Haloperidol for the treatment of nausea and vomiting in palliative care patients.

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BackgroundCholestatic itch is caused by intrahepatic liver diseases, such as primary biliary cirrhosis and extrahepatic obstruction of the biliary tree, often caused by tumours. The pathophysiology of cholestatic itch is complex and no single treatment has proved definitive. Naltrexone is an opioid receptor antagonist, which reduces central opioidergic tone, believed to be raised in patients with cholestatic pruritus.AimTo review and assess the efficacy of oral naltrexone for the treatment of cholestatic itch.MethodsSearch of electronic databases, grey literature, clinical trials registries and handsearching for studies including naltrexone for cholestatic itch. Full papers were obtained if relevant and studies graded.ResultsThirteen papers were included in the analysis, including three randomised controlled trials, one controlled clinical trial, one open-label pilot study, seven case reports and one retrospective notes review. All studies found naltrexone to be effective in relieving pruritus. In all five studies performing statistical analysis, naltrexone significantly reduced pruritus compared with baseline. 37% of patients reported side effects, notably opioid withdrawal-type reactions and recurrence of previous pain, from all pathologies.ConclusionsOral naltrexone therapy helps relieve cholestatic itch and although it should be used with caution in patients using exogenous opioids for analgesia, it should be considered when treating refractory pruritus in patients with end-stage liver disease.

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We report the case of a recently bereaved elderly lady admitted on the acute surgical take who gave consent for emergency surgery in the hope of dying intraoperatively. To her dismay she survived and, thereafter, refused all food and medical intervention leading to her death 15 days later. This case highlights concerns regarding both the process of consent following emergency admission and failure to identify a vulnerable patient's wishes.