Pain | Constipation | Loss of Appetite | Eating and drinking problems | Breathing difficulties | Nausea and vomiting | Dry mouth | Itching | Pressure Sores | Smells | Incontinence | Confusion

Terminally ill people usually experience a whole range of physical symptoms. Symptoms vary according to the illness and the same illness may affect people differently.

Many symptoms can be reduced or relieved, so tell your doctor or hospice nurse about the symptoms. Do not assume it is just part of the illness and that nothing can be done. Remember, one of your aim is to provide your loved one with comfort in his last days of life.

Good symptom control requires you to work closely with your doctor, nurses and other healthcare professionals since medications may need to be prescribed. The main job of the caregiver is to recognise and identify the symptoms early and to seek appropriate treatment for them.

Ill people are often reluctant to bother their caregivers about "minor" symptoms such as dry mouth and insomnia. Thus, the caregiver should enquire from time to time rather than rely on spontaneous complaints from the patient.

 
Pain

Not necessarily all terminally ill people will experience pain e.g. one in four people with advanced cancer have no pain at all.

However, pain, whenever it exists, needs to be managed effectively so that your loved one may have a better quality of life in his last days. Ask your loved one if he has any pain. Look out for facial grimaces when he is moved. Inform your doctor or hospice nurses whenever pain is experienced as most pain, including severe cancer pain, can be relieved.

Doctors usually start with regular analgesics and gradually work upward with stronger analgesics, including morphine, to control cancer pain. There are a few misconceptions about the use of morphine in the care of the terminally ill, and I would like to address some of these concerns.

1. Morphine causes addiction.
   Morphine DOES NOT cause addiction when used to control pain.

2. Morphine is used only as the last resort when the patient is terminally ill.
   Morphine can be used at ANY STAGE to control pain so that the patient may have a better quality of life.

3. Morphine should not be given more frequently than every 8 hours.
   Morphine should be given every 4 hours. This interval is increased only in elderly patients and/or the presence of severe liver and renal impairment.

4. There is a limit to the amount of morphine that one should prescribe.
   There is no upper limit to morphine dosage. The dose of morphine that should be prescribed is the dose that the patient requires to control pain.

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Constipation

This may be caused by loss of appetite, inactivity or medication. Drinking plenty of water or fluid and increasing the fibre content of food can help.

In severe constipation or if the patient is very distressed by the absence of regular bowel movement, your doctor may prescribe some laxatives such as liquid paraffin or duphalac.

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Loss of Appetite

People who are ill often have little appetite. This is particularly so for terminally ill cancer patients. Encourage the person you care for to eat smaller but more frequent meals and snacks as and when he likes. Prepare and serve him his favourite dishes.

Accompany him when he eats. Meal time can provide a good opportunity to communicate with your loved one, and to find out how he feels. Furthermore, his appetite may improve a little if he has someone to talk to. Eating alone can sometimes be very depressing and further reduces his appetite.

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Eating and drinking problems

Some patients with terminal illness may have difficulty chewing and swallowing. This may be due to denture problem, gum problem or obstruction at the esophagus due to the illness. Patients with neurological problems may also have difficulty swallowing.

In such cases, your doctor should be consulted so that alternative methods of feeding may be instituted, such as the use of feeding tubes or intravenous infusion.

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Breathing difficulties

This may be encountered in some patients with lung or heart problems, and is a common problem towards the end of life. This is a rather distressing symptom.

A person who is breathing noisily may not be having difficulty breathing. He may just be having a lot of phlegm and is too weak to clear the phlegm by himself. Some simple physiotherapy may help to clear the phlegm in the airways. If that is not helpful, your doctor or hospice nurse may be able to suck the phlegm out using a suction pump.

For those with genuine difficulty in breathing, oxygen therapy may be required. Your doctor is the best person to advice on this.

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Nausea and vomiting

Nausea and vomiting are frequent symptoms encountered in people with terminal illnesses, either as a result of the illness itself or from the side effects of chemotherapy. The symptoms are disturbing and may affect appetite. Fortunately, these symptoms can usually be alleviated with simple medications such as metoclopramide (maxolon) or stemetil.

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Dry mouth

As the terminal illness progresses, your loved one may eat and drink less. He will become dehydrated and his lips and mouth become dry. Feed him with sips of water, from a straw if necessary. If he is unable to do that, then wet his lips with cotton that you have dipped in water to keep his lips moist.

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Itching

Itching occurs in dry skin and skin that is not clean. Learn to bathe your loved one in bed, if necessary. Ask your hospice nurse to teach you if you do not know how. After bathing him, apply moisturising lotion on his body evenly. This will provide him with gentle massage as well as prevent itch and even bed sores.

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Pressure sores

Someone who sits or lies in one position for a long time is likely to find the skin breaking down over the bony parts of the body (e.g. base of spine) causing pressure sores. Thus bed-ridden patients are prone to get pressure sores.

To minimise this, turn your loved one as frequently as you can. Ideally, this should be done every two hourly. Turning allows areas that are under pressure to be relieved from the pressure, thus improving blood flow to the affected area.

As a caregiver, inspect your loved one's skin each time you bathe him. Look out for redness of the skin or bruises. These may be early signs of pressure sores. Also, apply moisturiser to his skin after bath. Take care also to straighten creases on the bed linen. All these simple steps will prevent bed sores.

If pressure sores occur, obtain the advice and help of your hospice nurse in managing the sores.

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Smells

Sometimes a wound or urine infection can cause a smelly discharge, which can be very upsetting for the person you care for. The use of various perfume or scented oils may help disguise smells.

Smells from pressure sores and fungating tumours may be substantially reduced using metronidazole (flagyl). Crush the flagyl tablets into powder and sprinkle it onto the wound or sore. If you are not sure, ask your hospice nurse for advice.

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Incontinence

Incontinence is the loss of bladder or bowel control. This can happen in the later stages of an illness. Your hospice nurse, available via your Doctor, can often help with advice and simple equipment.

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Confusion

Confusion often occurs in the final stages of a terminal illness. It can sometimes be helped with medication. However, sometimes it is the medication that is the cause of the confusion.

Becoming confused can be very upsetting for both the caregiver and the person you care for. Try to reassure your loved one.

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Generally, it is advisable to inform your doctor or nurse about any symptoms your loved one may experience. They may be able to offer additional suggestions or prescribe medications to relieve the symptoms.