Treatment of Persistent Nausea in Hospice

Many patients in hospice care will suffer from nausea and vomiting, but there is hope for those who may be coping with this symptom.

There are several medications that can be prescribed by the hospice doctor, that are effective in reducing or eliminating stubborn persistent symptoms of nausea.  When these medications are used appropriately, patients can find some much needed relief.  Trying to determine the origin or cause of nausea and vomiting is a priority.

There are many reasons why this symptom is so common, and sometimes there may be an underlying condition that is contributing to, and worsening the problem.  If you or a loved one are having problems with nausea and vomiting, I would encourage you discuss these symptoms with your doctor.  It is important to not to dismiss the presence of nausea and vomiting, as it may be a warning sign of a more serious problem.

As a hospice nurse, there are several questions that come to mind when assessing for causes of nausea and vomiting.  It is necessary to get an idea of the whole picture, so these symptoms can treated for the patient in the best way.

What has been the recent pattern of eating?

It is important to evaluate to the onset and progression of the symptoms of nausea and vomiting.  If someone had a relatively normal pattern of eating prior to the symptoms, then some type of infection may be occurring.  With food poisoning, which is bacterial in nature, and viral infections, there tends to be a more abrupt onset of illness.  Severe vomiting is often accompanied with diarrhea.  If this is the reason for vomiting, then the body is functioning as it has been designed, to purge out the unwanted.  Fluids should be encouraged to prevent dehydration, but initially these symptoms have a deliberate purpose.

Are you having any pain?

A sudden onset of severe pain is a warning sign that something is wrong. Severe pain alone is enough to cause someone experience nausea and vomiting. There are many major organs that can flare up in the stomach like gallbladder, pancreas, stomach, liver, kidneys, appendix, and the intestines. Many severe illnesses and diseases can be the cause for abdominal pain and digestion problems. It that case, managing pain is a top priority, in addition to the associated symptoms of nausea and vomiting. Chest pain is always taken very seriously. Nausea and vomiting is often seen when someone is having an event like a heart attack. Chest pain can be improved by administering medications prescribed by your doctor, like Nitrodur or Nitroglycerin. It is always recommended to start the patient on their oxygen machine, setting the dial to four. The entire hospice team will be consistently be asking you or loved if there is any pain. Your hospice doctor will prescribe the best treatment for pain based on those assessments.

Are you drinking enough fluids?

Dehydration can cause symptoms of nausea and vomiting worsened by an electrolyte imbalance. This can be a medical emergency, and often people will seek treatment in the hospital, because of the inability to rehydrate by solely drinking fluids.  The kidneys will often react to the stress of prolonged dehydration, which can lead to organ damage and failure.  In an aggressive setting, the standard treatment would be to administer the same anti-nausea medications that are given in hospice.  In hospice care we do not typically give IV hydration to our patients, and there is seldom a reason why it would be needed.  Fortunately, hospice patients will have frequent interactions with their nurse.  This allows for early intervention when someone starts having symptoms of nausea and vomiting.  Hospice patients have easier access to medications and healthcare professionals.  This is often why people that that have less access to healthcare will often wait several days before seeking treatment, in hopes that they might spontaneously improve.  In most scenarios, the earlier you intervene, the better the outcome.

 What medications are you taking?

The hospice nurse will assess the medications that you are taking.  If there is concern that the nausea and vomiting is a side effect to taking opioid, then the hospice doctor will often recommend that an anti-nausea medication be taken first.  This will help prevent those symptoms when that is the probable cause.  Other medications are well known to irritate the stomach.  Chronic use of pain medications like ibuprofen and aspirin can cause nausea and sometimes pain to the abdomen.  Steroids and antibiotics are also known to cause stomach upset.  Try taking all these types of medications with food, if you feel that you need to take these medications.

Are you having regular bowel movements?

Constipation is so common in hospice patients. The problem is worsened by medications and decreased activity level. Nausea and vomiting can be a directly related to the inability to have an adequate bowel movement. Especially vigorous vomiting, or vomit is very dark in color can be an indicator of a blockage in the intestines. The hospice nurse will check the patient’s abdomen by listening for activity in the bowel, and through observation of pain and bloating. It is not unusual for the doctor to order an xray called a KUB to assess for severe constipation or other problems. Most hospice agencies have an agreement with a mobile xray company, and they will go directly to the patient’s residence to take the images.

Have there been any recent falls or head injuries?

Nausea and vomiting that occurs after a fall, when there is a head injury can be a warning that there is something else going on. The head especially does not tolerate changes in pressure or impingement on the brain. Increased pressure from concussions, bleeding, infection, or a tumor will often make someone quite ill in addition to the symptoms of nausea and vomiting.

Are there any other suspect infections occurring?

Nausea and vomiting, associated with a lack of appetite, can be a signal that an infection may be present.  Common areas of concern for infections are the lungs, urine, areas of compromised skin, and wounds.  When a severe infection travels into the bloodstream, this is called sepsis, which is a very serious condition and can cause nausea and vomiting.  Your hospice nurse will be alert to treating infections early, in an effort prevent any type of sepsis from occurring.

Is there cancer present or a history of recent chemotherapy?

Cancer patients in particular can be very sensitive to smell, and this can trigger nausea and abrupt vomiting.  This seems to be worsened when overall appetite is decreased.  The smell of food that may have once been appealing is now having the opposite effect.  In my experience, odors of meat can be particularly offensive.  Nausea and vomiting can also be a symptom of the cancer and or a side effect of treatments.  These patients are vulnerable, and often require constant maintenance with medications to keeps to these symptoms in check.

COMMON TREATMENT APPROACH

The stomach most easily digests clear liquids, which makes this a good starting point following episodes of nausea and vomiting.  This is like the expression that you need to crawl before you walk.  Start with clear liquids, followed by foods that are bland and easy to digest.  Grandma was making a lot of sense when she was preparing that chicken noodle soup and crackers. Fluid intake is really the key here, and once the stomach settles down the food will follow.

Medications for Treatment of Nausea and Vomiting

There are two medications that are more frequently used by your hospice doctor to address these symptoms.

  • Zofran aka Odansetron is a very good medication that works on specifically to treat this symptom.  This is the preferred medication for nausea related to cancer or chemotherapy.  This medication can ordered in regular tablet or an oral disintegrating tablet (ODT).  I personally prefer the ODT, and they do work a little quicker.  While Zofran works well, without making the patient too sleepy, but tends to take a little longer to work.  Often times it is recommended that patient takes it on a scheduled basis or as a preventative measure, when nausea and vomiting is chronic and stubborn.
  • Phenergan aka Promethazine is very commonly prescribed in all healthcare setting for treatment of nausea and vomiting, and it falls under the classification of a first generation anti-histamine.  This medication tends to work a little quicker than Zofran, and is quite effective.  Your hospice doctor may order Phenergan in tablet or suppository form.  It is also possible to have the pharmacy put this medication into a topical gel that can just be rubbed into the skin.  Caution should be used with this medication because it can make someone very sleepy.

Not all medications work the same way for everyone.  Sometimes it is necessary to make adjustments unique to the individual circumstance.  Your hospice nurse will able to guide you on how to take anti-nausea medications.  When nausea is vomiting is chronic, it not unusual to use both of these medications in combination with each other.  When the symptoms are not well managed with Zofran and Phenergan, there are some other medications that may also be a helpful addition to the regimen.

  • Scopolamine Patch–  This is the same medication that people will often use to prevent sea sickness when they go on a boat or a cruise.  It looks like a little round patch, and has a slow continuous release of medication for up to 72 hours.  This can be beneficial for patients with severe chronic nausea, but the side effects of dry mouth are sometimes a drawback.  Therefore this medication would be used after Zofran and Phenergan are failing.
  • Reglan aka Metoclopramide – This medication fall into the class of a Prokinetic.  It is not recommended for long term use, but can be helpful in treating chronic symptoms of nausea.  If a patient tells me that they have a feeling of fullness in the stomach with bloating frequently with nausea, then there may be an issue of sluggish digestion.  Reglan will help speed up the digestive process and may be prescribed by the hospice doctor if the patient might benefit.
  • Proton Pump Inhibitors–  These medications are frequently used to treat heartburn.  They are taken once or twice a day, and basically decrease the amount of acid that is produced in the stomach.  These are an excellent addition to a medication regimen aimed at symptom management for the hospice patient.  Some of the medications can be purchased over the counter like Prilosec and Nexium, others are through a prescription from a doctor, like Protonix or Aciphex.  There are several different brands of PPIs, and typically these medications are covered by hospice.
  • Marinol  aka Dronabinol – This pill is considered a cannabinoid, which is basically synthetic marijuana.  The key ingredients are isolated that are specific to stimulate appetite and curb nausea.  While this medication has some value in treating symptoms of nausea and vomiting, it typically not used in hospice due the expensive nature and better alternatives.
  • ABH gel is commonly used in the hospice setting, and is a combination of Ativan-Benadryl-Haldol.  This is a cream infused with medication that can easily be rubbed directly on to the skin.  While this medication can be effective in treating stubborn nausea, it can also make someone quite sleepy.  Your hospice nurse will guide you on this medication and requires close supervision.

While nausea and vomiting are common in hospice care, it does not have be considered a “new normal”.  There are many approaches that can be taken to effectively help someone suffering from these symptoms.  With some guidance and support, you or your loved one can find some comfort in hospice.

I hope that you found this information useful.  Please feel free to ask a question or leave a comment.

 

2 Comments

  • Jaime Cuevas November 28, 2017 at 4:45 am

    Hello. This post is very interesting. All you said there is true. But there is something more. Dehydration can cause nausea and vomit, but also when the patient present nausea or vomit because of a different cause, if not treated, can dehydrate him/her.

    If nausea or vomit persist, it is recommended to take the patient to a Gastroentherologist. And about treatment, here in Dominican Republic we use metoclopramide, dimenhydrinate, ondasentron, granisentron.

    Reply
    • Heather Williams RN CHPN January 2, 2018 at 2:37 am

      Thank you Dr. Cuevas for your input. I am always interested in hearing how things are done in other parts of world. Take Care, Heather

      Reply

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