• Optimally treat heart failure and co-morbidities, including anxiety
• Consider referral for Exercise Rehabilitation
• Oral morphine 2.5-5mg 4 hourly and titrate (in normal renal function)

• Search for reversible factors
• Consider treatment of anaemia
• Appropriate exercise
• Avoid steroid and progestogens

Use WHO Analgesic ladder (in normal renal function):

• Step 1: Paracetamol 1g QDS (not soluble as high Na+ content)
• Step 2: Paracetamol 500mg + codeine 30mg, 2 tablets QDS or tramadol 50-100mg QDS +/- regular paracetamol
• Step 3: Morphine 5-10mg 4 hourly and PRN, titrate every 48 hours if pain not controlled

Seek advice if renal function poor, opioid toxicity or inadequate pain control.

For further information see: Chapter: Pain  and Chapter: Renal Failure

• Search for reversible factors
• Oral Metoclopramide 10mg TDS or Haloperidol 1.5-3mg O.D.
• Avoid Cyclizine

Laxative:

• 1st line:  Stimulant (e.g. Senna ); provide routinely to patients on opioids
• 2nd line: Softener ( e.g.lactulose, polyethylene glycol)

• Avoid acids
• Mucin-based saliva substitutes, sugar fee chewing gum

• Use aqueous cream as soap substitute, use emollient as moisturiser
• 2% menthol in aqueous cream for itch

• Have a low index of suspicion for depression
• Short-term Psychotherapeutic interventions
• Avoid Tricyclic antidepressants and drugs with many potential drug interactions (e.g. Fluoxetine)
• Consider Sertraline 50mg OD, Citalopram 10-20mg OD, Mirtazapine 15mg OD

• Look for reversible problems e.g. dry mouth, oral candida, untreated nausea or constipation, ill-fitting dentures
• Have small meals
• Help preparing food – if patient too fatigued to cook
• Dietician advice

• Angina (consider transdermal nitrate if patient cannot take oral nitrate medication)

• Claudication

• Diabetic neuropathy

• Abdominal bloating (due to e.g. liver capsule distension, gut wall oedema, constipation)