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!

[a21chdchic]

6-26-2007

My first instinct would have been to question a bowel obstruction also.

We usually order 'comfort packs' that include compazine suppositories, although phenergan isjust as good, For those bouts of nausea.

Ana

[Shellea]

When my mom died of gallbladder cancer, with mets to the liver, she projectile vomited at the time of death. It was quite shocking and disturbing. She hadn't had anything to eat or drink for days, so it was all yellow/green bile, and a lot of it.

[Cheechwizard, BSN, RN]

You're really committed to this idea of purging toxins.

Have you consider constipation? It's pretty common with palliative patients, especial on a pca pump or scheduled opiods.

What other ways might you think our bodies would expel toxins? What was the vomit like? Bloody, watery? 

In every patient I've helped pass, many were nauseous. It was always gas, constipation, wasting/starvation, dehydration and medication which directly contributed to it.

But I'm willing to hear more about the body removing toxins.

[Stringer]

Late to this thread, but a couple of points:

Squeeze a bag full of liquid.  If there is an exit point, forceful expulsion will occur.  The definition of projectile vomiting does not depend on cause.  It is a simple label for a physiological event.  One cause can be related to CNS pathology.

I have seen projectile vomiting at the time of death several times.  In all but one, the dying patient's stomach was full of fluid due to obstruction/ileus, and was not being effectively emptied--NGT occluded, suction turned off, gastric filling not identified.  Muscle contraction is not an uncommon event in the dying process.  If it is the abdominal and chest muscles squeezing down hard, anything in the stomach that can come out will come out through the mouth and nose.

Position those participating in the vigil at the patient's side, never at the feet.

Second, I don't find the notions of toxins particularly useful in discussions that aren't informed by the medical definitions/examples.  Specifically, what toxins?  How did they get there?  What is the physiologic function that causes "toxins" to be deposited in the stomach?  When those organs involved in filtering and waste disposal are shutting down, normally occurring compounds build up to abnormally high concentration and become "toxic", but are not in and of themselves toxins.  

I'm with Leslie.  The simpler the better when you are working with friends and family at the end of life.  Stuff can come out of the body at the end: stool, urine, stomach contents, tears, vocalizations, flatus, belches, blood.  Prepare them gently and pray for a peaceful transition.