Symptom Control

Pain

•    WHO analgesic ladder:

o    Step 1: non-opioids (e.g., paracetamol, NSAIDs).

o    Step 2: weak opioids (e.g., codeine, tramadol) ± non-opioids.

o    Step 3: strong opioids (e.g., morphine, oxycodone) 

                                    ± adjuvants (e.g., gabapentinoids for neuropathic pain).

•    Breakthrough pain:

o    Managed with an immediate-release opioid dose equivalent to ~1/6 of the total daily dose.

o    Can be repeated every 1–2 hours as needed, reassessing efficacy.

•    Opioid conversion:

o    Important to avoid overdose when switching routes or drugs.

o    Morphine is the reference opioid.

o    Oral to subcutaneous morphine: divide by 2.

o    Oral morphine to oral oxycodone: multiply by 2/3 (or reduce by ~30%).

o    Always consider renal or hepatic dysfunction — fentanyl preferred if significant renal failure.

•    Total pain concept:

o    Pain is multidimensional — includes physical, psychological, social, and spiritual aspects.

•    Neuropathic pain:

o    Caused by nerve damage (e.g., tumour invasion, post-herpetic neuralgia).

o    Use adjuvants:

    Gabapentin or pregabalin (start low, titrate slowly).

    Tricyclic antidepressants (e.g., amitriptyline at night, caution in elderly due to anticholinergic effects).

•    Bone pain:

o    Consider:

    NSAIDs (unless contraindicated, e.g., renal dysfunction, peptic ulcer).

    Radiotherapy — effective for focal bone metastases.

    Bisphosphonates (e.g., zoledronic acid, pamidronate) for metastases and hypercalcaemia.

    Denosumab as an alternative in some cases.

•    General approach:

o    Use regular background analgesia + breakthrough dosing.

o    Always assess response and side effects.

Dyspnoea

•    Opioids:

o    Reduce central perception of breathlessness even if no pain.

o    Start with low-dose morphine (e.g., 2.5–5 mg oral or SC).

•    Non-pharmacological measures:

o    Cool airflow or fan to face can reduce subjective breathlessness.

o    Repositioning (e.g., sitting upright, supported lean-forward posture).

•    Other options:

o    Anxiolytics (e.g., low-dose benzodiazepines) may help if significant anxiety component.

Nausea and Vomiting

•    Assess cause and target treatment:

o    Gastric stasis: metoclopramide (prokinetic effect).

o    Chemical causes (e.g., opioids, metabolic): haloperidol.

o    Vestibular: cyclizine or hyoscine hydrobromide.

o    Raised intracranial pressure: dexamethasone ± metoclopramide.

o    Bowel obstruction: cyclizine ± dexamethasone ± octreotide.

•    Key points:

o    Avoid metoclopramide in complete obstruction.

o    Always reassess and combine antiemetics cautiously.

Constipation

•    Opioid-induced constipation:

o    Stimulant laxative (e.g., senna or bisacodyl) ± softener (e.g., docusate).

o    Avoid bulk-forming laxatives (e.g., fybogel) as they may worsen obstruction.

•    General approach:

o    Encourage adequate hydration if appropriate.

o    Regular assessment of bowel function.

Delirium and Agitation

•    First-line: haloperidol (0.5–1 mg orally or SC, titrate as needed).

•    Severe terminal agitation ("terminal restlessness"):

o    Midazolam (e.g., 2.5–5 mg SC bolus, can be repeated).

o    Continuous SC infusion may be required (e.g., 10–30 mg/24 h).

•    Identify and treat reversible causes (e.g., pain, urinary retention, constipation) where possible.

Respiratory Secretions ("Death Rattle")

•    Caused by pooled upper airway secretions in unconscious patients.

•    Anticholinergics:

o    Glycopyrronium (200–400 micrograms SC q4h or by continuous infusion).

o    Hyoscine butylbromide (20 mg SC q4h or by continuous infusion).

•    Key points:

o    Usually not distressing to the patient, more so for family.

o    Explain to relatives before starting medication.

 Extra Revision Pearls

•    Sedation at end of life: midazolam is preferred; dose tailored to symptoms and restlessness.

•    Dyspnoea with secretions: consider adding anticholinergic to morphine regimen.

•    Constipation prevention: always start laxatives when starting opioids.

•    If confusion worsens with opioids: consider opioid-induced neurotoxicity — reduce dose or rotate.

•    Nausea in palliative care: multiple mechanisms → assess carefully rather than blanket antiemetic.