What are the purposes of palliative medications?
Palliative medications are one component of a 'whole-person' approach to supporting people with life-limiting and terminal illnesses. Medications may be needed to treat and / or prevent symptoms associated with the palliative diagnosis. These include problems such as pain, nausea and vomiting, depression, shortness of breath, among other issues. Some specific disease modifying treatments aimed at controlling and slowing down the progress of a disease (rather than curing it), are also often called 'palliative treatments'. This may include chemotherapy, hormone treatments and radiotherapy. For more information about these go to the National Cancer Institute website, or the Cancer Council of Australia website.
What medications are we talking about?
The classes of medication commonly used in palliative care are:
- analgesics (to treat pain)
- antiemetics (to treat and also to prevent nausea and vomiting)
- laxatives / aperients (to prevent and treat constipation)
- adjuvant medications (medications that work with analgesics to improve pain or symptom control)
- steroids (that may reduce a range of symptoms related to inflammation), and
- antidepressants (to treat depression, or sometimes pain) and other neuroleptic medications (to treat depression, anxiety, or pain delirium) and sedatives.
What is different about palliative medications?
Trials to determine the efficacy of new medications do not generally include older people or the very young. This means for members of these groups the evidence as to what we can reasonably expect is lacking. The occurrence of adverse events or the impact of polypharmacy are just two examples where this could be important. See the section on Evidence for Medications for more on this. To keep up with the emerging evidence consider forming a Journal Club or becoming a member of one.
Standard medications may be used differently in the palliative care setting, based on well established practices for which there are varying degrees of evidence. Examples include the use of antipsychotic medications to treat nausea, anticonvulsants to treat pain, and opioids to treat dyspnoea. Where these indications are unlisted in the product information (found in the package insert or the eMIMS®) this is termed 'off-license' prescribing. Sometimes it may be difficult to access these medications for patients in the community. There are also cost implications as they are unable to be subsidised through the Pharmaceutical Benefits Scheme (PBS).
In a palliative approach to treatment, giving medications should be as simple and non-traumatic as possible, with the potential for them to be given at home. The route of administration may differ from that usually used in a hospital based acute care situation.
A frequent issue is the need to continue medications for a person who can no longer swallow, and a common alternative route of administration is a subcutaneous injection or infusion. This is less traumatic and less difficult to maintain than intravenous medication, and it can often be managed at home with nursing support. Some medications are only available by the oral route. At the time a person can no longer take solid oral preparations, other options (including dissolving the tablet in water) may need to be substituted.
Stopping unnecessary medications
When people have a number of other medical conditions that are unrelated to their palliative care diagnosis, they may be on numerous medications. Many of these will have a role in maintaining health and preventing the long-term consequences of diseases including, but not limited to, diabetes and hypertension. The burden in terms of cost and discomfort of taking many drugs, as well as the escalating risk of drug interactions from polypharmacy, means that long-term medications should be frequently reviewed.
Deprescribing is the process of tapering or stopping inappropriate medicines. Decisions about which medications to stop should be made by balancing the likely prognosis from the palliative care diagnosis, with short, medium, and long-term risks associated with stopping medications to manage co-morbidities.
Syringe Drivers are small portable (usually battery operated) devices used to administer medications in palliative care. A single drug, or more often a combination of drugs, is given via a slow continuous subcutaneous infusion to help control symptoms when other routes of administration are no longer viable, feasible or preferred.
As with any intervention, or change to patient care, adequate education and support should be provided to the care recipient and their support network. They will often be required to care for someone at home who has a syringe driver. Caring@home provides online education for nurses on supporting carers to manage subcutaneous medicines. For online education on using the NIKI T34™ syringe driver visit PallConsult, an initiative of Queensland Health.
Common indications for use of syringe drivers in palliative care include: [2,3]
- Intractable Nausea
- Intractable Vomiting
- Poor enteral absorption of oral medications
- Weakness or altered level of consciousness
Detailed information about commonly used medications, incompatibilities, contraindications, equipment and techniques are available in:
- the Therapeutic Guidelines (subscription required),
- The Syringe Driver: Continuous Subcutaneous Infusions in Palliative Care, 4th ed.,
- Syringe Driver Drug Compatibilities – Guide to Palliative Care Practice 2016,
- the Oxford Textbook of Palliative Medicine (subscription required),
- the Oxford Handbook of Palliative Care (subscription required), and
- Syringe driver compatibility: Guidance document, Saver Care Victoria, 2021
Caution must be taken when looking at any overseas information as other drugs, dosages and devices are used.
Issues that can occur when using syringe drivers include:
- Local reactions at the needle insertion site are not uncommon, can be uncomfortable and may result in sub-optimal symptom control.  These reactions can be caused by irritation from medication(s) or infection.
- Precipitation of drugs. It is important to check the compatibility of drugs before combining in a syringe. If you notice indicators of precipitation such as the solution is cloudy or discoloured then discard. 
- If the alarm sounds check for empty syringe, blocked needle or tubing (includes kinked tube), or jammed plunger. 
- Mitchell K, Pickard J, Herbert A, Lightfoot J, Roberts D. Incidence and causes for syringe driver site reactions in palliative care: A prospective hospice-based study. Palliat Med. 2012 Dec;26(8):979-85. Epub 2011 Nov 14.
- Thomas T, Barclay S. Continuous subcutaneous infusion in palliative care: a review of current practice. Int J Palliat Nurs. 2015 Feb;21(2):60, 62-4.
- Watson M, Ward S, Vallath N, Wells Jo, Campbell R, editors. Oxford Handbook of Palliative Care. 3rd ed. Oxford, UK: Oxford University Press; 2019.
Last updated 01 April 2021