Skip to main content

Symptom Management of the Dying Oncology Patient

  • Chapter
  • First Online:
Dying and Death in Oncology

Abstract

The symptoms and suffering of the dying patient can be distressful to both the patient and the patient’s caregivers. Every effort is needed to assist the patient in comfortable and dignified death. Common symptoms at the end of life include pain, nausea, dyspnea, and, at the very end, a death rattle. Pain is the most common problem and has a multitude of potential approaches. For the dying patient, management with medications is the most common and useful approach. Nausea can be approached with either a standard approach or a mechanistic approach. Dyspnea responds best to morphine or other opioids, and the death rattle, although bothersome to the observer, is not a problem for the patient and there is no good treatment. Patients with intractable pain can benefit from palliative sedation. With proper management, patients should be able to have a comfortable death.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 54.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  • Abernethy AP, McDonald CF, Frith PA, Clark K, Herndon JE 2nd, Marcello J, Young IH, Bull J, Wilcock A, Booth S, Wheeler JL, Tulsky JA, Crockett AJ, Currow DC (2010) Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet 376:784–793

    Article  PubMed  PubMed Central  Google Scholar 

  • Armstrong SC, Cozza KL (2003) Pharmacokinetic drug interactions of morphine, codeine, and their derivatives: theory and clinical reality, part I. Psychosomatics 44:167–171

    Article  PubMed  Google Scholar 

  • Bandieri E, Romero M, Ripamonti CI, Artioli F, Sichetti D, Fanizza C, Santini D, Cavanna L, Melotti B, Conte PF, Roila F, Cascinu S, Bruera E, Tognoni G, Luppi M (2015) Randomized trial of low-dose morphine versus weak opioids in moderate cancer pain. J Clin Oncol 34(5):436–442, Online pre-print

    Article  PubMed  Google Scholar 

  • Ben-Aharon I, Gafter-Gvili A, Leibovici L, Stemmer SM (2012) Interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. Acta Oncol 51:996–1008

    Article  CAS  PubMed  Google Scholar 

  • Boyden JY, Connor SR, Otolorin L, Nathan SD, Fine PG, Davis MS, Muir JC (2015) Nebulized medications for the treatment of dyspnea: a literature review. J Aerosol Med Pulm Drug Deliv 28:1–19

    Article  CAS  PubMed  Google Scholar 

  • Bruera E, Miller MJ, Macmillan K, Kuehn N (1992) Neuropsychological effects of methylphenidate in patients receiving a continuous infusion of narcotics for cancer pain. Pain 48:163–166

    Article  CAS  PubMed  Google Scholar 

  • Bush SH, Kanji S, Pereira JL, Davis DH, Currow DC, Meagher DJ, Rabheru K, Wright DK, Bruera E, Agar M, Hartwick M, Gagnon PR, Gagnon B, Breitbart W, Regnier L, Lawlor PG (2014) Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development. J Pain Symptom Manage 48:231–248

    Article  PubMed  PubMed Central  Google Scholar 

  • Cherny NI, ESMO Guidelines Working Group (2014) ESMO Clinical Practice Guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol 25(Suppl 3):iii143–iii152

    Article  PubMed  Google Scholar 

  • Cherny NI, Radbruch L, Board of the European Association for Palliative Care (2009) European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 23:581–593

    Article  PubMed  Google Scholar 

  • De J, Wand AP (2015) Delirium screening: a systematic review of delirium screening tools in hospitalized patients. Gerontologist 55:1079–1099

    Article  PubMed  Google Scholar 

  • Diop AD, Fontarensky M, Montoriol PF, Da Ines D (2014) CT imaging of peritoneal carcinomatosis and its mimics. Diagn Interv Imaging 95:861–872

    Article  CAS  PubMed  Google Scholar 

  • Drummer OH, Syrjanen ML, Phelan M, Cordner SM (1994) A study of deaths involving oxycodone. J Forensic Sci 39:1069–1075

    Article  CAS  PubMed  Google Scholar 

  • Feuer DJ, Broadley KE (1999) Systematic review and meta-analysis of corticosteroids for the resolution of malignant bowel obstruction in advanced gynaecological and gastrointestinal cancers. Systematic Review Steering Committee. Ann Oncol 10:1035–1041

    Article  CAS  PubMed  Google Scholar 

  • Flacke JW, Flacke WE, Bloor BC, Van Etten AP, Kripke BJ (1987) Histamine release by four narcotics: a double-blind study in humans. Anesth Analg 66:723–730

    Article  CAS  PubMed  Google Scholar 

  • Ford AC, Brenner DM, Schoenfeld PS (2013) Efficacy of pharmacological therapies for the treatment of opioid-induced constipation: systematic review and meta-analysis. Am J Gastroenterol 108:1566–1574

    Article  CAS  PubMed  Google Scholar 

  • Gaudreau JD, Gagnon P, Harel F, Roy MA, Tremblay A (2005) Psychoactive medications and risk of delirium in hospitalized cancer patients. J Clin Oncol 23:6712–6718

    Article  CAS  PubMed  Google Scholar 

  • Glare P, Miller J, Nikolova T, Tickoo R (2011) Treating nausea and vomiting in palliative care: a review. Clin Interv Aging 6:243–259

    Article  PubMed  PubMed Central  Google Scholar 

  • Grassi L, Caraceni A, Mitchell AJ, Nanni MG, Berardi MA, Caruso R, Riba M (2015) Management of delirium in palliative care: a review. Curr Psychiatry Rep 17:550

    PubMed  Google Scholar 

  • Gupta M, Davis M, LeGrand S, Walsh D, Lagman R (2013) Nausea and vomiting in advanced cancer: the Cleveland Clinic protocol. J Support Oncol 11:8–13

    PubMed  Google Scholar 

  • Hasselstrom J, Sawe J (1993) Morphine pharmacokinetics and metabolism in humans. Enterohepatic cycling and relative contribution of metabolites to active opioid concentrations. Clin Pharmacokinet 24:344–354

    Article  CAS  PubMed  Google Scholar 

  • Issaka RB, Shapiro DM, Parikh ND, Mulcahy MF, Komanduri S, Martin JA, Keswani RN (2014) Palliative venting percutaneous endoscopic gastrostomy tube is safe and effective in patients with malignant obstruction. Surg Endosc 28:1668–1673

    Article  PubMed  Google Scholar 

  • Jannetto PJ, Wong SH, Gock SB, Laleli-Sahin E, Schur BC, Jentzen JM (2002) Pharmacogenomics as molecular autopsy for postmortem forensic toxicology: genotyping cytochrome P450 2D6 for oxycodone cases. J Anal Toxicol 26:438–447

    Article  CAS  PubMed  Google Scholar 

  • Jin M, Gock SB, Jannetto PJ, Jentzen JM, Wong SH (2005) Pharmacogenomics as molecular autopsy for forensic toxicology: genotyping cytochrome P450 3A4*1B and 3A5*3 for 25 fentanyl cases. J Anal Toxicol 29:590–598

    Article  CAS  PubMed  Google Scholar 

  • Kalso E (2007) How different is oxycodone from morphine? Pain 132:227–228

    Article  PubMed  Google Scholar 

  • Laval G, Marcelin-Benazech B, Guirimand F, Chauvenet L, Copel L, Durand A, Francois E, Gabolde M, Mariani P, Rebischung C, Servois V, Terrebonne E, Arvieux C, French Society for Palliative Care, French Society for Digestive Surgery, French Society for Gastroenterology, French Association for Supportive Care in Oncology, French Society for Digestive Cancer (2014) Recommendations for bowel obstruction with peritoneal carcinomatosis. J Pain Symptom Manage 48:75–91

    Article  PubMed  Google Scholar 

  • Lee D Opiod Potency Comparison. Emedicine Health. http://www.emedicinehealth.com/opioid_potency_comparison/article_em.htm

  • Lin HS, Eeles E, Pandy S, Pinsker D, Brasch C, Yerkovich S (2015) Screening in delirium: a pilot study of two screening tools, the Simple Query for Easy Evaluation of Consciousness and Simple Question in Delirium. Australas J Ageing 34:259–264

    Article  PubMed  Google Scholar 

  • Lokker ME, van Zuylen L, van der Rijt CC, van der Heide A (2014) Prevalence, impact, and treatment of death rattle: a systematic review. J Pain Symptom Manage 47:105–122

    Article  PubMed  Google Scholar 

  • Maltoni M, Setola E (2015) Palliative sedation in patients with cancer. Cancer Control 22:433–441

    PubMed  Google Scholar 

  • Maltoni M, Scarpi E, Rosati M, Derni S, Fabbri L, Martini F, Amadori D, Nanni O (2012) Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol 30:1378–1383

    Article  PubMed  Google Scholar 

  • Navigante AH, Castro MA, Cerchietti LC (2010) Morphine versus midazolam as upfront therapy to control dyspnea perception in cancer patients while its underlying cause is sought or treated. J Pain Symptom Manage 39:820–830

    Article  CAS  PubMed  Google Scholar 

  • Navigante AH, Cerchietti LC, Castro MA, Lutteral MA, Cabalar ME (2006) Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer. J Pain Symptom Manage 31:38–47

    Article  CAS  PubMed  Google Scholar 

  • National Comprehensive Cancer Network (2016) NCCN Guidelines Version 1.2016 Palliative Care. National Comprehensive Cancer Network. http://www.nccn.org/professionals/physician_gls/PDF/palliative.pdf

  • Procon.org (2016) State-by-State Guide to Physician-Assisted Suicide – Euthanasia – ProCon.org.http://euthanasia.procon.org/view.resource.php?resourceID=000132. Accessed 3/20/2016

  • Roarty TP, Weber F, Soykan I, McCallum RW (1997) Misoprostol in the treatment of chronic refractory constipation: results of a long-term open label trial. Aliment Pharmacol Ther 11:1059–1066

    Article  CAS  PubMed  Google Scholar 

  • Sands MB, Dantoc BP, Hartshorn A, Ryan CJ, Lujic S (2010) Single Question in Delirium (SQiD): testing its efficacy against psychiatrist interview, the Confusion Assessment Method and the Memorial Delirium Assessment Scale. Palliat Med 24:561–565

    Article  CAS  PubMed  Google Scholar 

  • Schrijver EJ, de Graaf K, de Vries OJ, Maier AB, Nanayakkara PW (2016) Efficacy and safety of haloperidol for in-hospital delirium prevention and treatment: a systematic review of current evidence. Eur J Intern Med 27:14–23

    Article  CAS  PubMed  Google Scholar 

  • Silva AC, Pimenta M, Guimaraes LS (2009) Small bowel obstruction: what to look for. Radiographics 29:423–439

    Article  PubMed  Google Scholar 

  • Soffer EE, Metcalf A, Launspach J (1994) Misoprostol is effective treatment for patients with severe chronic constipation. Dig Dis Sci 39:929–933

    Article  CAS  PubMed  Google Scholar 

  • Soriano A, Davis MP (2011) Malignant bowel obstruction: individualized treatment near the end of life. Cleve Clin J Med 78:197–206

    Article  PubMed  Google Scholar 

  • Toll L Opiod receptors, introduction. IUPHAR/BPS Guide to PHARMACOLOGY. http://www.guidetopharmacology.org/GRAC/FamilyIntroductionForward?familyId=50

  • Trescot AM, Datta S, Lee M, Hansen H (2008) Opioid pharmacology. Pain Physician 11:S133–S153

    PubMed  Google Scholar 

  • van Eijk MM, Roes KC, Honing ML, Kuiper MA, Karakus A, van der Jagt M, Spronk PE, van Gool WA, van der Mast RC, Kesecioglu J, Slooter AJ (2010) Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial. Lancet 376:1829–1837

    Article  PubMed  Google Scholar 

  • Wee B, Hillier R (2008) Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev (1):CD005177

    Google Scholar 

  • Wilwerding MB, Loprinzi CL, Mailliard JA, O’Fallon JR, Miser AW, van Haelst C, Barton DL, Foley JF, Athmann LM (1995) A randomized, crossover evaluation of methylphenidate in cancer patients receiving strong narcotics. Support Care Cancer 3:135–138

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Lawrence Berk MD, PhD .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Berk, L. (2017). Symptom Management of the Dying Oncology Patient. In: Berk, L. (eds) Dying and Death in Oncology. Springer, Cham. https://doi.org/10.1007/978-3-319-41861-2_12

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-41861-2_12

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-41859-9

  • Online ISBN: 978-3-319-41861-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics