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Palliative care - general issues
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Exam Tips
- Use a structured answer: assess physical + psychological + social + spiritual domains, set goals, review, and escalate to specialist palliative care when complexity exceeds generalist competence.
- In OSCE communication, explicitly ask how much prognostic detail the patient wants; give time-based estimates only and acknowledge uncertainty.
- For persistent symptoms, prescribe regular prophylactic treatment plus PRN rescue, and deprescribe low-benefit long-term preventive medicines when appropriate.
- Know common UK anticipatory end-of-life injectable medicines and safe starting doses (morphine, midazolam, haloperidol, glycopyrronium/hyoscine butylbromide).
- Always include safety points: renal dose adjustment for opioids, constipation prophylaxis, and contraindications (for example metoclopramide in complete bowel obstruction).
- See Figure from standard palliative medicine textbook chapter on the 'total pain' model (useful visual framework for viva and SAQ answers).
Definition
Palliative care is active, holistic care for people with advanced progressive illness, focused on improving quality of life for the person and those important to them. It aims to prevent and relieve suffering through early identification, careful assessment, and treatment of physical, psychological, social, and spiritual problems, while neither hastening nor delaying death.
Pathophysiology
There is no single disease mechanism; palliative care addresses multidimensional suffering caused by life-limiting illness. Symptom burden arises from interacting biological processes (for example tumour invasion, organ failure, inflammation, neurochemical disturbance), treatment effects (for example chemotherapy-related nausea), and psychosocial-spiritual distress; this interaction is often described as 'total pain'. In the terminal phase, progressive physiological decline leads to reduced oral intake, altered consciousness, peripheral shutdown, and changing respiratory patterns (including periods of apnoea/Cheyne-Stokes breathing).
Risk Factors
- Advanced, progressive cancer (especially metastatic disease)
- End-stage organ failure (heart, lung, liver, kidney) with repeated decompensation
- Progressive neurological disease (for example MND, advanced Parkinsonism, dementia)
- Frailty, multimorbidity, and frequent unplanned hospital admissions
- High symptom burden (pain, breathlessness, delirium, nausea, fatigue)
- Psychological distress, poor social support, or high carer strain
Clinical Features
Symptoms
- Pain, breathlessness, nausea/vomiting, constipation, fatigue, insomnia
- Anxiety, low mood, fear, demoralization, existential/spiritual distress
- Reduced appetite and oral intake, weight loss, weakness
- Delirium symptoms: fluctuating confusion, agitation, hallucinations
- In the last days: increasing drowsiness, reduced communication, social withdrawal
Signs
- Functional decline, reduced mobility, increasing dependence, bed-bound state
- Cognitive fluctuation or reduced consciousness
- Features of delirium (restlessness, inattention, disorganized thinking)
- Peripheral cyanosis, mottled cool peripheries
- Altered breathing pattern (irregular breathing, apnoeic episodes, Cheyne-Stokes)
Investigations
Holistic palliative assessment (physical, psychological, social, spiritual):Identifies unmet needs, symptom severity, patient priorities, and achievable care goals
Medication review:Stops non-beneficial preventive drugs in limited prognosis (for example statins) and simplifies regimen
Targeted blood tests (U&E, calcium, glucose, FBC, CRP as appropriate):May reveal reversible contributors to symptoms such as hypercalcaemia, uraemia, infection, dehydration
Focused assessment for delirium and agitation:Distinguishes likely terminal delirium from reversible causes (urinary retention, constipation, sepsis, drug toxicity)
Prognostic assessment (including Gold Standards Framework 'surprise question'):Supports advance care planning when deterioration suggests possible death within months
Management
Lifestyle Modifications
- Use shared decision-making with regular review at key illness transitions (diagnosis, relapse, treatment change, approaching death)
- Proactive symptom enquiry rather than waiting for spontaneous reporting
- Coordinate multidisciplinary care across community, hospice, and hospital with clear keyworker/contact points
- Provide practical and social support: carers' needs, personal care, equipment, benefits, and bereavement support
- Use quiet, private settings for sensitive conversations; involve trained interpreters where needed
- Respect preferences about prognostic information and reassess these preferences over time
Pharmacological Treatment
Strong opioid for background and breakthrough pain
- Morphine sulfate oral immediate-release 2.5-5 mg every 4 hours (opioid-naive, frail lower end)
- Morphine sulfate oral modified-release every 12 hours once stable total daily dose known
- Breakthrough dose: oral immediate-release morphine usually 1/6 of total 24-hour opioid dose
- If unable to swallow: morphine sulfate subcutaneous 2.5-5 mg every hour PRN (opioid-naive)
Co-prescribe stimulant laxative +/- softener and antiemetic. Reduce dose in renal impairment; consider specialist advice and opioid switch. Monitor sedation and respiratory depression; avoid abrupt large dose escalations.
Neuropathic or mixed pain adjuvants
- Gabapentin 100-300 mg at night, titrate gradually to effect
- Amitriptyline 10 mg at night, titrate cautiously
- Dexamethasone 4-8 mg in the morning for selected indications (for example raised intracranial pressure, nerve compression)
Watch anticholinergic burden, falls risk, and steroid adverse effects (hyperglycaemia, mood change, proximal myopathy). Taper corticosteroids if used beyond short courses.
Breathlessness (including end-of-life)
- Morphine sulfate oral immediate-release 1.25-2.5 mg every 4 hours in opioid-naive patients
- Midazolam subcutaneous 2.5-5 mg hourly PRN for severe anxiety-associated breathlessness
Use non-pharmacological measures first (fan, positioning, reassurance). Use lower opioid starting doses in frailty/renal impairment; monitor sedation.
Nausea and vomiting (cause-directed where possible)
- Haloperidol 0.5-1.5 mg at night orally or subcutaneously
- Cyclizine 50 mg up to three times daily (oral/subcutaneous)
- Metoclopramide 10 mg up to three times daily (oral/subcutaneous) if no complete bowel obstruction
- Levomepromazine 6.25 mg subcutaneous PRN for refractory nausea
Select by likely mechanism (chemical, vestibular, gastric stasis, raised ICP). Avoid metoclopramide in complete bowel obstruction or Parkinsonism risk states; monitor QT prolongation/extrapyramidal effects with antipsychotics.
Agitation or terminal delirium
- Midazolam subcutaneous 2.5-5 mg hourly PRN
- Haloperidol 0.5-1.5 mg orally/subcutaneously, repeat/titrate cautiously
- Levomepromazine 12.5-25 mg subcutaneous PRN if refractory
Treat reversible causes when appropriate (retention, constipation, infection, metabolic disturbance). Use lowest effective dose; monitor for oversedation and extrapyramidal effects.
Respiratory tract secretions in dying phase
- Glycopyrronium bromide 200 micrograms subcutaneous every 4 hours PRN
- Hyoscine butylbromide 20 mg subcutaneous every 4 hours PRN
Most effective if started early when secretions emerge. Antimuscarinics can worsen urinary retention, constipation, and confusion.
Surgical / Interventional
- Not routine in general palliative care; consider specialist palliative procedures for symptom relief (for example pleural/peritoneal drainage, biliary or enteric stenting, nephrostomy, palliative radiotherapy, selected nerve blocks)
- Refer to specialist palliative care for complex refractory symptoms or when interventions exceed generalist team competence
Complications
- Uncontrolled pain or other refractory symptoms
- Delirium, distress, and loss of dignity near end of life
- Adverse drug effects (opioid toxicity, constipation, nausea, sedation, falls)
- Carer burnout and complicated grief
- Unplanned admissions and fragmented care due to poor communication/coordination
- Potentially avoidable interventions that do not match patient goals
Prognosis
Prognosis depends on underlying disease trajectory, frailty, and symptom burden. In the terminal phase, decline is usually over hours to days, but prognostic estimates are inherently uncertain and should be communicated as ranges (days, weeks, months) with regular review. Early integrated palliative care is associated with better symptom control, improved patient/family experience, and often fewer burdensome interventions.
Sources & References
💊BNF Drug References(21)
- Baclofen[management.pharmacological]
- Co-danthramer[management.pharmacological]
- Co-danthrusate[management.pharmacological]
- Dexamethasone[management.pharmacological]
- Diazepam[management.pharmacological]
- Dipipanone hydrochloride with cyclizine[cautions]
- Domperidone[management.pharmacological]
- Glycopyrronium bromide[management.pharmacological]
- Haloperidol[management.pharmacological]
- Hyoscine butylbromide[management.pharmacological]
- Hyoscine hydrobromide[management.pharmacological]
- Levomepromazine[management.pharmacological]
- Loperamide hydrochloride[management.pharmacological]
- Methadone hydrochloride[management.pharmacological]
- Metoclopramide hydrochloride[management.pharmacological]
- Midazolam[management.pharmacological]
- Morphine[management.pharmacological]
- Naloxone hydrochloride[cautions]
- Nifedipine[management.pharmacological]
- Octreotide[management.pharmacological]
- Oxycodone hydrochloride[management.pharmacological]
✅NICE Guidelines(1)
- Palliative care - general issues[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1778, 1779)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1781)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1788)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1778)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1827)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1790, 1791)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1777)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1786)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1784)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1788)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 539, 540)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 548, 549)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 552)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 551, 552)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 550, 551)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 547)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 875)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 7, 8)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 7, 8, 9)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 549, 550)[context]