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During any stage of illness, patients should be screened routinely for symptoms. Any symptoms that cause significant suffering should be addressed quickly and aggressively with frequent elicitation, individualized treatment, and reassessment. While patients at the end of life may experience a host of distressing symptoms, pain, dyspnea, and delirium are among the most feared and burdensome.


Dyspnea is the subjective experience of difficulty breathing and may be characterized by patients as tightness in the chest, shortness of breath, breathlessness, or a feeling of suffocation. Up to half of people at the end of life may experience severe dyspnea.

Treatment of dyspnea is first directed at the cause (see Chapter 9) if a workup is consistent with the patient’s goals. Dyspnea responds to opioids, which have been proven effective in multiple randomized trials. Starting doses are typically lower than would be necessary for the relief of moderate pain. Immediate-release morphine given orally (2–4 mg every 4 hours) or intravenously (1–2 mg every 4 hours) treats dyspnea effectively. Sustained-release morphine given orally at 10 mg daily is safe and effective for most patients with ongoing dyspnea. Many patients who become seriously ill with COVID-19 experience dyspnea and may require opioids as well as supplemental oxygen. Supplemental oxygen may be useful for the dyspneic patient who is hypoxic with any illness. Fresh air from a window or fan may provide relief for dyspneic patients who are not hypoxic. Judicious use of noninvasive ventilation (eg, high-flow oxygen via nasal cannula) as well as nonpharmacologic relaxation techniques, such as meditation and guided imagery may benefit some patients. Benzodiazepines may be useful for treatment of dyspnea-related anxiety.


Nausea and vomiting are common and distressing symptoms. Management of nausea may be optimized by regular dosing and often requires multiple medications targeting one or more of the four major inputs to the vomiting center (see Chapter 15).

Vomiting associated with opioids is discussed below. Some patients with prolonged vomiting will require hospitalization. Nasogastric suction may provide rapid, short-term relief for vomiting associated with constipation (in addition to laxatives), gastroparesis, or gastric outlet or bowel obstruction. Metoclopramide (5–20 mg orally or intravenously four times a day) or domperidone (not available in the United States) can be helpful in partial gastric outlet obstruction. Transdermal scopolamine (1.5-mg patch every 3 days) can reduce peristalsis and cramping pain, and H2-blocking medications can reduce gastric secretions. High-dose corticosteroids (eg, dexamethasone, 20 mg orally or intravenously daily in divided doses) can be used in refractory cases of nausea or vomiting or when it is due to bowel obstruction or increased intracranial pressure. Malignant bowel obstruction in people with advanced cancer is a poor prognostic sign and surgery is rarely helpful.

Vomiting due to disturbance of the vestibular apparatus may be treated with anticholinergic ...

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