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PROTOCOLS FOR PALLIATIVE CARE PATIENTS

END OF LIFE CARE

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Disclaimer

The information in the guide is meant to help decide on the treatment approach to each patient
individually. Therefore, the professional’s advice is to take full responsibility of their safety and know
their limits. Before treating your patient using this guideline be sure that your patient is well
diagnosed and has been treated before. Every professional should take full responsibility for the
safety of their patient.
This guide reflects opinions synthesized from an organized group of experts into a written
document. It should reflect the expert views of the treatment of the disease.
The team of professional experts reviewed the guidelines and discussed it with the panel of
individuals who are well versed on the topic of interest while carefully examining and discussing the
scientific data available.
This guideline has been designed to provide a practical and accessible guidance for health care
practitioners. It is the responsibility of treating physicians to decide what is suitable for their
patients. Therefore, the guidelines are not a substitute for the attending doctor’s clinical judgment.

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PALLIATIVE CARE

The World Health Organization (WHO 1996) defined palliative care as:
“the active, holistic care of patients with advanced, progressive illness. Management of pain and
other symptoms and provision of psychological, social and spiritual support is paramount. The goal
of palliative care is achievement of the best quality of life for patients and their families.”
The principles of palliative care are relevant to patients with both malignant and non-malignant
disease and may be relevant to patients from early in their disease trajectory. Palliative care may be
required from the time of diagnosis. It may be delivered in conjunction with disease-modifying
treatment, and usually becomes a more important part of management as the disease progresses.
Key principles of symptom management
• Detailed assessment in partnership with patient and careers.
• Diagnose cause of symptom(s) using knowledge of pathophysiology and disease processes.
• Investigations and treatment should be appropriate to the stage of disease and prognosis,
balancing benefit and harm (as defined by the patient).
• Choose the most appropriate treatment for the individual balancing benefit against side effect
burden and considering factors such as route of administration.
• Avoid making too many changes at once or review will be complex

USING ADJUVANT ANALGESIC DRUGS IN PALLIATIVE CARE

A step-wise approach (e.g. WHO analgesic ladder) provides a framework for palliative pain
management. Adjuvant analgesic drugs may be used alongside any step. An adjuvant analgesic is
a drug whose primary indication is for something other than pain, but which has analgesic effects
in some painful conditions.

Common adjuvant analgesic drug groups Common adjuvant analgesic drug groups
Indications Indications
Corticosteroids Corticosteroids -for dose guidance
Raised intracranial pressure, nerve Raised intracranial pressure, nerve
compression, liver capsule pain, soft tissue compression, liver capsule pain, soft tissue
infiltration infiltration
Antidepressants, Anticonvulsants Neuropathic Antidepressants, Anticonvulsants Neuropathic
pain*, tenesmoid pain Muscle relaxants (e.g. pain*, tenesmoid pain Muscle relaxants (e.g.
baclofen, benzodiazepines) Muscle baclofen, benzodiazepines) Muscle
cramp/spasm, myofascial pain cramp/spasm, myofascial pain
Bisphosphonates Bone pain Antispasmodic Bisphosphonates Bone pain Antispasmodic
(e.g. hyoscine butylbromide) Bowel colic, (e.g. hyoscine butylbromide) Bowel colic,
bladder spasm bladder spasm
Common adjuvant analgesic drug groups Common adjuvant analgesic drug groups
Indications Indications
Corticosteroids Corticosteroids

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CORTICOSTEROIDS IN PALLIATIVE CARE
(these are all the doses needed in palliative care treatment)
Drug choice, formulation and indications
Corticosteroids are used extensively in palliative care.
Dexamethasone is the preferred choice due to its relatively high anti-inflammatory potency and
lower incidence of fluid retention and biochemical disturbance. (Potency: dexamethasone 1mg ~
prednisolone 7.5mg).
Route and formulations:
Dexamethasone tablets 4mg tablet.

Standard starting doses for the different indications are not well established and must take
account of patient factors. Ensure daily dose is administered before noon in order to minimise
insomnia. Clinical response must be reviewed within 7 days. Titrate down to minimum effective
dose.
Anorexia: 2 - 6mg daily. Judge response within 2 weeks. Although enhanced effect can still be
present at 4 weeks, short courses are recommended to reduce risk of side effects. Adjuvant
analgesic: 8 -16mg in cancer-related pain (e.g. liver capsular pain, nerve compression). Anti-
emetic: for chemotherapy follow Oncology guidelines. Refractory nausea and vomiting: 8 - 16mg
daily. Obstructive syndromes e.g. bowel obstruction, upper airways compression, SVCO,
lymphangitis carcinomatosis: 6 - 16mg daily.
Spinal cord compression: 16mg daily for 5 days. Maintain on 8mg daily during radiotherapy, then
reduce dose over 2 weeks. If symptoms recur, increase to previous effective dose for at least 2
weeks before reducing again.
Raised intracranial pressure: 8-16mg daily for one week, and then reduce over 2-4 weeks to
lowest dose which maintains benefit. (If treated with radiotherapy, steroids should be continued
until one-week post treatment, and then reduced as above). Consider trial of dose increase if
symptoms recur.
Prostate cancer: refractory to hormone control: consider prednisolone 10-20mg daily (seek
Oncology advice).
Adverse effects
Glucose metabolism: Steroids can increase blood sugar levels.
Insomnia: Give single or divided daily dose before noon to prevent insomnia.
Dyspepsia: Give after food. Co-prescribe PPI if history of peptic ulcer disease or patient also
taking Aspirin, NSAIDs, SSRIs or is anti-coagulated with Warfarin, LMWH or other agent.
Psychiatric disturbance: depression, mania, psychosis, delirium. Change in appearance: moon
face, truncal obesity, negative body image.
Musculoskeletal problems: proximal myopathy, osteoporosis, avascular bone necrosis.
Increased susceptibility to infection: especially oral/pharyngeal candidosis (examine mouth
regularly).
Skin changes: thinning, bruising, acne, impaired wound healing. Other: hypertension, oedema,
pancreatitis. Drug interactions: see BNF.
Anti-epileptics: accelerate steroid metabolism so patients may require higher doses of steroids.
Warfarin: steroids alter the metabolism of warfarin increasing INR. Monitor INR more regularly.
Safe use: monitoring and stopping treatment
Use the lowest effective dose for the shortest period of time. Close careful monitoring is
essential.

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Steroid withdrawal: stop without tapering dose if total treatment duration of less than 3 weeks
AND daily dexamethasone dose of 6mg or less AND symptoms unlikely to relapse.
Gradual dose reduction: is necessary if any of following: 3 or more weeks treatment, daily dose
of more than 6mg dexamethasone, risk of recurrent severe symptoms, repeated courses of
steroids, other possible causes of adrenal suppression. Daily dose can be reduced rapidly (e.g.
halving dose) to 4mg/day, then more slowly by 1 - 2mg weekly in order to prevent a hypo-
adrenal crisis (malaise, profound weakness, hypotension).
Steroids at end of life: For ongoing serious symptom control, continue at the most convenient
SC dose. If recent and/or low dose prescription for appetite stimulation, discontinue. If long-
term, continue at physiological dose 1mg dexamethasone base.
Steroid treatment card: Patients on systemic steroids for > 3 weeks must be given a steroid
card.
The prescriber must take responsibility for steroid monitoring. The patient and other involved
professionals must be informed of the indication for steroid use and the plan for dose reduction
and monitoring.
CORTICOSTEROIDS

Additional approaches to pain relief will be dictated by clinical circumstances:

• Interventional methods - spinal analgesia, nerve block, radiotherapy, surgical stabilization.
• Non-drug measures - TENS, acupuncture, massage, complementary therapies, cognitive
behavioral therapy
• Rehabilitative support - physiotherapy, occupational therapy
Adverse effect
Prescribers must know the adverse effects and contraindications of all medications that they
prescribe and should consult the BNF if they are unsure. See p5 for common opioid adverse
effects.
NB: Combinations of certain drugs (e.g. NSAIDs, corticosteroids, SSRIs and anticoagulants)
substantially increase the risk of GI bleeding. Co-prescription of a PPI and close monitoring is
essential.

Neuropathic pain (see NICE CG173: Neuropathic pain in adults, first line drugs for neuropathic pain
include amitriptyline and gabapentin. Local prescribing variations may include pregabalin,
duloxetine and nortriptyline. All have comparable efficacy and tolerability, though the supporting
evidence for amitriptyline, gabapentin and pregabalin is more extensive. Choice may be influenced
by individual patient characteristics, drug characteristics and cost. Consider a step-wise approach.
Step 1: Gabapentin/Pregabalin OR Amitriptyline
Step 2: Gabapentin/Pregabalin AND Amitriptyline Step 3: SPCT advice

Drug Cautions Additional Common side Typical dosing

indications effects schedule

Amitriptyline Avoid in patients Depression, Dry mouth, 10mg ON after

Once daily with arrhythmias, anxiety, bladder sedation, postural 3-7 days, then
tablet / syrup heart block, spasm, urgency of hypotension, increased by
ischaemic heart micturition hyponatraemia, 25mg every 1-
disease, urinary hesitancy 2 weeks. Max
congestive heart 150mg ON (if

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failure. May successive
reduce seizure increases are
threshold. beneficial and
Glaucoma, tolerated)
hepatic
impairment.
Gabapentin Absence Sedation, Seizures, (300mg ON,
Three times seizures, dizziness, ataxia spasticity increased by
daily - tablet, psychotic illness. 300mg every
capsule (can be Reduce dose in 2-3 days. Max
opened), renal impairment. 600mg TDS).
solution Elderly / frail
patients†:
100mg ON,
increased by
100mg every
2-3 days.
Reduce
dose/frequency
in renal
impairment.
Pregabalin Avoid in patients Seizures, anxiety Sedation, (75mg BD
Twice daily with congestive dizziness, ataxia increased by
capsule / heart failure. 75mg every 3-
solution Reduce dose in 7 days. Max
renal impairment 300mg BD).
Elderly / frail
patients†: start
2550mg BD
and titrate
more slowly.
Reduce dose/
frequency
This is likely to be a more appropriate titration schedule in most palliative care patients.

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USING OPIOIDS FOR PAIN IN PALLIATIVE CARE

Using opioid drugs safely

Morphine and other opioids are valuable drugs for the relief of severe pain in patients with
advanced malignant and non-malignant disease. These drugs are safe, effective and appropriate
provided that clinicians:
• start and titrate opioids cautiously
• remember different opioids have different properties and potencies (see p7 and 8)
• monitor and manage adverse effects caused by opioids
• remember that some types of pain do not respond well to opioids and require adjuvant
analgesics

The place for opioids in pain management may be guided by a step-wise approach (such as the
traditional WHO “analgesic ladder”), moving up the steps if pain control is not achieved.
STEP 1
Non-opioid (Paracetamol and/or NSAID) +/- adjuvant
STEP 2
Opioid for mild to moderate pain* +/- non-opioid (Paracetamol and/or NSAID) +/- adjuvant (* e.g.
codeine, dihydrocodeine, tramadol
STEP 3
Opioid for moderate to severe pain* +/- non-opioid (Paracetamol and/or NSAID) +/- adjuvant (*
e.g. morphine, oxycodone, fentanyl)

Mild pain (pain score 1-3/10)

Start Non-opioid analgesic:
Non-NSAID:
□ Acetaminophen 500-1,000 PO Q4-6 h (max 4000mg/day) x 24 hours
* Contraindicated if liver dysfunction.
OR

NSAID (Choose 1 only) (contraindicated if renal dysfunction, GI bleeding or coagulopathy):

□ Ibuprofen 200-400 q4-6h (max: 3,200; 2,400; 1,200)
□ Diclofenac In some patients, initial 50, 100 TID (max : 150)
* Patch available—to be applied twice daily to painful area (intact skin
only), Gel and solution dosing joint specific
□ Indomethacin 20 mg 3 times daily or 40 mg 2 or 3 times daily.
(maximum dose 150 ; 200)
* Contraindicated if history with urticaria , asthma and proctitis

OR

NSAID (Choose 1 only) (Contraindicated if renal dysfunction, GI bleeding or coagulopathy): (pain

score 3-5)

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□ Ketorolac 15- 30mg IV Q6-8 h as needed
(Dose for elderly and those under 50 kg) (max
120mg/day) OR
* 1 spray (15.75 mg) in each nostril every 6-8 h in adults <65 yr and
weight ≥ 50 kg
*Contraindicated if use as prophylactic analgesic in major surgery, in
the setting of CABG ,Labor or delivery , breastfeeding , advanced renal
impairment ,bleeding risk ,active peptic ulcer disease.
□ Ibuprofen 400-800mg PO Q6-8 h as needed (max 3200mg/day)

Moderate pain (pain score 4-6/10)

(weak opioids + nonopioids)

Non-NSAID
□ Acetaminophen 500-1,000 PO Q4-6 h (max 4000mg/day) x 24
hours
* Contraindicated if liver dysfunction.
OR

NSAID (Choose 1 only) (contraindicated if renal dysfunction, GI bleeding or coagulopathy):

□ Diclofenac □ In some patients, initial 50, 100 TID (max : 150)
* Patch available—to be applied twice daily to painful
area (intact skin only), Gel and solution dosing
joint specific

□ Indomethacin 20 mg 3 times daily or 40 mg 2 or 3 times daily.

\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ (maximum dose
150 ; 200)
* Contraindicated if history with urticaria , asthma and
proctitis

OR
NSAID (Choose 1 only) (Contraindicated if renal dysfunction, GI bleeding or coagulopathy): (pain
score 3-5)

□ Ketorolac 15- 30mg IV Q6-8 h as needed (Dose for

elderly and those under 50 kg) (max
120mg/day) OR
* 1 spray (15.75 mg) in each nostril every 6-8 h
in adults <65 yr and weight ≥ 50 kg
*Contraindicated if use as prophylactic
analgesic in major surgery, in the setting of

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CABG ,Labor or delivery , breastfeeding ,
advanced renal impairment ,bleeding risk
,active
peptic ulcer disease.

□ Ibuprofen 400-800mg PO Q6-8 h as needed (max

3200mg/day)
OR
ORAL Non-opioid analgesics Plus Opioid Combination OR Oral opioid:
□ Acetaminophen + Codeine Acetaminophen (300 to 1,000 mg/dose)
/codeine (15 to 60 mg/dose) every 4 hours as
needed
(max acetaminophen 4,000 mg/codeine 360
mg per 24 hours).

□ Tramadol 50-100 mg every 4 hours PRN( max

400mg/day ).
* Contraindicated if gastrointestinal
obstruction, concurrent use of (MAOI) or use
within 14 days, acute intoxication with alcohol,
renal impairment or severe/acute
asthma.

Patch to oral (fentanyl)

Remove patch 6 hours before giving first dose of oral MR opioid.
For first 24 hours (i.e. first two doses) give HALF the calculated equivalent dose since the
transdermal opioid will take time to be cleared from plasma and subcutaneous reservoir.
After 24 hours, increase to the calculated equivalent dose if clinically indicated by pain.

Patch to subcutaneous
infusion If the patient is thought to be in the last hours to days of life, leave the patch in place and
continue to change it at the right time intervals, and add a syringe driver with injectable medication
alongside to make up the additional opioid treatment needed.

Subcutaneous infusion to patch

Apply patch. Continue subcutaneous infusion for a further 6 hours then discontinue syringe driver.

Morphine is the first line strong opioid of choice

Drug Dose Specification
Morphine: First line Initial: opioid naïve 5-10 mg every 4 for use by mouth and
strong opioid hours as needed (usual dose 5 to injection/infusion. When used
15mg every 4 hours) by SC infusion, doses greater
than 360mg/24hours are
Iv initial dose: 2.5 to 5mg every 3 to 4 difficult to deliver because of
hours. the volume of the

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corresponding breakthrough
dose
Oxycodone: Semi- Initial dose: 5 to 15mg every 4 to 6 Alternative opioid if morphine
synthetic oral and hours as needed not tolerated or toxicity occurs.
injectable opioid. 5 to 20mg per dose for severe chronic Considered to be 1.5 to 2
pain give every 4 to 6 hours. times as potent as morphine.
When switching either way
between morphine and
oxycodone, start the new drug
at the lowest dose based on
the ratios and retitrate as
needed.
Hydromorphone: Oral and injectable
Semi-synthetic opioid. preparation. Considered to be
5 to 7.5 times more potent
then morphine. Less often
used due to limited IR
preparations. Despite its active
metabolites being renally
excreted, it is sometimes used
as a preferred strong opioid in
renal impairment.
Alfentanil: Please seek Synthetic injectable highly potent Opioid withdrawal symptoms
specialist advice about opioid. Thirty times as potent as oral (like ‘gastric ‘flu’) may occur
the use of alfentanil. morphine (1mg SC alfentanil is (rarely) when switching from
approximately equivalent to 30mg PO other opioids. If so, give ‘as
morphine). Used in preference to other required’ dose of previous
SC opioids in renal failure because opioid for a few days.
there is no accumulation of neurotoxic
metabolites. Single SC doses (as
required doses) are very short-lasting
(<2hours) and this may make alfentanil
unsuitable as an opioid for
breakthrough analgesia even in the
context of renal impairment. Reduce
dose in liver failure.
Buprenorphine: Strong opioid used as sublingual
tablets and transdermal patches (7-day
range and 3-4 day range). Analgesic
efficacy may be reviewed 24hrs after
starting 3-4-day patch or 72hrs after
starting 7-day

Nausea and vomiting in palliative care patients

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Treatment Cause Indication
First line: Haloperidol DOSE: Infection: UTI, pneumonia, Renal impairment,
PO/SC: 0.5-3mg ON. Syringe gastro-enteritis, oropharyngeal hypercalcaemia, other
Driver: 0.5-3mg/24hrs. (5mg candidiasis, meningitis. metabolic upset, drugs,
max dose if necessary). infection. Persistent, often
levomepromazine DOSE: Metabolic: renal impairment, severe, nausea unrelieved by
PO/SC: 6.25-25mg ON. hypercalcaemia, tumour vomiting.
Syringe Driver: 6.25-25mg/24 toxins.
hrs.
Drug-related: opioids,
diuretics, NSAIDs, antibiotics,
chemotherapy.
Metoclopramide DOSE: Gastric stasis: pyloric Fullness/regurgitation, reduced
PO/SC: 10mg TDS to QDS. tumour/nodes, ascites, appetite, nausea relieved by
Syringe Driver: 30- hepatomegaly, opioids, vomiting (often large volume
40mg/24hrs. Higher doses anticholinergic drugs, and undigested). Functional
and long term use under autonomic neuropathy. obstruction (failure of GI
specialist supervision. Be GI disturbance: constipation, motility). Partial bowel
aware of regulatory advice gastritis, ulceration, obstruction (flatus PR, no
(MHRA/EMA) on dose and obstruction, hepatomegaly, colic).
duration related to ascites
neurological side effects.
Or
Domperidone DOSE: PO:
10mg TDS. Higher doses and
long term use under specialist
supervision as may prolong
QT interval with risk of cardiac
dysrhythmia.
*consider trial of steroids
See next diagram GI disturbance constipation, gastritis,
ulceration, obstruction,
hepatomegaly, ascites
Ondansetron:PO/SC: 4-8mg Organ damage: distension, Useful to distinguish between
BD-TDS. Syringe Driver distortion, obstruction, ‘acute’ and ‘delayed’ phase.
16mg/24hrs. radiotherapy.
And or Harm to thoracic, abdominal
Corticosteroids or pelvic viscera caused by
And malignancy or treatment.
Cyclizine DOSE: PO/SC:
50mg TDS. Syringe Driver:
150mg/24hrs. If SC use
causes skin irritation, dilute to
maximum possible volume
with water for injection and
seek specialist advice if
problem persists.

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Cyclizine: DOSE: PO/SC: Neurological: raised intracranial Headache, visual disturbance,
50mg TDS. Syringe Driver: pressure, vestibular disease, other neurological signs.
150mg/24hrs. If SC use motion sickness
causes skin irritation, dilute to
maximum possible volume
with water for injection and
seek specialist advice if
problem persists.
(consider steroids)
Consider non-drug treatment Psychological: anxiety, Anxiety, fear, anticipation
options first. associations of sights/smells
Benzodiazepine,
Then
Levomepromazin:DOSE:
PO/SC: 6.25-25mg ON.
Syringe Driver: 6.25-25mg/24
hrs.

Neurogenic constipation In patients with spinal cord compression or sacral nerve damage who have
lost sensation and/or control:
• Avoid oral stimulant laxatives which may cause uncontrolled bowel function
• Oral faecal softeners will prevent faeces becoming dry and hard
• Consider initiating a 3-day bowel regime (i.e. aim for a formed, not hard, stool and use stimulant
suppositories to evacuate the bowel every 1-3 days)

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