Clinical Review

Nausea and vomiting in palliative care

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h6249 (Published 03 December 2015) Cite this as: BMJ 2015;351:h6249
  1. Emily Collis, consultant in palliative medicine1,
  2. Harriet Mather, specialty trainee in palliative medicine2
  1. 1Camden, Islington ELiPSe and UCLH & HCA Palliative Care Service, Central and North West London NHS Foundation Trust, London, UK
  2. 2Department of Palliative Medicine, Mount Vernon Hospital, Northwood, UK
  1. Correspondence to: E Collis emily.collis{at}nhs.net

What you need to know

  • Nausea and vomiting in advanced disease is often multifactorial. Common causes include gastric stasis, chemical disturbances, intestinal obstruction, and raised intracranial pressure

  • It can cause serious physical complications, including nutritional deficiency, electrolyte disturbance, dehydration, and aspiration pneumonia

  • Knowledge of the emetogenic pathway and antiemetic actions can help select an antiemetic that targets the underlying cause

  • Check renal function, electrolytes, and calcium level when appropriate

  • Give antiemetics orally unless the patient is vomiting or has suspected malabsorption or gastric stasis

  • When symptoms persist, prescribe a regular antiemetic with another antiemetic to be taken as required

  • Consider parenteral fluid replacement after an individual assessment of benefits and risk

What is the likely cause?

It is important to determine the cause of nausea and vomiting to identify potentially reversible causes and to inform antiemetic strategy. In advanced cancer, six broad causes of nausea and vomiting have been identified (table 1). Gastric stasis and chemical disturbance are the most common.1 2 However, the aetiology is often multifactorial, and in many cases a cause cannot be confidently established.1

View this table:
Table 1

 Causes of nausea and vomiting, key clinical features, and investigations (adapted from Stephenson and Davies1)

Sources and selection criteria

We searched Medline and Embase combining the terms “nausea,” “vomiting,” “palliative care,” “anti-emetics,” and “emesis” and conducted a narrative review of relevant articles. We included studies in adults receiving palliative care treated with an antiemetic for nausea or vomiting, or both. We excluded studies of chemotherapy or radiotherapy induced nausea and vomiting and studies of postoperative nausea and vomiting. We prioritised systematic reviews and controlled trials. We also used professional guidelines to develop our recommendations. The evidence comes largely from studies in patients with advanced cancer.

Specific management of chemotherapy and radiotherapy induced nausea and vomiting is outside the scope of this article and has been recently covered in a comprehensive review. …

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