Nausea and vomiting in palliative care

Key points

1. Nausea is sometimes, but not always, followed by vomiting. 
2. Nausea and vomiting near the end of life often have more than one cause, including physical and psychological factors.
3. Treatment of nausea and vomiting may include a combination of non-medicine and medicine treatment. 
4. There are several ways you can help relieve your nausea and vomiting. 

What are nausea and vomiting?

Nausea is a queasiness in your stomach that often comes with the urge to vomit (throw up). Nausea is sometimes, but not always, followed by vomiting.

Vomiting is your body's way of getting rid of stomach contents that are harmful or irritating, by forcibly emptying them back out your mouth.

What are the causes of nausea and vomiting?

Nausea and vomiting near the end of life often have more than one cause, including physical and psychological factors. Common causes include:

• medicines such as opioids, antibiotics, anti-cancer drugs, NSAIDs
• metabolic causes such as high blood calcium (hypercalcaemia), high blood urea (uraemia)
• cancer treatments such as chemotherapy and radiotherapy
• constipation
• infection
• brain disorders such as raised intracranial pressure (high pressure in your brain), brain tumours or metastases
• bowel obstruction (your bowel is blocked)
• enlarged liver (hepatomegaly)
• stomach not emptying properly (gastric stasis)
• stomach ulcer
• vestibular disorders (parts of your inner ear and brain that control balance and eye movement are damaged)
• anxiety and fear.

How are nausea and vomiting diagnosed?

Your doctor may ask you some questions to find out the possible causes of your nausea and vomiting. They may also do a physical examination to check for signs of illness or disease and carry out tests, such as blood and urine tests, to rule out physical causes.

How are nausea and vomiting treated?

Treatment of nausea and vomiting may include a combination of non-medicine and medicine treatment. If you have a medical condition or any obvious causes of nausea and vomiting are found, treatment will focus on the condition or cause. 

Non-medicine treatment

Non-medicine treatment that can help relieve or prevent nausea and vomiting include:

• acupuncture – this treatment can be carried out through wearing a wristband
• counselling – talking to a counsellor or psychologist can help reduce anxiety
• music therapy – listening to music can help you to relax and lower your anxiety
• distraction – looking at some videos or photos with great memories can help distract you from feeling sick.

Medicines

There are a variety of medications that can be used to ease nausea and vomiting that work in different ways to one another. The choice of medicine depends on what has caused your nausea and vomiting. These medicines are called anti-sickness medicines or antiemetics. Read more about antiemetics. 

Common antiemetics that may be prescribed include:

• domperidone
• metoclopramide
• haloperidol
• cyclizine
• levomepromazine (methotrimeprazine)
• dexamethasone
• prochlorperazine
• hyoscine (Scopoderm TTS)
• lorazepam
• ondansetron.

These medicines can be taken as a tablet, an injection, a suppository in your bottom or via a syringe driver. Read more about syringe drivers. Sometimes, a combination of these medications is needed to treat nausea and vomiting. 

How can I care for myself with nausea and vomiting?

There are several things you can do to help manage nausea and vomiting. These include the following:

• Sit quietly when you feel nauseous
  • Moving around can make you feel worse.
  • Rest after eating and keep your head raised above your feet.
  • Avoid activity straight after eating.
• Take cool sips of drinks 
  • Drink water or diluted fruit juice.
  • Sip your drink slowly.
    
  • You may find it helps to drink liquids between instead of during meals.
• Eat small meals throughout the day instead of three large meals
  • Eat light, bland foods (such as water crackers or plain bread).
    
  • Avoid fried, greasy or sweet foods.
  • Don't mix hot and cold foods.
  • If the smell of hot or warm foods makes you feel nauseous, eat foods that are cold or at room temperature.
  • Rinse your mouth after eating to make sure your mouth feels fresh.
• Ginger – some people find ginger helps to relieve feelings of nausea, but this finding is not clinically proven.
• Mint or peppermint – try taking mint or drink peppermint tea. 
• Fresh air – avoid smells that make you feel sick. 
• Positioning – try sitting in a comfortable position as lying down can sometimes make you feel sick.
• Relax – listening to music or practising relaxation exercises can reduce anxiety and fear. 

What support is available with nausea and vomiting?

People living with nausea and vomiting can feel distressed and have reduced quality of life. Talk through your feelings with your family/whānau and friends to get the support you need. 

Below are some support services and information for people affected by cancer and their family/whānau:

Emotions and cancer Cancer Society of NZ
How we can help Cancer Society of NZ
NZ cancer services - find a hospital/service near you Healthpoint, NZ
More cancer support groups

Learn more

Nausea and vomiting Mercy Hospice, NZ
Nausea and vomiting in palliative care HealthInfo, NZ
Nausea and vomiting Marie Curie, UK 
Managing the symptoms of cancer Macmillan Cancer Support, UK 

Reviewed by

	Dr Karen Chung is a GP. She works for Counties Medical and the Auckland Regional Public Health Service. She is also a clinical editor at Auckland Regional HealthPathways and has worked on the palliative care pathways.

References

1. Nausea and vomiting in palliative care Auckland HealthPathways, NZ
2. The palliative care handbook Hospice NZ 
3. Nausea and vomiting Marie Curie, UK 
4. Nausea and vomiting Scottish Palliative Care Guidelines, UK