women; safety concerns – sleep walking/eating
Mirtazapine (Remeron®) 15 mg PO QHS to enhance sleep, also improves appetite and mood
Buspirone (Buspar®) 5-20 mg PO TID
Trazodone (Desyrel®) 25-50 mg PO QHS
Avoid antihistamines (diphenhydramine) for sleeping aid, especially in elderly or frail
Assess frequency, volume, consistency and normal patterns of BMs
Diarrhea may be due to impaction; rectal exam indicated
Goal 3/week without straining, pain, tenesmus
Identify potential causative factors that can be addressed: opioids, anticholinergics, antihistamines, phenothiazines, tricyclic antidepressants, diuretics, iron, chemotherapy, ondansetron, antacids, dehydration, inactivity, hypercalcemia, hypokalemia, partial bowel obstruction, spinal cord compression, autonomic neuropathy, depression, anorexia, hypothyroidism
Encourage varied diet
First evacuate bowel – magnesium hydroxide (Milk of Magnesia) 30 mL PO QD, magnesium citrate 150-300 mL per day, bisacodyl 2-3 tabs PO QD or 10 mg suppository or Fleet’s Enema (nothing per rectum if patient thrombocytopenic [< 50,000 platelets] or neutropenic [ANC < 500-1000]) – limit Fleet’s and other sodium phosphate agents in renal dysfunction; if these are ineffective, give:
Methylnaltrexone (Relistor®) SQ [for opioid induced constipation only] – dosing is weight based; contraindicated in obstruction
Naloxegol (Movantik®) 12.5 or 25 mg po q am (for opioid induced constipation only)
All patients on opioids should have an order for a stimulant laxative and softener
Add stimulant and softener combination (e.g., senna/docusate) and titrate to effect (max 8 tabs/day)
Increase with upward titration of opioid dose
If persistent, consider adding bisacodyl 2-3 tabs PO QD or 1 rectal suppository QD; lactulose 30-60 mL PO QD; metoclopramide (Reglan®) 10-20 mg PO QID; Magnesium hydroxide (Milk of Magnesia) 30 mL PO QD
When constipation is related to opioids or in debilitated patient, changing the diet or adding fiber supplements is rarely helpful
Educate patients/families; there is much stigma about discussing bowel function
Even when not eating, patients should have bowel movements every 1-2 days. Untreated constipation can lead to discomfort and increased pain, as well as agitation in the cognitively impaired patient.
Evaluate for potential causes of diarrhea common in palliative care and correct/treat when feasible: medications (overuse of laxatives, antibiotics, magnesium, chemotherapy), infection, diet, herbal products (e.g., milk thistle, cayenne, ginger) fecal impaction, malabsorption syndromes from surgery or tumor, radiotherapy that includes abdomen in treatment field, inflammatory bowel disease and other comorbid disorders
Loperamide (Imodium®) 2 mg PO –start with 4 mg, followed by 2 mg after each BM, not to exceed 8 capsules/24 hours
Diphenoxylate/atropine (Lomotil®) 1-2 tabs PO QID, maximum 8 per 24 hours
Tincture of opium – 0.6 mL PO q 4-6 hours prn
Methylcellulose (e.g. Metamucil®) or pectin can help provide bulk to liquid stools
Octreotide (Sandostatin®) 50 mcg SQ/IV q 8 hours, maximum 1500 mcg/day
Cholestyramine – 2-4 g PO/day before meals (especially for c. difficile diarrhea)
Pancrelipase (Creon, Pancreaze®) 500 – 2500 lipase units/kg PO with meals
Identify and treat reversible causes: airway obstruction (e.g., bronchodilators and/or corticosteroids), infection (e.g. antibiotics), CHF or fluid overload (e.g., diuretics), anxiety (e.g., anxiolytics)
Opioids are first line therapy; start with morphine 2.5-5 mg PO every hour (any opioid can be used) - titrate upward aggressively
Liquids may be easier to swallow or can be placed sublingually (although absorbed enterally): morphine liquid; oxycodone liquid
Parenteral (IV or SQ) opioids - can be used if patient unable to swallow
Add anxiolytics (benzodiazepines) only if anxiety is present (e.g., lorazepam every 4 hours as needed)
Elevate head of bed (can use a fan for comfort)
Consider oxygen only if patient is hypoxemic
Educate and counsel patient/family regarding anorexia as a natural response to disease; interventions below only when loss of appetite bothersome to patient
Environmental alterations: small, frequent meals, moist foods or those with sauce/gravy take less energy to eat, assistance with meal preparation to improve energy for eating
Dexamethasone (Decadron®) 4 mg PO QD or prednisone 20 mg PO QD, especially when prognosis < 6 weeks
Dronabinol (Marinol®) 2-10 mg PO every 4 hours, use with caution in the older adult
Mirtazapine (Remeron®) 15 mg PO QHS to enhance sleep, also improves appetite
Rule out potentially reversible causes: constipation, central nervous system disease, pain, altered electrolytes, ICP, obstruction, antibiotics, chemotherapy, radiation therapy, opioids, digoxin
If N & V due to activation of chemoreceptor trigger zone (CTZ) (e.g., medication-induced):
Prochlorperazine (Compazine®) 10 mg PO q 6 hours or 25 mg PR q 8 hours
Haloperidol (Haldol®) 0.5-4 mg PO or IV/SQ q 6 hours
Ondansetron (Zofran®) 4-8 mg PO or IV q 8 hours (best when used for chemo or RT induced N/V; less effective when treating opioid induced N&V)
Olanzapine (Zyprexa®) 2.5 – 10 mg PO QD - BID
Promethazine (Phenergan®) 12.5 –25 mg IV q 6 hours or 25 mg PO or PR q 6 hours
If N & V due to gastric stasis causing early satiety, GI tract spasm:
Metoclopramide (Reglan®) 10-20 mg PO or IV TID AC & HS (not with bowel obstruction)
Hyoscyamine (Levsin®) 0.125-0.25 mg PO/SL q 4 hours prn
If N & V due to vestibular effects (nausea exacerbated by movement):
Scopolamine transdermal patch 1.5 mg q 3 days (especially if underlying mechanism is vestibular - increased nausea or dizziness with ambulation)
Cyclizine (Meclizine®) 25-50 mg PO every 8 hours; best for motion sickness or increased intracranial pressure
If mechanism of N & V is unclear, or unresponsive to other therapies:
Dexamethasone (Decadron®) 4-8 mg PO/IV daily
Dronabinol (Marinol®) 2-10 mg PO every 4 hours
Administer antiemetics around the clock (scheduled). If nausea is controlled, then try reducing after 2-3 days.
Observe for escalating pain and increase medications accordingly
May need to change route if swallowing is diminished; alternatives include transdermal, concentrated liquids taken orally in small volumes, parenteral
Abruptly discontinuing opioids or benzodiazepines may precipitate withdrawal syndrome - reduce dose 25% daily if no sign of pain in comatose patient; return to previous dose if any sign of return of pain
Myoclonus may occur; treat with Clonazepam (Klonopin®) 0.5 mg PO TID, MAX 20 mg/day or Lorazepam (Ativan®) 0.5-2.0 mg PO/IV q 4 hours if patient unable to swallow; may require Midazolam (Versed®); IV/SQ; rotate opioids
Identify and treat reversible causes: full bladder, fecal impaction, pain, dyspnea (hypoxemia, secretions, pulmonary edema), severe anxiety, nausea, pruritus, medications (e.g., corticosteroids, neuroleptics, anticholinergics), dehydration, infection
Haloperidol (Haldol®) 0.5-4 mg PO or IV/SQ q 6 hours (may repeat q 1 hour PRN in severe delirium)
Lorazepam (Ativan®) 0.5-2 mg PO/SL/IV q 4 hours PRN, then schedule ATC once effective dose is determined (not recommended as SQ)
Olanzapine (Zyprexa®) 2.5 – 20 mg PO QHS or Zyprexa (Zydis®) (orally disintegrating tablet) 5-20 mg PO QHS
Risperidone (Risperdal®) 0.5 mg PO q PM, increase by 0.25-0.5 mg q 2-7 days
Quetiapine (Seroquel®) 12.5 – 100 mg PO q 12-24 hours
Chlorpromazine (Thorazine®) 12.5-25 mg PO/SQ q 4-12 hours, or 25 mg pr q 4-12 hours (IV can cause hypotension-avoid unless other agents ineffective and oral/rectal route unavailable)
Atropine 0.4 mg SQ q 15 minutes PRN
Scopolamine transdermal patch 1.5 mg TOP, start with 1 mg (about 4 hour onset), increase to 2 mg after 24 hrs. If insufficient, begin scopolamine 50 mcg/hr IV or SQ; double every hour to maximum of 200 mcg/hr
Glycopyrrolate (Robinul®) 1-2 mg PO or 0.1 mg –0.2 mg IV/SQ q 4 hours PRN or 0.4-1.2 mg/day continuous IV/SQ infusion (this agent does not cross the blood brain barrier – less likely to cause confusion)
Hyoscyamine (Levsin®) 0.125 – 0.25 mg PO q 4 hours (liquid can be placed sublingually)
Change patient’s position
D/C IV and/or enteral fluids as they may increase discomfort (e.g., cough, pulmonary congestion, sensations of choking/drowning, vomiting, edema, pleural effusions, ascites)
If fluids not discontinued, IV or SQ rate ought not exceed 500 mL/24 hours
Furosemide (Lasix®) PRN to control overhydration.
Control thirst by moistening lips and mouth with substitute saliva (Oral Balance Moisture Gel® or Salivart®, at bedside apply as frequently as needed)
Patients may be too weak to expectorate. This is not painful, but distressing to family. Suctioning is traumatic, can cause bleeding and is painful. Do not suction beyond the oral cavity.
References (and for more details):
Ferrell, B., Coyle, N., & Paice, J. (Eds). (2015). Oxford textbook of palliative nursing, 4th Edition. New York,
NY: Oxford University Press.
Dahlin, C., Coyne, P., & Ferrell, B. (Eds). (2016). Advanced practice palliative nursing. New York, NY:
Oxford University Press.
Authors:
Patrick Coyne, MSN, ACHPN, ACNS-BC, FAAN, FPCN
Constance Dahlin, ANP-BC, ACHPN, FPCN, FAAN
Polly Mazanec, PhD, AOCN®, ACNP-BC, FPCN
Judith Paice, RN, PhD, FAAN
Published 2017 by:
City of Hope
Division of Nursing Research & Education (NRE)
1500 E Duarte Road, Duarte, CA 91010
Phone: 626.218.2346 Email: NRE@coh.org
www.cityofhope.org/nursing-research-and-education