Symptoms and management options

  • 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


  • 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)


This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.