Protocol · WHO palliative care
Palliative symptom control
Palliative care relieves pain and other suffering for people with serious illness and supports their families. Most needs can be met at first-level care with a small set of cheap medicines, oral morphine among them. Ask about physical, emotional, social and spiritual problems; agree a plan with the person and family; and keep relieving symptoms when cure is no longer possible.
- Based on WHO palliative care
- For doctors, clinical officers, nurses and community health workers
- Reviewed October 2026
1Who / when
- Adults and children with serious, life-limiting illness: advanced cancer, advanced HIV or TB, organ failure (heart, lung, kidney, liver), severe stroke or dementia.
- Start alongside disease treatment, not only at the end of life.
- Families and caregivers, including in bereavement.
2Red flags: refer now
- Severe pain not controlled despite regular, correctly dosed treatment.
- New weakness of the legs, numbness, or loss of bladder or bowel control with back pain (possible spinal cord compression).
- Confusion, vomiting, great thirst and constipation in cancer (possible high calcium).
- Opioid toxicity: very drowsy, pinpoint pupils, slow or shallow breathing. Give naloxone if breathing is slow, and seek help.
- Heavy bleeding, seizures, or a sudden new symptom the family cannot manage.
Refer or seek advice the same day, while keeping the person comfortable. Agree in advance with the person and family what care they want.
3Assess
- Ask about each symptom: pain (where, what kind, how bad on a 0 to 10 scale), breathlessness, nausea, constipation, mouth problems, sleep, mood, confusion, wounds, itch.
- What the person and family understand, fear and want; who cares for them; money, food and transport.
- Current medicines and what has helped. Check for treatable causes (infection, anaemia, constipation, medicines).
- Neuropathic pain: burning, shooting or electric pain with numbness or tingling.
4Classify
| Pain severity | Start with | Then |
|---|---|---|
| Mild | Paracetamol and/or an NSAID | Add an opioid if pain persists |
| Moderate or severe | Oral morphine (with paracetamol or NSAID if helpful) | Increase regularly until comfortable |
| Neuropathic component | Add amitriptyline at night | Consider steroids where nerve compression is likely |
| Bone pain from metastases | Analgesics as above | Refer for single-dose radiotherapy or a bisphosphonate where available |
5Treat
Four rules for pain medicinesBy mouth. By the clock (at fixed times, before the last dose wears off). For the individual (the right dose is the dose that relieves the pain). With attention to detail.
| Medicine | Typical starting dose (adult) | Notes |
|---|---|---|
| Paracetamol | 500 to 1000 mg every 6 hours | Maximum 4 g a day; less in frail people or liver disease |
| Ibuprofen | 400 mg every 8 hours with food | Avoid with bleeding risk, kidney disease, heart failure |
| Morphine, oral immediate-release | 5 mg every 4 hours (2.5 mg if frail, elderly or kidney impairment) | Same dose for breakthrough pain. Increase by 30 to 50% if pain persists. No ceiling dose |
| Amitriptyline | 10 to 25 mg at bedtime | Dry mouth, drowsiness, dizziness on standing |
Other symptoms
- Constipation: give a stimulant laxative (senna 2 to 4 tablets of 7.5 mg at night, or bisacodyl) with every opioid, unless there is diarrhoea; add lactulose if stools are hard.
- Nausea and vomiting: metoclopramide 10 mg every 8 hours, or low-dose haloperidol; treat constipation and review medicines.
- Breathlessness: sit upright, fresh air, treat the cause (fluid, infection, anaemia); low-dose oral morphine relieves breathlessness in the last stage of illness; oxygen if saturation is low.
- Delirium or agitation: look for causes (pain, full bladder, constipation, infection, medicines); low-dose haloperidol (for example 0.5 to 1 mg) if distressing.
- Low mood or persistent anxiety: listen and support; fluoxetine is first-line medicine (see the depression protocol).
- Noisy breathing in the last days: reposition; hyoscine butylbromide can reduce secretions. Mouth care and pressure care throughout.
6Follow-up
- Review pain soon after starting or changing morphine, and regularly after that; home visits where possible.
- Prescribe enough morphine to avoid frequent long journeys. Store it locked and record what is given and returned.
- Teach the family to give medicines and to recognise when to call for help.
- If an opioid is stopped after long use, reduce it gradually.
7Counsel
- Morphine is an essential, safe medicine for pain in serious illness when the dose is adjusted carefully for each person.
- Take pain medicine at fixed times, not only when the pain is bad.
- Constipation is common with morphine, so keep taking the laxative every day.
- Talk with the family about wishes for care and place of death, and about spiritual needs.
We may not be able to cure this illness, but we can control your pain and other symptoms. Take this medicine at the times we agreed, and tell us if the pain comes back before the next dose.
8When to refer
- Same day: any red flag above.
- Pain not controlled despite regular morphine increased over several days.
- Possible need for radiotherapy, surgery, a nerve block or specialist palliative care.
- No access to oral morphine locally: link with a facility that can prescribe and supply it.
- Severe psychological distress, or a family that cannot cope (social work, community support).
9Sources
- World Health Organization. WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. 2018 (ISBN 9789241550390). Recommendations on initiation, maintenance with oral morphine, rescue doses, steroids, bisphosphonates and single-dose radiotherapy; the four principles; Annex 6 typical starting doses (paracetamol, ibuprofen, morphine, amitriptyline); naloxone; gradual opioid reduction.
- World Health Organization. Integrating palliative care and symptom relief into primary health care: a WHO guide for planners, implementers and managers. 2018 (ISBN 9789241514477). Essential package of medicines (morphine, senna or bisacodyl, lactulose, metoclopramide, haloperidol, hyoscine butylbromide, fluoxetine, dexamethasone, naloxone); morphine for terminal dyspnoea; safe storage and records.
- World Health Organization. IMAI district clinician manual: hospital care for adolescents and adults, volume 1. 2011 (ISBN 9789241548281). Analgesic table (morphine 2.5 to 10 mg every 4 hours, increase by 30 to 50%, laxative with opioids); metoclopramide 10 mg every 8 hours; senna 7.5 mg tablets; haloperidol 0.5 to 1 mg in medically ill patients; hypercalcaemia features.
- World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020 (ISBN 9789240009226). Practice points for palliative care in primary care.
- World Health Organization. WHO Model List of Essential Medicines. 2025.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.