Pain Management

Symptom Management
Common Symptoms:
Bowel Management
Nausea and Vomiting
Terminal Phase
Changing Awareness
Altered Elimination
Respiratory Changes
Agitation or Restlessness
Signs of Impending Death
Caregiver Support

Common Symptoms and
Management in Advanced Disease

Bowel Management

Constipation is a problem in the majority of patients with a cancer diagnosis. Opioid therapy is the main cause; disease progression, changes in fluid intake, diet, or tumor growth impinging on the bowel itself can all be factors as well. Medications other than opioids can also cause constipation such as anticholinergics, tricyclic antidepressants, or antihypertensives.

When any patient is started on a pain regimen, constipation should be anticipated and prevented. Laxative medications should be ordered routinely, not as needed (PRN) when initiating a pain regimen with opioids or other constipating pain medications.

Do not start laxative therapy for constipation until fecal impaction has been ruled out.

Start with a peristaltic stimulant medications such as senna, cascara or biscodyl for soft stool constipation.

If necessary, add a stool softener such as docusate sodium to keep stool soft and easier to pass.

Use osmotic cathartics such as Chronulac or Lactulose for hard bowel movements.

A fecal impaction should be suspected with new onset of diarrhea and leakage of stool.


Diarrhea is defined as the passage of three to four loose stools in 24 hours (Waller and Caroline, 2000). It is often a problem in AIDS patients due to cryptosporidium infection (most common), salmonella, clostridium difficile (c. dif) or other infectious agents; diarrhea can also signal fecal impaction or impending bowel obstruction, or as an effect of cancer therapies such as radiation, chemotherapeutic agents, or surgery.

Stop all laxatives and rest the bowel with a clear liquid diet and light carbohydrates such as crackers or rice.

Avoid fiber, diary products and fat.

Treat dehydration as necessary.

Review medications for contributing factors.

Disimpact if indicated, using appropriate pain medication and/or anxiolytics for patient comfort prior to procedure.

Loperamide may be given if the diarrhea does not resolve with more conservative methods.


Bowel obstruction can occur mainly with ovarian cancer or colorectal cancer, less frequently with stomach, pancreatic, bladder or endometrial cancers.

Surgery should be considered in every patient with a bowel obstruction, even for those patients at the end of life. Although morbidity and mortality rates are high with this type of surgery, the pain from a bowel obstruction is often difficult to manage and can have a very distressing effect on the patient and caregiver/family.

Discontinue any laxatives, or gastrokinetic agents such as metaclopramide.

Antispasmodics such as loperamide or scopolamine along with opioids are used for cramping colicky pain.

Haloperidol is given for nausea and vomiting. Hydorxyzine and/or octreotide can be added if needed.

Nasogastric suctioning is not recommended in palliative/hospice care as it interferes with cough and can lead to aspiration. An NG tube also causes discomfort and a barrier between the family/caregiver and patient. Most patients can be kept comfortable using medications. If decompression is needed, a percutaneous venting gastrostomy can be considered.