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Palliative Care Prescribing

BNF Medicines guidance Prescribing in palliative care

Guidelines

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

If early satiety due to delayed gastric emptying, offer prokinetic drugs (metoclopramide / domperidone)

Appetite stimulants:
  • Dexamethasone
  • Prednisolone
  • Progestogen (e.g. megestrol acetate)

Hyoscine butylbromide (Buscopan) is the drug of choice.

  • ​​​​​​​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

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

  • If due to tumour obstruction → dexamethasone
  • If due to oesophagitis and oesophageal spasm → sublingual GTN before meals

1st line options (depending on cause):
 
Cause of N&V Choice of Drug
↓ Gastric motility Prokinetics:
  • Metoclopramide
  • Domperidone
↑ ICP and/or vestibular dysfunction Cyclizine + dexamethasone
Chemical-induced Haloperidol

If the above failed, levomepromazine (broad spectrum antiemetic) can be used (but note the risk of sedation, extrapyramidal symptoms and anticholinergic effect).

  • If anxiety prominent → benzodiazepine
  • If delirum prominent → antipsychotic 

BNF notes that there is comparable efficacy between CBTCognitive Behavioural Therapy and drugs.

Chocie of drugs depends on prognosis:
  • Days to weeks of life → benzodiazepines (e.g. diazepam, lorazepam, midazolam)
  • Months or more of life → SSRI +/- benzodiazepines

Dexamethasone can provide temporary symptomatic relief from pain or headache if raised ICP secondary to cerebral oedema.

  • 1st line: levetiracetam (as the dose can be titrated rapidly and it has few drug interactions)
  • For last days of life: midazolam

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 COPDChronic obstructive pulmonary disease:
  • Nebulised bronchodilators (beta-2 agonist +/- antimuscarinic)
  • As required dose of SABA prior to exertion

For last day of life: opioid + benzodiazepine

If hiccups due to gastric distension +/- GORDGastro-oesopahgeal reflux disease:
  • Prokinetic (e.g. metoclopramide) OR
  • Antiflatulent (e.g. peppermint oil or simeticone) OR
  • Proton pump inhibitor (e.g. lansoprazole or omeprazole)

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

 

​​​​​​​Cough suppressants should NOT be given for wet (productive) cough, because they inhibit mucus clearance, leading to secretion retention and increased risk of infection.

Subutaneous hyoscine butylbromide (Buscopan) / glycopyrronium bromide
  • To be given as soon as the rattle begins

References

Author: Adams Lau
Reviewer:
Last edited: 25/05/25