advances (Chochinov and Breitbart, 2000). The complex interplay of psychological and physical complaints is especially significant in the evaluation and treatment of fatigue.

Nausea and Vomiting

Clinical practice guidelines for management of nausea and vomiting have been widely promulgated in the care of cancer patients as advances in antiemetic therapy have vastly reduced the distress associated with chemotherapy. Nausea may be centrally mediated or caused by local factors such as decreased motility, medication effects, or gastrointestinal lesions (Reuben and Mor, 1986). Vomiting may contribute to dehydration, metabolic disarray, and aspiration. Obstruction and gastrointestinal bleeding are particularly difficult to manage and may be the source of great physical and emotional distress. There are practice guidelines for intractable vomiting, including surgery, PEG drainage, restricted oral intake, and symptomatic medications. Patients have described nausea as a particularly demoralizing symptom, affecting self-concept and self-esteem as well as psychosocial functioning. Inability to eat excludes patients from one of the primary sources of social interaction, occurring at meals. Nausea, vomiting, and anorexia are substantial sources of distress for patients and families, often leading to anxiety and depression.

Development of clinical practice guidelines for nausea and vomiting, central in end-of-life care, requires piloting antiemetic regimens that have been successful in the management of chemotherapy-related side effects. Modification to the special needs of patients in the end of life is the next step (see Table 7-2).

Dyspnea

Respiratory distress and shortness of breath are common in the final days of life, affecting more than half of patients. Although the causes of dyspnea are diverse and often multifactorial, there are common approaches to management (Dudgeon and Rosenthal, 1996). The sensation of air hunger causes great anxiety, and the appearance of respiratory distress is traumatic for patient and family (Ahmedzai, 1998). Despite the prevalence of this devastating symptom, there are no formal clinical practice guidelines for its management in end-of-life care.

Palliation of dyspnea, if the underlying cause cannot be addressed, often depends on the use of opiates for cough control and the reduction of air hunger. The use of bronchodilators and oxygen can provide symptom relief depending on the etiology and pathological process. Respiratory secretions can be minimized with scopolamine and atropine if necessary.



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