Palliative care

What is it about ?

Palliative care covers the care given to someone with an illness that can no longer be cured. These treatments are aimed at relieving or preventing suffering and improving the quality of life. The duration of palliative care can vary from a few days to several years.

‘Palliative care’ is not just about ‘terminal care’, it goes far beyond that.

• The terminal care are given in the last weeks or months of illness, immediately preceding death.
• The palliative care constitute all the care offered when no cure is possible. They are not intended to speed up or delay death.

Aspects of palliative care

At each stage of the disease, health care providers try to find a treatment that provides more advantages than disadvantages to the palliative care patient. Radiation therapy can thus alleviate symptoms in patients who are still in good shape, while care and pain relief is essential for a dying patient.

Palliative care is considered and offered taking into account the whole person. They aim to calm physical complaints while being attentive to the person and his entourage on the psychological, social and spiritual level.

In practice

The Belgian health system provides specific assistance for people in palliative care, in the form of financial interventions, leave for palliative care for relatives and palliative networks. Do not hesitate to ask your doctor for advice.

What can your doctor do?

Below is an overview of the ways the doctor can help manage different physical complaints in a palliative care patient.

Cough

Causes

In a person in palliative care, a cough can have different causes:

• heart failure;
• ‘chronic bronchitis’ (chronic obstructive pulmonary disease (COPD));
• metastases in the lungs;
• an infection ;
• etc.

Processing

Treatment for a cough depends on the cause:

• Pneumonia is treated with antibiotics and fever medication.
• COPD will be treated as usual.
• If you have dry, sticky mucus, use an air humidifier and administer medicines that thin the mucus (mucolytics) to the patient.
• In the event of a troublesome cough, a cough suppressant based on codeine can provide relief to the patient.

Shortness of breath (dyspnea)

Causes

The doctor looks for treatable and reversible causes of shortness of breath. Some of the possible causes include:

• Heart failure, pulmonary embolism, pneumonia, the presence of fluid in the belly, radiotherapy to the lungs, …
• A tumor that can put pressure on the windpipe.
• Anxiety and hyperventilation.

Processing

Shortness of breath can be treated with medications. At the same time, it is important to inform the breathless patient well of the progress of the disease and to reassure him. Anxiety can indeed reinforce the feeling of shortness of breath.

The patient can also learn to react to an acute attack of shortness of breath. To do this, the doctor will provide him with written instructions concerning among others:

• taking certain medications;
• measures that can reduce shortness of breath, such as:
  • adopt a (semi) sitting position;
  • inhale and exhale calmly;
  • open the window.
• calling for help when needed (keeping useful phone numbers handy).

It is also possible to apply breathing exercises, to do physiotherapy and / or administer oxygen.

Dry mouth and inflammation of the oral mucosa

Dry mouth is very bothersome and can affect the well-being of a patient in palliative care.

• If possible, drugs that cause dry mouth will be stopped.
• The application of artificial saliva, regular visits to the Dentiste, a good oral hygiene and the consumption of adapted meals (soft foods served at an appropriate temperature) may provide relief.
• The number one cause of oral infection is a fungus (the yeast Candida). We are therefore talking about a mycosis, more precisely a candidiasis, which is treated by a antimycotic.
• In case of herpetic infection of the mouth, antivirals such as aciclovir or valaciclovir are given.
• a spray with lidocaine, a morphine solution or some painkillers can reduce pain.

Loss of appetite

Causes

The causes that can explain a loss of appetite are numerous:

• certain painkillers;
• an infection of the mouth with a fungus (oral yeast infection);
• a dry mouth;
• nausea ;
• constipation;
• depression ;
• …

Approaching the end of life is often accompanied by a gradual decrease in the feeling of hunger and thirst.

Processing

If possible and desired, appropriate treatment can be started.

• Some medications can improve appetite.
• Others advice useful:
  • dress and share the meal with your loved ones;
  • eat small portions of high calorie food on small plates;
  • eat in an odorless place;
  • eat cold foods, such as ice cream;
  • treat yourself to a small aperitif, such as an alcoholic drink.

Nausea and vomiting

Causes

Chemotherapy, radiation therapy, constipation, and anxiety, among others, can cause nausea.

Treatments

Treatment depends on the cause.

Nausea can be reduced by administering medications orally or intravenously.

Constipation

Constipation refers to difficulty in having a bowel movement or a decrease in the frequency of bowel movements, ranging from less than three times per week to less than once in 3 days. Constipation is very common in palliative care patients, with at least one in two people suffering from it. And it can be even more common, for example in people who take opioid medications (out of 10 of these people, 8 to 9 suffer from constipation).

Constipation is a very uncomfortable condition that you should always report to your doctor.

Causes

Constipation may be due to the following causes:

• changes in eating habits;
• loss of appetite;
• reduced physical activity;
• lack of privacy.

Processing

When using morphine or related drugs, laxatives are always added to prevent constipation.

Diarrhea

Causes

• In a cancer patient, diarrhea is usually due to cancer treatment.
• Persistent constipation can also lead to overflow diarrhea (or paradoxical diarrhea).

Processing

the symptomatic treatment may consist of:

• rehydration;
• administration of loperamide;
• administration of morphine.

Intestinal obstruction

A bowel obstruction (obstruction) can be recognized by the following signs:

• nausea and vomiting;
• cramps;
• absence of winds and saddles.

A bowel obstruction can have different causes.

• If the patient is still relatively fit, a surgery can be considered in the event of mechanical obstruction, that is to say in the presence of an obstacle which blocks the intestine.
• The doctor must assess the need for rehydration or nutrition by infusion for each patient. If the obstruction is higher in the intestine, the patient will vomit quickly after taking food or medication.
• The laying of a percutaneous endoscopic gastrostomy probe (PEG probe for Percutaneous Endoscopic Gastrostomy), a small tube inserted through the abdominal wall, may be considered.
• If the occlusion is further into the intestine, medications can be administered to allow a normal diet.

Hiccups

Hiccups can be the result of irritation to the nerve that innervates the diaphragm. The diaphragm is the muscle that separates the thorax from the stomach.

Causes

The possible causes of hiccups are as follows:

• an enlarged liver;
• brain tumor or brain metastases;
• excess urea in the blood;
• certain cancer drugs.

Processing

The methods the following can relieve hiccups:

• try to sit down;
• breathe in a paper bag;
• drink two glasses of water;
• swallow two teaspoons of sugar.

Depending on the cause, medications are sometimes prescribed.

Itching

Causes

• The number one cause of itching in cancer patients is dry skin.
• Morphine, allergic reactions, and skin metastases can also be itchy.

Processing

• In the treatment of itching, whatever its cause, the most important thing is to take good care of the skin using a oily and moisturizing ointment.
• The application of menthol refreshing gels and the wearing of light cotton clothing can also provide relief.
• The cortisone creams can reduce itching.
• Some medications taken orally can sometimes be helpful.

Palliative radiotherapy

Palliative rays are a therapeutic option for:

• treat bone pain that does not respond to painkillers;
• prevent fractures in the bones that carry the body’s weight (load-bearing bones);
• prevent and treat spinal cord compression;
• control pressure and bleeding in brain tumor;
• treat skin tumors and metastases;
• reduce occlusions.

Palliative radiotherapy aims to quickly relieve symptoms with as few side effects as possible. It is not applied in people who are in very poor general condition or who are dying.

The treatment is painless, but requires standing still for 15 minutes on a rigid board.

Want to know more?

Source

Foreign clinical practice guide ‘Palliative treatment’ (2000), updated on 14.06.2017 and adapted to the Belgian context on 12.06.2019 – ebpracticenet