15.1 Palliative Symptom Management, Constipation (NCG No. 10) & Syringe Drivers

Palliative Symptom Management, Constipation (NCG No. 10) & Syringe Drivers

RCSI lists Death and dying as a topic heading, with current OSCE examples of palliative care, end-of-life care and after the patient dies. Its reading list names the Irish Hospice Foundation compassionate end-of-life toolkit and Think Ahead planning pack, Marie Curie resources on syringe drivers and mouth care, the AIIHPC Palliative Hub, the HSE booklet When Someone You Care About is Dying in Hospital, the Irish Hospice Foundation end-of-life symbol, and NCEC National Clinical Guideline No. 10 on the management of constipation in patients receiving palliative care, specifically pages 29 to 48.

---

What Palliative Care Is

Palliative care is an approach that improves the quality of life of people and families facing a life-limiting illness, through early identification, assessment and treatment of pain and other physical, psychosocial and spiritual problems.

Three misconceptions worth dismantling, because they cause real harm:

1. Palliative care is not only for the last days of life. It is appropriate from the point of diagnosis and can be delivered alongside active, life-prolonging treatment.
2. Palliative care is not only for cancer. Advanced heart failure, COPD, end-stage renal and liver disease, advanced dementia and neurodegenerative conditions all warrant it.
3. Palliative care does not mean stopping care. It is a change in the goals of care, not a withdrawal of it. The words "there's nothing more we can do" are almost never true and should not be said.

Levels of provision in Ireland run from a palliative care approach delivered by all healthcare staff, through general palliative care by staff with additional training, to specialist palliative care delivered by multidisciplinary specialist teams in hospices, hospital support teams and the community.

---

Symptom Assessment

Assess systematically and repeatedly, because symptoms change quickly. Cover pain, breathlessness, nausea and vomiting, constipation, fatigue, anorexia, mouth problems, anxiety and low mood, insomnia, and existential or spiritual distress.

• Use the patient's own words and a validated scale where they can self-report.
• Where the person cannot report - advanced dementia, reduced consciousness - use behavioural indicators: facial expression, guarding, restlessness, moaning on movement, changes in breathing, resistance to care.
• Ask about what matters to the person, not only what hurts. Being able to get to a family event, or to be at home, may matter more than a lower pain score.

Pain

• Assess before treating: site, character, radiation, severity, what makes it better or worse, and its effect on sleep and function. RCSI lists the OPQRST mnemonic for pain assessment.
• Total pain is the key palliative concept: physical pain is amplified by psychological, social and spiritual distress, and treating only the physical component often fails.
• Regular analgesia plus breakthrough doses. Pain that returns predictably needs regular dosing, not as-required dosing alone.
• Breakthrough (rescue) dose of an opioid is commonly calculated as roughly one sixth of the total 24-hour dose, prescribed as required.
• Neuropathic pain - burning, shooting, with altered sensation - responds poorly to opioids alone and needs adjuvants such as gabapentinoids, tricyclic antidepressants or, in some cases, corticosteroids.
• Anticipate and pre-empt side effects: constipation always, nausea commonly and transiently, and drowsiness which usually settles.

Breathlessness

Non-pharmacological measures come first and are genuinely effective: positioning upright or leaning forward, a hand-held fan directed at the face (stimulating the trigeminal nerve reduces the sensation of breathlessness), a cool room and open window, pacing activity, breathing techniques, relaxation, and calm reassurance because anxiety and breathlessness amplify each other. Pharmacological management may include low-dose opioids, benzodiazepines for the anxiety component, and oxygen only where the person is hypoxaemic - oxygen given to a non-hypoxaemic breathless person is no better than a fan and adds a mask between them and their family.

Nausea and Vomiting

Identify the mechanism and match the antiemetic to it: chemical or drug-induced, gastric stasis, bowel obstruction, raised intracranial pressure, vestibular, or anxiety-related. Add non-drug measures: small portions, avoiding cooking smells, mouth care, a calm environment, and treating constipation.

Mouth Care

Marie Curie mouth care and RCN guidance on mouth care during end-of-life care both appear on RCSI's reading list, and this is care that is frequently neglected precisely when it matters most. A dry, coated, sore mouth causes distress, impairs communication and taste, and increases infection risk. Provide frequent, gentle oral care - soft brush, non-foaming products, water or a prescribed mouthwash, lip balm, treatment of oral candidiasis - and teach the family to do it if they wish to help. It is one of the few things relatives can do that makes an immediate, visible difference.

---

Constipation in Palliative Care: NCEC National Clinical Guideline No. 10

NCEC National Clinical Guideline No. 10 addresses the management of constipation in adult patients receiving palliative care. RCSI directs candidates to pages 29 to 48.

Constipation is near-universal in this population, and it is not a minor discomfort: it causes pain, nausea, vomiting, anorexia, urinary retention, agitation, delirium and, at its extreme, obstruction.

Why it is so common here:

Management principles:

• Anticipate and prevent. Anyone starting a regular opioid needs a stimulant laxative, usually with a softener, prescribed at the same time. Bulk-forming laxatives are inappropriate in this group - they add bulk to a slowed bowel and risk impaction.
• Assess the usual pattern, the current pattern, the Bristol type, abdominal and rectal findings where appropriate, and the impact on the person.
• Address the reversible: fluids as tolerated, dignity and privacy, position on a toilet or commode with feet supported, and timing after meals to use the gastrocolic reflex.
• Titrate laxatives to effect rather than leaving a fixed dose that is not working, and review daily.
• Use rectal measures where oral treatment is insufficient or impaction is present, with consent and attention to dignity.
• Escalate for red flags - absolute constipation with vomiting and distension, suspected obstruction, suspected spinal cord compression, or a rectal mass.
• Document on a bowel chart using the Bristol type.

Balance matters here: over-treating constipation in a dying person can cause distressing diarrhoea and undignified soiling, so the goal is comfort, not a bowel motion of a particular frequency.

---

Syringe Drivers: Continuous Subcutaneous Infusion

A syringe driver (syringe pump) delivers a continuous subcutaneous infusion of medication, usually over 24 hours. In Ireland the McKinley T34 and similar ambulatory pumps are widely used.

When It Is Used

A syringe driver is indicated when the oral route is unreliable or unavailable: persistent nausea and vomiting, dysphagia, bowel obstruction, profound weakness, reduced consciousness, or malabsorption.

The conversation you will have to have. Families frequently believe a syringe driver means death is imminent or that it is being used to hasten death. Both beliefs are wrong and both cause distress and sometimes refusal. Explain that it is simply a way of giving the same medicines by a different route when swallowing is difficult, that it gives steady symptom control without repeated injections, that it does not hasten death, and that it can be stopped if the person improves and can take medicines by mouth again. Say it plainly and let them ask questions.

Nursing Responsibilities

Setting up:

• Check the prescription: drug, dose, diluent, volume, duration, compatibility of the combination, and the patient's allergies.
• Two-nurse check where local policy requires it; controlled drugs are checked and recorded per the Misuse of Drugs Regulations and local CD policy.
• Prepare using aseptic technique and the correct diluent.
• Choose a site with good subcutaneous tissue and avoid oedematous, broken, infected, irradiated or bony areas - typical sites are the anterior chest wall, upper arm, abdomen and anterior thigh.
• Secure with a transparent dressing so the site stays visible, label the line, and ensure the pump is secured and the line is not kinked or under tension.
• Record the start time, the volume, the rate and the expected finish time.

Monitoring - at least once per shift, and the list is examinable:

Breakthrough doses are given subcutaneously as prescribed and each one recorded; a pattern of repeated breakthrough doses means the 24-hour dose needs review, not more rescue doses.

Documentation covers the drugs and doses, the site and site changes, the observations each shift, the breakthrough doses given, the effect, and the family's understanding.

---

Anticipatory Prescribing

Anticipatory or "just-in-case" medicines are prescribed in advance, before they are needed, so that distressing symptoms can be treated without waiting for a prescription - particularly at night, at weekends or at home.

A typical anticipatory set covers five symptoms:

In the community these are supplied in a just-in-case box kept in the home, with the public health nurse, GP and out-of-hours service aware. The nursing role is to ensure they are prescribed before they are needed, that they are available and in date, that the family understands what they are for, and that every dose given is documented with its effect. Anticipatory prescribing is a hallmark of good planning - having to send someone to an emergency department at 3 a.m. for a symptom that could have been treated at home is a failure of foresight, not of the patient.