Palliative: Symptoms Management

• Principles: What is Palliative Care? | Recognising Who Needs It | Advance Care Planning | Difficult Conversations
• Pain: Assessing Pain | Using Opioids | Opioid Conversions and Special Situations | Other Pain Treatments
• Gut: Nausea and Vomiting | Constipation | Malignant Bowel Obstruction | Mouth Care, Appetite and Weight Loss
• Other symptoms: Breathlessness | Cough, Haemoptysis and Hiccups | Anxiety, Depression and Delirium | Itch, Sweats, Wounds and Swelling | Palliative Care Beyond Cancer
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🕊️ Palliative care aims to improve quality of life for people with serious illness - and for their families - by relieving pain and other symptoms and supporting psychological, social and spiritual needs. It is not only for the last days of life: it can start at diagnosis and run alongside active treatment. Most palliative care is given by generalists (GPs, ward teams, nurses), with specialist teams for complex needs. Care in the last days of life is covered in the End-of-Life Care chapter.
Your four questions for every patient: What matters most to this person now? What is causing each symptom, and is the cause treatable? Is the drug, dose and route right (kidneys, swallowing, side effects)? Have future wishes been discussed and recorded?

What is Palliative Care?

• Holistic care - physical, psychological, social and spiritual needs, for the patient and those close to them.
• "Total pain" (Cicely Saunders) - pain is made worse by fear, low mood, family worries, money problems and loss of meaning. Treat all of these.
• Early palliative care alongside cancer treatment improves quality of life and mood, and in some studies survival.
• Generalist vs specialist:
  • Most needs are met by the usual team.
  • Refer to specialist palliative care for complex symptoms, difficult family or ethical situations, or rapidly changing needs.
• Settings: Home (district nurses, GPs, hospice at home), hospices, care homes and hospitals.
• Not only cancer - heart failure, COPD, kidney failure, liver disease, dementia, frailty and neurological conditions have similar or greater symptom burdens, but are referred less often.

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Recognising Who Needs It

• The "surprise question" - "Would I be surprised if this patient died in the next 6–12 months?" If not, plan ahead.
• Tools: SPICT (Supportive and Palliative Care Indicators Tool) and the Gold Standards Framework prognostic indicator guidance.
• General indicators:
  • Falling function - spending more time in bed or a chair, needing more help.
  • Two or more unplanned admissions in 6 months.
  • Weight loss; low albumin.
  • Persistent symptoms despite optimal treatment.
  • The patient or family asking about palliative care or stopping treatment.
• Disease-specific indicators (examples):
  • Heart failure - NYHA IV, recurrent admissions, low BP, kidney decline.
  • COPD - FEV1 under 30%, breathless at rest, home oxygen, repeated exacerbations.
  • Kidney - eGFR under 15 and choosing not to dialyse, or stopping dialysis.
  • Dementia - unable to walk, talk meaningfully or feed independently; recurrent infections.
  • Frailty - Clinical Frailty Scale 7 or more.
  • Cancer - progressive disease despite treatment, performance status 3 or 4.
• Add the patient to the GP palliative care register and share information with out-of-hours services.

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Advance Care Planning

What it is: Conversations over time about what matters to the person, their values, and their wishes for future care - while they can still take part.

• Tools and documents:
  • Advance statement - wishes and preferences (place of care, what matters, who to involve). Not legally binding, but must be considered.
  • Advance decision to refuse treatment (ADRT) - legally binding if valid and applicable. Refusing life-sustaining treatment must be in writing, signed and witnessed, and state it applies "even if life is at risk".
  • Lasting Power of Attorney for health and welfare - someone to decide if the person loses capacity.
  • ReSPECT form (Recommended Summary Plan for Emergency Care and Treatment) - records recommendations on emergency care, including CPR.
  • Preferred place of care and death.
  • Organ and tissue donation wishes.
• CPR decisions:
  • CPR is unlikely to work in advanced illness and can cause harm.
  • If CPR won't work, it isn't offered - but the decision must be discussed with the patient (or family if the patient lacks capacity) unless this would cause physical or psychological harm (Tracey judgment, 2014).
  • A DNACPR decision applies only to CPR - not to other treatments.
• Share the plan - electronic care records (e.g. EPaCCS), GP, ambulance service, care home.
• Review regularly - wishes change.

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Difficult Conversations

• Breaking bad news - the SPIKES approach:
  • Setting - private, sitting down, enough time, phones off, family present if wished.
  • Perception - "What do you understand about your illness so far?"
  • Invitation - "How much detail would you like?"
  • Knowledge - a warning shot ("I'm afraid I have some difficult news"), then plain words, in small chunks; avoid jargon.
  • Emotions - pause, acknowledge feelings, allow silence.
  • Strategy and summary - next steps, support, written information, a contact.
• Talking about prognosis:
  • Use ranges ("weeks to months") and be honest about uncertainty.
  • "Hope for the best, plan for the worst."
• Exploring goals:
  • "What matters most to you now?"
  • "What worries you most?"
  • "What would you be willing to go through for the chance of more time?"
• Collusion - when families ask doctors not to tell the patient. Explore their worries, but the patient has a right to information if they want it.
• Interpreters - use professional interpreters, not family members, for serious conversations.
• Document conversations clearly and share them with the team.

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Assessing Pain

• Types of pain:
  • Somatic - well localised, aching (bone, soft tissue).
  • Visceral - poorly localised, deep, often referred (liver capsule, bowel).
  • Neuropathic - burning, shooting, electric, with numbness or allodynia (nerve compression or damage).
  • Bone pain - often worse on movement (incident pain).
  • Colic - cramping, waves (bowel obstruction).
• Assess each pain separately: Site, character, severity (0–10), timing, triggers, effect on function and sleep, and what has helped.
• People who can't report pain (dementia, reduced consciousness) - observational tools such as the Abbey Pain Scale or PAINAD (facial expression, vocalisation, body language, behaviour change).
• Look for new causes: Fracture, cord compression, infection, obstruction, constipation, urinary retention.
• Ask about fears of opioids (addiction, "the end is near") - address them openly.

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Using Opioids

Principles (NICE CG140 and the WHO approach):

• By mouth where possible, by the clock (regular, not just "as needed"), with breakthrough doses.
• Mild to moderate pain: Paracetamol and NSAIDs (if safe), with or without a weak opioid (codeine) - or a low-dose strong opioid.
• Moderate to severe pain: A strong opioid - oral morphine first line.

Starting morphine (opioid-naive, normal kidney function):

• Immediate-release morphine (e.g. oral solution) 2.5–5 mg every 4 hours as needed, then convert to regular dosing; or
• Modified-release morphine 10–15 mg twice daily, plus immediate-release morphine for breakthrough pain.
• Use lower doses in frail or older people.

Breakthrough doses:

• About one-sixth of the total 24-hour regular dose (some use 1/10 to 1/6), given as needed (often hourly).
• Titration: Add up the regular and breakthrough doses used in 24 hours; adjust the regular dose (usually increasing by 30–50% at a time).

Side effects:

• Constipation - almost universal. Always prescribe a laxative (e.g. senna with a softener, or macrogol).
• Nausea - common in the first week; give an antiemetic as needed (haloperidol or metoclopramide).
• Drowsiness - usually settles in a few days; warn about driving.
• Dry mouth; itch; urinary retention.
• Opioid toxicity:
  • Myoclonic jerks.
  • Hallucinations or confusion.
  • Pinpoint pupils.
  • Excessive drowsiness.
  • Slow breathing (rare with careful titration).
  • Often triggered by AKI or rapid dose increases.
  • Action: Reduce or stop the dose, hydrate, and switch opioid if needed. Naloxone only for serious respiratory depression (small titrated doses - e.g. 20–40 micrograms IV at a time) to avoid sudden severe pain.

Safety:

• Write doses clearly in mg (not mL).
• Check the previous opioid dose.
• Take care with modified-release vs immediate-release products.
• Driving on stable doses is legal if not impaired - advise patients.

💡 Clinical Pearl: Opioids used properly for pain in palliative care do not shorten life. Fear of addiction or of "speeding up death" should not stop good pain relief.

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Opioid Conversions and Special Situations

Approximate conversions (check the BNF or local palliative care guidance; reduce the calculated dose by about 25–50% when switching to a different opioid, because cross-tolerance is incomplete):

• Kidney impairment - morphine, diamorphine and codeine metabolites build up (toxicity):
  • eGFR under 30: Use oxycodone at reduced doses with longer intervals, or fentanyl or alfentanil (and buprenorphine). Seek specialist advice.
  • Avoid codeine and tramadol.
• Liver impairment - lower doses and longer intervals; caution with constipation (encephalopathy).
• Codeine - needs CYP2D6 to work; some people get no benefit, and fast metabolisers can become toxic.
• Tramadol - seizures, low sodium, hypoglycaemia, serotonin syndrome (with SSRIs); many interactions.
• Patches and fever - heat increases fentanyl absorption (toxicity).
• Patients unable to swallow - switch to a subcutaneous syringe pump (see the End-of-Life Care chapter), or a patch if the pain is stable.
• Methadone - complex, long and variable half-life; specialist use only.

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Other Pain Treatments

• Neuropathic pain:
  • Amitriptyline, gabapentin, pregabalin or duloxetine (often with an opioid).
  • Dexamethasone for nerve compression by tumour.
  • Radiotherapy.
• Bone pain:
  • NSAIDs (with a PPI; caution in kidney disease).
  • Radiotherapy (single fraction).
  • Bisphosphonates or denosumab.
  • Orthopaedic fixation.
• Liver capsule pain (stretching from metastases) - dexamethasone, NSAIDs.
• Headache from raised intracranial pressure - dexamethasone.
• Bowel colic - hyoscine butylbromide (avoid stimulant laxatives in obstruction).
• Bladder spasm - oxybutynin.
• Muscle spasm - baclofen, diazepam.
• Mouth pain - benzydamine mouthwash; treat candida.
• Interventions:
  • Coeliac plexus block (pancreatic cancer).
  • Intrathecal drug delivery.
  • Cordotomy (mesothelioma).
  • Ketamine (specialist).
• Non-drug: TENS, heat, positioning, physiotherapy, relaxation, psychological support.

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Nausea and Vomiting

Find the cause, then choose the antiemetic that matches it:

• Route: Use subcutaneous or syringe pump routes if vomiting prevents absorption.
• Avoid combining metoclopramide with cyclizine (opposite effects on gut movement).
• Parkinson's disease - avoid haloperidol and metoclopramide; use domperidone or ondansetron.
• Treat reversible causes: Constipation, hypercalcaemia, drugs, infection, gastritis (PPI), oral candida.

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Constipation

• Very common - from opioids, immobility, low intake, dehydration, hypercalcaemia, anticholinergic drugs, and spinal cord compression.
• Assess: Bowel pattern; rectal examination (impaction, empty rectum); abdominal X-ray only if obstruction is suspected.
• Prevention with opioids - always co-prescribe a laxative:
  • A stimulant (senna, bisacodyl) plus a softener (docusate), or macrogol.
  • Avoid bulk-forming laxatives (worsen constipation if fluid intake is poor).
• Rectal measures for impaction - glycerol or bisacodyl suppositories, phosphate or arachis oil enemas (check for peanut allergy).
• Opioid-induced constipation not responding to laxatives:
  • Methylnaltrexone (SC) or naloxegol (oral) - block opioid effects in the gut.
  • Contraindicated in bowel obstruction.
• Overflow diarrhoea - exclude faecal impaction before giving antidiarrhoeals.
• New constipation with back pain or leg weakness - think cord compression.

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Malignant Bowel Obstruction

• Who: Commonest in ovarian and colorectal cancer; also gastric and pancreatic cancer and peritoneal spread.
• Features:
  • Colicky abdominal pain; constant background pain.
  • Vomiting (early and large volume if high obstruction; faeculent if low).
  • Distension; constipation or failure to pass wind.
• Assess: CT to define the level and number of obstructions. Surgical or stenting options (single-level obstruction, fitter patient, reasonable prognosis) - discuss with the surgical and oncology team.
• Medical management (usually via a subcutaneous syringe pump):
  • Pain - an opioid (e.g. SC morphine or diamorphine).
  • Colic and secretions - hyoscine butylbromide 60–120 mg over 24 hours (antispasmodic and reduces secretions).
  • Vomiting:
    • Cyclizine 150 mg over 24 hours and/or haloperidol 1.5–5 mg over 24 hours.
    • Levomepromazine if refractory.
    • Avoid metoclopramide in complete obstruction with colic (it may help in partial obstruction without colic).
  • Reduce gut secretions - octreotide 300–600 micrograms over 24 hours.
  • Dexamethasone (e.g. 6–16 mg daily for 5 days) may reduce swelling and help resolve obstruction - stop if no benefit.
  • Stop stimulant laxatives and bulk-formers; a softener can continue in partial obstruction.
• Nasogastric tube for persistent large-volume vomiting; a venting gastrostomy for long-term relief.
• Eating and drinking - sips and small amounts for pleasure are fine; mouth care is important. IV or SC fluids by individual decision.
• Obstruction may resolve on its own for a time.

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Mouth Care, Appetite and Weight Loss

• Mouth problems (very common, often missed):
  • Oral candida - white plaques, sore red mouth. Nystatin suspension or fluconazole 50 mg daily for 7 days (watch interactions). Clean dentures.
  • Dry mouth - sips, ice chips, saliva substitutes, frequent mouth care; review anticholinergic drugs.
  • Painful mouth - benzydamine; treat infection (herpes - aciclovir).
  • Regular mouth care is essential, especially near the end of life.
• Anorexia and cachexia:
  • Loss of appetite and muscle mass is part of advanced illness, and is not reversed by feeding alone.
  • Treat reversible causes: Nausea, constipation, sore mouth, depression, pain, taste changes, high calcium.
  • Offer small, appealing meals; relax dietary restrictions (e.g. diabetic diets near the end of life).
  • Short-term dexamethasone (e.g. 2–4 mg in the morning) can improve appetite for a few weeks; progestogens (megestrol) are an alternative (VTE risk).
  • Support families - worry about "not eating" is common. Explain that the body needs less food as illness progresses; forcing food can cause distress.
• Fatigue - the commonest symptom:
  • Look for anaemia, infection, low mood, poor sleep, drugs, hypothyroidism, hypercalcaemia.
  • Energy conservation and pacing; light exercise where possible.
  • Short-term dexamethasone.

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Breathlessness

• Look for treatable causes:
  • Pleural effusion (drain, pleurodesis, indwelling pleural catheter).
  • Chest infection.
  • Anaemia.
  • Heart failure.
  • PE.
  • Bronchospasm (COPD, asthma).
  • Airway obstruction or SVC obstruction (stents, radiotherapy).
  • Ascites (drainage).
  • Anxiety.
• Non-drug measures - very effective:
  • A hand-held fan directed at the face.
  • Positioning (sitting upright, leaning forward).
  • Breathing control techniques.
  • Pacing activities.
  • An open window; calm reassurance.
  • Breathlessness services.
• Opioids reduce the sensation of breathlessness:
  • Low doses - e.g. oral morphine 1–2.5 mg as needed, or modified-release 5–10 mg over 24 hours in opioid-naive patients.
  • Safe at these doses in COPD and heart failure.
• Benzodiazepines for associated panic and anxiety - lorazepam 0.5 mg sublingually as needed; midazolam SC near the end of life.
• Oxygen - only helps if the patient is hypoxic. A fan is as good as oxygen for breathlessness without hypoxia.
• Corticosteroids - for lymphangitis, airway obstruction or SVC obstruction.

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Cough, Haemoptysis and Hiccups

• Cough:
  • Treat the cause (infection, effusion, reflux, ACE inhibitor, postnasal drip, heart failure).
  • Simple linctus; opioid linctus (codeine or low-dose morphine).
  • Nebulised saline for thick secretions.
  • Radiotherapy for tumour-related cough.
• Haemoptysis:
  • Tranexamic acid (oral or nebulised).
  • Palliative radiotherapy; bronchoscopic treatment; embolisation.
  • Review anticoagulants.
  • Massive terminal haemoptysis - plan ahead: dark towels, staff presence, midazolam for distress (see the End-of-Life Care chapter).
• Hiccups (persistent, distressing):
  • Causes: Gastric distension, diaphragm irritation (liver metastases), uraemia, hypercalcaemia, brain lesions, drugs (dexamethasone).
  • Treatment:
    • Simple measures (swallowing iced water).
    • Treat gastric distension - metoclopramide, PPI.
    • Baclofen.
    • Chlorpromazine or haloperidol.
    • Gabapentin; nifedipine.

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Anxiety, Depression and Delirium

• Anxiety:
  • Explore fears; provide information and reassurance; psychological support.
  • Lorazepam 0.5–1 mg sublingually for acute anxiety or panic; an SSRI or mirtazapine for ongoing anxiety.
• Depression:
  • Common and under-treated. Sadness is normal, but persistent low mood, hopelessness and loss of enjoyment need treatment.
  • Mirtazapine (also helps sleep and appetite) or sertraline. They take 2–4 weeks to work.
  • Psychology input.
  • Ask about suicidal thoughts.
• Spiritual and existential distress - loss of meaning, guilt, fear of death. Chaplaincy and spiritual care teams (all faiths and none); dignity therapy; legacy work.
• Delirium (very common in advanced illness):
  • Look for reversible causes:
    • Infection.
    • Drugs (opioid toxicity, benzodiazepines, steroids, anticholinergics).
    • Hypercalcaemia, low sodium, uraemia.
    • Hypoxia.
    • Urinary retention; constipation.
    • Pain.
    • Alcohol or nicotine withdrawal.
    • Brain metastases.
  • Non-drug care - calm environment, familiar people, glasses and hearing aids, orientation.
  • Drugs for distressing agitation or risk:
    • Haloperidol 0.5–1 mg (oral or SC).
    • Midazolam 2.5–5 mg SC if there is also distress or agitation near the end of life.
    • Levomepromazine (specialist).
  • Terminal agitation - see the End-of-Life Care chapter.

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Itch, Sweats, Wounds and Swelling

• Itch:
  • Cholestatic (biliary obstruction) - biliary stent if possible; colestyramine; sertraline; rifampicin; naltrexone (specialist).
  • Uraemic - emollients, gabapentin; difelikefalin (on dialysis).
  • Opioid-induced - antihistamine; switch opioid.
  • Lymphoma - treat the lymphoma; steroids.
  • Everyone - emollients, cool environment, keep nails short.
• Sweats:
  • Infection; drugs (opioids, antidepressants); hormone therapy; lymphoma; liver metastases.
  • Fans, cotton clothing.
  • Paracetamol or NSAIDs (tumour fever); oxybutynin; propantheline.
• Malignant wounds (fungating tumours):
  • Smell - topical metronidazole gel (or oral metronidazole); charcoal dressings.
  • Bleeding - non-adherent dressings, tranexamic acid (topical or oral), adrenaline-soaked gauze, radiotherapy.
  • Pain at dressing changes - breakthrough analgesia beforehand; topical morphine gel.
  • Tissue viability nurse input; attention to body image.
• Lymphoedema - skin care, compression, manual lymphatic drainage, exercise; treat cellulitis promptly.
• Malignant ascites - paracentesis; indwelling peritoneal drains for recurrent ascites; diuretics (spironolactone) help some, especially with liver metastases.
• Pressure ulcers - prevention (repositioning, mattresses); comfort-focused care at the end of life.

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Palliative Care Beyond Cancer

• Heart failure:
  • Keep disease-modifying drugs as long as they help (stop if they cause low BP, AKI or falls).
  • Diuretics for comfort (including subcutaneous furosemide at home).
  • Low-dose opioids for breathlessness.
  • Discuss ICD deactivation (to avoid painful shocks at the end of life).
• COPD and interstitial lung disease:
  • Breathlessness services; pulmonary rehabilitation.
  • Low-dose opioids; anxiety management.
  • Oxygen only for hypoxia.
  • Plan for exacerbations and NIV ceilings.
• Kidney failure:
  • Conservative kidney management (choosing not to dialyse) - often in older or frail people; survival can be similar to dialysis in some.
  • Symptoms: Itch, fatigue, nausea, restless legs, breathlessness.
  • Opioid choice - avoid morphine; use oxycodone, fentanyl or alfentanil.
  • Planned stopping of dialysis.
• Liver failure: Ascites drains, encephalopathy treatment, cautious opioids (see the Cirrhosis chapter).
• Dementia:
  • Comfort-focused care; careful hand feeding (not PEG).
  • Assess pain with observational tools.
  • Avoid unnecessary hospital admissions; advance care planning early while the person can take part.
• Neurological disease (MND, Parkinson's, MS):
  • Planning around NIV and gastrostomy.
  • Secretions; spasticity; communication aids.
  • Withdrawing NIV with symptom control.
• Frailty - slow decline with intercurrent illnesses. Focus on function, falls and deprescribing; ACP.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 68-year-old with prostate cancer and bone metastases takes co-codamol 30/500 two tablets four times daily but still has pain. eGFR is 70.
Answer: Switch to a strong opioid.

• 240 mg codeine a day ≈ 24 mg oral morphine a day: start MR morphine 10–15 mg twice daily (keep paracetamol).
• Breakthrough IR morphine about 5 mg as needed.
• Laxative; antiemetic as needed.
• Consider palliative radiotherapy and NSAIDs for bone pain; review in 24–48 hours.

2. A woman on MR morphine 30 mg twice daily used 4 breakthrough doses of 10 mg yesterday and her pain is still not controlled.
Answer: Total 24-hour use: 60 + 40 = 100 mg.

• Increase MR morphine to about 50 mg twice daily.
• New breakthrough dose: about 15–20 mg (one-sixth of 100 mg).
• Reassess for side effects and other causes of pain.

3. A man with pancreatic cancer and liver metastases has nausea with early fullness and vomits large amounts after small meals.
Answer: Gastric stasis.

• Metoclopramide 10 mg three times daily before meals (SC if vomiting).
• Exclude gastric outlet obstruction (CT or OGD) - consider a duodenal stent.
• Small frequent meals.

4. A 74-year-old with advanced ovarian cancer has colicky pain and vomiting. CT shows multilevel small bowel obstruction; surgery isn't possible.
Answer: Inoperable malignant bowel obstruction.

• Syringe pump: diamorphine or morphine for pain, hyoscine butylbromide for colic, cyclizine or haloperidol for vomiting; add octreotide if large volumes.
• Trial of dexamethasone for 5 days.
• Stop stimulant laxatives; mouth care; sips for comfort; NG tube if needed.

5. A man with lung cancer is breathless at rest. SpO2 is 95%. He is anxious and panics.
Answer: Look for treatable causes (effusion, anaemia, infection, PE).

• Fan, positioning, breathing techniques.
• Low-dose oral morphine (e.g. 1–2.5 mg as needed, or MR 5 mg twice daily).
• Lorazepam 0.5 mg sublingually for panic.
• Oxygen is not needed as he isn't hypoxic.

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Key Points

• Palliative care is holistic and can start at diagnosis, alongside active treatment - for cancer and non-cancer illnesses.
• Use the surprise question and SPICT to recognise who needs palliative care; plan ahead.
• Advance care planning: advance statements, ADRTs, LPA, ReSPECT; CPR decisions must be discussed.
• Use SPIKES to break bad news; ask "what matters most?"
• Strong opioid: oral morphine first line; breakthrough about 1/6 of the 24-hour dose; titrate by 30–50%; always add a laxative.
• Opioid toxicity (myoclonus, hallucinations, drowsiness) is often triggered by AKI.
• eGFR under 30: avoid morphine, diamorphine and codeine; use oxycodone, fentanyl or alfentanil.
• Oral morphine to SC morphine: divide by 2; to SC diamorphine: divide by 3. Reduce doses when switching opioid.
• Neuropathic pain: amitriptyline, gabapentinoids, duloxetine; bone pain: NSAIDs and radiotherapy.
• Match antiemetics to the cause: haloperidol (chemical), metoclopramide (gastric stasis), cyclizine (raised ICP, vestibular); levomepromazine if refractory.
• Malignant bowel obstruction: opioid, hyoscine butylbromide, antiemetic, octreotide, dexamethasone trial - avoid metoclopramide with colic.
• Breathlessness: fan and low-dose opioids; oxygen only for hypoxia; lorazepam for panic.
• Delirium: look for retention, constipation, drugs, hypercalcaemia and infection before sedating.
• Deactivate ICDs near the end of life; avoid PEG feeding in advanced dementia.