Sometimes anorexia can be alleviated without resorting to medications. Provide small, frequent snacks or dietary supplements, such as Ensure, Sustacal, or Carnation Instant Breakfast made with milk. Offer persons their favorite foods, even if at odd hours. Spice up the taste of foods with seasonings, and use plastic utensils to avoid a metallic taste.

Encourage them to sit up in bed to eat, or at least elevate the bed. If medications make them nauseous, wait awhile after medicating before giving them food. Try to eliminate any strong smells, which can often cause nausea and loss of appetite. Yet, remember not to force food on the person.

Anxiety

Hospice patients understandably have many worries and anxieties--about their condition and its pain, about how their family will go on after them, and about their death.

It is important to encourage patients to verbalize their fears and worries. Reassurance should be given that the hospice team will do everything possible to keep them physically comfortable.

If significant anxiety persists, treatment including relaxation therapy and anxiolytic medication is indicated.

Bedsores

Immobile patients are liable to bedsores, but this problem can be prevented by careful attention to the following measures.

•  Keep the patient's skin clean and dry and the bedclothes dry and wrinkle-free.
• Change the patient's position frequently to promote circulation.
• Apply lotion to the skin over bony prominences, such as the elbows, and massage gently.
• Use sheepskin or an eggcrate mattress to relieve pressure on the skin.
• If the patient is not allergic to it, use fabric softener when washing the clothes.
• Finally, if a sore does occur, clean it with soap and water.

Constipation

Constipation is a common concern for even the healthy older adult. It also affects people with cancer, patients on narcotics, and those who are inactive. Thus, it is not surprising that constipation is a common problem for the hospice patient. It makes people uncomfortable, anoretic, weak, and can even cause a change in mental status.

Constipation has many causes--poor appetite, a diet low in roughage, inactivity, dehydration due to fever and vomiting, and such medications as narcotics,tricyclic antidepressants, and phenothiazines.

The treatment should be tailored to the cause.

• Try using what has worked in the past for the person and avoiding those foods that have caused problems before.
• Increase the person's fluid intake, particularly of prune juice or warm liquids.
• Stool softeners, such as Colace; laxatives, such as Milk of Magnesia; and fiber additives, such as Metamucil, can be very helpful. Suppositories may be necessary.

Delirium and Mental Status

ChangeDelirium and mental status changes can occur with electrolyte imbalances, brain metastasis, cerebrovascular disease,and infection, especially those of the chest or urinary tract.

In addition, they can be drug-induced or be psychogenic in origin, stemming from severe anxiety or depression.

Although in the non- terminally ill older adult, these changes are a warning sign of serious illness and so must be carefully diagnosed and treated, the same approach is not necessarily indicated in the terminally ill. Mental status changes can be a prelude to death and therefore are sometimes an inevitable event in the course of terminal illness.

However, several simple environmental measures can be taken to reduce the hospice patient's confusion.

• Make sure there is adequate fluid intake.
• Keep a clock and calendar in the room to orient the person to time. A radio or television is also a helpful source of stimulation.
• And be sure to supervise closely the delirious person's activities to ensure his or her safety.

Depression

Diagnosing depression in the terminally ill patient can often be a difficult task. Many symptoms that are often associated with terminal illness are also common in depression, including insomnia, anorexia, somatic concerns, and inactivity.

Furthermore, grief resembles depression. Even suicidal thoughts are natural in a person who is facing terminal illness and the end of life.

• It is important to allow terminally ill persons to verbalize feelings about the end of life.
• Life review is helpful, as is helping them feel good about their achievements and what they are leaving behind.
• At the same time, if there is persistent and excessive depressed feelings, then psychotherapy or antidepressant medication can be helpful.

• Alleviate this condition by offering sips of juice, cracked ice, popsicles, or hard candy to suck on as frequently as is needed.
• Encourage the patient to eat moist foods, such as soups, casseroles, and custards.
• Have the patient brush the teeth and gargle after meals and before sleeping.
• Keep the patient's lips moist with petroleum jelly or Chapstick, and use a vaporizer.

• Instruct the patient not to lie flat after meals or to wear constricting garments.
• Encourage the frequent eating of small snacks.
• Give the patient liquid antacids, 1 oz., one hour before meals and at bedtime. Chilling the antacid will make it more palatable.

• Provide a relaxed atmosphere at mealtimes.
• To stop hiccups, give the patient two teaspoons of sugar and instruct him or her to re-breathe into a paper bag.
• Belching can be reduced by encouraging the patient to keep the mouth closed when chewing or swallowing and to lie with the head elevated after eating.
• Do not give the patient gas-forming foods, such as beans, broccoli, cabbage, or milk products.
• Offer liquids between meals, and not with food.
• Finally, use antacids, such as Maalox Plus or Mylanta II.

In contrast, if the person is not drinking enough to prevent dehydration, offer jello, popsicles made from any beverage, ice cream, or sherbet. Providing salty fluids, such as broth and canned soups, may increase the person's desire to drink.

Insomnia

Insomnia can have many causes: the underlying illness, depression, anxiety, boredom, loneliness, fear of nighttime incontinence, "night sweats," nightmares, or fears of dying. It can lead to lowered pain thresholds, caregiver burnout and the breakdown of home care. One goal of hospice care is to provide every patient a good night's sleep.

• Nonpharmacologic treatment that addresses the cause of the insomnia should be tried first.
• If the person is sleeping during the day but is awake at night, provide more stimulation during the day; a radio or television can be helpful for this purpose.
• Avoid waking the person at night to take medications.
• Try offering an alcoholic drink, such as wine or brandy, to encourage sleeping.
• If these measures are ineffective, then treatment with anxiolytics, hypnotics, antidepressants, and opiates alone or in combination should be used.

• Avoid the use of powder or the application of heat, which often exacerbates the itching.
• Bathe the patient in warm not hot water, and use bath oil in the tub or basin.
• Use mild soap, preferably one that incorporates cold cream.
• Rinse the skin well, blot it dry, and apply a lanolin-based lotion, such as Lubriderm.
• Massage the skin with this lotion as many times a day as needed.
• Cold compresses are sometimes a source of relief.

• Encourage as much activity as possible, broken up by frequent rest periods;
• provide assistance as needed with activities.
• Provide daily multivitamin and high-calorie snacks, such as ice cream.
• Instruct in energy-saving techniques, such as wash in the morning, rest, eat lunch, rest, do an activity, etc.

The discomfort of incontinence can be reduced by decreasing fluid intake before going to bed, using disposable pads on the bed, and wearing disposable security pads.

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Conditions That Are Often Left Untreated

In hospice every attempt is made to treat conditions that will improve the quality of life, but other conditions are often left untreated. For instance, the anemic patient might be transfused if he or she has the energy to stand up and go outside. Yet, if the patient is bedbound and not symptomatic, it would not be necessary to check for anemia, much less give a transfusion.

In another example, only the patient with pneumonia who is coughing and uncomfortable would be treated.

Electrolyte imbalances and some infections are sometimes not treated, and IV antibiotics are almost never used.

An effort is made to perform as few laboratory tests as possible, especially those that are exhausting or uncomfortable to the patient.

Stages of Dying

Dying patients often go through a series of emotional and physical stages in the months prior to their death.

One to three months before dying they

• become less interested in communicating verbally and develop an increased appreciation of being touched and left in silence.

• They spend increasing amounts of time sleeping and resting, often taking a nap in the morning as well as the afternoon.

• Their appetite gradually lessens and changes, with a preference for liquid and soft foods over solids. Their taste for meats goes first, then for vegetables, and finally for other soft solid food. (Baxley Media Group, Urbana Ill., The Heart of the New Age Hospice, 1987.)

One to two weeks prior to death they

• sometimes become disoriented and spend even more time sleeping.

• Their activities when awake often seems aimless, e.g., they pick at their clothes.

• Their blood pressure drops and they may have changes in pulse, temperature, skin color and respiration.

• Perspiration and congestion may increase.

One to two days before death,

• many dying patients have a resurgence of energy and may again become fully oriented and desire to socialize with their families.

• They make requests for food and have a return of appetite.

• Others become increasingly restless and non-responsive and may have their eyes open with a vacant glazed stare.