Who needs this? Causes of nausea and vomiting in hospice patients
By Lauri Weiss, CRNP
Linda was a young hospice patient—just 54. She had battled cancer and agreed, with her family and physicians, that further treatment wasn’t going to prolong her life in any meaningful way. So, she was surprised when she experienced ongoing nausea, even after ending her chemotherapy treatments. Her family, already wrung out by her treatment regimen and their own emotions, thought this would be a period in which Linda would be more comfortable. They were tired, she was tired, and everyone just wanted the nausea to end.
When someone is already weak, nausea and vomiting just seem to add insult to injury—discomfort and stress and make a hard situation harder for both the hospice patient and the caregiver.
Nausea and vomiting are common symptoms experienced by people with serious or life-limiting illness. They are highly distressing and often have a very negative impact on quality of life. Nausea and vomiting are two distinct phenomena; however, they are often addressed interchangeably. Nausea is a subjective symptom involving an unpleasant sensation in the back of the throat and stomach, which may or may not result in vomiting. Vomiting is the expulsion of stomach contents through the mouth caused by contractions of the stomach muscles. Although vomiting is a protective mechanism designed to rid the body of toxins, the experience of vomiting is usually highly unpleasant. Nausea may occur spontaneously or in response to a specific event and may be continuous or intermittent. Vomiting may occur in association with nausea or be independent of nausea.
Physical, emotional, and spiritual consequences
Nausea and vomiting impact all dimensions of quality of life, especially if symptoms are long lasting. Physical consequences may include dehydration, malnutrition, aspiration, throat and mouth irritation, decreased activity tolerance and fatigue. Psychological, social and spiritual consequences may include depression, altered socialization, decisions to stop potentially beneficial treatments, loss of hope and increased caregiver burden. The high level of discomfort and distress caused by nausea and vomiting make effective management a priority.
Specific types or patterns of nausea and vomiting include:
- Acute Nausea and/or Vomiting – occurs within hours or minutes of a specific event, such as chemotherapy
- Delayed Nausea and/or Vomiting – occurs at least 24 hours after an event but lasts for several days
- Anticipatory Nausea – occurs before the actual event and is thought to be a learned response based on poorly controlled symptoms connected with previous similar events
The vomiting reflex is controlled by the vomiting center of the brain. The vomiting center of the brain is stimulated by several pathways that trigger the vomiting reflex. These pathways are:
- The chemoreceptor receptor trigger zone detects foreign substances, such as drugs and toxins, circulating in the blood and the spinal fluid. Common causes of nausea and/or vomiting which stimulate the chemoreceptor trigger zone are medications (including opioids, chemotherapy, and antibiotics), radiation and infection.
- The cerebral cortex is the outer layer of the brain and is responsible for integrating sensory impulses and for higher intellectual functions. The cerebral cortex activates the vomiting center of the brain with signals from sensory organs (such as disturbing sights and smells and painful stimuli); thoughts (such as fear, anticipation and memories) and changes in intracranial pressure.
- The vestibular system is a sensory system located in the inner ear, which contributes to balance and spacial orientation. Signals from the vestibular system caused by motion or certain medications can stimulate the vomiting center of the brain.
- The gastrointestinal tract includes the organs of digestion, beginning at the mouth and ending at the anus. Mechanical and chemical signals from the gastrointestinal tract (such as mechanical stretch, injury to the mucosa and drugs or toxins) can trigger the vomiting center in the brain.
Be a sleuth: find the causes
Nausea and vomiting have many different causes and often multiple causes. Getting to the root of the problem and finding likely underlying physiological mechanisms ultimately guides management of these distressing symptoms. Since multiple factors may contribute to nausea and/or vomiting, a combination of treatments may be needed to bring relief. Your hospice team will ask lots of questions to get to the bottom of the issue. Find the cause and you can start working on the solution, and give your loved one a little more peace.
Lauri’s next post will discuss assessment and management of nausea and vomiting.