Palliative care and cancer pain

• Palliative care is care that starts early when a serious illness is diagnosed, runs alongside disease-directed treatment, and aims to relieve suffering in all its dimensions (physical, psychological, social and spiritual) so that the patient and family can live as well as possible.
• Cancer pain is common: WHO estimates it is felt by 55% of patients receiving anti-cancer treatment and 66% of those with advanced, metastatic or terminal disease; despite this, most cancer pain can be relieved with medicines.^[1]
• The classic teaching framework is the WHO three-step analgesic ladder: non-opioid analgesics, then weak opioids, then strong opioids such as morphine, plus (where useful) adjuvant medicines. Recent reviews argue that the middle step is often skipped, starting a low dose of a strong opioid instead. Both views are current, and your local guideline is the one to follow.^[5][3]
• NICE (UK, 2012, updated 2016, last reviewed 2024) advises oral morphine as first-line strong opioid treatment in advanced progressive disease, with morphine for breakthrough pain, and gives a concrete starting schedule.^[3]
• Near the end of life the target changes from "cure" to comfort: recognise dying, keep the patient comfortable with an individualised plan, treat distressing symptoms, and support the family. NICE lists the common symptoms and how to manage them.^[4]

By the end of this page you should be able to:

1. Define palliative care and describe when it should begin relative to cancer treatment.
2. Assess cancer pain by mechanism, site and severity, and recognise pain as "total pain".
3. Explain the WHO analgesic ladder, its steps, and how newer evidence and NICE guidance modify its use.
4. Prescribe a first opioid regimen for cancer pain in an adult without renal or hepatic impairment, titrate it, and manage breakthrough pain, constipation and nausea.
5. Recognise and manage the symptoms that become prominent in the last days of life (breathlessness, nausea, agitation, noisy secretions, dry mouth, pain).
6. Explain the ethical principles that guide decisions about prolonging, withholding or withdrawing treatment and about clinically assisted hydration and nutrition.
7. Identify the practical and equity issues of palliative care in low-resource settings.

Palliative care is not "giving up". The WHO wording above makes the point directly: palliative care is an active, skilled approach to a person's total suffering, delivered alongside chemotherapy, radiotherapy, surgery and other anti-cancer treatment from the moment of diagnosis when it is needed.^[2] Two ideas follow.

First, timing. Palliative care is most effective when it is considered early in the illness; early palliative care improves quality of life for patients and reduces unnecessary hospital admissions and use of health-care services.^[2] This is a change from the older habit of asking for palliative care only in the last few days.

Second, scope. Pain is only part of it. The majority of adults in need of palliative care have chronic diseases other than cancer: WHO lists cardiovascular disease (38.5%), cancer (34%), chronic respiratory disease (10.3%), AIDS (5.7%) and diabetes (4.6%), plus many other conditions.^[2] Palliative care is needed whenever a person has a serious illness. This page, however, concentrates on cancer and on its pain.

A practical narrative anchor: among patients in need of palliative care, pain and difficulty in breathing are two of the most frequent and serious symptoms. WHO estimates that 80% of patients with AIDS or cancer, and 67% of patients with cardiovascular disease or chronic obstructive pulmonary disease, will experience moderate to severe pain at the end of life, and that opioids are essential for managing it.^[2]

Cancer pain is not a single problem. A patient can have several pains, from different causes, at the same time, and the physical pain sits inside anxiety, low mood, existential fear and family exhaustion. Clinicians call this total pain: the whole of the suffering that the disease creates.

WHO estimates 56.8 million people, including 25.7 million in their last year of life, are in need of palliative care worldwide, yet only about 14% receive it.^[2] WHO's 2019 cancer pain guideline lists 18.1 million new cancer cases and 9.6 million cancer deaths in 2018, and notes that pain is experienced by 55% of patients during anti-cancer treatment and by 66% of those with advanced, metastatic or terminal disease, but that pain can be relieved in most cases with medicines and other treatments.^[1]

Good analgesia starts with assessment. The questions below are restated in clinical language from the principles in NICE NG31 (recognising dying and symptom control) and WHO.

• Severity. Use a simple numeric pain scale (or faces/verbal scales when the patient cannot use numbers). Record worst, average and current pain.
• Where and what. Bone pain from metastases, visceral pain from organ capsule stretch, neuropathic pain from tumour or treatment (burning, electric, allodynia), incidental or "breakthrough" pain on movement.
• Breakthrough pain. Sudden, usually brief flares on top of controlled background pain. Distinguish predictable (on movement) from spontaneous; these guide the choice of rescue analgesia.
• Mechanism and cause. Is the pain from the tumour, from treatment, or unrelated (for example osteoarthritis or infection)? NICE advises assessing all possible causes when making prescribing decisions for pain.^[4]
• Total pain. Anxiety, depression, spiritual distress and fear amplify pain and blunt the response to analgesics. Treating only the physical component often fails.
• Red flags. New severe pain with fever; suspected spinal cord compression (back pain with weakness, numbness in a dermatomal band, new incontinence or retention); pathologic fracture; a pain that is opioid-naive but escalates rapidly; a "wind-up" neuropathic pain; signs of opioid toxicity. Spinal cord compression is a neurological emergency: start dexamethasone and image urgently, following local oncology protocols.

WHO's guideline organises cancer pain work into three focal areas: analgesia of cancer pain (choice of analgesic medicine when starting, choice of opioid for maintenance, optimisation of rescue medication, route, rotation and cessation); adjuvant medicines (steroids, antidepressants, anticonvulsants); and management of pain from bone metastases (bisphosphonates, radiotherapy).^[1]

The stepwise framework is:

Two points about the ladder are important in modern practice.

First, the ladder was hugely influential and observational studies of the WHO approach report adequate analgesia in a large majority of patients.^[7] Second, the middle step has come under serious criticism. A 2025 review in Clinical Medicine ("Cancer pain - all change please?") argues that weak opioids such as codeine and tramadol offer limited benefit with more side effects than initiating treatment with strong opioids, and that the ladder is being re-evaluated; long-term opioid use also carries risks (cognitive impairment, opioid-induced hyperalgesia, endocrine dysfunction) that require attention.^[5] NICE (CG140, 2012) takes a different line for adults with advanced progressive disease: when strong opioids are needed, use oral morphine first line, not transdermal patches, and use morphine liquid or tablets for rescue doses rather than fast-acting fentanyl first line.^[3]

The honest position for a student: national and global guidelines differ on exactly when to introduce a strong opioid, but they agree on the principles - match analgesic potency to pain severity, titrate to effect, keep the regimen simple, prefer the oral route, and monitor side effects. Use the ladder as a framework, not a law, and follow your local guideline.^[1][3][5]

NICE CG140 recommends oral morphine as first-line when strong opioids are needed in adults with advanced and progressive disease, with oral immediate-release morphine rescue doses for breakthrough pain, in patients without moderate-to-severe renal or hepatic impairment.^[3]

Starting schedule from NICE CG140 (adults, no renal or hepatic comorbidity): a typical total daily starting dose of 20 to 30 mg of oral morphine - for example, 10 to 15 mg of oral sustained-release morphine twice daily - plus 5 mg of oral immediate-release morphine for rescue doses during the titration phase.^[3]

Maintenance: offer oral sustained-release morphine as first-line maintenance treatment; do not routinely offer transdermal patch formulations when oral opioids are suitable.^[3] If pain remains inadequately controlled, review the analgesic strategy and consider specialist advice. Transdermal patches, when used, should be those with the lowest acquisition cost in patients whose oral intake is unsuitable and whose analgesic requirements are stable, supported by specialist advice.^[3]

Rescue (breakthrough) pain: offer oral immediate-release morphine first line; do not offer fast-acting fentanyl first line.^[3] For patients titrating on 4-hourly normal-release morphine, the rescue dose is the same 4-hourly dose, repeated as often as required (up to hourly), with the total daily dose reviewed daily - classic EAPC (2001) practice, still widely taught.^[7]

Routes. The EAPC (2001) recommends the oral route as the simplest and most acceptable; if a patient cannot take morphine by mouth, the preferred alternative route is subcutaneous; intramuscular injection is generally not indicated for chronic cancer pain.^[7] When converting, the average relative potency ratio of oral to subcutaneous or intravenous morphine is around 2-3 to 1 (oral morphine is less potent than parenteral morphine, due to first pass metabolism).^[7] Treat these as starting estimates only - individual variation is large, so titrate afterwards and involve a palliative care specialist when switching.

Dose titration and review. NICE says adjust the dose until a good balance exists between acceptable pain control and side effects; if this balance is not reached after a few adjustments, seek specialist advice, and offer frequent review, particularly in the titration phase.^[3] Give the patient information and access to frequent review of pain control and side effects.^[3] Monitor driving and manual-task warnings because impaired concentration can be a side effect.^[3]

Renal and hepatic impairment. Seek specialist advice before prescribing strong opioids for patients with moderate to severe renal or hepatic impairment.^[3] Morphine metabolites accumulate in renal impairment, leading to neurotoxicity (sedation, confusion, myoclonus).

Switching opioids. If intolerable adverse effects appear before adequate analgesia, consider changing to an alternative opioid or changing the route. NICE advises optimising constipation and nausea management first before switching.^[3] Without good evidence of superiority, morphine remains the default in most guidelines for reasons of familiarity, availability and cost; hydromorphone or oxycodone, where available in normal and modified release, are effective alternatives; methadone is effective but may be more complicated (pronounced interindividual differences) and its use by non-specialists is not recommended; transdermal fentanyl is best reserved for patients with stable requirements.^[7] Specialist palliative care advice is recommended for opioid rotation and for spinal (epidural or intrathecal) administration.^[7]

Cancer pain uncontrolled? Review the cause, assess the pain's components (including neuropathic and bone pain), check adherence and supply, consider dose escalation, route change, adjuvants and radiotherapy, and escalate to specialist palliative care. Bisphosphonates and radiotherapy for bone metastases are a formal focal area of the WHO 2019 guideline.^[1]

Non-opioids (paracetamol, NSAIDs, COX-2 inhibitors) remain the backbone for mild and inflammatory cancer pain and are often continued when opioids are added. WHO lists adjuvant medicines as a formal focal area: steroids, antidepressants and anticonvulsants.^[1] In practice:

• Neuropathic (nerve) pain often responds poorly to opioids alone; agents such as anticonvulsants and certain antidepressants are used. Dosing and titration here follow local guidelines and formularies.
• Bone metastasis pain may need antiresorptive therapy (bisphosphonates or denosumab) and radiotherapy; these are a separate focal area of the WHO cancer pain guideline.^[1]
• Corticosteroids can relieve pain from raised intracranial pressure, nerve compression and inflammatory components.
• Balance analgesia against harms: NSAIDs raise risks in renal impairment, gastrointestinal ulcer disease and cardiovascular disease; corticosteroids have their own side-effect profile.
• Where opioids appear ineffective, consider a different pain syndrome (for example, incident or movement pain) and interventional options (nerve block, intrathecal therapy) with specialist support.^[7]

NICE CG140 provides the management rules for the side effects of strong opioids.^[3]

• Constipation. It affects nearly all patients receiving strong opioids. Prescribe a laxative regularly at an effective dose for everyone starting, inform patients that treatment takes time to work and adherence matters, and optimise laxative treatment before considering switching opioids. Where laxatives fail, NICE lists the partial opioid antagonists naldemedine (TA651, 2020) and naloxegol (TA345, 2015) as options for opioid-induced constipation after laxatives.^[3]
• Nausea. Nausea may occur when starting a strong opioid or after a dose increase, but it is usually transient. If it persists, prescribe and optimise anti-emetic treatment before considering switching opioids. If nausea remains troublesome, add therapy before considering switching opioids.^[3]
• Drowsiness and impaired concentration. Mild drowsiness or impaired concentration may occur when starting or increasing a dose, but is often transient. Warn patients that impaired concentration may affect their ability to drive and undertake manual tasks. In patients with persistent or moderate-to-severe central nervous system side effects: consider dose reduction if pain is controlled, or switching opioids if pain is not controlled. If side effects remain uncontrolled despite optimising treatment, seek specialist advice.^[3]
• Addiction, tolerance and fears that opioids imply the final stages of life. NICE CG140 recommends asking patients about these concerns at the start. In therapeutic use for cancer pain, the feared problems are largely unfounded: extensive clinical experience supports that regular morphine can be safely instituted early and continued for months, and stopped without difficulty when pain improves. This position is drawn from the classic EAPC (2001) review of morphine and alternative opioids.^[7]
• Respiratory depression is rarely a problem in tolerant patients receiving stable, appropriate doses; risk rises with rapid escalation, in older or frail patients, and when other sedatives are combined.
• Opioid-induced hyperalgesia and long-term harms. A 2025 review links long-term opioid use to cognitive impairment, opioid-induced hyperalgesia and endocrine dysfunction.^[5] Consider dose reduction, rotation or a multidisciplinary plan when these appear.
• Bowel obstruction. In patients with obstructive bowel disorders and nausea/vomiting, NICE (NG31) advises hyoscine butylbromide as first-line pharmacological treatment, then octreotide if symptoms do not improve within 24 hours. ^[4]
• Safe storage and follow-up. NICE asks for verbal and written information (how, when and how often to take opioids, how long pain relief should last, side effects and signs of toxicity, safe storage, follow-up and prescribing, who to contact out of hours, especially during initiation) and access to frequent review.^[3]

Pain is only one of the distressing symptoms of advanced cancer. A JCO review (2020) of symptom management concludes that good symptom management in oncology is associated with improved patient and family quality of life, greater treatment compliance, and may even offer survival advantages.^[6] Assess systematically (for example with a validated symptom score) and revisit often.

Breathlessness is common in advanced cancer, and not every breathless patient is hypoxic. NICE advises identifying and treating reversible causes (pulmonary oedema, pleural effusion); considering non-pharmacological management; not routinely starting oxygen (give it only when there is symptomatic hypoxaemia); and considering management with an opioid, a benzodiazepine, or a combination of the two (these uses were off-label when the NICE guidance was drafted in December 2015).^[4] A fan, a cool draught, pacing and physiotherapy support sometimes help as much as drugs.

Nausea and vomiting. Assess likely causes (medications, recent chemotherapy or radiotherapy, psychological causes, biochemical causes such as hypercalcaemia, raised intracranial pressure, gastrointestinal motility disorder, ileus or bowel obstruction). Discuss options with the patient. Try non-pharmacological methods. When choosing medicines, balance the cause, reversibility, sedative effects, other symptoms, drug interactions and compatibility. For obstructive bowel disorders, as above, hyoscine butylbromide is first line, with octreotide at 24 hours if needed.^[4]

Constipation. See the opioid section. Prescribe laxatives routinely and escalate if not controlled.

Anxiety, delirium and agitation. Explore causes (including unrelieved pain, a full bladder or rectum). Treat reversible causes (for example renal failure, hyponatraemia, psychological distress). Consider non-pharmacological management. A benzodiazepine may help anxiety and agitation; an antipsychotic may help delirium or agitation. Seek specialist advice if the diagnosis is uncertain, if symptoms do not respond to antipsychotic treatment, or if there is unwanted sedation.^[4] Agitation needs particular care: it may be the first sign of pain, urinary retention or constipation rather than distress that needs sedation.

Noisy respiratory secretions ("death rattle"). This is distressing for family, but patients are usually not distressed by it, and it is unlikely to cause discomfort. Reassure the family. Consider non-pharmacological measures. Consider a short trial of an anticholinergic drug (atropine, glycopyrronium bromide, hyoscine butylbromide or hyoscine hydrobromide; off-label when drafted) with review of benefit and side effects (dry mouth, delirium, excessive sedation), monitoring improvements preferably every 4 hours and at least every 12 hours; reconsider or stop the drug if secretion distress persists beyond 12 hours or unacceptable side effects develop.^[4]

Dry mouth and oral care. In the dying phase the mouth often becomes dry. Offer frequent mouth and lip care, help with cleaning teeth or dentures, and frequent sips of fluid if the person can swallow safely; those close to the patient can help with care giving.^[4]

Drowsiness, fatigue and weakness. Fatigue is common in advanced cancer; identify reversible causes (anaemia, depression, side effects, metabolic disturbance) and pace activities; avoid attributing all fatigue to cancer without assessment.^[6]

Pruritus, hiccup, sweats and cramps occasionally need attention; address causes first and use targeted treatment from your local formulary.

NICE NG31 covers care of adults in the last days of life and is designed to be used alongside clinical judgement; being certain that a person is dying is often difficult.^[4]

Signs that suggest a person may be entering the last days of life include: agitation; Cheyne-Stokes breathing; deterioration in level of consciousness; mottled skin; noisy respiratory secretions; progressive weight loss; increasing fatigue; loss of appetite; and functional changes (communication, mobility or performance status, social withdrawal).^[4] Improvement in these can indicate that the person may be stabilising or recovering, so review daily.^[4]

Good practice in this phase^[4]:

• Gather and document information on physiological, psychological, social and spiritual needs; current clinical signs and symptoms; medical history and clinical context; the person's goals and wishes; the views of those important to the person.
• Review medicines and, after discussion and agreement, stop any that are not giving symptomatic benefit or may cause harm.
• Use the individualised care plan (developed with the person, their family and the multidisciplinary team) for goals, wishes, preferred care setting, current and anticipated needs including symptom preferences, and resource needs; share and update it.
• Decide routes based on ability to swallow and the person's preferences; if oral medicines are not tolerated, avoid intramuscular injection and use subcutaneous or intravenous routes.
• Start with the lowest effective dose for someone newly prescribed symptom relief medicines and titrate; reassess symptoms at least daily.
• Seek specialist palliative care advice promptly if symptoms are not controlled or side effects (such as unwanted sedation) occur.

Anticipatory (just-in-case) prescribing. NICE advises specifying the indications and dosages of medicines that may be needed for common end-of-life symptoms (pain, breathlessness, nausea/vomiting, anxiety/agitation, noisy secretions); prescribe them early, review as needs change, and consider place of care and time needed to obtain medicines. A syringe driver (continuous subcutaneous infusion) is appropriate if more than 2 or 3 as-required doses are given within 24 hours.^[4] This prevents crises and unnecessary transfers.

Hydration. Support the person to drink if they wish and can. Reassess hydration daily and discuss clinically assisted hydration (subcutaneous, intravenous or enteral) honestly: it may relieve symptoms associated with dehydration, but it has uncertain effects on prolonging life or the dying process; also monitor at least every 12 hours and stop if there is possible harm, such as fluid overload, or the person no longer wants it. Hydration at the end of life is a frequent source of distress for relatives, and patient wishes and advance decisions guide practice.^[4]

Ethics is not a separate appendix here; it runs through every section above. The main principles, and the points where sources or jurisdictions differ, are set out below.

Autonomy and shared decision-making. NICE NG31 requires communication about prognosis as soon as a person may be dying (unless they do not want to know), discussion with those important to the person, and creation of an individualised care plan with the person and family. Treatment choices belong to the patient, including refusing or limiting treatment, and advance statements, advance decisions to refuse treatment and lasting power of attorney for health and welfare all matter. Be honest about uncertainty (including the uncertain effect of clinically assisted hydration) but avoid false optimism.^[4]

Beneficence and non-maleficence. Act in the patient's best interests and avoid harm: stop non-beneficial medicines, avoid futile investigations in the last days of life, and treat symptoms promptly and effectively. WHO frames relief of suffering and symptom control as an ethical duty to respect a person's dignity.^[2]

Double effect and sedation. Increasing analgesia or using a sedative to relieve refractory suffering can incidentally hasten death; this is accepted in palliative care when the intent is symptom relief and the minimum necessary dose is used. NICE advises starting with the lowest effective dose, titrating, monitoring daily, and seeking specialist advice if control is inadequate or unwanted sedation appears.^[4]

Withholding and withdrawing treatment. When treatment no longer offers benefit, or the burden outweighs benefit, it is ethically appropriate to withhold or withdraw (for example, chemotherapy or artificial nutrition). WHO notes that early palliative care "improves quality of life for patients" and reduces unnecessary hospital admissions, and that all such decisions should be explained.^[2] Legal frameworks for advance decisions differ between countries; this page states principles, not legal advice.

Equity and access to controlled medicines. WHO's 2020 fact sheet stresses that unnecessarily restrictive regulation of morphine and other essential palliative medicines denies adequate care, that 79% of the world's population (mainly in low- and middle-income countries) consumed only 13% of the morphine used for pain and suffering in 2018, and that providing palliative care should be considered an ethical duty for health professionals. Pain relief is therefore not only a clinical, but an equity, obligation.^[2]

Assisted dying / euthanasia. Laws and acceptance differ widely between countries and jurisdictions; this topic does not cover eligibility, prescribing or legal detail. Good palliative care, aggressive symptom relief and shared decision-making are the universal obligation regardless of the law. Clinicians should know local regulations and consult specialist ethics or legal colleagues when in doubt.

• Moderate to severe renal or hepatic impairment. Seek specialist advice before prescribing strong opioids; morphine and its metabolites behave differently across organs. Dose adjustments are required and the choice of opioid may change.^[3]
• Older adults. Older patients often need lower starting doses due to changed pharmacokinetics, comorbidity and falls risk; start low, titrate carefully, and reassess regularly. Cognitive impairment means pain may present as agitation: use a validated behavioural pain assessment.^[4]
• Children. Paediatric palliative pain care is a specialist area and is not addressed in detail here; opioid doses and formularies differ. Principles (assess, treat cause, match analgesic to pain, manage side effects) are the same.
• Pregnancy and breastfeeding. Opioid use requires individual risk-benefit discussion and specialist (obstetric/oncology/palliative) input; this page does not provide dosing rules for these groups.

Where palliative care services are scarce, WHO's fact sheet and guidance highlight practical priorities: integrate palliative care into primary and community care; ensure access to essential medicines (including oral morphine) through appropriate national policy and regulatory frameworks; train the existing workforce (physicians, nurses, pharmacists, community volunteers); and avoid "all-or-nothing" thinking.^[2]

Practical points for a clinician working with limited resources:

• Money and distances often dictate. Prefer cheap, oral, single-agent strong opioids (oral morphine) and make sure at least one formulation is available before a patient leaves hospital.
• Teach the basics to the whole workforce. Assume each clinic or district may have only one trained palliative care clinician; teach pain assessment, oral opioid titration, bowel regimen and end-of-life care to everyone.
• Anticipate needs. In a setting where a doctor may be far away, anticipatory prescribing (with relatives taught when and how to give and when to seek help) prevents untreated crises.^[4]
• Do not over-investigate near the end of life. WHO explicitly advises against investigations that do not affect care in the last few days; NICE mirrors this.^[4]
• Oxygen should be targeted. Reserve oxygen for symptomatic hypoxaemia and use fans, positioning and opioids for breathlessness otherwise.^[4]
• Cultural practices vary. Families often wish to provide mouth care, food and presence; support this within safety.
• Access and equity. WHO's fact sheet documents that, of countries surveyed in 2019, funding for palliative care was available in 68% and only 40% reported that services reached at least half of patients in need; access is largely a political choice. ^[2]

• Medical ethics and communication in serious illness (plain text, MedGrasp topics)
• Pharmacology of opioids and controlled drugs (plain text, MedGrasp topics)
• Delirium (plain text, MedGrasp topics)
• Dyspnoea and respiratory support (plain text, MedGrasp topics)