Guidelines for a Palliative Approach in Residential Aged Care

6.7 NAUSEA AND VOMITING
Nausea is the unpleasant feeling of the need to vomit. Vomiting is the forceful expulsion of
gastric contents from the mouth. [213] Nausea can occur without vomiting (the reverse is also
true). For example, if a resident says they feel sick but they have not vomited, then the resident
has only nausea. This distinction facilitates accurate assessment and management, because there
are differential diagnoses for nausea and vomiting.
Although nausea and vomiting are common among individuals with advanced cancer, little is
known about the prevalence of these symptoms in RACF residents. Residents often experience
a range of co-morbidities that can cause nausea and vomiting, including renal failure and
cardiac failure. [214] The causes of nausea and vomiting may be related to the slowing of
gastrointestinal motility due to colonic (large bowel) slowing or gastroparesis (slowing of the
upper gastrointestinal tract) from medications or poor neuromuscular coordination. This is
particularly the case for residents with diabetes, residents who have had a stroke and have nerve
damage around the pharynx and epiglottis or positional changes due to weight loss in the neck
that affects the upper pharynx.
Nausea may also occur as a side effect of a number of medications commonly used in RACFs.
Consequently, the potential causes of nausea are usually numerous and a full history and
clinical examination are necessary. It is estimated that a major cause of nausea in residents
in RACFs is constipation, and secondary causes include reduced fluid intake, low fibre diet,
decreased mobility, or medication. Both pharmacological and non-pharmacological approaches
have been found to be effective in treating these symptoms [214] (Level EO).
6.7.1 Assessment
The resident needs to be properly assessed to determine the cause of nausea and/or vomiting.
This should involve the family, where possible, to gain a history of the resident’s eating habits and
previous nutritional difficulties, if any. During this assessment the family can also be educated
about the causes of nausea and/or vomiting and what treatment, if any, the resident desires.
Before the prescription of antiemetic drugs, the resident’s environment should be assessed to
reduce the stimulus to nausea. [214] Such stimuli could include cooking smells and unpleasant
odours. Mannix (1998) [214] includes the following steps for an appropriate antiemetic strategy:
• Determine the probable cause(s) of nausea and/or vomiting;
• Determine a suitable route of administration to ensure that the drug reaches its site of action; and
• Ensure careful titration of the dose, frequent reviews of the resident and regular provision of
the antiemetic.
6.7.2 Management
Pharmacological management
It is often not possible to identify or correct the underlying cause of nausea and/or vomiting
when a person is in the end stages of life. However, when causes are known, the potential
benefit of any intervention should not outweigh the burden. If the cause is gastrointestinal,
98 Guidelines for a Palliative Approach in Residential Aged Care