Palliative Care Symptom Management: A Guide for Care Staff

Recognising and easing distressing symptoms in the last days of life is one of the most valuable skills a care team can bring to a resident's final chapter. NICE guideline NG31 (Care of Dying Adults in the Last Days of Life) sets out the evidence base care staff should know, even where prescribing decisions sit with a doctor or specialist nurse.

Pain

NICE guidance is clear that dying patients do not necessarily experience pain, and staff should never assume distress automatically means pain is present. Where pain is suspected, staff should help assess its severity and flag reversible causes such as urinary retention or constipation, since treating the underlying cause can sometimes achieve more than escalating analgesia alone. NICE advises that pain relief should be matched to severity, taking into account any preference the person has expressed for how it should be given. For residents who can no longer communicate pain clearly, validated behavioural assessment tools — of the kind covered in the Abbey Pain Scale for dementia care — give staff a structured way to recognise pain through observation rather than relying on self-report alone.

Breathlessness

Staff should support attempts to identify and reverse an underlying cause where possible — for example, an infection or fluid build-up that can be treated directly. NICE specifically recommends simple, non-drug measures as first-line support: a fan, an open window, and calm reassurance. Oxygen should not be started routinely and is only appropriate where low blood oxygen is confirmed or strongly suspected. Where breathlessness distress persists despite these measures, medication such as opioids or anti-anxiety medicines may be used, but the first response from care staff remains the simple environmental and reassurance measures.

Noisy Respiratory Secretions ("Death Rattle")

This is one of the symptoms families find most distressing to witness, and one of the most important things care staff can do is offer clear, honest reassurance that these sounds, while difficult to hear, do not cause the dying person discomfort. Repositioning is usually the first practical step. If medication becomes necessary, staff should understand that regular review — checking for improvement roughly every 12 hours — and monitoring for side effects such as delirium, agitation, dry mouth, and sedation are part of using these medicines safely.

Agitation and Anxiety

As with pain, the first step is ruling out an unmet physical need — a full bladder or bowel is a common, easily missed cause of apparent agitation in someone who can no longer communicate clearly. Reversible medical causes should be treated where appropriate, and non-pharmacological approaches — a calm environment, familiar voices, gentle reassurance — should always be tried before or alongside any medication.

Nausea and Vomiting

Identifying the likely cause matters here too: medication side effects, constipation, bowel obstruction, or a biochemical imbalance can all present as nausea, and the right first-line treatment differs depending on the cause. NICE guidance stresses that treatment options should be discussed directly with the dying person and those important to them wherever possible, keeping the person's own preferences central even at this stage.

The Care Staff Role Alongside Clinical Teams

None of this symptom management happens in isolation from wider end-of-life planning. Good symptom control works best when it builds on decisions already recorded through DNACPR conversations and advance care planning, so that the whole team is working from the same understanding of what the resident and their family want, rather than making decisions about symptom relief in a vacuum. NICE's key underlying principle applies throughout: symptom management should be individualised, discussed with the person and their family wherever possible, and reviewed at least daily, with the reasoning documented clearly in the care plan.

Recording and Handover

Because symptom control needs daily review and can change quickly in the last days of life, clear, contemporaneous recording matters enormously. Staff should document exactly what was observed, what was tried, and how the person responded, so that the next shift, and any visiting clinician, can see the full picture rather than starting the assessment from scratch. This is particularly important overnight and at weekends, when the staff on duty may not be the ones who know the resident best, and a clear written record becomes the main way that continuity of good symptom control is maintained.

Frequently Asked Questions

Does every dying person experience pain?
No. NICE guidance is explicit that pain is not an inevitable part of dying, and assuming it is present without proper assessment can lead to inappropriate treatment.

Is the "death rattle" distressing for the dying person?
The evidence suggests it is not experienced as distressing by the dying person themselves, even though it can be very difficult for family members and staff to hear. Clear reassurance to families on this point is an important part of good care.

Should oxygen be given for breathlessness as standard practice?
No. NICE guidance recommends against routinely starting oxygen, reserving it for cases where low blood oxygen is confirmed or strongly suspected, with non-drug measures as the first response.

Confident, well-trained symptom recognition in the last days of life does not replace clinical decision-making, but it dramatically improves how quickly distress is noticed and addressed — and it gives families genuine reassurance that their loved one is being cared for with real skill and attention at the most difficult time.