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Palliative care: symptom management
Palliative care relieves suffering alongside any other treatment and at any stage of serious illness; at the end of life pain, breathlessness, nausea, confusion and secretions are treated by mechanism, and opioids at an adjusted dose are safe and effective for both pain and breathlessness.
Why it matters in the exam
The exam presents a patient with advanced disease and a particular symptom and asks for the right treatment: an opioid for breathlessness, haloperidol for chemically mediated nausea or delirium, metoclopramide for slow gastric emptying (not in complete bowel obstruction), dexamethasone for raised intracranial pressure, and an antisecretory drug or repositioning for "death rattle". Candidates are also asked when to refer to palliative care — early, not only in the last days.
Recurring points: a laxative is given with every opioid; in older adults start low and go slow; in kidney failure fentanyl, or with caution oxycodone or hydromorphone, is preferred over morphine; pethidine is unsuitable; oxygen helps breathlessness only when there is hypoxaemia, while a fan to the face helps everyone; and palliative sedation (usually midazolam) is reserved for a symptom that responds to nothing else.
The exam also asks about communication: how to break bad news (find out what the patient knows and wants to know, give information in small portions and respond to emotion), and how to conduct a goals-of-care conversation. Candidates are also asked about "double effect" — giving a drug whose aim is relief of suffering, even if it carries a theoretical risk of shortening life, is ethically accepted. Palliative care is also given in diseases other than cancer: heart failure, chronic obstructive lung disease, kidney failure and advanced dementia.
Key points
- Palliative care integrated early, alongside disease treatment.
- Low-dose opioid — for pain and breathlessness; always with a laxative.
- In kidney failure — fentanyl, not morphine.
- Nausea by mechanism: haloperidol, metoclopramide, dexamethasone.
- Oxygen only in hypoxaemia; palliative sedation for a refractory symptom.
Summary table
| Symptom | First treatment | Note |
|---|---|---|
| Pain | Paracetamol, low-dose opioid (morphine about 2.5–5 mg orally as needed) | Regular laxative; in kidney failure — fentanyl |
| Breathlessness | Low-dose opioid, fan, positioning | Oxygen only in hypoxaemia |
| Nausea | By mechanism: haloperidol (chemical), metoclopramide (slow stomach), dexamethasone (raised intracranial pressure) | Metoclopramide — not in complete obstruction |
| Delirium at the end of life | Search for a reversible cause, haloperidol | Midazolam for severe distress |
| Secretions at the end of life | Repositioning, antisecretory drug (glycopyrronium or hyoscine butylbromide) | Deep suctioning does not help and is distressing |
| Opioid-induced constipation | Osmotic or stimulant laxative | Methylnaltrexone if no response |
A free exam question
חולה עם סרטן לבלב, המטופלת ב- gemcitabine , סובלת מכאבים והופנתה לטיפול קרינתי פליאטיבי לגרורה ב. L1 ?. כיצד לנהוג במקרה זה (the question as examined, in Hebrew)
- א. אין צורך בביצוע שינוי בטיפול בתרופה, מאחר ואין כמעט אינטראקציה בינה לבין הטיפול הקרינתי
- ב. ניתן להפחית את מינון התרופה או להקטין את שדה הקרינה, על מנת להקטין את הסיכוי לתופעות לוואי מהמשלב
- ג. לתרופה ישנה אינטראקציה של הקרינה ומומלץ על משלב זה, אשר מגביר את יעילות הטיפול הקרינתי
- ד. Gemcitabine בעל מחצית חיים ארוכה ונחשב כמרגש לטיפול קרינתי ולכן מומלצת הפסקת טיפול ארוכה טרם הטיפול הקרינתי
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Sources
- Oxford Textbook of Palliative Medicine, 6th edition (2021) — Symptom management in advanced disease
- NICE guideline — Care of dying adults in the last days of life, NG31 (2015) — Managing symptoms
- ESMO clinical practice guidelines — management of cancer pain in adult patients, 2018 — Opioid use and adjuvants
- Geriatrics Review Syllabus (American Geriatrics Society), 11th edition (2022) — Palliative care
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.