Treatming nausea and abdominal angina in end-of-life

[notanumber]

This is an elderly lady with a complex history autoimmune disorders (SLE headlining), history of acute on chronic abdominal pain without significant findings, one physician queried mesenteric ischemia, and the symptoms fit quite well. The least controlled symptom right now is nausea/vomiting and we're moving toward parenteral routes for all medications. We are at comfort care stage and have the tools available here in LTC to provide it well for 99% of our residents. With this lady, I'm wondering if dexamethasone may be helpful. I know it's used for refractory nausea especially in the case of malignant obstruction - would intestinal ischemia be an indication as well? Or is there a contraindication? I would expect it to help with the abdominal pain as well, no? We have zofran and gravol on board at the moment, and I'm hoping to get something better in place by tomorrow (N/V isn't persistent, mostly occurs after PO intake).

[Tencat12]

Hi! How is patient's swallowing going? How alert is she? Has she just started morphine? Or has she had it for a while? Or is she on Oxycodone? When a patient reaches the comfort care stage, pain meds are the priority. Is she regularly getting pain meds? Parenteral administration of meds might be possible, if the lady has any veins at this point, but does sticking patient with needles at this point further patient comfort? If this woman is on comfort care only, why is she having PO intake for anything other than morphine or oxycodone? It may be that the morphine is causing the N/V, so a switch to Oxy might be in order.

I think it's great that you're looking for ways to help this woman!

[notanumber]

Thank you for the reply! She's on transdermal fentanyl and morphine PO which has been a longstanding PRN. The GP ordered generic comfort orders for when NPO but declined to d/c scheduled meds at this time. Swallowing is ok, easy to rouse but increasingly fatigued, confused, with marked generalized weakness. Still asks for favorite snacks on occasion but can only tolerate a tsp or two.

Only parenteral admin we can provide is subcut or IM. Most people tend to do well on butterflies IME with regular, frequent admin. I know it limits our rx options but it is sufficient - most res have a predictable palliative course and do not require invasive interventions to control symptoms.

[Tencat12]

Hmmm.....It would be worth chatting with Doc about. I'm surprised they haven't taken her off of her PO meds that aren't comfort meds. I have never heard of Dexamethasone being used for abdominal pain in hospice, but maybe it would work. PRN morphine is a problem in facilities because too many times I've seen that staff will not give it if it's PRN. Maybe patient needs an increase of pain meds, or more scheduled doses of morphine. Is patient constipated as all get out? Sometimes that will cause abdominal pain. With that much narcotics on board, anyone would be constipated. Is an outside hospice agency coming in to see her? If so, chatting with the Case Manager would be worthwhile.