Palliative Care Symptom Management: Constipation, Nausea/Vomiting, Anorexia/Cachexia, Fatigue

Constipation in Palliative Care

• Definition and scope
  • In palliative care, constipation is defined as a difficult passage of hard or infrequent stools with a change in normal pattern, typically a bowel movement every <3\text{ days}, often with straining or pain.
  • The goal is a comfortable bowel movement, generally aiming for every <3\text{ days} rather than a fixed stool form.
• Why constipation happens in this setting
  • Very common and multifactorial; opioids (including strong opioids and tramadol) contribute to constipation.
  • Contributing factors in frail patients include loss of independence, lack of privacy when passing stools, and caregiver-patient dynamics that disrupt regular bowel routines.
  • Disease-related factors: hypercalcemia (metabolic), malignant spinal cord compression leading to reduced mobility and bowel propulsion.
• History and assessment
  • Ask about cramps, bloating, nausea, flatulence to identify underlying contributors.
  • Don’t omit the rectal exam; it helps identify stool burden, impaction, or potential higher bowel obstruction.
• Laxatives and treatment approach
  • Use combinations of laxatives with different mechanisms to enhance bowel movement.
  • Bulk-forming/laxatives that require lots of water are often impractical in palliative patients due to nausea, poor appetite, and limited hydration; avoid relying on them when feasible.
  • Prevention is better than cure; consider prophylactic laxatives to avoid painful episodes later.
• The Five F’s ( mnemonic for common constipation causes )
  • Five F’s provide an easy recall for common etiologies in patients with advancing disease (the transcript mentions the mnemonic but does not enumerate the five terms).
• Psychosocial considerations and functional impact
  • Caregivers: privacy, independence, and potential embarrassment when needing to pass stool or be cleaned up.
  • Some patients may only attempt a bowel movement when a specific nurse is on duty, which is unsafe and compromises quality of life.
• Underlying causes, interventions, and the care plan
  • Distinguish underlying, potentially reversible causes from symptom-directed interventions.
  • The goal is to prevent constipation and ensure a comfortable bowel movement.
• Bowel obstruction: partial vs complete; anatomical site; mechanical vs physiological
  • Mechanical obstruction often presents as partial or complete depending on the blockage; partial obstructions may respond to propulsive laxatives, while complete obstructions usually require escalation.
  • Anatomical site (small bowel vs large bowel) influences management decisions.
  • Propulsive laxatives may be used in partial obstruction (low burden). Example discussed: \text{methadrylproamide} (propulsive approach).
  • Complete obstruction: if relief is not possible surgically or with a stent, stoma creation (colostomy or gastrostomy) may be considered.
• Rectal exam and monitoring
  • A rectal exam is essential to assess for impaction or obstruction and should not be skipped.
• Goals of constipation management
  • Prevent constipation where possible; once it occurs, aim for a comfortable bowel movement every <3\text{ days}.
• Practical considerations for caregivers
  • Coordinating care to maintain hygiene and dignity; balancing caregiver workload with patient comfort.
• Additional notes
  • Bowel management is integrated with cancer care; consider interactions with other medications and overall symptom burden.

Nausea and Vomiting in Palliative Care

• Definitions and prevalence
  • Nausea: unpleasant feeling of the need to vomit; Vomiting: forceful expulsion of gastric contents.
  • Approximately 50\% of patients with advanced cancer experience nausea and vomiting.
• Pathways and pathophysiology
  • Vomiting center in the brainstem integrates multiple pathways:
  • Cortical stimuli (pain, fear, anxiety, smells, memories)
  • Vestibular system (motion sickness, balance disorders)
  • Vagal afferent signals from upper GI tract
  • Chemoreceptor trigger zone (CTZ) in the brain
• Common causes to consider
  • Bowel obstruction, gastritis or gastric stasis, constipation, ascites causing early satiety, excessive coughing with reflex retching.
• Goals of treatment
  • Address underlying reversible causes where possible.
  • If not reversible, have discussions with patient/family about tolerable goals (e.g., one morning vomit but acceptable symptom control the rest of the day).
• Routes and pharmacologic considerations
  • Route of antiemetic can be tailored for home care; subcutaneous injections for family administration and sublingual ondansetron for rapid absorption bypassing the GI tract.
  • Understanding pathways guides choice of antiemetic (CTZ-targeting, vestibular, or gastric motility agents).
• Practical management
  • Consider the patient’s preferences and daily functioning when selecting antiemetics.
  • Mouth care, hydration strategies, and small frequent meals can help alongside medications.
• Special considerations
  • Distinguish nausea vs vomiting to target the most bothersome symptoms for the patient.

Anorexia and Cachexia

• Definitions and clinical significance
  • Anorexia: reduction in desire to eat and drink, leading to reduced oral intake.
  • Cachexia: involuntary loss of more than >10\% of pre-morbid body weight due to metabolic abnormalities that cannot be fully reversed by nutrition alone.
• Pathophysiology and contributors
  • Chronic inflammatory state drives a catabolic process affecting muscle and fat; metabolic abnormalities are not fully reversed by caloric supplementation.
  • Treatment-related factors such as chemotherapy altering taste (foods may taste like cardboard); dysphagia; mucositis; depression; sleep disturbance; dyspnea.
• Clinical implications for patients and families
  • Weight loss and appetite changes are significant concerns; patients and families may worry about prognosis and quality of life.
  • In advanced disease, appetite naturally declines and activity reduces, reinforcing a cycle of reduced intake.
• Nutritional goals at end of life
  • Do not force weight gain or aggressive nutrition; the focus is on comfort, meaning, and manageable intake.
  • Hydration and nutrition decisions should balance burden versus potential benefit for the patient.
• Diet, supplements, and practical feeding strategies
  • Diet: offer nutrient-dense foods in small volumes; emphasize foods with high caloric density (e.g., peanut butter, eggs) and avoid high-volume meals when ascites or obstruction is present.
  • Supplements: used to reduce the volume of food needed rather than to drive weight gain; prioritise foods with high calories per unit volume.
• Appetite stimulants and medical options
  • Pharmacologic appetite stimulants include steroids, progestogens, and cannabinoids.
• Psychological and social considerations
  • Feeding is often a culturally important way of showing care; patients may feel pressured or judged when not eating; caregivers need guidance and support.
  • Ethical debates around continuing or withdrawing nutrition/hydration at end of life; decisions should balance patient preferences, medical benefit, and caregiver burden.
• Practical tips
  • Mouth care and taste alterations matter; consider palliative flavor enhancers or preferred textures.
  • Emphasise comfort and enjoyability of meals; avoid pressuring patients to eat more than they can.

Fatigue in Palliative Care

• Causes and multifactorial nature
  • Fatigue is very common due to sarcopenia, dyspnea, anemia, pain, depression, insomnia, and overall illness burden.
• Management principles
  • Identify and address reversible contributors; adopt a multi-factorial approach; prioritize non-pharmacological strategies first.
  • Energy budgeting: establish a daily energy allowance and plan activities around it.
• Non-pharmacological strategies
  • Gentle activity and regular, yet limited, physical therapy; passive movements; energy-conserving activities; scheduling meaningful tasks when energy is highest.
• Pharmacologic options
  • Steroids can temporarily boost energy.
  • Methylphenidate (Ritalin) can provide short-term energy for planned events (e.g., a family celebration).
  • Short-term stimulant use is considered for specific goals and patient preference.
• Practical recommendations
  • Encourage small, manageable activities; avoid overexertion; adapt daily routines to energy levels; involve family to support activities.

Ethical, Communicative, and Empowerment Considerations

• Core philosophy
  • Quality of life is what the patient says it is; pain is subjective; constipation and other symptoms must be understood from the patient’s perspective.
• Approach to care
  • Adopt a multi-problem, multi-factorial approach; prioritize prevention and early management; educate and empower patients and families to participate in care.
• End-of-life nutrition and hydration discussions
  • There is ongoing ethical debate about continuing nutrition and IV hydration in actively dying patients; decisions should balance burden, benefit, and patient values.
• Communication strategies
  • Open, honest conversations about goals and expectations; involve patient and family in decision-making; provide practical support (mouth care, comfort measures) to preserve dignity.

Practical Takeaways for Clinical Practice

• Prevention first: prevent constipation, manage nausea, support nutrition and energy, and implement early supportive care.
• Do not overlook the rectal exam; it informs whether stool impaction or obstruction is present.
• Constipation management: use a combination of laxatives with different mechanisms; avoid relying solely on bulk-forming laxatives when hydration/comfort limits apply.
• Nausea and vomiting: distinguish between nausea and vomiting; tailor antiemetic therapy to the likely pathway; prefer non-oral routes when vomiting is frequent.
• Anorexia/cachexia: prioritize comfort and meaningful intake; use calorie-dense foods and small portions; avoid pressuring weight gain; consider appetite stimulants only if aligned with patient goals.
• Fatigue: address reversible factors; implement energy budgeting and meaningful activities; consider short-term stimulant therapy for critical events.
• Communication and ethics: continually engage patients and families; educate and empower; address the emotional and cultural context of feeding and hydration at end of life.
• Final message: the goal is relief of suffering, preservation of dignity, and patient-centered care through clear communication and collaborative decision-making.