Symptom management

Pain, nausea, dyspnoea, agitation, catastrophic haemorrhage and troublesome respiratory secretions should all be expected. Simple measures and anticipatory medications should be prescribed to manage them.


Pain: explanations of the cause of pain and expectations for its treatment can be helpful. Covering open wounds or splinting fractures can provide additional relief. If pain is due to a full bladder, full rectum or a wet bed, addressing these causes is important.

Dyspnoea: opening a window or providing a bedside fan to move air can help with breathlessness.

Agitation: a calm, quiet environment with low lighting levels can help ease agitation. Playing a patient’s favourite music or having a relative present can also be calming.

Catastrophic haemorrhage: a dark room with dark towels and bed linen can reduce the distress caused to patients and families by significant blood loss.

Respiratory secretions: repositioning and oropharyngeal suctioning can help reduce secretion burden.


This is a sample of possible pharmacological prescribing options4,5,13. Your own hospital or trust should have comprehensive guidelines on anticipatory prescribing approved for use in your ED which you should refer to.

Symptom Medication Option Starting dose
Normal renal function Morphine or equivalent 2.5mg S/C, 2-4hrly/PRN
eGFR <30ml/min Fentanyl 25mcg S/C, 1-2hrly/PRN
No delirium Midazolam 2.5mg S/C, hourly/PRN
With delirium Add haloperidol 0.5-1mg S/C, 2-4hrly/PRN
  Or levomepromazine 6.25mg S/C, 4hrly/PRN
Chemical cause Levomepromazine 2.5-6.25mg S/C, 6hrly/PRN
  Or Haloperidol 0.5-3mg S/C, daily
Alternative Cyclizine 50mg S/C, 8hrly/PRN
Bowel obstruction Hyoscine butylbromide 20mg S/C, hourly/PRN
Respiratory secretions    
  Hyoscine butylbromide 20mg S/C, hourly/PRN
  Or Hyoscine hydrobromide 400mcg S/C, hourly/PRN
  Or Glycopyrronium 200-400mcg S/C, hourly/PRN
  Morphine 2.5mg S/C, hourly/PRN
  And/or Midazolam 2.5mg S/C, hourly/PRN

Patients already on oral opioids or anti-emetics may have their medication continued by subcutaneous infusion if needed. If three or more doses of as required subcutaneous medication are given, consider changing to a continuous infusion through a syringe driver.

Timely discharge

Depending on the clinical situation, patient preference and community resources in your area, it may be possible to arrange a timely discharge for those who wish to die at home.

NHS Continuing Healthcare in England may provide fast track funding for equipment such as a commode, hospital bed or home oxygen through the community nurse4.

A comprehensive handover to the patient’s GP and the community nurse, the local hospice or to the domiciliary palliative care nursing care team is essential to prevent the patient deteriorating unsupported at home causing distress and an unplanned reattendance at the ED.

Learning Bite

A range of options exist to manage the symptoms associated with dying. The drug-based options should be prescribed early so they can be administered promptly as required.