Palliative and Hospice Care: How to Balance Symptom Relief with Side Effects

When someone is living with a serious illness, the goal isn’t always to cure it. Sometimes, the most important thing is to make sure they’re as comfortable as possible. That’s where palliative care comes in. It’s not about giving up. It’s about focusing on quality of life-reducing pain, shortness of breath, nausea, anxiety, and other distressing symptoms-while being careful not to cause new problems. Hospice care is a type of palliative care for people with six months or less to live who have chosen to stop curative treatments. Both aim for comfort, but getting that balance right is harder than it sounds.

It’s Not Just About Medication

Many people assume palliative care means turning up the morphine until the pain goes away. But that’s not how it works. Too much pain medicine can cause drowsiness, confusion, constipation, or even trouble breathing. And if you’re already weak from illness, those side effects can make things worse. The key is precision. Not more drugs, but the right drug, at the right dose, at the right time.

In the NHS North West guidelines, doctors are trained to assess pain using a detailed checklist: location, type (sharp, dull, burning), what makes it better or worse, and how it affects daily life. Patients often have more than one kind of pain at once-bone pain from cancer, nerve pain from chemotherapy, muscle pain from lying in bed too long. Treating them all the same way leads to overmedication. That’s why using a 0-to-10 pain scale isn’t enough. You need to know what kind of pain you’re dealing with before you choose the treatment.

Managing the Most Common Symptoms

Pain, shortness of breath, nausea, and anxiety are the big four. Each has proven approaches, but they’re not one-size-fits-all.

For pain, opioids like morphine or oxycodone are the first-line treatment. But they’re not the only tool. Nerve pain responds better to gabapentin or duloxetine. Bone pain often needs bisphosphonates. The Dana-Farber Cancer Institute breaks these into separate guides-their "Pink Book" for pain, "Green Book" for nausea-because mixing them up leads to mistakes.

Shortness of breath is often treated with low-dose opioids, even if the patient isn’t in pain. Evidence shows they help the feeling of air hunger. But you can’t just give a high dose. A 2017 review by the American Academy of Family Physicians rated opioids as "B" evidence for dyspnea-meaning they work, but only when carefully titrated. Oxygen isn’t always helpful unless the patient is truly low on oxygen. Often, a fan blowing gently on the face or sitting upright does more than a nasal cannula.

Nausea and vomiting need different drugs depending on the cause. Is it from bowel obstruction? Then corticosteroids like dexamethasone are preferred. Is it from chemotherapy? Then ondansetron or metoclopramide work better. Octreotide, sometimes used for bowel issues, has limited benefit and can cause high blood sugar or diarrhea. Using the wrong drug can make things worse.

Anxiety and agitation are often treated with lorazepam, but only if the patient is truly anxious-not confused or in pain. Delirium looks like anxiety but needs different handling. The UPenn Comfort Care Guidelines recommend checking for delirium every 12 hours using the CAM-ICU tool. If it’s there, haloperidol is the go-to, but only up to 10 mg IV. Higher doses can cause dangerous heart rhythms. And once the patient is calm, you stop the meds. Long-term use isn’t safe.

The Hidden Problem: Overmedication

One of the biggest risks in palliative care isn’t under-treating symptoms-it’s over-treating them. A 2022 Fraser Health survey found that 68% of nurses didn’t have enough time to complete full symptom assessments. So they defaulted to giving more meds. That’s how patients end up drowsy, confused, or unable to talk to their families.

At UPenn, they solved this by requiring documentation after every dose. If a nurse gives lorazepam, they must write down: the patient’s level of agitation before, the dose given, the time, and how the patient responded 30 minutes later. That simple habit cut breakthrough symptoms by 52% and reduced unnecessary sedation.

Another problem? Families. They often fear their loved one will be "drugged up" and ask for less medicine. But when they see the difference-when Dad can smile again, or Mom can hold their hand without crying from pain-they change their minds. That’s why communication matters as much as medication. The National Coalition for Hospice and Palliative Care says families have a "right to live and die free of pain, with dignity." That’s not a slogan. It’s a promise.

Non-Drug Tools Matter Just as Much

Medicines aren’t the only way to help. In fact, the best palliative care teams use them as a last resort after trying simpler things.

For pain: heat packs, gentle massage, repositioning, distraction with music or photos. For shortness of breath: positioning the patient upright, using a handheld fan, practicing slow breathing. For anxiety: having a chaplain sit quietly with the patient, playing familiar songs, letting a pet visit. For constipation: fiber, fluids, stool softeners-not just laxatives.

The NIH’s 2023 strategic plan allocated $47 million to study non-drug approaches because they work-and they don’t come with side effects. A 2023 Fraser Health update found that adding cannabinoid therapy reduced opioid use by 37% in some patients. Not because it cured pain, but because it helped them relax enough to need less morphine.

Why Timing Is Everything

Pain is easier to prevent than to fix. That’s why proactive care beats reactive care. Waiting until someone is screaming before giving pain meds is a mistake. Giving scheduled doses-like every 4 hours-even if the patient says they’re fine, prevents spikes. It’s like filling a glass before it’s empty.

In hospice, teams use "comfort care order sets"-pre-made checklists that guide nurses on what to check, what to give, and when. One 2008 study showed that using these order sets increased nurse confidence in managing symptoms by 37%. That’s huge. When nurses feel prepared, patients get better care.

The same applies to bowel issues. If a patient is at risk for obstruction, start laxatives early. Don’t wait for bloating. If someone has dry mouth from medications, offer ice chips or lip balm before they ask. These small actions add up.

Who’s Really in Charge?

Palliative care isn’t a single doctor’s job. It’s a team. A doctor, a nurse, a social worker, a chaplain, and sometimes a pharmacist. Each brings something different. The doctor prescribes. The nurse monitors. The social worker helps with finances or housing. The chaplain talks about meaning, fear, or regret.

And the patient? They’re the boss. No one decides what comfort looks like except them. One person wants to stay alert to watch their grandchild’s graduation. Another wants to sleep through the last days. Neither is right or wrong. The job of the care team is to honor that.

What’s Changing Now?

The field is evolving fast. Digital tools are being tested-apps where patients rate their pain daily on their phone. Early results show 18% better symptom control because problems are caught earlier. Tele-palliative care is expanding, especially in rural areas where 55% of counties have no specialist. By 2027, 40% of rural patients may get care via video call.

The next version of the National Coalition’s guidelines, due in 2025, will focus on integrating these tools. Also, researchers are looking at genetics. A 2022 JAMA study found that certain gene variants predict how someone will respond to opioids. That could mean personalized dosing in the future-no more guessing.

But the biggest challenge remains: not enough people. There are only 7,000 certified palliative care doctors in the U.S., but over 22,000 are needed. Most general practitioners don’t know how to adjust morphine for kidney failure, even though 87% of palliative specialists say that’s a common gap.

What You Can Do

If you or someone you love is entering palliative or hospice care:

• Ask: "What symptoms are we trying to manage today?" Not just "Is the pain gone?"
• Request a full assessment-not just a pain score, but a description of the pain type.
• Ask about non-drug options before accepting more pills.
• Insist on documentation: "Can you write down what we gave and how they responded?"
• Speak up if your loved one seems too sleepy, confused, or unresponsive. It might be too much medicine.
• Remember: comfort isn’t the absence of all symptoms. It’s having control over them.

Palliative care isn’t about dying. It’s about living-right up until the end-with dignity, peace, and as little suffering as possible. Getting there takes time, skill, and courage. But it’s possible. And it’s worth it.