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In the UK, symptom management for adults in the last days of life is governed by NICE Guideline [NG31] and the "One Chance to Get It Right" framework.
While individual NHS Trusts may have branded "pathways" or "algorithms," they all follow a standardized clinical logic for the five most common terminal symptoms: Pain, Breathlessness, Nausea/Vomiting, Agitation/Delirium, and Respiratory Secretions.
1. The Core Decision Algorithm
NHS clinical practice generally follows this stepwise approach for any new or worsening symptom:
Recognize: Confirm the person is entering the dying phase (bedbound, drowsy, limited intake).
Exclude Reversibles: Check for easily treatable causes (e.g., a full bladder causing agitation, or constipation causing pain).
Non-Pharmacological First: Repositioning, mouth care, or using a fan for breathlessness.
Anticipatory Prescribing: Ensure "PRN" (as needed) subcutaneous (SC) medications are already written on the chart.
Syringe Driver (CSCI): If $\ge$ 3 PRN doses are needed in 24 hours, or the patient cannot swallow, start a Continuous Subcutaneous Infusion.
2. Symptom-Specific Management (Standard NHS Dosing)
| Symptom | First-Line Medication (SC) | Typical Starting PRN Dose |
| Pain | Morphine Sulfate (or Oxycodone if renal impairment) | 2.5mg – 5mg |
| Breathlessness | Morphine Sulfate (low dose) | 2.5mg |
| Agitation / Delirium | Midazolam (anxiety) or Haloperidol (delirium) | 2.5mg (Midaz) / 1.5mg (Halo) |
| Nausea / Vomiting | Levomepromazine or Haloperidol | 6.25mg (Levo) / 1.5mg (Halo) |
| Secretions | Hyoscine butylbromide (Buscopan) | 20mg |
3. Key Clinical Parameters
Renal Impairment: If the patient’s $eGFR < 30$, clinicians typically switch from Morphine to Oxycodone or Alfentanil to avoid toxic metabolite buildup.
The "1/6th Rule": Breakthrough (PRN) doses for pain are usually calculated as 1/6th of the total 24-hour dose.
Review Cycle: Symptoms must be reassessed at least every 24 hours, but often every 4 hours in acute settings.
4. Where to find the official documents
NICE [NG31]: The gold-standard national guideline for "Care of dying adults in the last days of life."
Palliative Care Adult Network Guidelines (PCAND): Detailed regional algorithms often used by NHS clinicians for complex drug conversions.
The Syringe Driver Database: Used for checking "compatibility" (which drugs can safely be mixed in one pump).
Important Note: These algorithms are for healthcare professional guidance. If you are managing care at home and symptoms are not controlled, contact the District Nurse or the Specialist Palliative Care Team (SPCT) immediately for a review.
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