Always 📘 check the BNF for exact dosing before prescribing.
💡 Remember: titrate to symptoms, use the lowest effective dose, and anticipate common side effects.
⚠️ Always consider renal/hepatic function, frailty, and co-morbidities when prescribing.

🤢 Nausea and Vomiting

Very common in advanced disease (uraemia, opioids, constipation, raised ICP, drugs).
Opioid-induced nausea usually improves after 4–5 days.
Non-drug measures: meticulous mouth care, removal of triggers (smells, fatty foods), relaxation, distraction, massage.
Evidence supports acupuncture and ginger in chemotherapy-induced nausea.

Drug	Starting Dose	Frequency	Route
Haloperidol	0.5–1 mg	8-hourly PRN / regular	SC / IV / PO
Levomepromazine	2.5–5 mg	12-hourly	SC
Cyclizine (↑ ICP)	50 mg	8-hourly	SC / IV / PO
Metoclopramide (prokinetic)	10 mg	8-hourly	SC / PO / IV
Domperidone (elderly)	10 mg	8-hourly	PO

🧠 Raised Intracranial Pressure (ICP)

🎯 Dexamethasone 8 mg OD (BD if severe), taper after 5 days according to response.
💬 Discuss radiotherapy with oncology if appropriate.
⚠️ Co-prescribe gastroprotection if on NSAIDs (steroids + NSAIDs ↑ GI bleed risk 4-fold).
⚡ First seizure → start anticonvulsant (Levetiracetam 250 mg OD recommended); seek neurology input.

😮‍💨 Breathlessness

At advanced stages, diagnosis (PE, pneumonia) often not pursued → focus on symptom control.
Always discuss with patient and family.
Causes: pulmonary oedema, effusion, anxiety, acidosis, tumour obstruction, lung disease.
Therapies:
- ⛅ Fan blowing air across face; O₂ if hypoxic.
- 💉 Thoracentesis for large pleural effusion (short-lived benefit, weigh risks).
- 💊 Opiates are mainstay when other options not feasible.
- 😟 Treat anxiety with Diazepam or Midazolam.
- 🫁 Bronchodilators for wheeze; Prednisolone 60 mg OD for SVC/tumour obstruction.
- 🩸 Consider anticoagulation if PE suspected and in patient’s best interest.

⚰️ Terminal Breathlessness (Opioid Naïve)

Doses tend to be lower than for pain; titrate to effect.

Drug	Starting Dose	Frequency	Route
Morphine (Oramorph)	2 mg	4-hourly PRN	PO
Morphine (MR)	5 mg	12-hourly	PO
Diazepam	2–5 mg	At night	PO
Midazolam	2–5 mg	6-hourly	SC
Morphine	1–2 mg	4-hourly	SC
Morphine	10 mg	Over 24 hrs	SC syringe driver
Diamorphine	1.25–2.5 mg	4-hourly	SC
Diamorphine	5 mg	Over 24 hrs	SC syringe driver
Buprenorphine	Standard dose	-	SC (renal failure safe)
Alfentanil	0.5–1 mg	Over 24 hrs	SC syringe driver (stage 4/5 renal failure)

💊 Analgesia: Mild–Moderate Pain

Drug	Starting Dose	Frequency	Route
Paracetamol	500 mg – 1 g	6-hourly PRN	PO
Codeine	30–60 mg	6-hourly	PO
Ibuprofen	400 mg	8-hourly	PO

💉 Moderate–Severe Pain (Opioid Naïve)

Drug	Starting Dose	Frequency	Route
Morphine (Oramorph)	5 mg	4-hourly PRN	PO
Morphine (MR)	10 mg	12-hourly	PO
Morphine	2–5 mg	4-hourly	SC
Morphine	20 mg	Over 24 hrs	SC syringe driver
Diamorphine	1.25–2.5 mg	4-hourly	SC
Diamorphine	10 mg	Over 24 hrs	SC syringe driver
Alfentanil	0.5–1 mg	Over 24 hrs	SC syringe driver (renal failure)

🫀 Hepatic Distension Syndrome (Capsular Pain)

Follow WHO analgesic ladder; usually responds well to opioids.
If uncontrolled → consider Dexamethasone (specialist advice).

💦 Palliation: Respiratory Secretions (“Death Rattle”)

At this stage, focus on comfort rather than diagnosis (PE/pneumonia not pursued).
Have an open conversation with patient/family about expectations.

Drug	Starting Dose	Frequency	Route
Hyoscine butylbromide (Buscopan)	20 mg	Hourly PRN	SC
Glycopyrronium bromide	200 mcg	4-hourly	SC
Glycopyrronium bromide	0.6–1.2 mg	Over 24 hrs	SC syringe driver

📚 References

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Palliation - Nausea Dyspnoea Secretions Pain

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