AS8.4-5 | Pain Management in Palliative Care and Terminal Illness — Summary & Reflection

KEY TAKEAWAYS

Palliative care addresses quality of life in life-threatening illness across all its domains — physical, psychological, social, and spiritual — and should be integrated early alongside disease-directed treatment. The ethical basis for adequate analgesic use in terminal illness is straightforward beneficence: appropriately titrated opioids do not hasten death. Cancer pain is typically mixed (nociceptive somatic, visceral, and neuropathic); each component requires targeted management. Morphine remains the first-line strong opioid: start at 5–10 mg four-hourly in opioid-naïve patients, titrate by calculating total 24-hour consumption and redistributing as regular MR plus breakthrough IR doses. Neuropathic cancer pain requires adjuvants (gabapentinoids, corticosteroids, TCAs); bone pain benefits from NSAIDs, bisphosphonates, and radiotherapy. When oral administration fails, switch to SC infusion: oral morphine total daily dose ÷ 2 = SC morphine 24-hour dose, with breakthrough doses every 4 hours as needed. Terminal symptoms (dyspnoea, agitation, secretions) are managed with anticipatory prescribing: SC morphine for dyspnoea/pain, SC midazolam for agitation, SC hyoscine butylbromide for secretions. Anticipatory prescribing — writing these orders before they are needed — is the single most important operational principle in end-of-life care.

REFLECT

Palliative care raises some of the most ethically and emotionally demanding clinical situations you will encounter. Reflect on the following: Have you encountered a dying patient whose pain or other symptoms were not adequately managed? What were the reasons — was it prescriber reluctance, inadequate training, family objection, or resource limitation? If you were that patient's doctor, what would you do differently now? Consider also the systemic challenge: in India, morphine availability per capita is among the lowest globally, despite the country having 1.35 million new cancer patients annually. What advocacy roles can a clinician take in improving access to opioids for patients who genuinely need them? How do you balance legitimate concern about opioid misuse with the moral imperative to relieve suffering at the end of life?