In the tables below is brief guidance on the management of the following palliative care symptoms:
Encourage good oral hygiene with regular sips of water before considering saliva replacement.
Therapeutic choice: Saliva replacement gel e.g. BioXtra® gel or Biotène Oralbalance® – use as required. See palliative care mouth care guidance at www.palliativecareguidelines.scot.nhs.uk.
|Excessive respiratory secretions|
Reduce risk by avoiding fluid overload; review any assisted hydration or nutrition if symptoms develop. Suction may also exacerbate secretions. Changing the patient's position, for example, head down or lateral position may help.
Hyoscine butylbromide* is first-line as it is a less sedating alternative to hyoscine hydrobromide. Be aware that conscious patients may be troubled by dry mouth on these medications; refer to palliative care mouth care guidance at www.palliativecareguidelines.scot.nhs.uk.
Hyoscine butylbromide* SC bolus 20mg hourly as required (max 120mg/day)
See Last Days of Life guideline for the management of respiratory secretion at end of life. Seek advice from local Palliative Care team if therapeutic options and doses are maximised.
*Hyoscine butylbromide (Buscopan®) injection: risk of serious adverse effect in patients with underlying cardiac disease (MHRA Drug Safety Update 2017).
Assess for cause and reverse as appropriate.
Refer to palliative care guidelines and seek advice from local Palliative Care team for further advice.
For terminal delirium, refer to Last Days of Life guideline.
|Nausea and vomiting|
Use guidelines to identify possible causes and suitable treatments (see www.palliativecareguidelines.scot.nhs.uk).
Prescribe anti-emetics regularly until symptoms controlled.
If vomiting regularly, switch to SC route, ideally administer via syringe pump over 24 hours.
Avoid pharmacologically antagonistic combinations e.g. cyclizine and metoclopramide.
Metoclopramide: use with caution in young, especially female patients, because of risk of extrapyramidal side effects.
For therapeutic options, see the nausea and vomiting guidance at www.palliativecareguidelines.scot.nhs.uk.
In intractable nausea and vomiting, oral prochlorperazine can be used second-line. Prescribe either the buccal preparation 3mg - 6mg twice daily, or the oral preparation 5mg - 10mg two to three times daily.
Prophylactic antiemetics may be necessary (when opioid initiated and/or opioid dose increased). Prescribe:
See Breathlessness section at www.palliativecareguidelines.scot.nhs.uk
Guideline reviewed February 2022
Page updated June 2022