Palliative care — principles, and interventions to relieve suffering in painful bone metastasis with nausea, vomiting, constipation and b…

WHO definition — palliative care improves the quality of life (QOL) of patients and families facing a life-threatening illness by giving pain and symptom relief, psychosocial and spiritual support. It also covers prevention, family support and bereavement counselling after death.

It advocates early identification of the dying process and impeccable assessment. It affirms life and treats dying as a normal process.

Palliative care can be given alongside curative treatment at any point in the disease trajectory, even from diagnosis. It does not depend on prognosis, stage of disease, or the need for other therapies.

Four fundamental elements: (i) systematic control of pain, symptoms, psychosocial distress, spiritual and practical needs; (ii) culturally sensitive information with repeated reassessment of benefits versus burdens; (iii) genuine coordination and continuity of care across settings; (iv) preparation of patient and family for dying, with hospice options and bereavement support.

Generic (primary) palliative care is delivered by all clinicians; specialist palliative care is delivered by trained interdisciplinary teams (palliative physician, nurse specialist, physiotherapist, occupational therapist, dietician, pharmacist, social worker, spiritual and psychological support).

Hospice is a subset of palliative care for those near the end of life (in the US, certified prognosis ≤6 months). Its focus is caring, not curing, and it may be delivered at home, in hospital, in a hospice, or in a nursing home.

Palliative care is appropriate not only in cancer but also in chronic disease, heart failure, COPD, end-stage renal disease, dementia and frailty. Best outcomes occur when it is started early.

Effective communication and advance care planning are core. Structured frameworks include REMAP, the Serious Illness Conversation Guide, and Byock's "Five Things" (thank you; forgive me; I forgive you; I love you; goodbye).

Standard pain assessment is essential: accurate pain history, a validated assessment tool, clinical examination, and appropriate laboratory and radiological investigation. Numerical rating, pictorial and verbal descriptor scales are more reliable than visual analogue scales in the elderly; the same scale must be used at follow-up.

25–40% of elderly cancer patients have daily pain and it is frequently undertreated. Risk factors for under-treatment are age >75 years, minority race and cognitive impairment. There is no proven change in pain perception with ageing — older patients simply complain less. In cognitive impairment, assess frequently and use behavioural cues (agitation, altered cognition, changed appearance or respiration).

Follow the WHO Analgesic Ladder — start with non-opioids (paracetamol, aspirin), then add opioids such as morphine. Give drugs "by the clock" every 2–6 hours, not on demand, especially in long-term care. Use sublingual, transdermal, rectal or subcutaneous routes when the oral route fails.

Opioid use in the elderly: start low, titrate slowly. Prefer short-acting immediate-release morphine, oxycodone or hydromorphone. Avoid meperidine, propoxyphene, fentanyl patches and methadone (complex metabolism, active metabolites). Anticipate delirium, falls, nausea and constipation.

Adjuvants for bone pain: NSAIDs and corticosteroids are useful for bone and visceral pain (watch GI bleeding and renal failure); topical lidocaine, NSAID gels, capsaicin; neuropathic adjuvants with the lowest anticholinergic burden; plus massage, heat, cold and focused physiotherapy.

Disease-directed therapy for malignant bone pain — surgery, chemotherapy, radiotherapy and/or bisphosphonates. Radiotherapy relieves pain in up to 80% and promotes bone healing. IV bisphosphonates (pamidronate, zoledronic acid, ibandronate) reduce pain and skeletal-related events in breast cancer and myeloma; caution if creatinine clearance <30 ml/min.

Pathological fracture — bone pain is the commonest presenting feature. About 50% follow breast cancer metastasis and the femur is the commonest site. Surgery is considered first where a fracture has occurred; long bones need rigid internal fixation before irradiation. Radiotherapy alone is used for ribs, scapula and pelvis. Surgery is justified if survival is ≥3 months for non-weight-bearing bones and even about 1 month for weight-bearing bones.

Identify the mechanism first — drugs (opioids, chemotherapy), constipation, bowel obstruction, electrolyte abnormality, hepatic or renal failure, radiotherapy, CNS/brain lesions and anxiety. Receptors involved are dopamine, serotonin, histamine and acetylcholine, acting via the chemoreceptor trigger zone, vomiting centre, gut and labyrinth.

Select the first-line antiemetic by cause, give it on a schedule until controlled, then taper to as-needed. Add a second agent if symptoms persist, since nausea is often multifactorial. Use side effects to advantage — haloperidol when delirium coexists; avoid ondansetron when constipation is the cause.

Defined as fewer than three bowel movements per week, hard stool and difficult passage. Prevention is the main strategy and opioid-induced constipation must be anticipated and treated prophylactically in every patient. Combine a stimulant laxative (senna, bisacodyl) with an osmotic laxative (lactulose, PEG, sorbitol). Stool softeners such as docusate are no better than placebo and are not recommended; bulking agents such as psyllium are dangerous at end of life and can cause impaction. Methylnaltrexone (SC) is effective for refractory opioid-induced constipation — it does not cross the blood–brain barrier and does not precipitate withdrawal.

Opioids are the main therapy for dyspnoea — patients and staff often need education about this indication. Benzodiazepines are added when anxiety coexists; the two act synergistically, allowing lower doses of each. Oxygen only when hypoxia is present and the patient finds it helpful. Non-drug measures: a cool, well-ventilated room, a fan or open window, upright positioning, glucocorticoids and bronchodilators for bronchospasm, antibiotics if infection is driving it.

Death rattle — avoid deep suctioning (uncomfortable, causes gagging). Reposition for postural drainage. Antimuscarinics (atropine, scopolamine, glycopyrrolate — preferred as it does not cross the blood–brain barrier) may be used, though clinical benefit is unproven. Stop blood pressure monitoring; monitor only respiratory rate and pulse.

Watch for iatrogenic harm — metoclopramide and haloperidol cause extrapyramidal and neuropsychiatric toxicity; opioids, anxiolytics, antidepressants, antihistamines, steroids, antipsychotics and fluoroquinolones cause delirium. For terminal agitation, treat the cause first, use behavioural measures, then low-dose haloperidol (chlorpromazine or quetiapine if sedation is required).

Total care must cover psychological, social and spiritual domains. Caregivers with emotional stress have significantly increased mortality — identify and refer them. Hospice programmes provide bereavement follow-up for about one year; screen for complicated grief.

The ASTRO 2024 clinical practice guideline (replacing the 2017 version, developed with ASCO and MSTS) confirms that 8 Gy in 1 fraction, 20 Gy/5, 24 Gy/6 and 30 Gy/10 give equivalent pain relief for previously unirradiated bone metastases. Retreatment is more frequent after single fraction, but its convenience makes it the preferred option in limited life expectancy.

For spinal cord or cauda equina compression in patients unfit for surgery: 8 Gy/1, 16 Gy/2, 20 Gy/ 5 or 30 Gy/10. Surgery plus post-operative radiotherapy is conditionally preferred over radiotherapy alone where feasible.

SBRT is conditionally recommended over conventional radiotherapy in selected patients with good performance status, no neurological deficit and no surgical indication.

Dexamethasone significantly reduces the incidence of pain flare when given with single-fraction radiotherapy.

Re-irradiation is now explicitly endorsed: spine 8 Gy/1, 20 Gy/5, 24 Gy/6 or 20 Gy/8; non-spine 8 Gy/ 1, 20 Gy/5 or 24 Gy/6.

Shared decision-making received a strong recommendation — regimen choice must weigh prognosis, prior dose, normal-tissue risk, quality of life, cost and patient values.

BETTER-B trial (Lancet Respiratory Medicine, 2024) — mirtazapine 15–45 mg daily for 56 days did NOT improve severe breathlessness in COPD or ILD and caused more adverse effects and greater care use. Mirtazapine is not recommended for breathlessness.

MABEL trial (Lancet Respiratory Medicine, 2025) — morphine did not improve worst breathlessness intensity in chronic breathlessness; the findings do not support its routine use in this setting.

ABCD trial — dexamethasone did not improve dyspnoea in advanced cancer and caused more toxicity, so routine steroid use for cancer dyspnoea is discouraged.

The ERS 2024 clinical practice guideline on symptom management in serious respiratory illness emphasises non-pharmacological first-line measures — fan-to-face, breathing techniques, pulmonary rehabilitation, pacing and psychological support — with opioids reserved for carefully selected, closely monitored patients.

Olanzapine 5 mg added to standard triple antiemetic therapy significantly improved control of carboplatin-induced nausea in a phase III trial (J Clin Oncol 2024), strengthening olanzapine's place as a broad-spectrum antiemetic.

The MASCC/ESMO 2023 updated consensus incorporates olanzapine into antiemetic pathways for moderately and highly emetogenic regimens; low-dose olanzapine is increasingly used for chronic, non-chemotherapy nausea in advanced cancer.

Peripherally acting mu-opioid receptor antagonists (PAMORAs) — methylnaltrexone, naldemedine, naloxegol — are now standard second-line therapy for opioid-induced constipation unresponsive to combined laxatives.

Supreme Court order, 24 January 2023 (Common Cause v Union of India) — the living will no longer needs a Judicial Magistrate's countersignature; it can be attested by a notary or gazetted officer. More than one guardian may be named. Approval now rests on a Primary Medical Board (treating doctor plus two experts of at least 5 years' experience) and a Secondary Medical Board (including a CMO nominee), with defined 48-hour timelines; courts intervene only in disputes.

MoHFW draft guidelines (September 2024) operationalise the 2018 and 2023 Supreme Court orders, defining terminal illness and the clinical pathway for withholding or withdrawing life-sustaining treatment.

Access data (2025) — 7–10 million Indians need palliative care annually; fewer than 4% receive it. India had 526 palliative care centres in 2022 (density 4 per 10 million). 44.5% of all centres are in Kerala (2.5% of the population, with about 95% population coverage). Median travel time to the nearest centre is 118 minutes; only 23.6% live within 30 minutes. Morphine is stocked in only about 66% of centres. Rural access is markedly worse; Bihar, Odisha and Madhya Pradesh are the worst served.

Essential medicines gap (2025) — no Indian national or state essential medicines list contains all recommended morphine formulations, and several states omit oral morphine entirely, despite morphine consumption being the NP-NCD indicator of palliative care coverage.