Scope of This Article
The following section summarises pharmacological prescribing recommendations in palliative care as outlined in the BNF.
It does not address the identification or management of reversible causes of symptoms, nor does it cover non-pharmacological interventions.
Key aspects of palliative care prescribing (important for exams and common in clinical practice) are:
- Pain
- Agitation and anxiety
- Nausea / vomiting
- Consitpation
- Respiratory secretions
Guidelines
Gastrointestinal Symptoms and Disorders
Anorexia
If early satiety due to delayed gastric emptying, offer prokinetic drugs (metoclopramide / domperidone)
Appetite stimulants:
- Dexamethasone
- Prednisolone
- Progestogen (e.g. megestrol acetate)
Bowel Colic
Subcutaneous hyoscine butylbromide (Buscopan) is the drug of choice
- Oral mebeverine (an anti-spasmodic) is sometimes used (off-label)
Constipation
- 1st line: oral stimulant laxative (e.g. senna, bisacodyl)
- 2nd line: ADD oral osmotic laxative (e.g. macrogol 3350, lactulose)
- 3rd line: glycerol / bisacodyl suppository OR sodium citrate micro-enema
- 4th line (last resort): enema (sodium acid phosphate with sodium phosphate)
- For opioid-induced constipation → methylnaltrexone bromide
Note that enemas and prokinetic agents (e.g. metoclopramide) are contraindicated in bowel obstruction (which could occur secondary to severe constipation and faecal impaction).
Be aware that the management of constipation in adults (in a non-palliative setting) is different: osmotic laxatives are 1st line (instead of stimulant laxatives).
In opioid-induced constipation, stimulant laxatives is 1st line (as the underlying mechanism is reduced bowel motility)
Dry Mouth
Options include:
- Good mouth care
- Sucking crushed ice and taking frequent sips of water
- Saliva stimulant (sugar free gum, artificial saliva)
For dry mouth associated with candidiasis:
- Oral miconazole / nystatin
- Moderate to severe infection / concurrent oesophageal candidiasis → oral fluconazole
Dysphagia
- If due to tumour obstruction → dexamethasone
- If due to oesophagitis and oesophageal spasm → sublingual GTN before meals
Nausea and Vomiting
1st line options (depending on cause):
| Cause of N&V | Choice of Drug |
|---|---|
| ↓ Gastric motility | Prokinetics:
|
| ↑ ICP and/or vestibular dysfunction | Cyclizine + dexamethasone |
| Chemical-induced | Haloperidol |
If the above failed, levomepromazine (a broad-spectrum antiemetic) can be used (but note the risk of sedation, extrapyramidal symptoms and anticholinergic effect).
Mental Health Conditions
Agitation
- If anxiety is prominent → benzodiazepine
- If delirium is prominent → antipsychotic
Anxiety
BNF notes that there is comparable efficacy between CBTCognitive Behavioural Therapy and drugs.
Choice of drugs depends on prognosis:
- Days to weeks of life → benzodiazepines (e.g. diazepam, lorazepam, midazolam)
- Months or more of life → SSRI +/- benzodiazepines
Neurological Disorders
Raised Intracranial Pressure (ICP)
Dexamethasone can provide temporary symptomatic relief from pain or headache if raised ICP secondary to cerebral oedema.
Seizures
- 1st line: levetiracetam (as the dose can be titrated rapidly and it has few drug interactions)
- For last days of life: midazolam
Respiratory Symptoms
Breathlessness
Morphine can be used for moderate to severe breathlessness at rest.
If breathlessness is from airflow obstruction (expiratory wheeze), usually seen in lung cancer patients with COPDChronic obstructive pulmonary disease:
- Nebulised bronchodilators (beta-2 agonist +/- antimuscarinic)
- As required dose of SABA prior to exertion
For last day of life: opioid + benzodiazepine
Hiccups
If hiccups due to gastric distension +/- GORDGastro-oesopahgeal reflux disease:
- Prokinetic (e.g. metoclopramide) OR
- Antiflatulent (e.g. peppermint oil or simeticone) OR
- Proton pump inhibitor (e.g. lansoprazole or omeprazole)
If hiccups are NOT due to gastric distension:
- 1st line → chlorpromazine/haloperidol
typical (first-generation) antipsychotics
- This is NOT stated in the BNF but is consistent with the literature and clinical practice
Intractable Cough
For wet (productive) cough:
- Expectorants (e.g. nebulised sodium chloride) – for sputum
- Mucolytics (e.g. N-acetylcysteine) – for mucus
For dry cough:
- 1st line: demulcent (e.g. citric acid, simple linctus)
- 2nd line: add morphine
Cough suppressants should NOT be given for wet (productive) cough, because they inhibit mucus clearance, leading to secretion retention and increased risk of infection.
Respiratory Secretions
Subcutaneous hyoscine butylbromide (Buscopan) / glycopyrronium bromide
- To be given as soon as the rattle begins