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

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):

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 CBT 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 COPD:

• 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 +/- GORD:

• 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  
• 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

Respiratory Secretions

Subcutaneous hyoscine butylbromide (Buscopan) / glycopyrronium bromide

• To be given as soon as the rattle begins

References