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.
