CLINICAL
KNOWLEDGE
The management of hiccups
in terminally ill patients
Departmant of Health (2002) PRODIGY
Guidance – Hiccups. Available at: www.
prodigy.nhs.uk/guidance.asp?gt=Hiccups
De Ruysscher, D. et al (1996) Treatment
of intractable hiccup in a terminal cancer
patient with nebulized saline. Palliative
Medicine; 10: 2, 166–167.
Hardy, J. (2003) The treatment of hiccups
in terminal patients. European Journal
Of Palliative Care; 10: 5, 192–193.
Kaye, P. (2003) A-Z Pocketbook of
Symptom Control (2nd edn). Northampton: EPL Publications.
Lewis, J.H. (1985) Hiccups: causes and
cures. Journal of Clinical Gastroenterology; 7: 6, 539–552.
This article has been double-blind
peer-reviewed.
For related articles on this subject
and links to relevant websites see
www.nursingtimes.net
According to Wilcock and Twycross (1996) hiccups
are ‘caused by a sudden involuntary contraction of
one or both sides of the diaphragm associated
with closure of the glottis’. Persistent hiccups are
those that last more than 48 hours, whereas intractable hiccups are those that last more than one
month (Lewis, 1985).
Common causes of hiccups in terminal disease
include gastric distension, gastro-oesophageal reflux, diaphragmatic irritation, phrenic nerve irritation, toxicity and central nervous system tumour
(Twycross and Wilcock, 2001).
Intractable hiccups are occasionally seen in patients with a terminal disease, and can be a distressing symptom for some. It is important to elicit
from the patient how a symptom affects them as
an individual, in order to be able to plan care that
effectively improves their quality of life.
Nursing management
A review of the literature shows that the effective
management of hiccups depends on the patient
and how they respond to a particular pharmacological approach.
Learning objectives
Each week Nursing Times publishes a guided learning article with reflection
points to help you with your CPD. After reading the article you should be able to:
32
l
Explain the physiological causes of hiccups;
l
Understand the effect of hiccups on a patient’s quality of life;
l
Know the pharmacological interventions for hiccups;
l
Describe the non-pharmacological interventions for hiccups.
Box 1. case study
A 55-year-old man with metastatic cancer
of the colon with subacute bowel
obstruction was admitted to a hospice. He
was distressed by his inability to drink as
this caused heartburn and more hiccups. He
was not sleeping well due to abdominal
distension and felt low in mood.
Metoclopramide did not alleviate the
hiccups. Haloperidol resolved the hiccups for
approximately two days, and when they did
return they were less severe. Haloperidol
was added to his syringe driver and the
hiccups were resolved. He was able to drink
more and his mood lifted.
The case study in Box 1 describes a patient who
had hiccups caused by gastric distension, the most
common cause of hiccups in terminal illness (Wilcock and Twycross, 1996). Metoclopramide did not
relieve the condition. However, other case reports
have found metoclopramide to be effective (Slipman et al, 2001).
Wilcock and Twycross (1996) discuss the case
of two terminally ill patients suffering with
hiccups where chlorpromazine, metoclopramide,
dexamethasone, haloperidol and baclofen were
used, all of which had been ineffective. Midazolam
was given to relieve the patient’s distress and the
hiccups stopped.
In a study by Ramirez and Graham (1992) baclofen was evaluated in a double-blind randomised
controlled trial and found to successfully terminate
intractable hiccups. In this study, four men with
intractable hiccups received baclofen and their hiccup-free periods increased by 69 per cent.
The use of pharmacological approaches has been
questioned because of the potential for adverse
reactions in patients who are terminally ill. De
­Ruysscher et al (1996) found that for one patient
domperidone, chlorpromazine, haloperidol and
nifedipine had been ineffective. However, the regular use of nebulised saline during the day and as
required overnight was found to be effective.
Metoclopramide and baclofen aim to relieve
gastric distension by improving gastric emptying
and relaxing the diaphragm. They are also important to assess the patient’s bowel functioning
and to treat constipation, if indicated, as this may
NT 2 August 2005 Vol 101 No 31 www.nursingtimes.net
SPL
References
Author Rachel Ann Phillips, BA in palliative
care, is clinical nurse specialist, palliative care
team, Wycombe General Hospital.
Abstract There is a reasonable amount of literature on the subject of hiccups. However, the
evidence shows that existing practice relies heavily on anecdotal case reports and clinical experience. Hiccups affect talking, eating and sleeping,
and can lead to weight loss, exhaustion, anxiety
and depression, all factors affecting quality of life.
keywords n Hiccups n Terminal disease n Quality of life
be contributing to the gastric distension. If the
hiccups are not resolved by this, haloperidol and
chlorpromazine could be used with the aim of suppressing the hiccup reflex.
Non-pharmacological approaches (Box 2) are
worth consideration but may not be appropriate
for patients in the terminal stage of their disease.
Alternative therapies such as acupuncture and
hypnotherapy have been reported as effective
treatments (Department of Health, 2002).
Box 2. Non-pharmacological
approaches to hiccups
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Impact on quality of life
An understanding of the palliative care needs of
patients is based on the central concept of quality
of life.
A broad understanding of a patient’s quality of
life is achievable by asking them how they view
their life. A more focused understanding can be
obtained by asking how they view their symptoms
and functioning.
Quality of life is subjective not only between individuals, but also for individual patients as they
travel through their illness trajectory. This is a concept known as the response shift, where patients
are able to change their perception of their quality
of life accordingly as their illness progresses (Rees
et al, 2004).
In palliative care, tools that can be used to
measure a patient’s quality of life include the
Quality-of-Life Index and the Hospice Quality-ofLife Index (McMillan, 1996). Such tools can be
used to measure outcomes in health care but could
be further developed to accurately measure quality of life in respect of the response shift (Rees et
al, 2004).
Quality of life is multifaceted and can challenge
an individual’s view of the world. In illness, the
patient may be challenged by the symptoms they
experience and question their psychosocial, spiritual and physical sense of self and the meaning this
places on relationships with those close to them.
These challenges may influence a patient’s decision-making with regard to treatment options as
the side-effects of therapies may affect their quality of life (Mystakidou et al, 2002).
Hiccups can often cause severe distress and
they can consequently affect the quality of life
for some terminally ill patients. Indeed, persistent
hiccups can effect the way patients talk, sleep, eat
and drink, and in some can lead to weight loss,
exhaustion, anxiety and depression (Wilcock and
Twycross, 1996).
For example, the patient discussed in the case
study (Box 1) was low in mood and despondent
because of his persistent hiccups.
The levels of anxiety and emotional distress
suffered by a patient may contribute to hiccups. In
palliative care, understanding the patient’s per-
NT 2 August 2005 Vol 101 No 31 www.nursingtimes.net
ingest two glasses of liqueur
References
McMillan, S.C. (1996) Quality-of-life
assessment in palliative care. Available
at: www.moffitt.usf.edu/pubs/ccj/
v3n3/article4.html
Mystakidou, K. et al (2002) Quality of
life in terminally ill cancer patients.
European Journal Of Palliative Care;
9: 6, 252–255.
from the ‘wrong’ side of a cup
Source: Twycross and Wilcock, 2001
ception of the impact of the symptom on his/her
quality of life is essential in order to alleviate distress and promote comfort.
Conclusion
Self-awareness of communication skills is vital in
order to achieve effective symptom management
for patients. The NICE guidance Improving Supportive and Palliative Care for Adults with Cancer
(NICE, 2004) highlights the importance of professionals being able to communicate with patients.
Skills that encourage the patient to explore the impact the symptom has had on their quality of life
from a physical, psychosocial and spiritual perspective is fundamental in palliative care.
Reflective practice may help professionals to
question and challenge assumptions about quality
of life and what may be considered to be ‘normal’.
Implementing a tool into clinical practice to measure quality of life for patients may improve the
outcome of patients’ care.
The effective management of symptoms (hiccups being an example) is dependent not only on
a number of clinical approaches but also on the
support offered by the multidisciplinary team. Listening to the patient’s feelings and fears may help
them to put the symptom into context and help
them to view their quality of life with new hope
and meaning. n
NICE (2004) Improving Supportive and
Palliative Care for Adults with Cancer.
London: NICE.
Ramirez, F.C., Graham, D.Y. (1992)
Treatment of intractable hiccup with
baclofen: results of a double-blind
randomised, controlled, cross-over study.
American Journal of Gastroenterology;
87: 12, 1789–1791.
Rees, J. et al (2004) Measuring quality
of life in patients with advanced cancer.
European Journal Of Palliative Care; 11:
3, 104–107.
Slipman, C.W. et al. (2001) Persistent
Hiccup Associated with Thoracic
Epidural Injection. American Journal of
Physical Medicine & Rehabilitation; 80;
8: 618-621.
Twycross, R., Wilcock, A. (2001)
Symptom Management In Advanced
Cancer. (3rd Ed.) Oxford: Radcliffe
Medical Press.
Wilcock, A., Twycross, R. (1996)
Midazolam for intractable hiccup.
Journal of Pain and Symptom
Management; 12: 1, 59-61.
Guided reflection
Use the following points to write a reflection for your PREP portfolio:
l
Write about why the subject of hiccups is relevant to your area of practice;
l
Outline the main points the article makes;
l
Identify a fresh piece of information you have learnt about hiccups;
l
Consider how you could use this information in your future practice;
l
Explain how you will follow up what you have learnt.
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