Palliative Care Revision Article ✅

🌿 Palliative care is active, holistic care for people with life-limiting illness. It is not “giving up” and it is not only the final hours of life. Good palliative care manages pain, breathlessness, nausea, agitation, secretions, family distress, communication, advance care planning and dignity. For exams and ward work, always ask: is this symptom reversible?, what is the likely mechanism?, what matters to the patient?, what route is available?, and does this person need anticipatory medicines?

✅ 1. Core Principles of Palliative Care

🌿 1.1 What Palliative Care Does

• Improves quality of life for people with life-limiting illness and those important to them.
• Can be delivered alongside active disease-modifying treatment such as chemotherapy, dialysis, heart failure therapy or NIV.
• Addresses physical, psychological, social and spiritual distress.
• Supports complex decisions about treatment escalation, preferred place of care and end-of-life planning.
• Helps patients live as well as possible, not just die comfortably.

🧭 1.2 Palliative vs End-of-Life vs Terminal Care

👥 1.3 Who Needs Palliative Care?

• Advanced cancer.
• End-stage heart failure, COPD, pulmonary fibrosis or pulmonary hypertension.
• Advanced dementia, Parkinson’s disease, MND or other neurodegenerative disease.
• End-stage renal or liver disease.
• Frailty with repeated admissions, weight loss, falls or functional decline.
• Any condition where symptom burden, uncertainty, treatment decisions or family distress are significant.

🧠 Exam pearl: Palliative care and active treatment are not opposites. A patient can receive palliative care while also receiving antibiotics, chemotherapy, radiotherapy, transfusion or NIV if these match their goals.

🧩 2. Holistic Assessment

📋 2.1 Total Pain and Total Suffering

• Physical: pain, breathlessness, nausea, fatigue, weakness, itch, constipation.
• Psychological: fear, anxiety, depression, anger, loss of control.
• Social: family roles, caring responsibilities, money, housing, isolation.
• Spiritual/existential: meaning, guilt, hope, faith, unfinished business.
• Practical: equipment, care package, medication access, transport, preferred place of care.

🗣️ 2.2 Symptom History Structure

• What is the symptom?
• How severe is it now, best and worst?
• What triggers it and what relieves it?
• What is the mechanism?
• What treatment has already been tried?
• What route is available: oral, subcutaneous, transdermal, buccal, rectal?
• What outcome matters most: complete relief, ability to sleep, ability to talk, ability to mobilise?

🧠 2.3 Reversible vs Irreversible Causes

📌 Clinical reasoning: Palliative care does not mean ignoring reversible problems. It means treating reversible problems when treatment is proportionate and aligned with the patient’s goals.

💊 3. Pain Management

NICE CG140 covers safe and effective prescribing of strong opioids for pain relief in adults with advanced and progressive disease. Opioid prescribing should be patient-centred, explained clearly, reviewed regularly and paired with prevention of predictable adverse effects.

🧠 3.1 Pain Mechanisms

🪜 3.2 Analgesic Ladder and Practical Approach

• Use regular background analgesia plus breakthrough doses for intermittent pain.
• Paracetamol may help mild pain and reduce opioid need; review if tablet burden high.
• NSAIDs may help inflammatory or bone pain but need caution in CKD, GI bleed, heart failure and anticoagulation.
• Weak opioids such as codeine may be poorly tolerated and constipating; in advanced disease, low-dose strong opioid may be more appropriate under guidance.
• Strong opioids include morphine, oxycodone, fentanyl, alfentanil and hydromorphone.
• Adjuvants are important for mechanism-specific pain: steroids, bisphosphonates, radiotherapy, neuropathic agents, antispasmodics.

💊 3.3 Starting Strong Opioids

• Explain the reason for opioid use and address fears about addiction, tolerance and end-of-life assumptions.
• Use immediate-release opioid for titration or modified-release plus rescue depending on clinical situation and local guidance.
• Prescribe breakthrough opioid, commonly around 1/6 of total 24-hour opioid dose, adjusted clinically and by local policy.
• Always prescribe laxatives unless contraindicated.
• Consider antiemetic for early nausea.
• Review pain, sedation, respiratory rate, nausea, constipation and confusion.
• Use lower starting doses in frailty, renal impairment, respiratory disease and opioid-naïve patients.

⚠️ 3.4 Opioid Side Effects and Toxicity

🫘 3.5 Opioids and Renal Impairment

• Morphine metabolites accumulate in renal impairment, increasing risk of sedation, myoclonus and toxicity.
• Oxycodone still needs caution and dose adjustment in renal impairment.
• Fentanyl and alfentanil are often preferred in severe renal impairment under specialist/local guidance.
• Always review renal function, hydration and other sedatives if opioid toxicity suspected.

🔥 3.6 Bone Pain

• Common in metastatic cancer, myeloma and pathological fracture.
• Mechanisms include periosteal stretch, microfracture, inflammatory mediators and nerve compression.
• Treatments include opioids, NSAIDs if safe, corticosteroids in selected cases, radiotherapy, bisphosphonates/denosumab and orthopaedic stabilisation if fracture risk.
• New back pain in cancer requires screening for metastatic spinal cord compression.

⚡ 3.7 Neuropathic Pain

• Burning, shooting, electric or pins-and-needles quality suggests neuropathic pain.
• Causes: nerve compression, plexopathy, chemotherapy-induced neuropathy, post-herpetic neuralgia, spinal cord compression.
• Options may include duloxetine, gabapentin/pregabalin, amitriptyline or steroids if compression/inflammation, depending on patient factors.
• Start low and titrate carefully in frail older adults due to sedation/falls risk.

🧠 Exam pearl: If pain is escalating rapidly despite opioids, ask whether the mechanism has changed — fracture, cord compression, obstruction or infection may need specific treatment.

🫁 4. Breathlessness

🔍 4.1 Breathlessness Assessment

• Ask whether breathlessness is at rest, on exertion, episodic or panic-associated.
• Assess oxygen saturation, respiratory rate, work of breathing and ability to speak.
• Look for reversible causes: infection, PE, heart failure, bronchospasm, anaemia, pleural effusion, ascites, anxiety.
• Ask what the breathlessness prevents: walking, washing, talking, sleeping, lying flat.
• Assess fear and panic because breathlessness and anxiety amplify each other.

🧯 4.2 Non-Drug Measures

• Position upright or forward-leaning with arms supported.
• Cool airflow/fan to face can reduce sensation of breathlessness.
• Breathing techniques: pursed-lip breathing, paced breathing.
• Reassurance, calm environment and reducing room crowding.
• Energy conservation and pacing.
• Physiotherapy/occupational therapy input for mobility aids and breathlessness management.

💊 4.3 Drug Measures

• Low-dose opioids can reduce refractory breathlessness even when oxygen saturation is not low.
• Benzodiazepines may help breathlessness-associated panic/anxiety but should be used cautiously due to sedation and falls.
• Oxygen helps hypoxaemia, but is not automatically useful for non-hypoxic breathlessness.
• Treat reversible causes: diuretics for pulmonary oedema, antibiotics for infection, bronchodilators for bronchospasm, drainage for effusion/ascites.

🫧 4.4 Pleural Effusion and Ascites

• Malignant pleural effusion causes breathlessness, reduced breath sounds and dullness to percussion.
• Management may include therapeutic aspiration, indwelling pleural catheter or pleurodesis.
• Ascites can worsen breathlessness by splinting the diaphragm.
• Drainage decisions should consider symptom burden, prognosis, clotting, albumin/renal risk and patient preference.

🌬️ Clinical pearl: Breathlessness is subjective. A patient can be extremely breathless with normal oxygen saturation, especially in advanced lung disease, cancer or anxiety-amplified dyspnoea.

🤢 5. Nausea and Vomiting

🧠 5.1 Mechanism-Based Nausea

🧪 5.2 Assessment

• Frequency, volume and character of vomit.
• Relationship to food, movement, medication or pain.
• Bowels: constipation, obstruction, diarrhoea.
• Hydration and renal function.
• Medication review: opioids, antibiotics, NSAIDs, chemotherapy, iron, digoxin.
• Check calcium, renal function and infection if clinically indicated.

💊 5.3 Antiemetic Principles

• Choose antiemetic based on likely mechanism.
• Review response within 24–48 hours if possible.
• Use regular antiemetic if persistent symptoms rather than only PRN.
• Use subcutaneous route if oral route is unreliable.
• Avoid metoclopramide/prokinetics in complete bowel obstruction.
• Consider broad-spectrum antiemetic approaches when mechanism is mixed or unclear, guided by local palliative formulary.

🚧 5.4 Malignant Bowel Obstruction

• Symptoms: colicky abdominal pain, distension, nausea, vomiting, constipation or overflow diarrhoea.
• Common in ovarian and colorectal cancer, but can occur with other abdominal malignancy.
• Assessment: performance status, prognosis, level of obstruction, single vs multiple levels, surgical fitness and patient goals.
• Management may include antiemetics, antisecretory drugs, analgesia, steroids, NG tube for acute decompression, stent or surgery in selected patients.
• Oral route may fail; syringe driver often required.

🚽 6. Constipation, Bowel Care and Diarrhoea

🚽 6.1 Constipation

• Very common in palliative care, especially with opioids, reduced mobility, dehydration and poor intake.
• Symptoms: reduced frequency, hard stool, straining, abdominal pain, nausea, overflow diarrhoea, delirium.
• Assess bowel chart, abdominal distension, rectal loading and obstruction red flags.
• Prevent constipation when starting opioids.
• Use stimulant and/or osmotic laxatives depending on stool pattern and local guidance.
• Rectal measures may be needed for impaction if appropriate and acceptable.

💩 6.2 Diarrhoea

• Causes: overflow from constipation, infection, antibiotics/C. difficile, chemotherapy, radiotherapy, pancreatic insufficiency, bowel resection, anxiety.
• Always consider overflow diarrhoea in frail or opioid-treated patients.
• Assess dehydration, electrolyte disturbance, sepsis and stool frequency.
• Loperamide may help non-infective diarrhoea but avoid in severe colitis/dysentery until assessed.

🩹 6.3 Bowel Care Near End of Life

• Continue bowel care if opioids continue and bowel symptoms are present.
• Oral laxatives may become impractical if swallowing is poor.
• Rectal interventions should be individualised and avoided if burdensome, contraindicated or not aligned with comfort goals.
• Document last bowel movement and whether constipation could be causing pain, agitation or urinary retention.

🧠 Exam pearl: Overflow diarrhoea is constipation until proven otherwise — especially in opioid-treated, immobile or frail patients.

🧠 7. Delirium, Agitation and Anxiety

🌀 7.1 Delirium in Palliative Care

• Delirium is acute fluctuating disturbance of attention and cognition.
• Common triggers: infection, opioids, steroids, anticholinergics, dehydration, constipation, urinary retention, hypercalcaemia, hypoxia.
• Hypoactive delirium is quiet, withdrawn and easily missed.
• Delirium near end of life may be multifactorial and not fully reversible.
• Management depends on whether the goal is reversal, comfort or both.

🔍 7.2 Agitation Assessment

• Pain: grimacing, guarding, tachycardia, distress during movement.
• Urinary retention: suprapubic pain, restlessness, low urine output.
• Constipation: abdominal distension, no bowel movement, overflow.
• Hypoxia or breathlessness.
• Medication toxicity or withdrawal.
• Fear, spiritual distress, family conflict or unfamiliar environment.

💊 7.3 Management

• Non-drug measures: calm environment, familiar voices, reduce noise, explain, reorientation if helpful.
• Treat reversible causes if proportionate: retention, constipation, infection, drug toxicity, hypercalcaemia.
• Antipsychotics may help distressing hallucinations/agitation in some cases, but use caution in Parkinson’s disease and Lewy body dementia.
• Benzodiazepines can help anxiety, panic, terminal agitation, seizures or alcohol withdrawal, but may worsen delirium in some patients.
• Specialist palliative care advice is important for refractory agitation.

😰 7.4 Anxiety and Existential Distress

• Anxiety may be caused by breathlessness, pain, fear of dying, family worries, previous trauma or loss of control.
• Listen before prescribing.
• Non-drug strategies: calm presence, breathing techniques, chaplaincy/spiritual care, psychology, family meetings.
• Medication may help panic or severe anxiety, but sedation burden should be discussed.

⚠️ Safety pearl: Agitation in a dying patient is not automatically “terminal agitation”. Check pain, urinary retention and constipation first — these are common and treatable.

💦 8. Respiratory Secretions and Mouth Care

💦 8.1 Noisy Respiratory Secretions

• Often called “death rattle”, caused by pooled upper airway secretions when the patient can no longer clear them.
• It is often more distressing to family than to the unconscious patient.
• Repositioning may help.
• Antimuscarinic drugs can reduce new secretion production but may not remove existing secretions.
• Deep suction is usually uncomfortable and often not helpful unless there is a specific removable obstruction.

🦷 8.2 Mouth Care

• Dry mouth is common due to dehydration, oxygen, anticholinergics, opioids and mouth breathing.
• Regular mouth care improves comfort and dignity.
• Use water-based oral moisturisers, lip balm and gentle cleaning.
• Treat oral thrush if present: white plaques, soreness, altered taste.
• Check dentures, ulcers, bleeding and pain.

💧 8.3 Thirst and Hydration

• Thirst may be relieved by mouth care even when fluids are not tolerated.
• Clinically assisted hydration decisions should be individualised.
• Potential benefits: relieve thirst, delirium from dehydration, renal drug accumulation.
• Potential burdens: oedema, respiratory secretions, ascites, need for cannula, discomfort.
• NICE NG31 recommends discussing risks and benefits and reviewing clinically assisted hydration.

💉 9. Syringe Drivers and Routes of Medication

The BNF palliative care medicines guidance notes that portable continuous infusion devices such as syringe drivers are used when medicines need to be given by continuous subcutaneous infusion, and that 20 mL syringes are generally recommended as the minimum size. Local compatibility charts and specialist advice should always be used.

💉 9.1 When to Use a Syringe Driver

• Unable to swallow safely.
• Persistent vomiting or bowel obstruction.
• Poor absorption from oral route.
• Reduced consciousness.
• Need for stable continuous symptom control.
• High tablet burden causing distress.
• End-of-life phase where anticipatory medicines are needed regularly.

🧪 9.2 Common Syringe Driver Medication Categories

⚠️ 9.3 Syringe Driver Safety

• Check drug compatibility before mixing.
• Use local palliative care formulary and compatibility charts.
• Prescribe over 24 hours unless local protocol differs.
• Keep PRN breakthrough medication available.
• Review symptom response and PRN use at least daily where possible.
• Check site for redness, leakage, swelling or pain.
• In renal impairment, choose opioid carefully and review toxicity.
• Do not assume starting a syringe driver means the patient is dying immediately; it is a route of administration.

🔄 9.4 Converting Oral to Subcutaneous Opioids

• Conversions must follow local palliative care guidance because ratios differ by opioid and patient factors.
• Use total opioid dose over previous 24 hours, including regular and breakthrough doses.
• Reduce dose if toxicity, frailty or renal impairment is present.
• Prescribe appropriate breakthrough subcutaneous opioid dose.
• Seek specialist advice for complex conversions, methadone, high doses or renal failure.

🧠 Exam pearl: A syringe driver does not replace PRN medication. Patients still need breakthrough doses for pain, agitation, nausea or breathlessness while the continuous infusion is titrated.

🧰 10. Anticipatory Prescribing

NICE NG31 includes recommendations on anticipatory prescribing for adults in the last days of life, with medicines available for common symptoms such as pain, breathlessness, nausea/vomiting, anxiety, delirium, agitation and noisy respiratory secretions.

📦 10.1 Why Anticipatory Medicines Matter

• They allow rapid symptom control if the patient deteriorates.
• They reduce delays out of hours.
• They support preferred place of care, especially home or care home.
• They prevent crisis transfers when symptoms could be managed in place.
• They must be individualised, not copied automatically.

💊 10.2 Common Anticipatory Symptom Groups

📝 10.3 Good Anticipatory Prescribing

• Document indication for each medicine.
• Prescribe dose, route, frequency and maximum dose in 24 hours.
• Consider renal function, current opioids, frailty and previous response.
• Ensure carers/nurses know when and how to use medicines.
• Review regularly and discontinue medicines no longer appropriate.
• Explain to family that these medicines are for comfort and do not mean care is being withdrawn.

⚠️ Safety pearl: Anticipatory medicines should be available before crisis, but they still require clinical judgement before administration.

🕊️ 11. Recognising Dying

NICE NG31 covers care of dying adults in the last days of life, including recognising dying, communication, hydration, symptom medicines and anticipatory prescribing.

🔍 11.1 Signs a Person May Be Entering the Last Days of Life

• Increasing weakness and bedbound state.
• Reduced oral intake and difficulty swallowing.
• Reduced consciousness or longer periods asleep.
• Changes in breathing pattern, including Cheyne-Stokes breathing.
• Peripheral shutdown: cool mottled limbs.
• Reduced urine output.
• Recurrent infections or deterioration despite treatment.
• Patient expresses sense of dying or withdrawal from surroundings.

⚖️ 11.2 Uncertainty

• Recognising dying is sometimes uncertain, especially in frailty, dementia, heart failure and COPD.
• Patients can stabilise or improve, so review regularly.
• Discuss uncertainty honestly: “We are worried time may be short, but we will keep reviewing.”
• Continue reversible treatments if they are proportionate and aligned with goals.
• Stop burdensome monitoring or interventions that no longer help.

🧑‍🤝‍🧑 11.3 Individualised Care Plan

• Assess symptoms regularly: pain, breathlessness, nausea, agitation, secretions, mouth care.
• Review medications and stop non-essential preventive medicines.
• Prescribe anticipatory medicines.
• Decide whether observations, blood tests, fluids or antibiotics are helpful or burdensome.
• Support family and explain expected changes.
• Clarify preferred place of care/death if appropriate and feasible.
• Document escalation plan and DNACPR/ReSPECT/local equivalent.

🧠 Exam pearl: Diagnosing dying is a clinical judgement, not a single observation. Review trajectory, reversibility, treatment response and patient goals.

🗣️ 12. Communication Skills

💬 12.1 Breaking Bad News

• Prepare: private space, time, relevant information, support person if wanted.
• Ask what the patient already understands.
• Ask how much detail they want now.
• Give a warning shot: “I’m afraid the news is not what we hoped.”
• Use clear language: avoid euphemisms like “things are changing” without explanation.
• Pause and allow emotion.
• Respond to emotion before giving more facts.
• Summarise next steps and check support.

🧭 12.2 Goals of Care Conversations

• Ask: “What matters most to you if time is short?”
• Ask: “What are you hoping for?” and “What are you worried about?”
• Explore unacceptable outcomes: permanent ventilation, nursing home, hospital death, loss of communication.
• Explain treatments in terms of likely benefit and burden.
• Clarify ceilings: ward care, antibiotics, fluids, NIV, ICU, CPR.
• Document clearly and communicate across teams.

👨‍👩‍👧 12.3 Family Meetings

• Identify who the patient wants involved, if they have capacity.
• Start with what family understand.
• Use consistent language and avoid mixed messages.
• Explain what is happening, what is uncertain and what the plan is.
• Address guilt: families may need reassurance that comfort-focused care is active care.
• Allow questions and silence.

💔 12.4 Responding to Emotion

🌿 Communication pearl: In palliative care, the most therapeutic sentence is often a question: “What are you most afraid of?”

⚖️ 13. Capacity, DNACPR and Treatment Escalation

🧠 13.1 Mental Capacity

• Capacity is decision-specific and time-specific.
• Assess whether the person can understand, retain, use/weigh and communicate the decision.
• Support decision-making before concluding lack of capacity.
• An unwise decision does not prove lack of capacity.
• If capacity is lacking, make a best-interests decision using the least restrictive option.

📝 13.2 DNACPR

• DNACPR applies only to cardiopulmonary resuscitation.
• It does not mean “do not treat”.
• Patients with capacity should be involved in discussions unless doing so would cause serious harm, not merely distress.
• Families do not “consent” to DNACPR but should usually be informed and involved where appropriate.
• Document reasoning clearly and communicate across settings.

📄 13.3 ReSPECT / Treatment Escalation Plans

• ReSPECT-style plans document emergency care recommendations based on patient goals and clinical judgement.
• They may include whether hospital transfer, IV antibiotics, fluids, NIV, ICU or CPR would be appropriate.
• Good plans are specific: “ward-based care and antibiotics, not ICU/CPR” is clearer than “not for escalation”.
• Review plans when condition or preferences change.

📜 13.4 Advance Decisions and Lasting Power of Attorney

• An advance decision to refuse treatment may be legally binding if valid and applicable.
• Refusal of life-sustaining treatment must meet specific legal requirements.
• Health and welfare LPA can make decisions only if the patient lacks capacity and within the authority granted.
• Always check documentation and involve senior/legal support if uncertain.

⚖️ Exam pearl: DNACPR is not a ceiling of care by itself. Always document what treatments are appropriate, not only what is not.

🏠 14. Community, Hospice and Hospital Palliative Care

🏠 14.1 Care at Home

• Requires symptom control, medication access, equipment, nursing support and carer confidence.
• Anticipatory prescribing reduces crisis calls and unwanted admissions.
• Document out-of-hours plans and who to contact.
• Consider hospital bed, commode, pressure mattress, syringe driver and care package.
• Support carers with practical instructions and reassurance.

🏥 14.2 Hospice Care

• Hospices provide specialist symptom control, respite, rehabilitation, psychosocial support and end-of-life care.
• Hospice is not only for the final days.
• Admission criteria vary by local service and need.
• Day hospice/outpatient palliative clinics may support people at home.

🏨 14.3 Hospital Palliative Care

• Hospital teams support complex symptoms, communication, ceilings of care and discharge planning.
• They can help align acute treatment with goals, especially when prognosis is uncertain.
• Early referral is helpful for uncontrolled symptoms, repeated admissions or family conflict.

👩‍⚕️ 14.4 When to Refer to Specialist Palliative Care

• Complex or refractory pain.
• Difficult opioid conversions or renal failure.
• Severe breathlessness, agitation, nausea or secretions not responding to usual measures.
• Complex communication, conflict or treatment escalation decisions.
• Young patients, dependent children or major psychosocial/spiritual distress.
• Discharge planning for preferred place of death with complex care needs.

🚨 15. Palliative Care Emergencies

🩸 15.1 Major Haemorrhage Planning

• Risk situations: head and neck cancer, lung cancer haemoptysis, GI bleeding tumours, pelvic malignancy, fungating tumours.
• Discuss risk sensitively if appropriate and prepare staff/family without causing unnecessary fear.
• Keep dark towels available if high risk.
• Focus on presence, comfort, rapid anxiolysis/sedation according to local plan and not leaving the patient alone.
• Escalation depends on goals: some patients may still want hospital/interventional treatment; others may prefer comfort care.

🚨 Safety pearl: In catastrophic terminal haemorrhage, the most important intervention may be staying with the patient and reducing fear. Do not abandon them to fetch equipment.

🌙 16. Last Days of Life Symptom Control

📋 16.1 Common Final-Day Symptoms

💊 16.2 Medication Review in the Dying Phase

• Stop non-essential preventive medicines: statins, vitamins, long-term antihypertensives if no comfort benefit, oral diabetes drugs if not needed.
• Continue medicines that maintain comfort: analgesia, antiemetics, anxiolytics, antiseizure medication, Parkinson’s medication if possible.
• Convert essential medicines to non-oral route where needed.
• Reduce monitoring that does not improve comfort or decisions.
• Explain medication changes to family so they do not feel care is being withdrawn.

💧 16.3 Fluids and Nutrition Near End of Life

• Reduced appetite and thirst are common as the body shuts down.
• Forcing food or fluids can cause distress, choking, vomiting or aspiration.
• Mouth care often relieves dryness better than IV fluids.
• Clinically assisted hydration may be trialled if symptoms suggest dehydration and benefit is plausible.
• Review for fluid overload, secretions or discomfort.

👨‍👩‍👧 16.4 Supporting Family

• Explain expected changes: reduced intake, sleepiness, breathing changes, cool limbs, noisy secretions.
• Encourage talking, touch and presence if the family wants.
• Explain that hearing may persist even when the patient is less responsive.
• Prepare them for uncertainty: hours, days or sometimes longer.
• Offer spiritual care, chaplaincy or cultural/religious support.

🧒 17. Special Situations

🧠 17.1 Dementia and Frailty

• Advanced dementia is a terminal condition when associated with recurrent infections, weight loss, dysphagia, immobility and reduced communication.
• Distress may present as agitation, calling out, resistance to care or reduced intake.
• Assess pain carefully using observational tools.
• Best-interests decisions often involve feeding, antibiotics, hospital transfer and DNACPR.

🫁 17.2 COPD and Heart Failure

• Trajectory is often unpredictable with acute exacerbations and partial recoveries.
• Patients may benefit from both disease-directed treatment and palliative symptom management.
• Breathlessness plans, rescue packs, fan therapy, opioids for refractory dyspnoea and advance care planning can reduce crisis admissions.
• Clarify views on NIV, hospital transfer and ICU before crisis if possible.

🧬 17.3 Motor Neurone Disease

• Symptoms: progressive weakness, dysphagia, dysarthria, respiratory failure, secretions, emotional lability.
• Anticipate communication support, nutrition decisions, secretion management and respiratory planning.
• Discuss NIV, cough assist, gastrostomy and advance care planning early.

🫘 17.4 Renal and Liver Failure

• Renal failure affects opioid choice and increases drug toxicity risk.
• Conservative kidney management may focus on itch, restless legs, nausea, fluid overload and fatigue.
• Liver failure causes ascites, encephalopathy, pruritus, bleeding risk and infection risk.
• Medication doses and sedatives require extra caution.

📚 18. OSCE / Exam Pearls

• Palliative care can occur alongside active treatment.
• Always assess pain mechanism before escalating opioids.
• Prescribe laxatives with regular strong opioids unless contraindicated.
• In renal failure, morphine can accumulate and cause toxicity.
• Breathlessness can be severe even with normal oxygen saturation.
• Agitation may be caused by pain, urinary retention or constipation.
• A syringe driver is a route of medication delivery, not a diagnosis of dying.
• Anticipatory medicines should cover pain, breathlessness, nausea, agitation and secretions.
• DNACPR applies only to CPR; document what treatments are appropriate.
• Recognising dying involves trajectory, reversibility and treatment response, not one sign.
• Communication starts by asking what the patient/family already understand.
• In catastrophic bleeding, stay with the patient and reduce distress.

📌 19. Quick Differentials Table

📚 References

• NICE. Care of dying adults in the last days of life. NG31.
• NICE. Palliative care for adults: strong opioids for pain relief. CG140.
• NICE. End of life care for adults: service delivery. NG142.
• BNF. Prescribing in palliative care medicines guidance.
• Resuscitation Council UK, GMC and local ReSPECT/DNACPR policies should be checked for emergency care planning and CPR decisions.
• Local specialist palliative care, hospice, anticipatory prescribing, syringe driver compatibility, renal opioid and end-of-life care guidelines should always be followed.

⚠️ Disclaimer

This article is for medical education and exam revision. Clinical decisions should follow current local specialist palliative care guidance, hospice/community pathways, anticipatory prescribing charts, syringe-driver compatibility guidance, renal dosing advice, formularies, senior advice, NICE guidance and legal/ethical frameworks. Palliative care emergencies such as metastatic spinal cord compression, hypercalcaemia, superior vena cava obstruction, seizures, major haemorrhage, opioid toxicity and severe terminal agitation require urgent senior input.