FastTrack: practical tips for core symptom management in end-of-life care

General practitioners and nurse practitioners play a central role in end-of-life care, where patients may deteriorate rapidly and develop significant symptoms requiring urgent treatment.

To support timely, standardised symptom relief, caring@home in collaboration with a national working party of clinicians – have developed a National Core Community Palliative Care Medicines List:

These medicines support comfort-focused care and reduce unwanted hospital transfers. To learn more about how these medicines can be used in clinical practice, see our previous FastTracks on the management of anxiety and emesis, and the management of pain and respiratory secretions.

Symptom management in end-of-life care 

General principles  

End-of-life care should be holistic and goal-directed, uphold dignity, and align with patient preferences.  The care should address: 

• physical comfort

• psychological distress

• family and carer needs 

Predictable symptoms can be effectively managed in the community with a core set of palliative care medicines. Early recognition and treatment are key to preventing distress for patients and families. 

Pain and dyspnoea

Pain and dyspnoea are common and can co-exist. Opioids such as morphine are effective for both symptoms. Dosing should start low and be titrated according to response, with careful monitoring for neuro-excitatory side effects such as hallucination, agitation, myoclonic jerks, hyperalgesia and seizures.

Anxiety, terminal restlessness/agitation

Anxiety and terminal restlessness/agitation may present as non-specific distress or behavioural disturbances and are often multifactorial. Benzodiazepines such as clonazepam can be effective for refractory agitation, particularly where anxiety is prominent. Haloperidol is less sedating and may be preferred for that reason, or in addition, when benzodiazepines alone are insufficient. 

Where appropriate, address reversible causes (eg urinary retention, pain, medication effects) alongside symptom treatment, particularly when interventions are unlikely to add burden. 

Nausea and vomiting

Nausea in end-of-life care is often multifactorial. Haloperidol is commonly used as a first-line agent due to its broad antiemetic effect. Ongoing reassessment is important to ensure treatment remains aligned with the likely underlying cause. 

Respiratory secretions

Noisy respiratory secretions (‘death rattle’) secondary to loss of consciousness can be distressing for families. Anticholinergic agents such as hyoscine butylbromide reduce secretions and may improve comfort. Non-pharmacological management – including repositioning the patient and providing reassurance to family and carers – is more important and should be provided whether or not medications are used. 

These symptoms often evolve together, and management should be individualised, with regular reassessment to ensure treatment remains aligned with the patient’s goals. 

Anticipatory prescribing: a fundamental of quality use of medicines (refer to the PalliMEDS app) 

Key principles 

• Anticipate common symptoms and prescribe early to support your patient’s terminal phase care needs

• Start with the lowest effective dose and titrate to effect

• Deprescribe non-beneficial medicines as appropriate to reduce treatment burden

• Transition early to subcutaneous or sublingual routes when oral intake declines

Recommended indications and dosing include:

• morphine – for pain or breathlessness (for patients not on regular opioids)

  • typical PRN dose: 2.5–5 mg subcutaneously one hourly as required

• haloperidol – for delirium, agitation due to delirium, or nausea

  • typical PRN dose: 0.5–1 mg subcutaneously every four hours as required

• hyoscine butylbromide – for respiratory secretions

  • typical PRN dose: 20 mg subcutaneously every two hours as required

• clonazepam – for anxiety, distress, or seizures

  • typical PRN dose: 0.2–0.5 mg sublingually or subcutaneously every two hours as required 

These medicines may also be prescribed via continuous subcutaneous infusion if symptoms persist.  For more information, refer to the free PalliMEDS app for dosing, medicine, and symptom information, as well as an opioid calculator. 

Use of midazolam

Midazolam has not been included in the National Core Community Palliative Care Medicines List as it is not PBS-subsidised. However, due to its rapid onset and shorter duration of action, midazolam may be preferred for: 

• rapid control of severe agitation

• recurrent or prolonged seizures

• refractory distress 

Midazolam may be available in some settings (at no/reduced cost to the patient) through: 

• doctor’s bag supply

• residential aged care home imprest systems

• specialist palliative care services 

 Typical PRN dose: 2.5-5 mg subcutaneously one hourly as required 
 

Prescribing and documentation to reduce medication errors 

Clear, unambiguous medication orders reduce the risk of administration errors, particularly for high-risk medicines such as benzodiazepines and opioids. 

When reviewing or administering end-of-life medicines, ensure medication orders: 

• use ‘micrograms’, ‘MICROg’ or ‘microg’ to avoid being mistaken as milligram (mg)

• use ‘mg’ (milligrams) written clearly

• avoid zeros (write 2 mg, not 2.0 mg)

• use a leading zero for doses less than 1 (write 0.5 mg, not .5 mg)

• clearly state the route in full (eg ‘subcutaneously’, ‘sublingually’, ‘orally’) – avoid unclear abbreviations

• clearly specify frequency (eg ‘every two hours as required’) 

For example:  clonazepam 0.5 mg subcutaneously every two hours as required for anxiety 

Ethical and legal considerations

The doctrine of double effect recognises that medicines prescribed for symptom management may unintentionally shorten life. While the scope of the law in Australia has not yet been tested, double effect is likely to apply only when: 

• the primary intention is to relieve pain and symptoms, not hasten death

• the medication is authorised to be administered

• the person is near death 

A comprehensive introduction to end-of-life law for clinicians applicable to all Australian states and territories can be found here. 

Access and supply

Access to palliative medicines can vary across regions, particularly after hours or in rural and remote areas. 

When supporting patients at home, carers and families can locate local pharmacies that stock the core palliative care medicines by searching healthdirect’s National Health Services Directory. These pharmacies may be identified by the description ‘palliative medicine service’ in the directory. 

Encouraging families to identify a pharmacy early supports timely access to medications and reduces distress. 

Key messages 

• Most terminal symptoms can be managed using the four core community palliative care medicines

• Anticipatory prescribing ensures medicines are available before symptoms escalate

• Prescribe clearly and consistently and use subcutaneous or sublingual routes early when oral intake becomes unreliable

• Start low, titrate to effect and review frequently 

• Early action – including identifying a pharmacy that stocks core medicines – improves access, supports carers and reduces distress and hospitalisation 

References

Australian Commission on Safety and Quality in Health Care. Recommendations for safe use of medicines terminology. Sydney: ACSQHC; 2024. Available from: https://www.safetyandquality.gov.au/our-work/medicines-safety-and-quality/safer-naming-and-labelling-medicines/recommendations-safe-use-medicines-terminology [Accessed 8 Apr 2026]. 

caring@home. National core community palliative care medicines list: factsheet. Brisbane: caring@home; 2025. Available at: https://www.caringathomeproject.com.au/__data/assets/pdf_file/0040/339997/caring@home-Core-Medicines-List-Factsheet.pdf (accessed 26 Mar 2026). 

Queensland Health. Community-based Palliative Care Anticipatory Medicines: Guidance for Queensland. Brisbane: Queensland Health; 2024. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0010/1310113/s1215_pallconsult_medicinesguidelines_web.pdf 

Queensland University of Technology. Legal protection for providing pain and symptom relief. Brisbane: QUT; 2025. Available from: https://end-of-life.qut.edu.au/pain-relief [Accessed 8 Apr 2026] 

The Royal Australian College of General Practitioners (2024). RACGP aged care clinical guide (Silver Book). 5th ed. Melbourne: RACGP. Available from: https://www.racgp.org.au/silverbook   

Tait P, Aylmer K, Christie L, Cooper K, Fong L, Lin CC, et al. A national core community palliative care medicines list for managing end‑of‑life symptoms. Aust J Gen Pract 2025;54(9):643–6. 

Therapeutic Guidelines Limited. Palliative care. Melbourne: Therapeutic Guidelines Limited; 2024. Available from: https://app.tg.org.au/guidelines/Palliative_Care [Accessed 8 Apr 2026]. 

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