Parveen is talking to Shelley King, who has a prescription for her father who was recently diagnosed with terminal cancer...

“Dad took a turn for the worse at the weekend and we’re hoping he’ll be able to move into the hospice soon. The doctor visited today and asked me to get this for him,” says Shelley. The prescription is for chlorpromazine. “I looked it up online and saw that it is used for people with psychosis. Has the doctor made a mistake? I tried to phone the surgery before I came out but you know what it’s like trying to get through...”

Answer

It is doubtful that the chlorpromazine is being used for its antipsychotic properties, given that Shelley’s father has no relevant history. It is more likely that it has been prescribed to relieve severe anxiety, which isn’t unusual as an individual approaches the end of life, or even more probably, hiccups.

Hiccups are not uncommon in terminal disease, with possible causes including gastric distension, a tumour in the brain or pressing on the phrenic nerve or diaphragm, kidney dysfunction due to altered electrolyte levels, or as a sideeffect of medication such as chemotherapy, corticosteroids or opioid analgesia.

Hiccups may be unrelenting and distressing for the sufferer and the usual approaches are generally considered inappropriate. Instead, preparations that combine an antacid with an antiflatulent may help, particularly if the cause is gastric distension, otherwise metoclopramide – which can be administered orally or by subcutaneous or intramuscular injection – may help. Baclofen, nifedipine or chlorpromazine are usually employed if other measures have failed, with chlorpromazine having the added bonus of alleviating anxiety.

The bigger picture

Hiccups are caused by either or both sides of the diaphragm involuntarily and suddenly contracting while the glottis is closed.

There are many causes, ranging from eating and drinking too much or too quickly, to stress, sudden changes in air temperature and overstretching the neck. Hiccups is listed as a side-effect of several drugs and may also result from drinking alcohol.

While hiccups usually go away on their own, various methods may be used to speed the process. These include drinking water (sometimes from the wrong side of the glass), breathing in and out of a paper bag or taking a deep breath and holding it for as long as possible. In some cases, hiccups may last more than a day (when they are termed “persistent”) or even longer (“intractable”). If they do last a long time other problems, such as weight loss, nausea, depression and insomnia, may result.

Extend your learning

Palliative care is often thought of as being concerned with pain relief, but many other symptoms may arise in this patient group. Read the section in the BNF ‘Prescribing in palliative care’ to refresh your knowledge. See also this month’s CPD module, ‘Managing pain in palliative care’.