The sensation of shortness of breath, dyspnea in medical terminology,
is common in patients with life-threatening conditions: 20-80% of palliative care
patients experience this symptom. Like pain, shortness of breath is subjective.
It is partly independent of oxygen and carbon dioxide levels.
There are many causes of shortness of breath, including:
Disease of the lung, such as emphysema, chronic bronchitis, cancer and
many others
Fluid in the lungs
Infection
Anemia
Emotional factors, such as anxiety
Sometimes simple measures can relieve the sensation of shortness of breath, including:
Providing a familiar voice to reduce anxiety
Changing position
Using relaxation techniques
Improving air circulation by opening a window or turning on a fan
Medication can sometimes be useful, including:
Opioids, such as morphine
Sedatives such as benzodiazepines
Oxygen through a face mask, in some cases
Corticosteroids, for patients with obstructive complications such as superior
vena cava syndrome
Bronchodilators, if airway spasm is involved
Fatigue
Fatigue is common among those with life-threatening diseases.
Fatigue can be caused by:
The disease
Medical problems related to the disease or treatment, like anemia
Treatments for the disease (for cancer patients, as an example, fatigue
may be caused by radiation or chemotherapy)
Other medication
Immobility
Sleep disturbance
Depression and anxiety
Management of fatigue can include having the patient:
Conserve energy whenever possible, and learn techniques of energy and
time management
Learn to improve sleep
Learn to use exercise or physical therapy
Medications used to treat fatigue include:
Psychostimulants, such as methylphenidate or pemoline
Low-dose corticosteroids (e.g., dexamethasone or prednisone)
Amantadine (for fatigue related to multiple sclerosis)
Antidepressants
Erythropoietin for fatigue caused by anemia
Friends and family can help by being responsive to the patient's pace. Activities
and/or conversations can be saved for periods when the patient feels that he or
she would enjoy them.
For more information on managing fatigue, see our fatigue
sub-page.
Dry Mouth
The sensation of a dry mouth, in medical terminology known
as xerostomia, is a common symptom in palliative care.
A dry mouth can be caused by:
Dehydration
Erosion of the mucous membrane lining the mouth
Depression or anxiety
Chemotherapy or radiotherapy for cancer
Many medications, including some pain relievers, antidepressants, diuretics
and tranquilizers
The sensation of a dry mouth can sometimes be relieved by simple measures, including:
Drinking lots of fluids
Good oral hygiene
Providing humidified air
Sucking on ice or vitamin C tablets
Chewing sugarless gum
The sensation of a dry mouth can sometimes be relieved by simple measures, including:
Artificial saliva, provided in a spray form
Pilocarpine
Appetite Loss
Patients with life-threatening diseases often lose their appetite and may lose
weight. When severe, this is called cachexia or wasting syndrome.
Causes of weight loss (from the disease or treatments) include:
Inadequate intake of nutrients because the patient cannot or does not
want to eat
Poor absorption of food that is consumed
Changes in the patient's metabolism
Management of weight loss depends on the patient's goals. It may include:
Eating small, frequent meals
Eating high-calorie, high-protein foods and nutritional supplements
Receiving nutritional counseling
Feeding through artificial means (such as a tube or IV)
Eating and drinking whatever the patient would like
Relieving thirst by sucking on ice chips or a moist cloth
Medication can include:
Corticosteroids, which stimulate appetite but do not usually increase
weight
Megestrol acetate, which stimulates appetite and causes slight weight
gain
Dronabinol, which prevents nausea and vomiting, and increases appetite,
enhances a sense of well-being and causes weight-gain
Cyproheptadine, which mildly enhances appetite, increases food intake
and enhances weight gain
Pentoxifylline, which potentially acts to lower levels of a substance
(tumor necrosis factor) that contributes to weight loss in cancer patients.
Gastrointestinal Symptoms
Gastrointestinal symptoms include such problems as nausea
(feeling queasy or sick to one's stomach), vomiting (throwing up), constipation
or diarrhea, anorexia (loss of appetite), and cachexia (severe weight loss). These
difficulties can be caused by a number of illnesses, treatments, medications,
and other factors, including:
cancer, AIDS, and other diseases
radiation therapy
dehydration
chemotherapy
certain foods
opioids, antibiotics, and other drugs
lactose (milk) intolerance
emotional distress and anxiety
surgery
taste changes
What You Can Do to Help
Nausea/Vomiting
Encourage the patient to take prescribed antinausea medication
Fix the patient frequent light meals throughout the day
Serve foods cool or at room temperature
Avoid fried foods, dairy products, and acidic foods (e.g., citrus fruits,
citrus juice, and vinegar)
Stay away from spicy foods; stick to bland foods, such as dry crackers
Make sure the patient's mouth is kept clean
Offer chewing gum or hard candy
Take the patient outside or open a window for fresh air
Encourage rest and relaxation
Make sure the patient drinks enough clear liquids, sipped slowly, to prevent
dehydration
Avoid unpleasant or strong odors
Distract the patient with music, television, or other activities
When to Call the Doctor for Nausea and Vomiting:
If there is blood or material that looks like coffee grounds in the vomit
If vomit shoots out for a distance (projectile vomiting)
If two doses of prescribed medications are not taken or kept down because
of nausea or vomiting
Limit caffeine intake (coffee, tea, soda with caffeine, and chocolate)
Avoid serving dairy or milk products
When to Call the Doctor for Diarrhea:
If the patient is losing a lot of fluid from severe diarrhea
If there is blood in the diarrhea
If diarrhea is oily in the toilet
If there is a fever
If the patient does not drink any liquids for more than 2 days
Loss of Appetite/Weight Loss
Do not force-feed the patient
Do not get angry if the patient does not want to eat
Prepare familiar favorite foods
Try light exercise or walking before meals
Encourage eating meals at the table with others
Serve meals over a prolonged period of time in a relaxed environment
Place meals on smaller plates with smaller servings more frequently
Cover up unpleasant odors
Serve a glass of wine before meals to stimulate appetite (as per MD's
advice)
Offer frequent high protein, high calorie snacks (pudding, ice cream,
milk shakes)
Try new spices or flavorings for foods
Prevent early feelings of fullness by: serving beverages between meals,
not with meals; eating slowly; and avoiding too many vegetables and carbonated
drinks
When to Call the Doctor for Appetite/Weight Loss:
If the patient reduces normal food intake for a long time
If the patient loses 5 pounds or more in a short time
If there is pain with chewing and/or swallowing
If the patient experiences dizziness upon standing
If the patient does not urinate for an entire day, or does not move the
bowels for many days
Skin Problems
There are a number of skin symptoms that can accompany cancer, AIDS, sickle
cell disease, and other illnesses. Such skin problems include dryness, rash,
itching, sores, ulcers, and swelling. It is important for you to be aware of
skin problems so that they can be treated as quickly as possible in order to
reduce discomfort and the risk of infection.
Common Skin Problems
Pressure Sores
– blisters or breaks in the skin caused when the body's weight stops
the flow of blood to a certain area, causing a breakdown in the skin.
Most likely to affect patients who are bedridden, underweight, malnourished,
or dehydrated.
Usually occur in bony areas, such as the head, elbows, heels, hips, shoulders,
and tailbone.
Sores are made worse when the patient rubs against his/her sheets.
Signs and symptoms:
- red areas on the skin that do not go away when pressure is removed
- cracked, blistered, scaly, or broken skin
- an open sore on the skin's surface or invading deeper, underlying tissue
- yellowish stains on clothing or sheets
- pain at pressure points
Ulcers – crater-like lesions
on the skin.
Usually caused by inflammation or infection of the area, or an underlying
condition that may affect the skin's ability to heal.
Edema – swelling of the skin
that is caused by water and salt retention.
Can occur from certain medications; heart, liver, or kidney failure; malnutrition;
and obstruction of veins or lymph nodes.
Signs and symptoms:
- swelling of feet and lower legs when sitting in a chair or walking
- tightness in the hands when making a fist
- swollen or distended abdomen
Itching – the desire to rub
or scratch the skin
Can be the result of dryness, allergies, and side effects of medications
or treatments.
Rash – bumpy, red, itchy skin.
Commonly caused by an allergy, irritation, radiation therapy, or certain
infections.
Dryness – rough, flaky, red,
sometimes painful skin due to a lack of water or oil in the skin layers.
Can be caused by dehydration, cold weather, heat, and side effects of
treatments (such as chemotherapy and radiation).
What You Can Do to Help
Pressure Sores
Keep skin dry and clean
Check skin daily for pressure sores and other skin irritations
Try to turn a bedridden person every few hours (or as often as possible),
alternating positions.
Encourage the patient to get out of bed as much as possible.
Never leave the patient lying or sitting in wet clothes or bedding.
Make sure the bedding is not wrinkled or irritating the patient's skin.
Promote a balanced nutritious diet, high in protein (fish, poultry, dairy
products).
Do not open or break blisters.
Put dry, clean gauze on any open areas.
Ulcers
Keep skin area clean and observe for signs of infection (pain, redness,
drainage that looks like pus). Follow treatment instructions from the doctor,
which may include wet dressings and topical antibiotics to control infection
in open ulcers.
Edema
Keep feet elevated when lying in bed or sitting
Take medication, and restrict fluids or salt intake, as prescribed by
the doctor
Itching/Rash
Bathing the patient with cool water may help
Add baking soda to bath water
Apply a cool, moist cloth to itchy areas
Wash sheets and towels in a mild laundry soap and change daily
Avoid harsh laundry detergents
Apply medications prescribed by the doctor for skin irritations
Dryness
Add mineral or baby oil to warm bath water
Apply moisturizers
Make sure the patient drinks 8-10 glasses of water per day
Do not scrub the patient's skin while bathing, and gently pat the skin
dry
When to Call the Doctor
If you see pressure sores (cracked, scaly, blistered, broken skin)
If a pressure sore is getting larger
If a cut becomes very red, sore, or swollen
If skin gets very rough, red, or painful
If a rash develops or hives appear
If pus comes out of a wound or cut
If severe itching lasts more than a few days
If a rash becomes worse after applying ointment or cream
If swelling spreads up legs or arms
If the patient's belly becomes swollen
Anxiety
Anxiety is a common symptom among patients with a life-threatening
disease, sometimes occurring with depression.
Characteristics of anxiety include:
Feelings of fear, worry or apprehension
Additional symptoms, such as tension, restlessness, jitteriness, insomnia,
fatigue, distractibility, shortness of breath, numbness or muscle tension
Long duration (generalized anxiety) or short, intense bouts (panic attacks)
Causes of anxiety can include:
Difficulty adjusting to the illness
Common fears about death, including isolation and separation
Poorly-controlled pain
Side effects of medication
Withdrawal from benzodiazepines or opioids, if these are decreased abruptly
Medical conditions, such as dehydration, electrolyte imbalance, or withdrawal
from drugs such as nicotine or alcohol.
Some anxiety is a normal response to the frightening situation facing patients
with a life-threatening illness. However, if anxiety begins to cause the patient
distress, there are several treatment options.
Treatment of anxiety can include:
Stress management techniques, such as progressive relaxation, guided imagery
and hypnosis
Counseling
Support from family, friends, spiritual leaders and peers
Control of pain, side effects from medication and other medical conditions,
where possible
Medication can include:
Benzodiazepines
Other tranquilizers, such as the phenothiazines and haloperidol
Antihistamines, especially hydroxyzine
Antidepressants
Opioids
Counseling for Anxiety
Counseling can help patients with a life-threatening disease by:
Establishing a bond to decrease the patient's sense of isolation
Fostering a sense of self-worth
Correcting misconceptions about the past and present
Integrating the present illness into a continuum of life experience
Emphasizing past strengths
Supporting ways of coping that the patient has used successfully in the
past
Helping the patient meet interpersonal goals, such as reconciling differences
with a family member or maintaining relationships with friends
Exploring issues of separation, loss and the unknown that arise when facing
death
Addressing practical concerns
Addressing needs of the family and other caregivers.
Depression
Depression is common in patients with a life-threatening disease, and often
affects members of the patient's family as well.
Symptoms of depression can include:
Profound sadness, inability to experience joy
Withdrawal from friends, family and associates
Dramatic changes in normal behavior patterns of eating, sleeping, self-care
or interacting with others
A feeling that everything is hopeless, nothing is enjoyable and life is
not worth living
Feelings of worthlessness and guilt
Thoughts of suicide
Alcohol or other drug use
Depression in patients can be related to:
Loss of the ability to function
Other losses, such as troubling change in body image, problems in intimate
relationships, etc.
Medications and other medical problems
Pain and other symptoms, such as shortness of breath
Role changes in the family and concerns about being a burden
Control of depression is important in alleviating a patient's distress. It can
include:
Antidepressant medication
Management of pain and other distressing symptoms
Counseling
The support of spiritual leaders, family, friends and peers found through
support groups
Stress and pain management techniques, such as relaxation, guided imagery
and distraction
Confusion
Confusion is an aspect of delirium, which is common, especially in patients
with advanced disease. Patients with a progressive medical disease often develop
confusion or drowsiness before death.
Delirium can be caused by:
Complications of the disease (e.g., organ failure)
