Symptom Control in Advanced Illness

Pain Control - The Ache Avengers

• Assessment: Use validated scales (NRS, VAS). Identify pain type: Nociceptive (somatic/visceral) vs. Neuropathic.

• WHO Analgesic Ladder: Foundational approach.

• Opioids: Start low, titrate to effect. Morphine (gold standard). Fentanyl patch (stable chronic pain). Breakthrough pain dose: 10-15% of total 24-hour dose.

• Adjuvants:

  • Neuropathic: Amitriptyline, Gabapentin, Pregabalin.
  • Bone pain: NSAIDs, Bisphosphonates, Radiotherapy.

• Opioid Side Effects:

  • Constipation: Universal! Prescribe prophylactic laxatives (stimulant + softener). 📌
  • Nausea/Vomiting: Antiemetics (e.g., Haloperidol).
  • Sedation: Usually transient; dose reduction if persistent.

⭐ In renal impairment, morphine metabolites (M6G, M3G) accumulate; prefer fentanyl or methadone, or use morphine with caution and dose adjustment.

Dyspnea & Cough - Breathless Battles

• Dyspnea: Subjective breathlessness.

  • Management:
    • Non-Pharmacological: Cool air (fan), positioning, pursed-lip breathing.
    • Pharmacological:
      • Opioids: Morphine (oral 2.5-5 mg, SC/IV 1-2 mg q4h PRN) cornerstone. Titrate.
      • Anxiolytics: Lorazepam (0.5-1 mg) for anxiety component.
      • Corticosteroids: e.g., COPD, tumor.
      • Oxygen: Only if SpO2 < 90%.
  • 📌 "PAM O2" for Dyspnea: Positioning, Airflow, Morphine, O2 (if hypoxic).

• Cough:

  • Treat underlying cause.
  • Non-Pharmacological: Honey, hydration, lozenges.
  • Pharmacological:
    • Opioids: Codeine, Morphine.
    • Dextromethorphan.
    • Refractory: Nebulized Lidocaine.

⭐ Opioids are effective for dyspnea even in non-hypoxic patients by reducing air hunger perception.

GI Distress - Gut Grumbles Gone

• Nausea & Vomiting (N&V)

  • Assessment: Identify cause (opioids, chemo, metabolic, obstruction, ↑ICP).
  • Management:
    • Non-pharmacological: Small meals, hydration.
    • Pharmacological:
      • Dopamine (D2) antag: Metoclopramide¹ (10mg TDS), Haloperidol (0.5-1.5mg OD-BD).
      • Serotonin (5-HT3) antag: Ondansetron (4-8mg BD/TDS) - esp. chemo/radio.
      • Antihistamine (H1): Cyclizine (50mg TDS) - motion, bowel obstruction.
      • Anticholinergic: Hyoscine butylbromide (20mg QID) - colic, secretions.
      • Steroids: Dexamethasone (4-8mg OD) - ↑ICP, MBO.
      • Refractory: Levomepromazine.

  ⭐ Metoclopramide¹ is generally avoided in complete bowel obstruction or Parkinson's disease.

• Constipation

  • Opioid-Induced Constipation (OIC) is common; prophylaxis vital!
  • Rx:
    • Lifestyle: Fluids, fiber (cautiously in MBO).
    • Laxatives:
      • Stimulant (Senna, Bisacodyl) + Softener (Docusate). 📌 MUSH & PUSH.
      • Osmotic (Lactulose, Macrogol/PEG).
    • Peripheral opioid antagonist: Methylnaltrexone (SC) if refractory OIC.

• Malignant Bowel Obstruction (MBO)

  • Medical management: Analgesia, antiemetics (Haloperidol, Cyclizine), antisecretory (Octreotide 100-600 mcg/24h SC/CSCI, Hyoscine Butylbromide 60-120mg/24h CSCI), Dexamethasone.

Neuropsychiatric Issues - Mind Menders

• Delirium

  • Acute onset, fluctuating course, inattention, disorganized thinking, altered consciousness.
  • Causes: 📌 I WATCH DEATH (Infection, Withdrawal, Acute metabolic, Trauma, CNS, Hypoxia, Deficiencies, Endocrinopathies, Acute vascular, Toxins, Heavy metals).
  • Management:
    • Non-pharm: Reorient, calm environment, sleep, hydration.
    • Pharm:
      • Haloperidol 0.5-1 mg PO/SC/IV.
      • Risperidone 0.25-0.5 mg PO.
      • Olanzapine 2.5-5 mg PO/SL/IM.
      • ⚠️ Avoid benzodiazepines (except alcohol/benzo withdrawal).

  ⭐ Haloperidol is first-line for delirium in palliative care; use atypicals (e.g., risperidone) or avoid in Parkinson's/LBD.

• Agitation/Restlessness

  • Assess reversible causes (pain, bladder/bowel issues).
  • Delirium-related: Antipsychotics.
  • Anxiety-related: Lorazepam 0.5-1 mg.
  • Terminal: Midazolam SC 10-30 mg/24h; Levomepromazine.

• Depression/Anxiety

  • Depression: SSRIs (e.g., Sertraline).
  • Anxiety: Benzodiazepines (e.g., Lorazepam, short-term).
  • Psychostimulants (Methylphenidate) for rapid effect: fatigue, apathy, depression.

High‑Yield Points - ⚡ Biggest Takeaways

• Opioids (e.g., morphine) are cornerstone for cancer pain; titrate to effect.
• Dyspnea: manage with low-dose morphine, oxygen (if hypoxic), anxiolytics.
• Nausea/Vomiting: target cause; use metoclopramide, ondansetron, or haloperidol.
• Opioid-induced constipation: requires prophylactic stimulant + softener laxatives.
• Delirium: treat reversible causes; haloperidol for severe agitation.
• Terminal agitation: consider midazolam or phenobarbital for sedation.
• WHO analgesic ladder: guides pain management strategy.