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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:
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Disease of the lung, such as emphysema, chronic bronchitis, cancer and
many others |
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Fluid in the lungs |
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Infection |
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Anemia |
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Emotional factors, such as anxiety |
Sometimes simple measures can relieve the sensation of shortness of breath, including:
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Providing a familiar voice to reduce anxiety |
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Changing position |
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Using relaxation techniques |
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Improving air circulation by opening a window or turning on a fan |
Medication can sometimes be useful, including:
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Opioids, such as morphine |
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Sedatives such as benzodiazepines |
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Oxygen through a face mask, in some cases |
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Corticosteroids, for patients with obstructive complications such as superior
vena cava syndrome |
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Bronchodilators, if airway spasm is involved |
Fatigue is common among those with life-threatening diseases.
Fatigue can be caused by:
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The disease |
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Medical problems related to the disease or treatment, like anemia |
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Treatments for the disease (for cancer patients, as an example, fatigue
may be caused by radiation or chemotherapy) |
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Other medication |
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Immobility |
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Sleep disturbance |
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Depression and anxiety |
Management of fatigue can include having the patient:
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Conserve energy whenever possible, and learn techniques of energy and
time management |
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Learn to improve sleep |
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Learn to use exercise or physical therapy |
Medications used to treat fatigue include:
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Psychostimulants, such as methylphenidate or pemoline |
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Low-dose corticosteroids (e.g., dexamethasone or prednisone) |
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Amantadine (for fatigue related to multiple sclerosis) |
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Antidepressants |
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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.
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:
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Dehydration |
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Erosion of the mucous membrane lining the mouth |
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Depression or anxiety |
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Chemotherapy or radiotherapy for cancer |
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Many medications, including some pain relievers, antidepressants, diuretics
and tranquilizers |
The sensation of a dry mouth can sometimes be relieved by simple measures, including:
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Drinking lots of fluids |
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Good oral hygiene |
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Providing humidified air |
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Sucking on ice or vitamin C tablets |
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Chewing sugarless gum |
The sensation of a dry mouth can sometimes be relieved by simple measures, including:
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Artificial saliva, provided in a spray form |
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Pilocarpine |
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:
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Inadequate intake of nutrients because the patient cannot or does not
want to eat |
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Poor absorption of food that is consumed |
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Changes in the patient's metabolism |
Management of weight loss depends on the patient's goals. It may include:
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Eating small, frequent meals |
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Eating high-calorie, high-protein foods and nutritional supplements |
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Receiving nutritional counseling |
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Feeding through artificial means (such as a tube or IV) |
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Eating and drinking whatever the patient would like |
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Relieving thirst by sucking on ice chips or a moist cloth |
Medication can include:
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Corticosteroids, which stimulate appetite but do not usually increase
weight |
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Megestrol acetate, which stimulates appetite and causes slight weight
gain |
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Dronabinol, which prevents nausea and vomiting, and increases appetite,
enhances a sense of well-being and causes weight-gain |
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Cyproheptadine, which mildly enhances appetite, increases food intake
and enhances weight gain |
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Pentoxifylline, which potentially acts to lower levels of a substance
(tumor necrosis factor) that contributes to weight loss in cancer patients. |
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:
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cancer, AIDS, and other diseases |
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radiation therapy |
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dehydration |
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chemotherapy |
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certain foods |
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opioids, antibiotics, and other drugs |
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lactose (milk) intolerance |
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emotional distress and anxiety |
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surgery |
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taste changes |
What You Can Do to Help
Nausea/Vomiting
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Encourage the patient to take prescribed antinausea medication |
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Fix the patient frequent light meals throughout the day |
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Serve foods cool or at room temperature |
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Avoid fried foods, dairy products, and acidic foods (e.g., citrus fruits,
citrus juice, and vinegar) |
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Stay away from spicy foods; stick to bland foods, such as dry crackers |
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Make sure the patient's mouth is kept clean |
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Offer chewing gum or hard candy |
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Take the patient outside or open a window for fresh air |
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Encourage rest and relaxation |
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Make sure the patient drinks enough clear liquids, sipped slowly, to prevent
dehydration |
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Avoid unpleasant or strong odors |
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Distract the patient with music, television, or other activities |
When to Call the Doctor for Nausea and Vomiting:
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If there is blood or material that looks like coffee grounds in the vomit |
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If vomit shoots out for a distance (projectile vomiting) |
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If two doses of prescribed medications are not taken or kept down because
of nausea or vomiting |
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If the patient cannot keep liquids or food down |
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If weakness or dizziness occur |
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If severe stomach pains occur with vomiting |
Constipation
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Discuss the use of laxatives and stool softeners with the doctor and follow
a regular schedule as directed |
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If the doctor agrees, give the patient foods high in fiber (whole grain
cereal and bread, dried fruit, nuts, beans, and raw fruits and vegetables) |
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Make sure the patient drinks enough liquids (up to 6-8 glasses per day) |
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Offer prune juice, hot lemon water, tea, or coffee, which may stimulate
the bowels |
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Encourage daily exercise, such as walking (in keeping with the doctor's
advice) |
When to Call the Doctor for Constipation:
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If the patient has not had a bowel movement in many days |
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If constipation occurs with severe abdominal pain |
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If constipation worsens and is followed by vomiting |
Diarrhea
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Give medicine for diarrhea as directed by the doctor |
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Replace lost fluids and nutrients by offering clear liquids (clear juices,
water, broth), often and in between meals (2-3 quarts per day) |
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Serve foods low in fiber and high in potassium and protein (eggs, bananas,
applesauce, mashed potatoes, rice, and dry toast) |
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Serve many small meals throughout the day rather than 3 big meals |
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Avoid serving foods that may increase bloating (vegetables, beans, fruits)
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Avoid serving fatty or acidic foods (fatty meat, fried food, spicy food)
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Limit caffeine intake (coffee, tea, soda with caffeine, and chocolate)
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Avoid serving dairy or milk products |
When to Call the Doctor for Diarrhea:
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If the patient is losing a lot of fluid from severe diarrhea |
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If there is blood in the diarrhea |
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If diarrhea is oily in the toilet |
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If there is a fever |
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If the patient does not drink any liquids for more than 2 days |
Loss of Appetite/Weight Loss
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Do not force-feed the patient |
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Do not get angry if the patient does not want to eat |
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Prepare familiar favorite foods |
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Try light exercise or walking before meals |
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Encourage eating meals at the table with others |
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Serve meals over a prolonged period of time in a relaxed environment |
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Place meals on smaller plates with smaller servings more frequently |
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Cover up unpleasant odors |
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Serve a glass of wine before meals to stimulate appetite (as per MD's
advice) |
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Offer frequent high protein, high calorie snacks (pudding, ice cream,
milk shakes) |
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Try new spices or flavorings for foods |
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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:
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If the patient reduces normal food intake for a long time |
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If the patient loses 5 pounds or more in a short time |
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If there is pain with chewing and/or swallowing |
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If the patient experiences dizziness upon standing |
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If the patient does not urinate for an entire day, or does not move the
bowels for many days |
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. |
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Most likely to affect patients who are bedridden, underweight, malnourished,
or dehydrated. |
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Usually occur in bony areas, such as the head, elbows, heels, hips, shoulders,
and tailbone. |
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Sores are made worse when the patient rubs against his/her sheets. |
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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
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Ulcers – crater-like lesions
on the skin.
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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.
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Can occur from certain medications; heart, liver, or kidney failure; malnutrition;
and obstruction of veins or lymph nodes. |
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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
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Can be the result of dryness, allergies, and side effects of medications
or treatments. |
Rash – bumpy, red, itchy skin.
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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.
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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
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Keep skin dry and clean |
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Check skin daily for pressure sores and other skin irritations |
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Try to turn a bedridden person every few hours (or as often as possible),
alternating positions. |
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Encourage the patient to get out of bed as much as possible. |
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Never leave the patient lying or sitting in wet clothes or bedding. |
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Make sure the bedding is not wrinkled or irritating the patient's skin. |
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Promote a balanced nutritious diet, high in protein (fish, poultry, dairy
products). |
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Do not open or break blisters. |
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Put dry, clean gauze on any open areas. |
Ulcers
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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
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Keep feet elevated when lying in bed or sitting |
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Take medication, and restrict fluids or salt intake, as prescribed by
the doctor |
Itching/Rash
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Bathing the patient with cool water may help |
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Add baking soda to bath water |
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Apply a cool, moist cloth to itchy areas |
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Wash sheets and towels in a mild laundry soap and change daily |
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Avoid harsh laundry detergents |
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Apply medications prescribed by the doctor for skin irritations |
Dryness
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Add mineral or baby oil to warm bath water |
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Apply moisturizers |
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Make sure the patient drinks 8-10 glasses of water per day |
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Do not scrub the patient's skin while bathing, and gently pat the skin
dry |
When to Call the Doctor
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If you see pressure sores (cracked, scaly, blistered, broken skin) |
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If a pressure sore is getting larger |
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If a cut becomes very red, sore, or swollen |
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If skin gets very rough, red, or painful |
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If a rash develops or hives appear |
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If pus comes out of a wound or cut |
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If severe itching lasts more than a few days |
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If a rash becomes worse after applying ointment or cream |
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If swelling spreads up legs or arms |
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If the patient's belly becomes swollen |
Anxiety is a common symptom among patients with a life-threatening
disease, sometimes occurring with depression.
Characteristics of anxiety include:
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Feelings of fear, worry or apprehension |
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Additional symptoms, such as tension, restlessness, jitteriness, insomnia,
fatigue, distractibility, shortness of breath, numbness or muscle tension |
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Long duration (generalized anxiety) or short, intense bouts (panic attacks) |
Causes of anxiety can include:
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Difficulty adjusting to the illness |
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Common fears about death, including isolation and separation |
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Poorly-controlled pain |
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Side effects of medication |
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Withdrawal from benzodiazepines or opioids, if these are decreased abruptly
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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:
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Stress management techniques, such as progressive relaxation, guided imagery
and hypnosis |
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Counseling |
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Support from family, friends, spiritual leaders and peers |
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Control of pain, side effects from medication and other medical conditions,
where possible |
Medication can include:
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Benzodiazepines |
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Other tranquilizers, such as the phenothiazines and haloperidol |
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Antihistamines, especially hydroxyzine |
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Antidepressants |
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Opioids |
Counseling for Anxiety
Counseling can help patients with a life-threatening disease by:
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Establishing a bond to decrease the patient's sense of isolation |
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Fostering a sense of self-worth |
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Correcting misconceptions about the past and present |
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Integrating the present illness into a continuum of life experience |
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Emphasizing past strengths |
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Supporting ways of coping that the patient has used successfully in the
past |
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Helping the patient meet interpersonal goals, such as reconciling differences
with a family member or maintaining relationships with friends |
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Exploring issues of separation, loss and the unknown that arise when facing
death |
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Addressing practical concerns |
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Addressing needs of the family and other caregivers. |
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:
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Profound sadness, inability to experience joy |
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Withdrawal from friends, family and associates |
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Dramatic changes in normal behavior patterns of eating, sleeping, self-care
or interacting with others |
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A feeling that everything is hopeless, nothing is enjoyable and life is
not worth living |
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Feelings of worthlessness and guilt |
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Thoughts of suicide |
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Alcohol or other drug use |
Depression in patients can be related to:
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Loss of the ability to function |
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Other losses, such as troubling change in body image, problems in intimate
relationships, etc. |
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Medications and other medical problems |
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Pain and other symptoms, such as shortness of breath |
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Role changes in the family and concerns about being a burden |
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Limited social and financial support. |
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Spiritual distress. |
Control of depression is important in alleviating a patient's distress. It can
include:
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Antidepressant medication |
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Management of pain and other distressing symptoms |
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Counseling |
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The support of spiritual leaders, family, friends and peers found through
support groups |
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Stress and pain management techniques, such as relaxation, guided imagery
and distraction |
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:
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Complications of the disease (e.g., organ failure) |
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Medications |
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Nutritional deficiencies |
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Other disorders that affect the brain |
Some signs of delirium include:
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Memory impairment or confusion |
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Change in mood |
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Illusions or hallucinations |
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Agitation |
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Disturbance in the sleep/wake cycle |
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Fluctuating level of consciousness |
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Disorientation to place, time, and/or person |
Management of delirium can include:
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Medications (e.g., haloperidol, methotrimeprazine, thioridazine, chlorpromazine)
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General support for and communication with the patient and family |
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Encouraging the family's interaction with the patient |
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Any treatment that can help reverse the underlying cause |
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