Synopsis
Relieve pain, breathlessness, nausea, delirium, anxiety and secretions with cause-led non-drug care, low starting doses and vigilant organ-function review.
- Assess the symptom, likely cause, severity, reversible contributors and the person's goal before selecting a medicine.
- Non-drug measures remain active treatment: repositioning, a fan, quiet reassurance, mouth care, bladder and bowel relief can work quickly.
- Choose oral or buccal routes while swallowing is reliable; use subcutaneous rather than intramuscular administration when oral treatment fails.
- In frailty, start below standard adult doses when appropriate, titrate to observed benefit and check after every early dose.
- Morphine metabolites accumulate in severe renal impairment; seek palliative advice and use a renal-appropriate opioid regimen.
- A continuous subcutaneous infusion maintains control but does not deliver rescue treatment; prescribe compatible breakthrough medicines separately.
- More than two or three effective as-required doses in 24 hours may justify incorporating their total into a reviewed 24-hour infusion.
- Sedation is a possible adverse effect, not the intended purpose of opioids; refractory distress requiring deeper sedation needs specialist oversight.
Key red flags
Bradypnoea, pinpoint pupils, new myoclonus, hallucinations or profound sedation suggest opioid toxicity, particularly after acute kidney injury.
Sudden agitation may represent urinary retention, faecal impaction, pain, hypoxia, hypoglycaemia, medicine withdrawal or an unsafe environment.
New stridor, massive haemoptysis, haematemesis or rapidly increasing breathlessness requires the pre-agreed emergency response and senior support.
Repeated as-required doses provide little benefit, indicating a wrong cause, wrong route, toxicity or need for specialist titration.
A syringe pump is started automatically without calculating previous opioid exposure, checking compatibility or prescribing breakthrough doses.
Haloperidol or metoclopramide is proposed in Parkinson's disease or Lewy body dementia without recognising extrapyramidal risk.
Investigation priorities
Measure distress and identify its mechanism.
Management branches
A new or worsening symptom is causing distress in advanced frailty.
- Define the symptom and goal, examine for reversible contributors and review the current escalation and capacity context.
- Apply proportionate non-drug measures immediately, including positioning, airflow, reassurance, mouth care, bladder or bowel relief.
- Choose one cause-matched medicine at a low appropriate dose, specify the route and review interval, and explain expected benefit.
- Reassess benefit and adverse effects promptly before repeating, escalating or adding another sedating medicine.