Palliative care is designed to enhance patients’ quality of life by addressing their needs holistically, rather than focusing solely on the disease. This is particularly true when the disease is unresponsive to curative treatments. Patients may receive palliative care in various settings, including hospitals, outpatient clinics, or at home under the supervision of a licensed healthcare provider.
Palliative care is essential for both cancer and non-cancer patients with progressive, life-limiting illnesses. It plays a crucial role in managing chronic pain and other distressing physical symptoms. For example, palliative care teams support patients with breast cancer, colorectal cancer, lung cancer, and prostate cancer, as well as those with non-cancer conditions such as end-stage cardiac or renal diseases, neurodegenerative disorders, life-threatening paediatric conditions, and HIV/AIDS cases that are unresponsive to antiretroviral therapy.
Palliative care involves close collaboration among healthcare professionals, including doctors, pharmacists, nurses, dietitians, physiotherapists, and occupational therapists. In the context of palliative care for cancer patients, the multidisciplinary team is responsible for addressing disease-related symptoms and treatment side effects as early as possible, as well as providing caregiver support to help maintain the best possible quality of life for patients. To achieve these goals, certain medicines are essential for effective symptom management.
- Medicines for pain relief
Pain management is a cornerstone of palliative care. For mild to moderate musculoskeletal pain, first-line treatment typically involves paracetamol and non-opioid analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs such as diclofenac and ibuprofen, may cause gastrointestinal side effects, including stomach upset, ulceration, or bleeding. These risks are higher in elderly patients and in individuals with a history of gastrointestinal disorders.
When pain progresses to a moderate level, weak opioids may be introduced as second-line therapy, either alone or in combination with non-opioid analgesics. In cases of severe pain, strong opioid analgesics form the mainstay of treatment. Commonly used opioids include morphine, oxycodone, and transdermal fentanyl. Beyond pain control, morphine is also effective in relieving symptoms such as shortness of breath. Transdermal fentanyl is particularly beneficial for patients with renal impairment or those who are unable to take oral medicines. Opioid analgesics are commonly associated with side effects such as dizziness, nausea, constipation, and sedation.
- Medicines for nausea and vomiting
To manage nausea and vomiting, metoclopramide is usually administered as a first-line treatment, while promethazine may be used as a second-line or alternative option. However, metoclopramide can cause side effects such as drowsiness, dizziness, and, in rare cases, tremors or rigidity (extrapyramidal symptoms); moreover, long-term use may lead to involuntary movements (tardive dyskinesia).
- Medicines for delirium
Haloperidol is frequently prescribed for the management of delirium, a condition marked by sudden confusion, impaired attention, disorientation, and fluctuating levels of consciousness, as well as for terminal restlessness. Although it is effective in alleviating these symptoms, haloperidol may lead to side effects such as sedation, muscle stiffness,low blood pressure, or agitation.
- Medicines for constipation
Constipation is a common issue among palliative care patients, making the use of laxatives essential. Common options include bisacodyl (tablets or suppositories), lactulose syrup, and glycerin enemas. Lactulose may cause bloating, flatulence, and diarrhoea, particularly at higher doses, and prolonged use can lead to electrolyte imbalances. Bisacodyl may result in abdominal cramps, diarrhoea, or dependence if used frequently.
- Medicines for neuropathic pain
For patients experiencing neuropathic pain, amitriptyline, carbamazepine, and gabapentin are commonly prescribed. Carbamazepine, in particular, is preferred for neuropathic pain in patients who also have epilepsy. It is important to note that amitriptyline may cause side effects such as dry mouth, sedation, constipation, difficulty in urination, and blurred vision, with older adults being particularly vulnerable. Similarly, gabapentin can lead to dizziness, sedation, and swelling of the limbs.
- Corticosteroids
Corticosteroids, such as dexamethasone and prednisolone, may be prescribed to cancer patients to help manage loss of appetite, reduce inflammation, relieve fatigue, and alleviate other cancer-related symptoms. However, their use may be associated with side effects, including weight gain, gastrointestinal upset, and insomnia. Long-term use can lead to more serious complications, such as osteoporosis, increased susceptibility to infections, and suppression of adrenal gland function, which affects cortisol production.
- Other medicines
There are several other types of medications used in palliative care. For example, hyoscine is commonly prescribed for managing cramp-like abdominal pain, excessive terminal respiratory secretions (the accumulation of mucus and saliva in the throat), and nausea or vomiting associated with bowel dysfunction. Its use helps relieve patient’s discomfort at the end of life. However, common side effects include dry mouth, blurred vision, difficulty in urination, constipation, and confusion, particularly in elderly patients.
In addition, loperamide is often used to manage diarrhoea in palliative care patients, helping to reduce fluid loss and maintain comfort. Its side effects may include constipation, abdominal discomfort, and bloating, while dizziness or dry mouth may occur rarely.
Advice for patients
On average, palliative care patients may be prescribed five to six medicines in a single regimen. As a result, adherence to the treatment plan can be affected, which presents a challenge in ensuring effective symptom management. However, adherence is crucial for improving a patient’s quality of life.
Therefore, patients, together with their caregivers, should communicate with their doctor or pharmacist to identify strategies that can enhance adherence and ensure optimal benefit from their prescribed treatments. Engaging in open and ongoing discussions with the healthcare team can help improve outcomes. Patients should also always consult their healthcare providers before taking any new medicines to ensure that the medication is appropriate for their specific needs, compatible with their treatment plan, and safe for their health status.
Patients should avoid using unregistered or unauthorized products, as these may pose serious health risks. Such products often contain potentially harmful ingredients, as their safety and effectiveness have not been verified through scientific testing. Patients can check whether a product is registered with the Ministry of Health by using the Product Search feature on the National Pharmaceutical Regulatory Agency (NPRA) website (www.npra.gov.my).
In summary, effective palliative care relies on a multidisciplinary approach, appropriate use of medicines, and active engagement between patients, caregivers, and healthcare providers. Ensuring safe, tailored treatments and maintaining open communication can significantly enhance patients’ comfort, well-being, and quality of life.
This article was prepared by Chua Yee Tyan (Pharmacist) from Hospital Queen Elizabeth 2 for Bahagian Amalan dan Perkembangan Farmasi (BAPF), KKM x The Malaysian Medical Gazette Series. It is hoped that this collaboration will help propagate information regarding medication to the general public.