Palliative Care Symptom Management Notes: Constipation, Nausea/Vomiting, Anorexia & Cachexia, Fatigue
Constipation in Palliative Care
Constipation in palliative care is presented with a pragmatic, patient-centered definition. There are established medical criteria based on frequency, consistency, and pain with passing stool, but in palliative settings the definition is looser because constipation is extremely common and the goal is to improve quality of life. The practical definition given is: there is a difficult passage of hard or infrequent stools with a frequency of less than once every three days, accompanied by a sense of straining or pain during defecation. In other words, constipation is understood as a change in the patient’s normal pattern, characterized by difficulty with bowel movements at a rate of fewer than 3 days between stools. The overarching aim is not a perfect bowel regularity but a comfortable bowel movement that optimizes quality of life for the patient. The statement that “quality of life is what the patient says it is” and “pain is what the patient says it is” anchors this patient-centered approach to symptoms like constipation.
The five F’s are introduced as an easy mnemonic for common causes of constipation in patients with advancing disease. While the five F’s aren’t enumerated in detail here, they are presented as a quick framework to consider contributory factors. It is noted that opioids, including strong opioids and tramadol, commonly cause constipation. In frail patients, several contributing factors amplify risk, including loss of independence and privacy issues around bowel movements—scenarios where patients may feel embarrassed or anxious about needing assistance, which can create tension between caregivers and patients. Examples given include patients delaying bowel movements until a specific nurse is on duty, which is unsafe and undermines quality of life.
Underlying pathophysiology and complications are highlighted. Hypercalcemia (metabolic) can contribute to constipation, and malignant spinal cord compression reduces mobility, thereby diminishing the physiological muscle movements that propel stool through the colon and rectum. These factors should be explored when taking a history, with attention to cramps, bloating, nausea, and flatulence, as they all affect quality of life. Laxatives are a central treatment modality, and various laxatives with different mechanisms of action are used in combination for refractory cases to move stool more effectively.
Rectal examination is emphasized as an essential part of assessment. It helps identify impacted stool, rectal obstruction, or a higher bowel obstruction even when the rectum is empty. Prevention, rather than cure, is stressed: it is better to prescribe laxatives proactively than wait for an uncomfortable situation to arise. A table of underlying causes is mentioned (with cause-directed and symptom-directed interventions), but the critical takeaway is that constipation management in palliative care aims to prevent constipation and, once it occurs, to achieve a comfortable bowel movement roughly every three days, rather than meeting a specific ideal frequency or stool form.
In palliative care, bulk-forming (fiber-based) laxatives are often less practical because they require adequate hydration, which many patients cannot sustain due to nausea, reduced appetite, or other symptoms. Therefore, the regimen often relies on a combination of laxatives with different mechanisms to stimulate bowel movement. The goal is to keep the patient clean and comfortable, reducing caregiver burden related to stool management and hygiene.
Management of bowel obstruction is discussed with a nuance between partial and complete obstruction. Propulsive agents (the “propulsive” approach) are used for partial obstruction to stimulate bowel movement. A higher-burden solution for complete obstruction is the creation of a stoma (colostomy or gastrostomy). Determining partial versus complete obstruction hinges on several factors: anatomical site (large vs small bowel) and, importantly, whether the obstruction is partial or complete (mechanical vs functional). In a complete obstruction, propulsive laxatives are unlikely to help and may worsen pain and distention; stoma creation or other definitive interventions may be required.
- Nausea and Vomiting (N/V) in Palliative Care
Nausea and vomiting are highly prevalent in advanced cancer, affecting about one half of patients. Nausea is characterized as an unpleasant sensation that can lead to the urge to vomit, whereas vomiting is the forceful expulsion of gastric contents. They are conceptually linked but distinct problems and should be evaluated separately because patients may tolerate one worse than the other.
Nausea and vomiting arise from a complex vomiting center in the brainstem with multiple pathways. Cortical stimuli (pain, fear, anxiety, intracranial pressure, smells, sights, memories) can trigger vomiting; the vestibular system (in the inner ear) is involved in motion sickness and cerebellar disease; vagal afferents monitor input from the upper GI tract; and the chemoreceptor trigger zone (CTZ) responds to blood-borne toxins and drugs. The combined pathways explain why different antiemetic drugs target different receptors and mechanisms.
Common etiologies include bowel obstruction, gastritis, gastric stasis (delayed gastric emptying), constipation, ascites causing early satiety, increased abdominal pressure, and severe coughing fits that provoke retching. The pharyngeal and esophageal reflexes are implicated in vomiting when coughing is intense. Understanding these pathways guides the selection of antiemetic therapy tailored to the predominant mechanism and neurotransmitters involved.
In practice, the treatment plan emphasizes addressing the underlying cause when possible. If the cause cannot be modified, clinicians work with patients and families to set tolerable goals—for example, allowing a small degree of vomiting in the morning if that permits a tolerable day otherwise. Route of administration is important for home settings. Subcutaneous administration of antiemetics (e.g., metoclopramide) is practical for family caregivers, and sublingual ondansetron provides rapid, gut-independent absorption for immediate relief without requiring oral intake.
- Anorexia and Cachexia in Palliative Care
Anorexia is defined as a reduction in the desire to eat and drink, leading to reduced oral intake. Cachexia is a more complex, metabolic syndrome characterized by involuntary loss of more than 10% of pre-morbid body weight, not fully attributable to reduced caloric intake alone. Cachexia reflects a catabolic state driven by chronic inflammatory processes, common in cancer and other chronic illnesses, and it persists despite nutritional supplementation. Importantly, cachexia may progress even when caloric intake appears adequate, making simple calorie counting insufficient.
Contributing factors to anorexia and cachexia include chemotherapy-induced taste changes (foods tasting like cardboard), dysphagia, mucosal inflammation, depression, sleepiness, dyspnea, and fatigue. In advanced disease, the body enters a catabolic state and hunger decreases; activity levels and caloric needs drop accordingly. In the final days of life, appetite and the need for nutrition are often absent, not due to patient weakness or self-denial but due to the natural physiology of dying.
Management of anorexia and cachexia centers on a compassionate, patient-centered approach. The aim is not to force weight gain but to support quality of life and comfort. Dietary advice emphasizes flexibility: many patients find value in small, energy-dense meals or snacks rather than large meals. Nutritional supplements are sometimes used to reduce the volume of food needed rather than to promote weight gain, with examples such as peanut butter or eggs—foods that are energy-dense and easy to consume in small volumes. Hydration and nutrition at end of life are ethically debated, with families often advocating for continued feeding and fluids; clinicians emphasize balancing burden and benefit and recognizing that body needs for nutrition decline naturally at the end of life.
Pharmacologic appetite stimulants have a role in specific situations. Steroids, progestogens, and cannabinoids can increase appetite, while methylphenidate (Ritalin) may be used short-term to boost energy for a particular event (e.g., a daughter’s wedding). Non-pharmacological strategies include counseling for psychological barriers, improving the mealtime environment, and supporting families in navigating the emotional dynamics around feeding. The caregiver–patient relationship is central: feeding is a common expression of care, but persistent pressure to eat can create distress for both patient and family. Ethical discussions about continuing versus withholding artificial hydration and nutrition in actively dying patients are complex and require weighing physiological necessities against patient comfort and family values.
- Fatigue in Palliative Care
Fatigue is one of the most common yet challenging symptoms in advanced illness. It is multifactorial: sarcopenia (loss of muscle mass), dyspnea, anemia, chronic pain, depression or anxiety, insomnia, and overall disease burden all contribute. Reversible contributors should be identified and managed where possible, but fatigue may persist despite optimization.
Non-pharmacological strategies are emphasized: energy budgeting and pacing (planning a daily energy envelope), prioritizing meaningful activities, and reducing nonessential tasks to preserve energy. Encouraging light activity or physiotherapy can help reduce fatigue, as can social engagement and meaningful tasks like joining family meals. Pharmacologically, steroids may improve energy and appetite, and stimulants such as methylphenidate (Ritalin) can provide temporary boosts for specific activities. Short-term trials may be used for targeted goals (e.g., helping a patient attend a significant event). Encouragement of mild activity and activity modification is preferred, as even passive movements or assisted stretching can yield fatigue benefits.
- Integrated Approach and Final Message
Across constipation, nausea/vomiting, anorexia/cachexia, and fatigue, the palliative approach is distinct from acute-care management. It requires a multi-factorial, problem-solving framework rather than a single-cause fix. A recurring emphasis is on prevention, patient-centered goals, and a collaborative relationship with patients and families. The overarching lesson is to communicate, educate, and empower patients to participate in their own care and to tailor interventions to individual priorities and tolerances. The final takeaway is a reminder to view symptom management through the lens of quality of life and to pursue a balanced, compassionate strategy that respects patient autonomy and dignity.