CLINICIAN’S CORNER PERSPECTIVES ON CARE AT THE CLOSE OF LIFE Management of Intractable Nausea and Vomiting in Patients at the End of Life

Mr Q is a 50-year-old electronics designer with metastatic esophageal cancer treated with third-line palliative chemotherapy. Recently, he has spent more than half of his time in bed due to a general lack of energy, although he walks without assistance or dyspnea. He was admitted to a university hospital in May 2006 for intractable nausea and vomiting. His medical history was remarkable for migraine headaches, depression, and ulcerative colitis during childhood. He was diagnosed with esophageal cancer by endoscopic biopsy in October 2005. Thoracic computed tomography (CT) scans at the time showed circumferential thickening of the distal esophagus and an enlarged gastrohepatic lymph node. In December 2005, he began presurgical chemotherapy with docetaxel and capecitabine. In February 2006, he underwent an exploratory laparotomy but the tumor was found to be unresectable. A 20 20-mm stent was inserted in the gastroesophageal junction for impending obstruction and a jejunostomy feeding tube (J-tube) was placed. In March 2006, CT scans showed evidence of liver metastases. Mr Q had experienced intermittent nausea and vomiting throughout his course of chemotherapy and reported a painful burning sensation in the chest and epigastrium since the esophageal stenting. Ten days before admission he had begun palliative chemotherapy with capecitabine. Afterwards, his nausea and vomiting worsened considerably, with vomiting episodes occurring up to 10 times a day, consisting of both dry heaves and emesis of bilious fluid. There was no apparent temporal relation of these symptoms to oral in-