Skip to main content
PMC home page
CMAJ : Canadian Medical Association Journal logoLink to CMAJ : Canadian Medical Association Journal
. 1998 Jun 30;158(13):1717–1726.

Management of specific symptom complexes in patients receiving palliative care

E Bruera 1, C M Neumann 1
PMCID: PMC1229444  PMID: 9676549

Abstract

During the past 10 years there have been major changes in the management of the most common symptoms of terminal cancer. Opioid agonists remain the mainstay in the management of cancer pain. Slow-release preparations are currently available for several of these agents. The increased use of opioids has led to the recognition of opioid-induced neurotoxic effects and to the development of effective adjuvant drugs and other strategies to counteract these side effects. A number of drugs are available for the management of symptoms of cachexia, including corticosteroids and progestational drugs. Prokinetic drugs, either alone or in combination with other agents such as corticosteroids, are highly effective in the treatment of chronic nausea. For patients with asthenia, it should first be determined whether there are any reversible causes; if not, corticosteroids and psychostimulants may diminish the symptoms. Haloperidol, other neuroleptics and benzodiazepines may be required to manage hyperactive delirium. Oxygen and opioids are effective in treating dyspnea, whereas there is limited evidence that benzodiazepines provide any relief of this symptom. More research on the assessment and management of these devastating clinical symptoms of cancer is badly needed.

Full Text

The Full Text of this article is available as a PDF (371.2 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Beller E., Tattersall M., Lumley T., Levi J., Dalley D., Olver I., Page J., Abdi E., Wynne C., Friedlander M. Improved quality of life with megestrol acetate in patients with endocrine-insensitive advanced cancer: a randomised placebo-controlled trial. Australasian Megestrol Acetate Cooperative Study Group. Ann Oncol. 1997 Mar;8(3):277–283. doi: 10.1023/a:1008291825695. [DOI] [PubMed] [Google Scholar]
  2. Breitbart W., Bruera E., Chochinov H., Lynch M. Neuropsychiatric syndromes and psychological symptoms in patients with advanced cancer. J Pain Symptom Manage. 1995 Feb;10(2):131–141. doi: 10.1016/0885-3924(94)00075-v. [DOI] [PubMed] [Google Scholar]
  3. Breitbart W., Marotta R., Platt M. M., Weisman H., Derevenco M., Grau C., Corbera K., Raymond S., Lund S., Jacobson P. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry. 1996 Feb;153(2):231–237. doi: 10.1176/ajp.153.2.231. [DOI] [PubMed] [Google Scholar]
  4. Bruera E. D., MacEachern T. J., Spachynski K. A., LeGatt D. F., MacDonald R. N., Babul N., Harsanyi Z., Darke A. C. Comparison of the efficacy, safety, and pharmacokinetics of controlled release and immediate release metoclopramide for the management of chronic nausea in patients with advanced cancer. Cancer. 1994 Dec 15;74(12):3204–3211. doi: 10.1002/1097-0142(19941215)74:12<3204::aid-cncr2820741220>3.0.co;2-g. [DOI] [PubMed] [Google Scholar]
  5. Bruera E. ABC of palliative care. Anorexia, cachexia, and nutrition. BMJ. 1997 Nov 8;315(7117):1219–1222. doi: 10.1136/bmj.315.7117.1219. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bruera E., Brenneis C., Michaud M., MacDonald R. N. Influence of the pain and symptom control team (PSCT) on the patterns of treatment of pain and other symptoms in a cancer center. J Pain Symptom Manage. 1989 Sep;4(3):112–116. doi: 10.1016/0885-3924(89)90003-1. [DOI] [PubMed] [Google Scholar]
  7. Bruera E., MacEachern T., Ripamonti C., Hanson J. Subcutaneous morphine for dyspnea in cancer patients. Ann Intern Med. 1993 Nov 1;119(9):906–907. doi: 10.7326/0003-4819-119-9-199311010-00007. [DOI] [PubMed] [Google Scholar]
  8. Bruera E., Miller L., McCallion J., Macmillan K., Krefting L., Hanson J. Cognitive failure in patients with terminal cancer: a prospective study. J Pain Symptom Manage. 1992 May;7(4):192–195. doi: 10.1016/0885-3924(92)90074-r. [DOI] [PubMed] [Google Scholar]
  9. Bruera E., Pereira J., Watanabe S., Belzile M., Kuehn N., Hanson J. Opioid rotation in patients with cancer pain. A retrospective comparison of dose ratios between methadone, hydromorphone, and morphine. Cancer. 1996 Aug 15;78(4):852–857. doi: 10.1002/(SICI)1097-0142(19960815)78:4<852::AID-CNCR23>3.0.CO;2-T. [DOI] [PubMed] [Google Scholar]
  10. Bruera E., Schoeller T., MacEachern T. Symptomatic benefit of supplemental oxygen in hypoxemic patients with terminal cancer: the use of the N of 1 randomized controlled trial. J Pain Symptom Manage. 1992 Aug;7(6):365–368. doi: 10.1016/0885-3924(92)90091-u. [DOI] [PubMed] [Google Scholar]
  11. Bruera E., Seifert L., Watanabe S., Babul N., Darke A., Harsanyi Z., Suarez-Almazor M. Chronic nausea in advanced cancer patients: a retrospective assessment of a metoclopramide-based antiemetic regimen. J Pain Symptom Manage. 1996 Mar;11(3):147–153. doi: 10.1016/0885-3924(95)00161-1. [DOI] [PubMed] [Google Scholar]
  12. Bruera E., Sloan P., Mount B., Scott J., Suarez-Almazor M. A randomized, double-blind, double-dummy, crossover trial comparing the safety and efficacy of oral sustained-release hydromorphone with immediate-release hydromorphone in patients with cancer pain. Canadian Palliative Care Clinical Trials Group. J Clin Oncol. 1996 May;14(5):1713–1717. doi: 10.1200/JCO.1996.14.5.1713. [DOI] [PubMed] [Google Scholar]
  13. Cleeland C. S., Gonin R., Hatfield A. K., Edmonson J. H., Blum R. H., Stewart J. A., Pandya K. J. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994 Mar 3;330(9):592–596. doi: 10.1056/NEJM199403033300902. [DOI] [PubMed] [Google Scholar]
  14. Cohen M. H., Anderson A. J., Krasnow S. H., Spagnolo S. V., Citron M. L., Payne M., Fossieck B. E., Jr Continuous intravenous infusion of morphine for severe dyspnea. South Med J. 1991 Feb;84(2):229–234. doi: 10.1097/00007611-199102000-00019. [DOI] [PubMed] [Google Scholar]
  15. Congleton J., Muers M. F. The incidence of airflow obstruction in bronchial carcinoma, its relation to breathlessness, and response to bronchodilator therapy. Respir Med. 1995 Apr;89(4):291–296. doi: 10.1016/0954-6111(95)90090-x. [DOI] [PubMed] [Google Scholar]
  16. Dewys W. D., Begg C., Lavin P. T., Band P. R., Bennett J. M., Bertino J. R., Cohen M. H., Douglass H. O., Jr, Engstrom P. F., Ezdinli E. Z. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med. 1980 Oct;69(4):491–497. doi: 10.1016/s0149-2918(05)80001-3. [DOI] [PubMed] [Google Scholar]
  17. Eve A., Smith A. M., Tebbit P. Hospice and palliative care in the UK 1994-5, including a summary of trends 1990-5. Palliat Med. 1997 Jan;11(1):31–43. doi: 10.1177/026921639701100104. [DOI] [PubMed] [Google Scholar]
  18. Gagnon B., Bruera E. A review of the drug treatment of cachexia associated with cancer. Drugs. 1998 May;55(5):675–688. doi: 10.2165/00003495-199855050-00005. [DOI] [PubMed] [Google Scholar]
  19. Lane N. E. Pain management in osteoarthritis: the role of COX-2 inhibitors. J Rheumatol Suppl. 1997 Jul;49:20–24. [PubMed] [Google Scholar]
  20. Lawlor P. G., Turner K. S., Hanson J., Bruera E. D. Dose ratio between morphine and methadone in patients with cancer pain: a retrospective study. Cancer. 1998 Mar 15;82(6):1167–1173. [PubMed] [Google Scholar]
  21. Leung R., Hill P., Burdon J. Effect of inhaled morphine on the development of breathlessness during exercise in patients with chronic lung disease. Thorax. 1996 Jun;51(6):596–600. doi: 10.1136/thx.51.6.596. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Levy M. H. Pharmacologic treatment of cancer pain. N Engl J Med. 1996 Oct 10;335(15):1124–1132. doi: 10.1056/NEJM199610103351507. [DOI] [PubMed] [Google Scholar]
  23. Mercadante S. The role of octreotide in palliative care. J Pain Symptom Manage. 1994 Aug;9(6):406–411. doi: 10.1016/0885-3924(94)90178-3. [DOI] [PubMed] [Google Scholar]
  24. Neuenschwander H., Bruera E., Cavalli F. Matching the clinical function and symptom status with the expectations of patients with advanced cancer, their families, and health care workers. Support Care Cancer. 1997 May;5(3):252–256. doi: 10.1007/s005200050069. [DOI] [PubMed] [Google Scholar]
  25. Pereira J., Hanson J., Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer. 1997 Feb 15;79(4):835–842. [PubMed] [Google Scholar]
  26. Ripamonti C, Bruera E. Pain and Symptom Management in Palliative Care. Cancer Control. 1996 May;3(3):204–213. doi: 10.1177/107327489600300302. [DOI] [PubMed] [Google Scholar]
  27. Stiefel F., Morant R. Morphine intoxication during acute reversible renal insufficiency. J Palliat Care. 1991 Winter;7(4):45–47. [PubMed] [Google Scholar]
  28. Walsh T. D., MacDonald N., Bruera E., Shepard K. V., Michaud M., Zanes R. A controlled study of sustained-release morphine sulfate tablets in chronic pain from advanced cancer. Am J Clin Oncol. 1992 Jun;15(3):268–272. doi: 10.1097/00000421-199206000-00018. [DOI] [PubMed] [Google Scholar]
  29. Watanabe S., Bruera E. Anorexia and cachexia, asthenia, and lethargy. Hematol Oncol Clin North Am. 1996 Feb;10(1):189–206. doi: 10.1016/s0889-8588(05)70334-8. [DOI] [PubMed] [Google Scholar]
  30. Watanabe S., Bruera E. Corticosteroids as adjuvant analgesics. J Pain Symptom Manage. 1994 Oct;9(7):442–445. doi: 10.1016/0885-3924(94)90200-3. [DOI] [PubMed] [Google Scholar]

Articles from CMAJ: Canadian Medical Association Journal are provided here courtesy of Canadian Medical Association

RESOURCES