Palliative Care

Question 1

What physical symptoms do patients usually experience in gynaecological malignancies?

Answer 1

• Pain
• Nausea and Vomiting
• Constipation
• Bleeding
• Treatment related (e.g. Chemotherapy)

Question 2

What emotional and psycho-social symptoms may patients experience in relation to gynaecological malignancy?

Answer 2

• Fear
• Worry about future
• Why me?
• What will happen to my family?

Question 3

What is the difference between nausea and vomiting?

Answer 3

Nausea - unpleasant feeling of the need to be sick, often with autonomic features

Vomiting - Forceful expulsion of gastric contents through the mouth

Question 4

What do you need to ask in order to take an adequate nausea and vomiting history?

Answer 4

• triggers?
• volume
• pattern
• exacerbating and relieving factors
• drugs tried + route
• bowel habit
• medication – contributing to the nausea and vomiting?

Question 5

What must you be aware of if a patient is already on medication and is experiencing nausea and vomiting?

Answer 5

• is drug contributing to nausea and vomiting?

- is drug being absorbed if patient is vomiting?

Question 6

What are the 4 main reasons that a patient experiences nausea and vomiting?

Answer 6

Cerebral Cortext - emotions, sight, smell, raised ICP, anxiety
`
Vestibular Centre - motion sickness

GI Tract - distension, stasis, tumour mass, constipation

Chemoreceptor Trigger Zone - metabolic (uraemia, Ca), drugs

Question 7

What drugs work to combat nausea and vomiting from the cerebral cortext and what receptors do these act on?

Answer 7

Dexamethasone, Benzodiazepines

NK1, 5HT (serotonin), ?GABA

Question 8

What drugs work to combat nausea and vomiting from the vestibular centre and what receptors do these act on?

Answer 8

Cyclizine, Hyoscine

H1, ACh

Question 9

What drugs work to combat nausea and vomiting from the GI tract and what receptors do these act on?

Answer 9

Metoclopramide, Levomepromazine, Ondansetron
5HT, D2, Ach
Caution in obstruction

Question 10

What drugs work to combat nausea and vomiting from the Chemoreceptor trigger zone and what receptors do these act on?

Answer 10

Haloperidol, Ondansetron

D2, 5HT, Ach

Question 11

How would you identify from a nausea and vomiting history that the patients symptoms are due to a cerebral cortex cause?

Answer 11

Clinical picture:
Vomiting worse in morning then gets better during day
Associated headache

Question 12

What would cause impaired gastric emptying?

Answer 12

• Locally advanced cancer
• drugs
• radiotherapy damage to gut
• autonomic neuropathy

Question 13

How would impaired gastric emptying present?

Answer 13

• Not usually nauseated until patient eats
• Then very nauseated
• Large volume vomits
• Feels better after being sick

Question 14

What clinical picture would indicate a chemical or metabolic cause of nausea and vomiting?

Answer 14

Persistent nausea

Little relief from vomiting

Question 15

What would cause a chemical or metabolic abnormality that stimulates nausea and vomiting?

Answer 15

Medication
advanced cancer
sepsis
kidney or liver impairment

Think: Ca, Na, Mg Urea

Question 16

What non-pharmacological palliative care is provided to counteract nausea and vomiting in patients with gynaecological malignancies?

Answer 16

Mouth care 
Keep bowels moving (avoid constipation)
Small meals, rather than large meals
Avoid cooking or preparing food (due to smell)
Acupressure bands (for example Seaband®)
Acupuncture

Question 17

What is meant by malignant bowel obstruction?

Answer 17

Clinical evidence of bowel obstruction in the setting of a diagnosis of intra-abdominal cancer OR non-intra abdominal cancer with clear intraperitoneal disease

Question 18

Bowel obstruction in advanced cancer may not always be DIRECTLY due to the malignancy. What other causes are possible?

Answer 18

benign causes

Eg; Adhesions post-radiotherapy

Question 19

Why do patients with malignant bowel obstruction vomit?

Answer 19

Proximal accumulation of secretions

=> these need to be removed

Question 20

How do patients with malignant bowel obstruction usually present?

Answer 20

Nausea + Vomiting
Pain (Continuous or Colicky)		
Anorexia
Systemic symptoms from underlying cancer
Reduced then absent bowel motions/flatus

Question 21

How is malignant bowel obstruction managed?

Answer 21

• Drip and suck’ before surgery
• Bowel rest
• Null by mouth

Surgical Resection
=> Palliative colostomy or ileostomy
OR Self expanding metallic stent

Question 22

What are the main aims of medical management of malignant bowel obstruction?

Answer 22

• If partial => promote resolution with prokinetics
• Relieve pain and colic
• Reduce vomiting without use of NG tube
• Relieve nausea
• Relieve thirst

Question 23

What pharmacological options can be given for malignant bowel obstruction?

Answer 23

• Analgesics => Opioids /Hyoscine butylbromide
• Anti-Emetics => Metoclopramide if not contra-indicated and partial/subacute obstruction
• Steroids => Dexamethasone to reduce inflammation (especially nodal that could be causing external obstruction)
• Anti-secretory agents => Buscopan, Octreotide (CSCI)
• Laxatives => Docusate or movicol to soften stool
• Fluids

Question 24

Why is it important to remember to not given nauseated/ vomiting patients oral medication?

Answer 24

MUST BE ABSORBED

=> IV Subcutaneous, Transdermal, Intramuscular.