P05: Palliative Care - Nausea
Updated:
Reviewed:
Introduction
Nausea and vomiting can profoundly affect the quality of life for palliative patients. The prevalence of nausea and vomiting is high in this group, affecting 40-60% of all individuals receiving palliative care. Gastroparesis and chemical disturbances are the most common cause.
Essentials
- Establish goals of care in consultation and conversation with the patient, family, and care team.
- Non-pharmacological interventions provide the best relief for mild and moderate nausea and vomiting.
- Keep air and room fresh; eliminate strong odors.
- Nausea and vomiting are separate, but related, phenomena that are present in many life-limiting conditions.
Additional Treatment Information
- A single dose of antiemetic is sufficient in the majority of patients.
- Antiemetics tend to suppress vomiting more readily than nausea. An increase in the antiemetic dose may improve control of nausea.
Referral Information
All palliative and end-of-life patients can be considered for inclusion in the Palliative Care Clinical Pathway (treat and refer) approach to care. Paramedics must complete required training prior to applying this pathway. EMRs are required to contact CliniCall for consultation to proceed with the ASTaR clinical pathway.
General Information
- Underlying causes can be classified into 6 broad groups:
- Chemical
- Cortical
- Cranial
- Vestibular
- Visceral
- Gastric stasis (impaired gastric emptying)
Interventions
First Responder (FR) Interventions
- Provide reassurance
- Promote fresh air in the patient’s room and eliminate strong odors where possible
- Promote non-pharmacological pain strategies such as positioning and reassurance
Emergency Medical Responder (EMR) & All License Levels Interventions
- Establish goals of care in consultation and conversation with the patient, family, and care team
- Complete a comprehensive nausea and vomiting assessment
Primary Care Paramedic (PCP) Interventions
- Assist family with the administration of any medications that are recommended as part of an established care plan
- Paramedics can only administer the patient’s own medications where the symptom management plan is clear, they are trained and experienced in the technique of administration, and are operating within BCEHS scope
- CliniCall consultation required prior to initiating treatment.
- For mild nausea, consider dimenhyDRINATE PO/SC
- ⚠️ Requires completion of PCP scope expansion education:
- Consider ondansetron PO/SC
- Consider intravenous fluids as appropriate to correct hypotension or dehydration
- CliniCall consultation recommended to discuss care planning options.
Advanced Care Paramedic (ACP) Interventions
- Paramedics should not use in situ subcutaneous access devices unless they are educated in their use and within their scope of practice
- For moderate to severe nausea, consider
- Metoclopramide 5 mg SC
- Paramedics should consider patient’s existing regimen of drugs; ACPs may administer a patient's own prescribed medication only if the ACP has completed the appropriate Schedule 2 (4(b)) license endorsement
- CliniCall consultation required prior to the administration of any out-of-scope medications.
Evidence Based Practice
Supportive
Neutral
Against
References
- Alberta Health Services. AHS Medical Control Protocols. 2020. [Link]
- Ambulance Victoria. Clinical Practice Guidelines: Ambulance and MICA Paramedics. 2018. [Link]
- BC Centre for Palliative Care. B.C. Inter-Professional Palliative Symptom Management Guidelines. 2017. [Link]
- Nova Scotia Health Authority. Nova Scotia Palliative Care Competency Framework. 2017. [Link]
- Pallium Canada. Learning Essentials Approach to Palliative Care. 2019. [Link]
- Pre-Hospital Emergency Care Council. Palliative Care by PHECC registered practitioners. 2016. [Link]
Practice Updates
- 2023-09-29: updated PCP interventions
- 2022-01-06: EMRs now authorized to access ASTaR clinical pathway.