• Scenario: Nausea and vomiting - assessment: covers the assessment of nausea and vomiting in palliative care and identification of an underlying cause, where possible.
• Scenario: Nausea and vomiting - management: covers management of nausea and vomiting in palliative care when the cause is known, or when the cause is not known. This scenario also covers treatment options when first-line anti-emetics have not worked.
• Scenario: Nausea and vomiting - end of life: covers the identification and management of nausea and vomiting in people at the end of life.

• Use findings from the history, examination, and investigations to try to identify the cause of the nausea and vomiting and assess the person's clinical state.
• Consider whether treatment of the cause is appropriate, or whether the emphasis should be on treatment of symptoms.
• Take the following factors into account:
• The stage of illness and the person's prognosis.
• The person's wishes and those of carers and family.
• The cause of the person's nausea or vomiting and whether it is reversible or untreatable.
• The severity of nausea or vomiting and the presence of complications.
• The urgency with which treatment is required.
• The input of the multidisciplinary team.

In depth

• Features:
• Nausea: onset, frequency, intensity, relieving and exacerbating factors, relationship to vomiting.
• Vomiting: onset, frequency, quantity, force, colour, timing, and pattern.
• Other symptoms:
• Dyspepsia, heartburn, fullness, early satiety, constipation, diarrhoea, flatus, cough, headache, confusion.
• Treatments:
• Simple measures.
• Current medication including chemotherapy and anti-emetics.
• Radiation.
• Medical history.
• Effect on nutrition.
• Effect on quality of life.
• For more information, see Features indicating a cause.

In depth

• Perform an appropriate examination for the stage of the person's illness to determine, if possible, the cause of the nausea or vomiting:
• Perform a general examination (e.g. for signs of dehydration, infection, confusion, drowsiness, weakness).
• Assess the condition of the oral cavity.
• Examine the abdomen for tenderness, swelling, or distension; signs of intestinal obstruction; or constipation.
• Perform a rectal examination if faecal impaction is suspected.
• Check the fundi for papilloedema if increased intracranial pressure is a possibility (absence of papilloedema does not exclude intracranial pathology).
• Determine whether anxiety could be contributing to the person's symptoms.

In depth

• The choice of diagnostic tests should be based on the stage of disease, the person's prognosis, the risk-to-benefit ratio of the investigation, and the wishes of the person and their family.
• Blood tests to exclude hypercalcaemia or uraemia are among the most useful investigations in all people with nausea or vomiting in a palliative care situation in primary care.
• Other investigations are more appropriately done in secondary care (e.g. abdominal radiography to exclude constipation, ultrasonography to detect ascites), but the primary care team may also be able to arrange these and receive the results.

In depth

• Make sure the person has access to a large bowl, tissues, and water.
• The sight and smell of food or drink may provoke nausea:
• Provide a calm environment away from where food is usually prepared or consumed.
• If the person is usually responsible for cooking, make alternative arrangements.
• Make sure that meals are small and palatable.
• Carbohydrate meals are often better tolerated.
• Offer cool, fizzy drinks (citrus flavours are often preferred).
• Consider parenteral hydration if appropriate.
• Consider relaxation and acupressure bands to relieve symptoms.
• Consider cognitive behavioural therapy for anticipatory nausea or vomiting.
• In general, avoid nasogastric suction.

In depth

• Manage the underlying cause or correct reversible causes if possible and appropriate.
• Try simple measures to relieve symptoms.
• Choose a first-line anti-emetic according to the cause of nausea and vomiting:
• Chemotherapy-induced: seek advice from the specialist supervising the person's chemotherapy.
• Drug-induced or metabolic causes: haloperidol, 1.5 mg at night and when required, increasing up to 10 mg/day.
• Intracranial disease: cyclizine, 25–50 mg three times a day and when required, up to a maximum of 150 mg/day; if intracranial pressure is raised, consider adding high-dose dexamethasone (e.g. 8–16 mg daily for up to 7 days, with subsequent reduction to 4–6 mg daily if possible). Stop dexamethasone if there is no obvious benefit within 3–5 days, or if it becomes ineffective.
• Movement-related (vestibular disorder): cyclizine 25–50 mg three times a day and when required, up to a maximum of 150 mg/day.
• Peristaltic failure or gastric stasis: metoclopramide, 10–20 mg three times a day (usually parenterally, unless mild) or 30–100 mg/24 hours via continuous subcutaneous infusion (CSCI). If extrapyramidal effects are a problem with metoclopramide use domperidone (30–60 mg rectally every 4–8 hours).
• Mechanical bowel obstruction:
• Exclude or treat constipation.
• Give cyclizine, 50–150 mg/24 hours via CSCI.
• If symptoms persist: add haloperidol, 2.5–10 mg/24 hours or as a single night-time dose, or levomepromazine, 5–25 mg/24 hours or as a single night-time dose.
• For colic and large-volume vomiting: hyoscine butylbromide, 20 mg immediately by subcutaneous injection, then 60–120 mg/24 hours via CSCI. If large-volume vomiting persists, consider octreotide (specialist palliative care advice is advised).
• Abdominal or pelvic tumour (causing distension, compression, or disturbance of abdominal or pelvic organs): give cyclizine 25–50 mg three times a day and when required (up to a maximum of 150 mg/day) or 75–150 mg/24 hours via CSCI.
• Anxiety-related: a benzodiazepine (e.g. lorazepam, 0.5–1 mg sublingually) or levomepromazine, 3–6 mg orally or 2.5–6.25 mg by subcutaneous injection.
• Ascertain the most appropriate route of administration of the anti-emetic.
• Prescribe anti-emetics regularly and as required.
• Review the effectiveness of anti-emetic treatment every 24 hours.
• Continue anti-emetics unless nausea and vomiting has resolved.

In depth

• Try simple measures to relieve symptoms.
• Review the history, examination, and medication and consider further investigations if appropriate.
• If the cause is still uncertain or further investigation is not appropriate:
• Try haloperidol, 1.5–10 mg daily:
• Starting dosage: 1.5 mg immediately and at night.
• Usual dosage: 3–5 mg at night or in divided doses.
• Usual maximum dosage: 10 mg/day (at night or in divided doses).
• Add cyclizine (25–50 mg three times a day) if haloperidol alone is not effective.
• If still ineffective, change to levomepromazine or consider a trial of dexamethasone (seek specialist advice first).
• Ascertain the most appropriate route of administration of the anti-emetic.
• Prescribe anti-emetics regularly and as required.
• Review the effectiveness of anti-emetic treatment every 24 hours.
• Continue anti-emetics unless nausea and vomiting has resolved.

In depth

• If a single first-line anti-emetic does not relieve nausea and vomiting:
• Confirm that the cause of nausea and vomiting has been correctly identified.
• Optimize the dose and route of the first-line anti-emetic.
• If nausea and vomiting persist after two or three doses of optimal first-line anti-emetic:
• Change to an anti-emetic with a different action, or
• Combine anti-emetics with complementary action.
• Refer to a specialist palliative care team if symptoms remain uncontrolled after 24 hours.

In depth

• It is essential to recognize the signs of dying in order to appropriately care for people at the end of life.
• People are likely to be in the terminal phase of their illness when they:
• Deteriorate day by day, or faster, because of their underlying condition.
• Become progressively weak and fatigued without an apparent cause (e.g. hypercalcaemia).
• Express a realization that they are dying.
• Have reduced cognition, and are drowsy or comatose.
• Are bed-bound.
• Take little food or fluid and have difficulty taking oral medication.
• Are peripherally cyanosed and cold.
• Have an altered breathing pattern.
• For further details, see the CKS topic on Palliative cancer care - general issues.

• Make sure the person has access to a large bowl, tissues, and water.
• The sight and smell of food or drink may provoke nausea:
• Provide a calm environment away from where food is usually prepared or consumed.
• If the person is usually responsible for cooking, make alternative arrangements.
• Make sure that meals are small and palatable.
• Carbohydrate meals are often better tolerated.
• Offer cool, fizzy drinks (citrus flavours are often preferred).
• Consider parenteral hydration if appropriate.
• Consider relaxation and acupressure bands to relieve symptoms.
• Consider cognitive behavioural therapy for anticipatory nausea or vomiting.
• In general, avoid nasogastric suction.

In depth

• Try simple measures to relieve symptoms.
• If an anti-emetic already controls symptoms well:
• Continue with the same drug.
• Give the same drug by syringe driver if the person becomes unable to take oral medication. If an injectable form is not available, use a drug with a similar mode of action.
• For new or uncontrolled nausea and vomiting:
• If appropriate, try to determine the underlying cause of nausea and vomiting and manage accordingly (see Scenario: Nausea and vomiting - management).
• Otherwise give levomepromazine, 6.25 mg once daily by subcutaneous injection. Repeat the dose after 1 hour if needed.
• If a repeat dose is needed, start levomepromazine by continuous subcutaneous injection (CSCI):
• Start at a dose of 12.5 mg in 24 hours by CSCI, plus a 6.25 mg subcutaneous injection as needed.
• If one or more extra doses are needed, increase the dose to 25 mg in 24 hours.
• If symptoms remain uncontrolled, contact the local palliative care team for advice.
• Review the effectiveness of anti-emetic treatment every 24 hours.

In depth