Projectile Vomiting just prior to death

[EmptytheBoat]

I've had two cases within the last few months, pt. w/projectile vomiting just prior to death, both cancer patients. I've explained this to the families as the body's method of expelling the buildup of toxins from the cancer.

In both cases, the episodes of projectile vomiting caused much family consternation and anguish, tainting the otherwise smooth, peaceful transition into the next life; and leaving this Hospice nurse with a feeling of inadequacy and helplessness.

I'm asking for your input. How do you explain the projectile vomiting to families? Is there anything you do to prepare patient or family for this possibility? Is there anything you do to try to prevent or do you think it may be prevented?

Thank you for your time, I wish you all the best. God Speed!

[tencat]

Hmmm.....I'm new to this, but I'll brainstorm with you. What about compazine or phenergan suppositories? I suppose it depends on whether or not the patient has warning of impending vomiting. Hmmmm....have to think more about this one.

[lesrn2005]

Did CA mets to the brain, by some chance, on both pts.? Just a thought.

[EmptytheBoat]

No warning on impending vomiting, both patients semi to fully comatose, non-responsive to verbal stimuli at the time. Neither had brain mets, both had

extensive tumors, thus my assumption of the body purging itself of toxins.

Do any of you instruct the families that projectile vomiting may be one of

the symptoms with impending death? Thanks for your replies.

[tencat]

You know, I haven't been instructing families that projectile vomiting could be a possibility, but I'm seriously considering doing that NOW that I've read your post.

It seems to me that it's so hard to know the exact path the course of the death journey will take. Everyone is different, and while we have some idea of what to expect, the body has other ideas a lot of the time.

Prepare for the worst and hope for the best?

[hospicemom]

I cant say that I have ever heard nor taught that vomitting prior to passing is r/t built up toxins in the body from the tumors. I would check with your medical director for guidance with this and with direction in what to tell the families. With anything that happens unplanned with a death of mine, I simply explain to the families that since all testing and treatments have stopped noone knows exactly what is happening inside the body with all the stress it is under. It is an honest answer and it seems to put the family at ease.

[leslie :-D]

The only times I've experienced projectile vomiting is when there was brain mets.

I finally got to speak with my med'l dir today and shared your concerns.

He said the first things that came to mind:

- gi obstxn

- reaction to current meds/txs/therapies

- increased icp

- metabolic imbalance causing stimulation of the n/v centers in the medulla.

He also confirmed what I thought-that it is indeed a rare occurence.

Hope this helps you, empty.

It sure helped me.

Leslie

[EmptytheBoat]

Thank you leslie, I was hoping for your input.

Best guess with my two patients would be metabolic imbalance, both patients had extensive, rapid growing tumors throughout their bodies (sarcoma and melanoma). I'm glad to hear this is rare, I've experienced the two cases in my 3 years of Hospice, but they came within a few months of each other, and I felt helpless. Thanks again leslie, and thanks to your medical director. Our medical director is a GP and new to Hospice. I will discuss with him at our next IDT. Take Care!

[NurseCherlove]

The metabolic imbalance definitely seems feasible here, especially when you also consider that the body can also attempt to "correct" these imbalances via diarrhea instead of vomitting, or sometimes both. I say that because isn't it a fairly common thing that people often poop right before death (not sure how common)? I've heard this referred to as "losing control" over one's bowels, I guess inferring that total loss of muscle (spincter) control (given the total ATP depletion perhaps?) is the culprit. But, when I stop and think about that, that really does not make sense because a person would still have to have some energy reserves to poop because peristalsis is required for pooping, even with mere spinal reflexes.

Thus, the idea of bowel obstruction also does not seem too off the mark - maybe not necessarily 'obstruction' per se, but perhaps very lazy bowels (which can have a nauseating effect) due to the amount of pain meds given to someone 'circling the drain' (not to mention the toxic effects of drug metabolites built up from high dosages/frequencies in combo with a very compromised metabolism). So, it makes sense that it could be RT a combo of all of the above. Just some thoughts...

Afterthought...nervous tissue is highly sensitive and so a metabolic disturbance could surely upset the vomitting center in the brain.

Not sure why I'm feeling so tangential right now....sorry..., but here is the real answer (I think?)...I just looked again at your title and keyed in on the word "projectile". If it was truly "projectile" and not just "regular vomitting", it makes sense that it would HAVE to be ICP-related. How can you be sure that there were no mets to the brain? Hospice patients don't usually go for a lot of tests. Of course, I've also seen the dx. Metabolic encephalopathy too...no sure what the patho is behind that...does the brain become edematous and if so, how much?

I will ask my fiance (he is a GI doc) if he has known of any "strictly GI cases" with 'projectile' vomitting - I'm curious to know if this is soley an ICP-related thing.

Sorry again for the digression...I really loved patho back in school...wish I had time/motivation to read it more

Sorry, one last thought and I will shut up...Maybe you could tell the family members that such a phenomenon is purely "reflexive" and go on to liken this to a knee jerk reflex or something...it's sudden and appears "violent", but that actively dying patients do not "feel" things (like hunger) the way we do...i.e. it's likely not the horrible feeling of nausea the way we feel it.

BTW, hospice nurse really are angels!

[EmptytheBoat]

Dear NurseCherlove,

Thanks for your input, you had some excellent thoughts.

Bowel obstruction may have been a factor especially with one of the two patients, she had rapid growing tumor(s) in the peritoneal/abdominal areas. I've considered the drug issues, both patients were on the Fentenyl transderm patch, one was being given morphine concentrate frequently, the other was not. Also, as you inquired, I can't be sure if there was mets to the brain, in either case. You're correct, we get several patients in Hospice that have the primary cancer, some mets to other organs confirmed, but the oncologist has stopped testing before getting CT of head, even when mets to the brain may be suspected. But, then again, I've had several Hospice patients with brain cancer or where mets to the brain has been diagnosed that did not have the projectile vomiting just prior to death. Thanks again for your input.

[leslie :-D]

NurseCherlove said:

The metabolic imbalance definitely seems feasible here, especially when you also consider that the body can also attempt to "correct" these imbalances via diarrhea instead of vomitting, or sometimes both. I say that because isn't it a fairly common thing that people often poop right before death (not sure how common)? I've heard this referred to as "losing control" over one's bowels, I guess inferring that total loss of muscle (spincter) control (given the total ATP depletion perhaps?) is the culprit. But, when I stop and think about that, that really does not make sense because a person would still have to have some energy reserves to poop because peristalsis is required for pooping, even with mere spinal reflexes.

Thus, the idea of bowel obstruction also does not seem too off the mark - maybe not necessarily 'obstruction' per se, but perhaps very lazy bowels (which can have a nauseating effect) due to the amount of pain meds given to someone 'circling the drain' (not to mention the toxic effects of drug metabolites built up from high dosages/frequencies in combo with a very compromised metabolism). So, it makes sense that it could be RT a combo of all of the above. Just some thoughts...

Afterthought...nervous tissue is highly sensitive and so a metabolic disturbance could surely upset the vomitting center in the brain.

Not sure why I'm feeling so tangential right now....sorry..., but here is the real answer (I think?)...I just looked again at your title and keyed in on the word "projectile". If it was truly "projectile" and not just "regular vomitting", it makes sense that it would HAVE to be ICP-related. How can you be sure that there were no mets to the brain? Hospice patients don't usually go for a lot of tests. Of course, I've also seen the dx. Metabolic encephalopathy too...no sure what the patho is behind that...does the brain become edematous and if so, how much?

I will ask my fiance (he is a GI doc) if he has known of any "strictly GI cases" with 'projectile' vomitting - I'm curious to know if this is soley an ICP-related thing.

Sorry again for the digression...I really loved patho back in school...wish I had time/motivation to read it more

Sorry, one last thought and I will shut up...Maybe you could tell the family members that such a phenomenon is purely "reflexive" and go on to liken this to a knee jerk reflex or something...it's sudden and appears "violent", but that actively dying patients do not "feel" things (like hunger) the way we do...i.e. it's likely not the horrible feeling of nausea the way we feel it.

BTW, hospice nurse really are angels!

Cherlove, you're driving me crazy! (:icon_hug: )

Relax, darlin'.

You're going to burn yourself out.

When I was in nsg school, I'd drive my instructors nuts, trying to understand and explain the 'why's and 'whats'.

At this point, I can 'see' everything that happens inside of the body;

I just don't have the energy to explain it.

Yes, it could definitely be obstxn.

Projectile vomiting does occur with this...Not maybe.

At the end of life, organs are shutting down, reflexes are relaxing.

That's why many pts have bms.

But when aggressive cancers infiltrate the systems, it's not as simple.

But you can keep it simple to your pts, by just stating that organs are reacting to the toxins in the body.

Keep it simple, my friend.

Everything will fall into place. :balloons:

Leslie

[NurseCherlove]

Thank you, Empty. It's puzzling for sure. I did get to briefly ask my fiance about this over the phone yesterday. He did not elaborate, but he did say that he has seen projectile vomiting as a result of "solely GI issues" - he did not have time to specify. He also went on to say that it is most always an ICP issue though.

The main thing is that the pt and family are comfortable (as much as can be), right? I like the previous poster's idea of phenergan suppositories, especially since phenergan potentiates narcotics.

Keep up the good work!