GP · palliative-care
Palliative symptom control in the community
Also known as Palliative care symptom management · End-of-life symptom control · Community palliative prescribing
GP-fellowship guide to palliative symptom control in the community: WHO pain ladder, neuropathic agents, opioid selection by renal function (morphine vs fentanyl/buprenorphine), breakthrough dosing at one-sixth total daily dose, opioids for breathlessness with fan therapy evidence, receptor-based antiemetic selection, laxative co-prescribing, terminal agitation and delirium management, syringe driver combinations, last-days care expectations, and family communication.
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Red flags
- Morphine accumulates in renal failure causing sedation and myoclonus from active metabolites — switch to fentanyl or buprenorphine when eGFR falls below 30 mL/min
- Always co-prescribe a stimulant laxative with every opioid; constipation has no tolerance and leads to overflow diarrhoea or agitation if missed
- Terminal agitation is a diagnosis of exclusion — check for urinary retention, faecal impaction, hypercalcaemia and pain before reaching for midazolam
- Never give steroid drops for a dendritic ulcer on fluorescein staining — corneal melting and perforation follow
Overview
Palliative symptom control is core GP work. Most patients with advanced disease spend most of their illness at home, and the GP prescribes and adjusts the medications that make that possible. The task is systematic: assess each symptom, match the drug to the mechanism, prescribe the breakthrough dose alongside the regular one, and review daily during adjustment.[1]
References5ShowHide
- [1]King S, Forbes K, Hanks GW, Ferro CJ, Chambers EJ A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project. Palliat Med, 2011.PMID 21708859
- [2]Chamberlain BH, Rhiner M, Slatkin NE, Stambler N, Israel RJ Methylnaltrexone Treatment for Opioid-Induced Constipation in Patients with and without Cancer: Effect of Initial Dose. J Pain Res, 2023.PMID 37533563
- [3]Jesuyajolu DA, Abubakar AK, Kowe T, Ogunlade S, Abioye AI, et al. The Management of Opioid-Induced Constipation in Cancer and Advanced Illness: A Meta-Analysis. J Pain Symptom Manage, 2024.PMID 38092261
- [4]Smallwood NE, Pascoe A, Wijsenbeek M, Russell AM, Holland AE, et al. Opioids for the palliation of symptoms in people with serious respiratory illness: a systematic review and meta-analysis. Eur Respir Rev, 2024.PMID 39384304
- [5]Pereira RA, Barcellos G, Lenz G, Christmann A, de Mello MAJ, et al. Fan Therapy for Dyspnea in Palliative and Supportive Care: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Respir Care, 2026.PMID 41761933