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Palliative Care
Lastly, corticosteroids can also be effective in the man-
agementofnauseaandvomiting, particularlywhenrelated
tochemotherapeuticagents,elevatedICPorinflammation
of neurologic or gastrointestinal etiology. Keep in mind
neutropenic precautions prior to starting. Additionally,
start at the lowest possible dose (dexamethasone 4 mg)
andensureoutpatient followup for either its continuation
or discontinuation once acute symptoms are managed.7
Constipation
Constipation is a burdensome symptom that affects
up to 48 percent of palliative care patients and, if on
concomitant opiate therapy, the statistic rises to a stag-
gering 87 percent.9 Once bowel obstruction has been
ruled out, a physician should remedy this complaint as
it can often be the underlying cause for persistent nau-
sea/vomiting, fatigue, anorexia and shortness of breath.
Additionally, if left untreated it can predispose patients
to further ominous conditions. Dehydration can be a
factor so adequate fluid intake should be encouraged.
Any patient on an opioid should be on a chronic bowel
regimen. In short, most patients should be using both a
stool softener and laxative (stimulant or osmotic agent).
In general, start with a stimulant laxative and titrate
to effect (BM every 48 hours). If this fails, the dose
or frequency of the stimulant may be increased or an
osmotic agent added. In the acute setting, care should
be escalated in a stepwise fashion. If conservative mea-
sures fail, consider suppositories or enemas. For opioid
induced constipation refractory to all other strategies,
methylnaltrexone is available. It is a peripherally acting
opioid antagonist. It does not cross the blood brain
barrier thus it will not mitigate analgesic effects, nor
will it precipitate withdrawal. It is given subcutaneously
according to the patient’s weight, and should be added
to existing laxative therapy. Studies demonstrate laxative
effect following a single dose in almost 50 percent of
patients within four hours. Additional doses may be
provided and demonstrate increased efficacy.10
Conclusion: “What can happen?”
Not all palliative patients presenting to the ED are
seeking lifesaving or prolonging measures. Often times,
symptomburdenistheircompellingincentive.Emergency
department physicians can becomemore versed in recog-
nizingpalliativeappropriatepatients andconceivablyalter
their future trajectory of care. If these complex patients
are presenting to the ED for uncontrolled symptoms, the
information provided should be earnestly contemplated.
Most of these patients will presumably have the “standard
of care” treatments already in place prompting escalating
alternatives. Hopefully, implementing some of these
strategies can alleviate suffering in patients and introduce
some reciprocated satisfaction for providers. “What can
happen” then becomes an aggregate success. v
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