9th January 2024

Nausea and Vomiting

Nausea is an unpleasant sensation of needing to vomit and is often associated with autonomic symptoms such as sweating, pallor, salivation and tachycardia. It is often accompanied by vomiting, which is the forceful ejection of stomach contents through the mouth. Patients generally report that nausea is more debilitating, lasts longer and feels worse than vomiting. There are many possible causes in a palliative patient, so thorough assessment is essential. Nausea and vomiting should be assessed separately. Ask about any triggers or patterns to the nausea and vomiting, as well as relieving factors and associated symptoms. If a patient vomits, does this relieve nausea, or does it persist?

Causes of Nausea and Vomiting

Possible causes of nausea and vomiting in palliative patients are highlighted below in Table 2.

Source: Watson M, Campbell R, Vallath N, Ward S, Wells J. Oxford Handbook of Palliative Care. 3rd ed. Oxford University Press; 2019.

Nausea caused by medication and metabolic disturbances will often present with persistent nausea with minimal relief from vomiting.

If there is delayed gastric emptying, there will be minimal nausea until vomiting is imminent. The patient will typically vomit a large volume, which will temporarily relieve nausea.

Additional symptoms should be considered. If a patient has headache, altered consciousness, and worse symptoms on movement, consider raised intracranial pressure.

Management of Nausea and Vomiting

Reversible causes should be treated, e.g., metabolic disturbance, pain, raised intracranial pressure, tense ascites, constipation and anxiety. Current medication use should be reviewed and adjusted accordingly.

Non-Pharmacological:

Being in a calm environment, away from the sight and smell of food can help. Offer the person regular small portions of food with little odour, instead of large meals.

Relaxation techniques and acupressure bands are helpful for some patients.

Pharmacological:

The choice of antiemetic should be based on the cause of nausea and vomiting, as shown in Table 3. Consider the most appropriate route of administration – patients may struggle to take tablets orally due to nausea, or absorption may be inadequate due to vomiting. Administering parenterally will reduce tablet burden, and giving via continuous subcutaneous infusion (CSCI), i.e., a syringe driver will ensure constant delivery of antiemetic.

Source: Watson M, Campbell R, Vallath N, Ward S, Wells J. Oxford Handbook of Palliative Care. 3rd ed. Oxford University Press; 2019.