Phys · oncological
Palliative Care and Symptom Management
Also known as palliative care · symptom management · end of life care · terminal care · supportive care · WHO analgesic ladder · cancer pain · anticipatory prescribing · palliative sedation · breaking bad news
Consultant-physician-depth guide to palliative care and symptom management for FRACP DWE and DCE — the WHO definition and the early-integration principle (Temel trial), the WHO three-step analgesic ladder for cancer pain (morphine, oxycodone, fentanyl; adjuvants gabapentin and dexamethasone; breakthrough at one-sixth; opioid rotation and methadone for refractory pain), cause-specific nausea and vomiting (metoclopramide for gastric stasis, haloperidol and olanzapine for chemical causes, cyclizine and hyoscine for bowel obstruction, dexamethasone for raised ICP), refractory breathlessness (oxygen if hypoxic, low-dose morphine, benzodiazepines, fan and positioning — Abernethy showed no benefit of oxygen over air in the non-hypoxaemic patient), terminal delirium and agitation (haloperidol first-line, midazolam for refractory), opioid-induced constipation (always co-prescribe a stimulant plus osmotic laxative), anorexia-cachexia (megestrol and corticosteroids with limited benefit), end-of-life care and anticipatory prescribing (the four injectable medicines), advance care planning, the SPIKES protocol for breaking bad news, and the ethics of capacity, substitute decision-making and voluntary assisted dying.
Checked against its sources on 13 Sept 2026
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Red flags
- A patient with advanced cancer and new severe pain must have the pain treated immediately by the analgesic ladder while a reversible cause (pathological fracture, cord compression, infection) is sought — pain is a medical emergency, not an expected inconvenience of the disease
- New back pain with a neurological sign in a patient with cancer is malignant spinal cord compression until proven otherwise — give dexamethasone 16 mg and order an urgent MRI of the whole spine (cross-referenced in the oncologic emergencies topic)
- Confusion and agitation in a palliative patient is delirium until proven otherwise — seek and treat the reversible precipitant (urinary retention, constipation, hypoxia, opioids, hypercalcaemia, infection) before ascribing it to the dying process
- Noisy respiratory secretions in the dying patient are usually more distressing to the family than to the patient — explain, reposition, reduce non-essential fluids, and give a subcutaneous antimuscarinic (glycopyrronium or hyoscine butylbromide) early
- Opioids must never be started without a laxative — opioid-induced constipation is universal, tolerance never develops, and failure to co-prescribe is a common and avoidable cause of distress
- A request for hastened death is a communication about suffering, not a settled request — explore the reason (often unrelieved pain, depression, fear, loss of autonomy), address any reversible suffering, involve specialist palliative care, and do not abandon the patient
Palliative Care and Symptom Management
The answer first
Palliative care is the active holistic care of patients of all ages with serious health-related suffering, aimed at improving the quality of life of patients, their families and their caregivers. The two ideas that define it for a physician trainee are these: palliative care is introduced early and in parallel with disease-directed therapy, not only at the end of life, and the unit of care is the patient and the family together. The Temel 2010 randomised trial — early palliative care in metastatic non-small-cell lung cancer — established that integrated palliative care alongside oncology improved quality of life and mood, reduced aggressive end-of-life care, and was associated with longer median survival (11.6 versus 8.9 months) [1]. This single trial reframes palliative care from a terminal service to an active clinical specialty that improves outcomes.
The clinical skill is symptom management by mechanism, with the WHO analgesic ladder as the framework for pain and a cause-specific pharmacological approach for every other symptom. The skill that examiners most often probe is the reasoning: why this drug, at this dose, for this mechanism of this symptom, in this patient. The unifying rule is that you treat the cause of each symptom first (drain the effusion, decompress the obstruction, treat the hypercalcaemia), and then you treat the symptom with the agent whose mechanism matches the pathophysiology. [1]
DWE high-yield: The two most examinable facts in palliative care are the WHO analgesic ladder (Step 1 non-opioid, Step 2 weak opioid, Step 3 strong opioid, adjuvants at every step) and the breakthrough opioid dose (one-sixth of the total 24-hour long-acting dose). Every cancer pain stem turns on these two facts. [1]
References11ShowHide
- [1]Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer N Engl J Med, 2010.PMID 20818875
- [2]Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer Oncologist, 2000.PMID 10964998
- [3]Loprinzi CL, Ellison NM, Schaid DJ, et al. Controlled trial of megestrol acetate for the treatment of cancer anorexia and cachexia J Natl Cancer Inst, 1990.PMID 2193166
- [4]Hui D, Frisbee-Hume S, Wilson A, et al. Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial JAMA, 2017.PMID 28975307
- [5]Hui D, De La Rosa A, Wilson A, et al. Neuroleptic strategies for terminal agitation in patients with cancer and delirium at an acute palliative care unit: a single-centre, double-blind, parallel-group, randomised trial Lancet Oncol, 2020.PMID 32479786
- [6]Wiffen PJ, Derry S, Bell RF, et al. Gabapentin for chronic neuropathic pain in adults Cochrane Database Syst Rev, 2017.PMID 28597471
- [7]Bruera E, Palmer JL, Bosnjak S, et al. Methadone versus morphine as a first-line strong opioid for cancer pain: a randomized, double-blind study J Clin Oncol, 2004.PMID 14701781
- [8]Lawlor PG, Turner KS, Hanson J, et al. Dose ratio between morphine and methadone in patients with cancer pain: a retrospective study Cancer, 1998.PMID 9506365
- [9]Abernethy AP, Currow DC, Frith P, Fazekas BS, McHugh A, Bui C Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea BMJ, 2003.PMID 12958109
- [10]Navari RM, Qin R, Ruddy KJ, et al. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting N Engl J Med, 2016.PMID 27410922
- [11]Abernethy AP, McDonald CF, Frith PA, Clark K, Herndon JE, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial Lancet, 2010.PMID 20816546