Palliative symptom control • Assessment • Pain • Nausea • Constipation • Bowel obstruction • Multidisciplinary care

Principles of Symptom Control and Assessment in Palliative Care

A systematic guide to identifying causes, relieving distress and preventing avoidable complications

Learning objectives

• Apply a structured model to assess and prioritize symptoms in serious illness.
• Explain physical, psychological, social and spiritual contributors to “total pain” and symptom burden.
• Recognize pain mechanisms, opioid complications, nausea, constipation and malignant bowel obstruction.
• Choose proportionate medication, non-drug and cause-directed interventions with monitoring.
• Plan nursing care, caregiver education, reassessment, referral and documentation.

1. What symptom control means

Palliative symptom control is the prevention and relief of physical, psychological, social and spiritual suffering caused by serious illness or its treatment. It begins at diagnosis and continues alongside curative or disease-modifying therapy. The aim is not to suppress every sensation; it is to restore comfort, function, dignity and the patient’s chosen goals with the least burden.

2. Models of pain and symptom burden

2.1 Mechanistic model

• Somatic nociceptive: skin, muscle, bone or joint injury; often localized, aching or movement-related.
• Visceral: organ distension, inflammation or ischaemia; diffuse, deep, cramping or associated with nausea/autonomic signs.
• Peripheral neuropathic: lesion/disease of a peripheral nerve, root or plexus; burning, electric, tingling, shooting or sensory loss.
• Central neuropathic/nociplastic: altered central processing, hypersensitivity and pain disproportionate to an identified lesion.
• Mixed: common in cancer, postsurgical and chronic pain.

2.2 Total pain

Domain	Examples	Assessment prompts
Physical	Tumour, inflammation, infection, fracture, neuropathy, constipation, urinary retention, treatment toxicity.	Site, onset, mechanism, associated symptoms, examination and red flags.
Psychological	Anxiety, depression, trauma, fear, loss of control, insomnia and anticipatory grief.	“What worries you most?” Screen for suicide, panic and delirium.
Social	Caregiver strain, poverty, transport, stigma, housing, work and family conflict.	“What makes care difficult at home?”
Spiritual/existential	Loss of meaning, guilt, anger, disrupted practice or fear of death.	“What gives you strength? Are there beliefs we should understand?”

3. Initial assessment and prioritization

1. Primary survey: airway, breathing, circulation, disability, exposure; check vital signs, glucose where indicated and level of consciousness.
2. Symptom story: onset, site, severity, quality, timing, triggers, associated symptoms, previous episodes, treatment and patient goal.
3. Medication review: opioids, NSAIDs, antibiotics, steroids, chemotherapy, anticholinergics, laxatives, herbs, alcohol and sedatives.
4. Examination: general appearance, hydration, abdominal, cardiopulmonary, neurological, skin and functional assessment guided by symptoms.
5. Investigations: perform only those likely to change management and fit goals; palliative status is not a reason to ignore a reversible emergency.
6. Prioritize: life-threatening or highly distressing symptoms first, then those preventing sleep, intake, movement or communication.

4. Pain management: principles and opioid complications

Use a validated pain tool, set a functional goal, select treatment by mechanism, schedule continuous relief, provide rescue for predictable flares and reassess. Combine analgesics, adjuvants, non-drug care and cause-directed treatment.

4.1 Opioid-induced hyperalgesia and narcotic bowel syndrome

The supplied reference describes worsening pain despite escalating opioids, “soar and crash” pain when a dose wanes, increasing frequency/intensity, diffuse allodynia, myoclonus or delirium. In narcotic bowel syndrome, abdominal pain worsens or incompletely resolves with continued opioid escalation and is not explained by current gastrointestinal pathology.

• Reassess diagnosis, constipation, obstruction, infection, renal failure, withdrawal, anxiety and disease progression.
• Look for diffuse pain beyond the original distribution, allodynia, myoclonus, delirium or seizures.
• Do not reflexively increase opioids. Seek specialist pain/palliative review for dose reduction, rotation, adjuvant therapy and non-drug care.
• Explain the plan compassionately; this is a pharmacological phenomenon, not a moral failure.

4.2 Common opioid complications

Complication	Assessment	Management principles
Constipation	Last bowel movement/flatus, stool form, distension, nausea, vomiting, obstruction signs and medicine list.	Prevent from the first opioid dose; use bowel regimen, hydration/mobility if safe, review obstruction and reassess.
Nausea/vomiting	Timing, triggers, bowel habit, vestibular symptoms, infection, medicines, dehydration and aspiration risk.	Find cause; choose an antiemetic by receptor/clinical pattern; consider route and hydration.
Sedation/respiratory depression	Alertness, respiratory rate/effort, oxygenation, pupils, dose timing, renal function and other sedatives.	Stop further opioid, support airway/breathing, call emergency help and use local naloxone protocol when indicated.
Delirium/myoclonus	Acute fluctuation, infection, hypoxia, glucose, renal/hepatic function, dehydration and medicines.	Treat reversible causes, review opioid/metabolite accumulation and seek senior advice.

5. Constipation in palliative care

Opioids reduce gastrointestinal propulsion and secretion and increase sphincter tone. Unlike nausea or drowsiness, opioid constipation usually does not improve with tolerance. It can cause pain, nausea, vomiting, overflow diarrhoea, delirium, urinary retention, obstruction and reduced medicine absorption.

5.1 Assessment

• Usual bowel frequency, last stool, stool consistency, straining, incomplete evacuation and flatus.
• Abdominal pain/distension, vomiting, bowel sounds, rectal symptoms, hydration, mobility and diet.
• Opioids, anticholinergics, iron, calcium, antiemetics, dehydration and neurological disease.
• Red flags: severe colicky pain, persistent vomiting, peritonism, complete obstipation, shock or suspected faecal impaction.

5.2 Prevention and treatment

• Explain the risk before or at the first opioid dose.
• Encourage oral fluids, fibre and activity only when safe and not contraindicated by obstruction or swallowing problems.
• Provide privacy, a regular commode/toilet schedule and safe positioning.
• Use a stimulant and/or osmotic laxative according to local formulary. Examples include senna, bisacodyl, lactulose or macrogol/PEG.
• For persistent constipation, review adherence, impaction, obstruction and medicine causes; consider suppository, enema or specialist medicines.
• Do not aggressively increase laxatives in suspected obstruction or acute colitis; seek urgent review.

Educational examples: macrogol/PEG commonly 17 g once daily, sometimes twice daily; bisacodyl suppository 10 mg daily when indicated. Product strengths, age and local protocols vary. A senna tablet does not have a universal milligram strength—follow the label and prescription rather than copying a tablet count.

6. Nausea and vomiting

Nausea is a subjective unpleasant urge to vomit; vomiting is forceful expulsion. Identify and treat the cause rather than rotating antiemetics randomly.

6.1 Receptor-target approach

Likely contributor	Receptors/pathways	Potential classes/examples	Important cautions
Vestibular disturbance	Histamine and muscarinic	Promethazine, cyclizine, hyoscine/scopolamine where available.	Sedation, anticholinergic effects, glaucoma, urinary retention and delirium.
Gastric stasis or partial obstruction	Dopamine, serotonin and motility pathways	Metoclopramide when obstruction is excluded or partial and specialist-approved.	Avoid in complete obstruction, perforation or significant extrapyramidal risk; review QT and renal function.
Chemotherapy, inflammation or toxins	5-HT3, dopamine, NK1 and vagal pathways	Ondansetron, prochlorperazine, haloperidol, olanzapine or an NK1 antagonist depending on cause.	QT prolongation, constipation, sedation, extrapyramidal effects and interactions.
Raised intracranial pressure	Central vomiting pathways	Dexamethasone and cause-directed therapy under specialist guidance.	Hyperglycaemia, infection, delirium and need for urgent neurological assessment.
Anxiety/anticipatory nausea	Cortical/limbic pathways	Communication, relaxation, psychological support; selected medicines only with careful review.	Do not mask hypoxia, obstruction or sepsis with sedation.

6.2 Educational adult examples

• Metoclopramide: often 10 mg orally/IV/SC up to three times daily in adults, with renal adjustment and local maximum. Avoid complete bowel obstruction, Parkinson disease or prior dystonia unless specialist-directed.
• Ondansetron: commonly 4–8 mg orally/IV at intervals set by the indication and formulary. Constipation and QT prolongation are important.
• Haloperidol: low-dose 0.5–1 mg orally or SC at intervals according to local palliative protocol; monitor QT, rigidity, akathisia and sedation.
• Promethazine: 12.5–25 mg at an interval prescribed locally; sedation, hypotension and anticholinergic effects can be significant.
• Prochlorperazine: 5–10 mg at local intervals for selected causes; monitor extrapyramidal effects and QT.
• Olanzapine: 2.5–5 mg at night may be used by specialists for refractory nausea; monitor sedation, orthostasis, glucose and metabolic effects.

Use one primary antiemetic matched to the likely pathway, reassess, and add a second with a different mechanism only when justified. Review oral route, hydration, constipation, electrolytes and aspiration risk.

7. Hiccups and reflux-related distress

Persistent hiccups can cause pain, sleep loss, nausea, dyspnoea and reflux. Assess gastric distension, medication triggers, electrolyte disturbance, central disease and diaphragmatic irritation. Non-drug measures include small sips when safe, slow breathing and reducing triggers. Specialist options may include chlorpromazine, baclofen, gabapentin or a proton-pump inhibitor depending on cause. The supplied reference gives chlorpromazine 25 mg IV every 6 hours as needed and then 25 mg orally twice daily in a case; this is not a universal regimen—monitor hypotension, sedation, QT and extrapyramidal effects.

8. Malignant bowel obstruction (MBO)

MBO is partial or complete obstruction caused by advanced cancer, adhesions, tumour, inflammation or treatment. It is both a symptom crisis and a potentially surgical condition.

8.1 Recognition

• Colicky abdominal pain, distension, nausea/vomiting, altered stool or flatus, dehydration and increasing weakness.
• Examine for tenderness, guarding, rigidity, bowel sounds, masses, hernia, fever, shock and peritonism.
• Consider CT or other imaging when it will change management and fits goals; involve surgical and palliative teams early.

8.2 Immediate management principles

1. ABCDE, analgesia, antiemetic, fluid/electrolyte assessment and urgent senior review.
2. Stop or review oral medicines, bulk laxatives and prokinetics if complete obstruction is suspected.
3. Consider nasogastric decompression for severe vomiting under appropriate monitoring.
4. Discuss surgery, stenting, venting gastrostomy or conservative comfort care according to prognosis, operative risk and patient goals.
5. Use opioids for pain, but review constipation, renal function and opioid-induced hyperalgesia.
6. Specialist palliative regimens may combine an antisecretory agent such as octreotide, an antispasmodic such as hyoscine butylbromide/glycopyrrolate, an antiemetic and a corticosteroid.

Do not give laxatives or prokinetics blindly in complete obstruction. Dehydration, perforation, ischaemia and sepsis require urgent medical/surgical care.

9. Other high-burden symptoms: assessment principles

Symptom	Assess for	Initial supportive measures and escalation
Breathlessness	Airway, oxygenation, infection, pulmonary oedema, embolism, anaemia, anxiety, effusion and goals.	Upright position, calm presence, fan if comfortable, oxygen only if hypoxaemic/indicated, prescribed opioids or cause-directed treatment; urgent review for new severe dyspnoea.
Delirium/agitation	Acute fluctuation, infection, hypoxia, glucose, pain, urinary retention, constipation, medicines, withdrawal and environment.	Safety, familiar person, low stimulation, treat causes, review medicines and escalate danger or severe distress.
Fatigue/weakness	Anaemia, infection, dehydration, medication, sleep, depression, cachexia and disease progression.	Energy conservation, assistive devices, nutrition/hydration goals and reversible-cause review.
Pruritus	Cholestasis, renal disease, opioids, allergy, scabies, dry skin and medicines.	Skin care, avoid heat, treat cause and select medicine based on mechanism.
Dry mouth	Dehydration, oxygen, mouth breathing, anticholinergics, thrush and medication.	Frequent mouth care, sips/ice if safe, lip moisturizer and review medicines.
Insomnia/anxiety	Pain, breathlessness, delirium, depression, fear, caffeine, medicines and unsafe home situation.	Communication, sleep routine, relaxation, counselling and careful medicine review; avoid reflex sedative prescribing.

10. Nursing care and caregiver education

• Use a symptom chart with severity, function, trigger, intervention, response and adverse effects.
• Offer mouth care, skin care, positioning, privacy, toileting, nutrition/hydration support and safe mobility.
• Teach caregivers bowel prevention, vomiting aspiration precautions, red flags, medicine timing and whom to call.
• Use teach-back and check that the home plan is feasible with available water, food, transport, medicines and supervision.
• Reassess after each intervention and at handover; never chart only “comfortable” without evidence.
• Escalate uncontrolled symptoms, repeated rescue doses, severe sedation, slow breathing, new confusion, bleeding, fever, shock or caregiver exhaustion.

11. Multidisciplinary and goal-concordant care

Complex symptom control may require clinicians, nurses, pharmacists, physiotherapists, occupational therapists, psychologists, social workers, spiritual-care providers, nutritionists, surgeons, oncologists and community health workers. Hold a family meeting with patient permission, clarify goals and document who will do what. Avoid burdensome investigations that cannot change care, but revisit decisions when a reversible emergency is plausible.

12. Clinical cases

13. Quick self-test

1. What are the stages of the symptom-control loop?
2. Why does opioid constipation require prevention from the first dose?
3. List four red flags in a patient with nausea, vomiting or abdominal pain.
4. Name three receptor/pathway targets for antiemetic selection.
5. What features suggest opioid-induced hyperalgesia?
6. Why should laxatives and prokinetics be reviewed in complete bowel obstruction?

Answers

1. Ask/observe, assess urgency, agree priorities, find causes, intervene, reassess, and adapt/document.
2. It usually does not improve with tolerance and can cause pain, nausea, obstruction, delirium, urinary retention and reduced quality of life.
3. Examples: peritonism, severe distension/obstipation, shock, fever/confusion, persistent vomiting, gastrointestinal bleeding or severe sudden pain.
4. Histamine/muscarinic vestibular pathways; dopamine; serotonin/5-HT3; neurokinin-1; central raised-pressure pathways; motility pathways.
5. Worsening or diffuse pain despite escalating opioids, allodynia, myoclonus, delirium, seizures or a strong “soar and crash” pattern.
6. They may worsen distension, perforation or vomiting and are ineffective or dangerous when transit is completely blocked.

Key take-home points

• Assess the person, not only the symptom; physical, psychological, social and spiritual factors interact.
• Stabilize first, identify reversible causes, set goals, treat proportionately and reassess.
• Opioid complications—especially constipation, nausea, sedation, delirium and hyperalgesia—must be anticipated.
• Choose antiemetics by likely pathway and do not stack medicines without a reason.
• Malignant bowel obstruction requires urgent assessment and coordinated surgical/palliative decision-making.
• Good nursing care, caregiver teaching and continuity are essential components of symptom control.

Further study and references

• Symptom Management in Palliative Care — supplied Slideshare reference
• WHO: Palliative care
• WHO cancer-pain guideline
• Related lesson: WHO analgesic ladder and pain management
• Related lesson: Adjuvant analgesics in palliative pain

Educational resource for supervised learning. Confirm all medicines, doses and routes against current Uganda guidance and local specialist protocols.