Setting a symptom management plan in palliative care

After undertaking a comprehensive assessment, and realistic and acceptable goals of care have been clarified with the patient, their family and carers, systematically develop a comprehensive and individualised management plan. Aspects of symptom management in palliative care are listed in Approaches to symptom management in palliative care.

Table 1. Approaches to symptom management in palliative care

Approach to symptom management

Example

Stop or change treatments or drugsRowett D, 2014

For adverse effects (eg extrapyramidal tremor) of metoclopramide or another dopamine-receptor antagonist antiemetic, consider an alternative antiemetic.

Use disease-modifying treatment for life-limiting illness

For pain due to malignant spinal cord compression, radiotherapy can provide symptom relief.

Treat intercurrent illness

For oropharyngeal candidiasis in a patient with severe dysphagia from untreatable carcinoma of the oesophagus, antifungal therapy can provide symptom relief as well as treating infection.

Use multimodal treatment options

For painful bone metastases from metastatic breast cancer, pain management may include:

  • aids and equipment to reduce pain associated with activities of daily living
  • regular background analgesic therapy and as-required doses of analgesics for breakthrough pain
  • palliative chemotherapy or radiotherapy as an adjuvant for bone pain
  • therapy to prevent other manifestations of disease due to bone metastases, such as hypercalcaemia.

Use a less burdensome route of drug administration

For uncontrolled vomiting caused by advanced gastric cancer, consider administering an antiemetic by continuous subcutaneous infusion via a small portable pump. Once vomiting is controlled, it may be possible to change to a regular dose of oral antiemetic.

Provide psychological and emotional support

For panic and anxiety in advanced chronic obstructive pulmonary disease (COPD), breathlessness improves when anxiety is treated with psychological support, behavioural interventions and (if required) drugs.

Managing other factors (social, spiritual, cultural, geographical)

For a patient with no local family or carer support and increasing forgetfulness and confusion, symptom management may be improved by facilitating medication adherence with the use of a dose administration aid delivered regularly by the local pharmacy. Alternatively, drugs can be administered by community nurses.

Anticipating and planning for new or worsening symptoms, including catastrophic terminal events

For a patient with pain from a large oral tumour who is managing to eat and drink, consider changing to a non-oral analgesic (eg transdermal patch) before they become unable to safely swallow oral drugs.

Note: Encourage patients to be involved in decision-making about their management.

Encourage patients to be involved in decision-making about their management; this facilitates patient-centred care, builds trust, enhances adherence to the management plan and allows patients to retain a sense of control.

Clear and timely communication between different healthcare professionals and carers is essential. Ensure that patients and their carers have clear instructions regarding the proposed symptom management plan; both a verbal explanation and written instructions are helpful. Clarify that the patient understands the instructions provided; do not assume that a patient can read written information.

Consider what information or education may be needed by those caring for the patient in the community in order to follow the management plan. For advice on guiding patients and carers with medication management, see Assisting patients and carers with medication management in palliative care. For advice on managing subcutaneous drug administration at home, see Assisting patients and carers to manage subcutaneous administration in the community.