GP trainer and palliative care lead Dr Nicolas Alexander advises on the key non-pain symptoms that patients experience during palliative and end-of-life care, and how they can be managed. Complete the full module on Pulse 365 today
This module will enhance your knowledge of the management of palliative care in general practice, including:
- Recognising typical non-pain symptoms in palliative and end-of-life care.
- Understanding the options for managing loss of appetite and weight loss.
- How to approach nausea and vomiting in palliative care.
- Considerations for management of psychological symptoms including anxiety and depression.
- Planning for anticipatory prescribing for end-of-life care.
1. What are the typical non-pain symptoms suffered by patients during their palliative and end-of-life phases, and how common are they?
Patients can be considered palliative if they have a life limiting illness for which there is no intervention which will reverse this process. At its simplest, we can consider the ‘surprise’ question – would you be surprised if this person died within the next year? If the answer is no, you wouldn’t be surprised, then a palliative approach is appropriate.
The underlying diagnoses may include cancer, end stage organ disease (heart failure, COPD, kidney and liver failure where transplantation isn’t appropriate), dementia and frailty.
Patients may experience symptoms from their underlying diagnosis, such as jaundice and ascites in liver failure, or hypercalcaemia and anaemia in end stage renal failure. These are condition-specific and will need input from their specialist teams and so are out of the scope of this article. Here we focus on symptoms we can treat in general practice.
The most common, almost universal symptoms are those in the end-of-life phase – pain, nausea and vomiting, agitation and distress, breathlessness and excess respiratory secretions. We can give anticipatory medications for these.
In the earlier and more stable palliative phases, symptoms may include constipation or (less commonly) diarrhoea, anorexia and weight loss, anxiety, depression, functional decline, drowsiness, fatigue and confusion. Not all patients will experience all of these, but you should keep them in mind when assessing the palliative patient.
2. Patients and relatives often worry about loss of appetite. What can be done about this? Is there a role for oral nutritional supplements?
Loss of appetite and consequent weight loss is common in palliative patients. This can affect quality of life and be distressing for patients and their family and carers. Regular weight recording may only increase anxiety.
Assessment goes beyond looking at weight and calorie intake. Consider the emotional, social and cognitive aspects of diet and nutrition. A dietitian may have more skill and time to help with this.
Treatment of loss of appetite involves treating any reversible causes, reassurance, explanation of the nature of the symptom and exploring the patient and relatives’ understanding and concerns.
Many factors contribute to loss of appetite. Some are reversible, including pain, breathlessness, ascites, nausea and vomiting, constipation, difficulty swallowing, anxiety and depression, and oral problems, such as ill-fitting dentures, mouth ulcers or oral candidiasis. Optimising and treating these conditions is likely to have some impact on appetite. If you suspect delayed gastric emptying, try treatment with metoclopramide 10mg three times daily.
First line treatment is dietary advice. This may include eating full fat milk, yoghurt and spreads, encouraging snacking and more frequent smaller meals, fortifying foods (such as adding butter to vegetables or full fat cream to soups) and advising carers to avoid offering large and excessive portions of food, as this can be off-putting.
Dietetics review can be helpful, with advice on oral nutritional supplements. Supplements, if recommended, should be an adjunct to food, not a replacement. Ideally patient should eat what they can and have the supplement afterward.
Oral nutritional supplements may be commenced earlier a structural issue caused problems with eating or drinking, for example in oral or oesophageal cancer. This is often guided by specialist teams.
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Dr Nicolas Alexander is a GP and GP trainer in North East London
