Sunday, December 26, 2004

Symptomatology 5: Nausea & Vomiting

As a review, some of the symptoms of dying that I have mentioned to some degree in previous posts include:

One to three months prior to death:
-Spiritual Distress

One to two weeks prior to death:
-Picking at Clothes / Tubing

Days or Hours prior to death:
-Fixed stare (Eyes glassy, tearing, half or fully open)
-Death rattle
-Wavering level of consciousness

Next, I want to write about nausea and vomiting.

I have often said that if there is a hell, my hell would be to be nauseous for eternity. I truly cannot stand the sensation. Not that anyone enjoys it, but for me, there is nothing worse than nausea and/or vomiting.

Fortunately, I have not had very many patients who were experiencing nausea and vomiting at the end of life. People with some diseases, such as cancers that have metastasized to the abdominal cavity (peritoneal mets), are at an increased risk of developing nausea and vomiting.

I have had one patient whom was having quite a bit of vomiting. Fortunately, she wasn't feeling nauseous. She would just vomit unexpectedly on a fairly regular basis. She was experiencing a bleeding ulcer in her stomach and was vomiting up the blood that had accumulated. (Sorry for those of you who are disturbed by graphic details such as these). For her, we put a tube through her nose and into her stomach which vacuumed out the blood. This resolved the vomiting and kept her comfortable until she passed.

There are other causes for nausea and vomiting at the end of life that may not be as easy to manage. Though she wasn’t my patient, one woman developed intractable nausea (nausea that persisted despite numerous medications). There is, however, a commonly used “cocktail” for the treatment of this persistent nausea.

Anti-emetic cocktail for hospice that “works for EVERYONE” - 5mL consisting of:
· 15mg Benadryl
· 0.5 mg Ativan
· 0.25mg Haldol
· 3.0 mg Decadron

This woman was a nurse, however, and knew that the side effect, particularly of the Decadron component of this cocktail was severe bloating through your entire body. She refused the cocktail despite the intolerable nausea. She wanted to die with dignity, looking as much like her self from before her sickness as she could. As days passed, however, she realized the nausea prevented her from enjoying what little time she had left with her family. She finally agreed to the cocktail. Her nausea subsided immediately. And though she did in fact puff up as she feared she would, she was no longer as concerned with her appearance as she was with saying "goodbye." She died in the end, comfortable and at peace with her family.


dein said...

may she rest in peace....amen

Anonymous said...

I have just experienced, as a bystander, the symptoms you have listed, as I sat by my mother's bedside during her last few days. She lost her life to what they diagnosed as pancreatic cancer, though it was a combination of complications that killed her (heart attack, unavoidable malnutrition, internal was a horrible death).
The death rattle was something she'd always talked about when recalling her father's death at home, and I too heard it as she struggled in her bedroom, Hospice treating her symptoms as much as they could.
What was more disturbing to me than that rattle, though, was the intense vomiting of yellow mucus; bile being ejected forcefully and with it bringing her such a fear. They did give her a drug cocktail SQ to still the action, but she continued draining similar liquids from that point on.
Unfortunately, she was still aware, even through that drug-induced haze, and had to endure a difficult end.
I know she was 'there', inside that shell, because she continued to respond audibly (unable to form concise words, but producing a focused effort) and sometimes with a limited physical motion until just a few hours before passing. I am afraid that she may very well have been mentally present, to some extent, right up to the end.

She fought the disease, and then fought her death, even trying at one point - as they'd warned us she might - to get out of bed, even though she'd been unable to move her body by herself for a whole week.

This was difficult to watch, as I was privy to the whole process while keeping vigil. But to not have been there with her would have been worse.