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← Palliative and end-of-life care

Common symptoms and how they are managed in the facility

Aged care staff GPs & clinicians Residents & families 9 min read

By Dr Josh Hatch, FRACGP

Near the end of life, symptoms can be managed in the facility when medicines and a plan are ready ahead of time. The Quality Standards require medicines for pain and symptoms, including anticipatory medicines, to be prescribed, administered, reviewed and available 24 hours a day in the last days of life 3. This page is education. It does not give doses or protocols, which belong to the prescriber and local guidance.

Numbers in the text link to the 9 sources listed at the foot of this page.

The general approach

  • Pain. Ask the person if they can answer. If they cannot, watch for facial expression, sounds, body movement and changes in behaviour, and use an observational pain tool. The dementia section describes these tools.

  • Breathlessness. Sitting up, a calm room, a fan on the face and treating any reversible cause. Medicines can help when these are not enough.

  • Restlessness and delirium. Look first for causes that can be fixed: a full bladder, constipation, pain, a new medicine, or an infection the person would want treated.

  • Nausea and constipation. Both are worth looking for when a person seems uncomfortable. In one Australian trial, constipation and nausea were more common with regular morphine than with placebo 25.

  • Noisy breathing. Repositioning the person, and explaining to the family what the sound is.

  • Anxiety and distress. Company, a familiar voice, music and explanation. Spiritual and cultural needs are part of palliative care under the Standards 3.

What the trials show

Graded on randomised evidence for the symptom that matters. Most trials were in hospices, palliative care units or outpatients, not in residential aged care.

Oral antipsychotics for distressing delirium symptoms

Risk outweighs benefit

Delirium symptoms were worse, not better, with risperidone or haloperidol than with placebo, and side effects were more common.

The evidence

In 247 people in 11 Australian inpatient palliative care services, delirium symptom scores after three days were higher with risperidone and with haloperidol than with placebo. Both caused more extrapyramidal side effects, and survival was shorter with haloperidol than with placebo (hazard ratio 1.73) 21.

In practice

All groups also had supportive care and treatment of the causes of delirium. 88% had cancer, and the trial was in inpatient units, not aged care. It did not test sedation for severe agitation in the last hours of life 21.

Oxygen for breathlessness when oxygen levels are not low

Not supported

Oxygen through nasal prongs relieved breathlessness no better than room air delivered the same way.

The evidence

In a double-blind trial of 239 outpatients with life-limiting illness and refractory breathlessness, breathlessness improved by similar amounts with oxygen and with room air, with no difference in side effects 23.

In practice

The trial included only people whose arterial oxygen level was above 7.3 kPa, so it does not apply to people who need oxygen because their oxygen levels are low 23.

Regular low-dose slow-release morphine for chronic breathlessness

Uncertain / conflicting

A small early trial found benefit, but two larger Australian trials did not.

The evidence

A crossover trial of 48 people, mostly with COPD, found less breathlessness and better sleep with morphine 24. A trial of 284 people found no difference from placebo in breathlessness, although the morphine group used less as-needed morphine 25. A trial of 160 people with COPD found no difference at one week 26.

In practice

These trials tested chronic breathlessness, mostly in outpatients, not breathlessness in the last days of life 242526.

Hyoscine butylbromide started early to prevent noisy breathing

Promising, not yet proven

Starting it when dying was recognised halved the rate of noisy breathing in one trial.

The evidence

In six Dutch hospices, noisy breathing occurred in 13% of people given the medicine early and 27% of those given placebo. Restlessness, dry mouth and urinary retention were similar between groups 22.

In practice

One trial, in hospices. It measured the noise, which mainly distresses those at the bedside; it did not show that the dying person was more comfortable 22.

Anticipatory medicines

Anticipatory medicines are prescribed before they are needed, so that a nurse can give one when a symptom appears without waiting for a doctor or a pharmacy. In the last days of life, the Standards require anticipatory medicines to be prescribed, administered, reviewed and available 24 hours a day 3.

In practice this depends on things outside the resident’s room: a prescription written in advance, a supply in the building, and a nurse who can give medicines under the skin. These are worth checking well before they are needed.

Does symptom relief shorten life?

Families sometimes worry that medicines for pain or breathlessness will hasten death. Queensland Health guidance for the last days of life advises explaining that deterioration is due to the dying process, and that medicines are given to manage symptoms and promote comfort, not to hasten death 28.

The law is clear on the principle. End of Life Law in Australia explains that giving medication to relieve pain is lawful even if it could hasten death, and that intention is the critical element 27. In Queensland, section 282A of the Criminal Code provides that a doctor, or a person the doctor authorises in writing, is not criminally responsible for a patient’s death when palliative care is given in good faith, with reasonable care and skill, and in line with good medical practice 27.

Related pages on this site

Sources cited on this page

  1. 3 Australian Government Department of Health, Disability and Ageing. Strengthened Aged Care Quality Standards (November 2025; implemented 1 November 2025). Outcome 5.7 Palliative care and end-of-life care, Actions 5.7.1 to 5.7.4. View source
  2. 21 Agar MR, Lawlor PG, Quinn S, et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA Intern Med. 2017;177:34–42. (247 participants, 11 Australian inpatient hospice or hospital palliative care services; 88% had cancer.) View source
  3. 22 van Esch HJ, van Zuylen L, Geijteman ECT, et al. Effect of prophylactic subcutaneous scopolamine butylbromide on death rattle in patients at the end of life: the SILENCE randomized clinical trial. JAMA. 2021;326:1268–76. (157 patients analysed, six Dutch hospices. Scopolamine butylbromide is called hyoscine butylbromide in Australia.) View source
  4. 23 Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet. 2010;376:784–93. (239 outpatients in Australia, the USA and the UK.) View source
  5. 24 Abernethy AP, Currow DC, Frith P, et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ. 2003;327:523–8. (48 participants, South Australian outpatient clinics; mostly COPD.) View source
  6. 25 Currow D, Louw S, McCloud P, et al. Regular, sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial. Thorax. 2020;75:50–6. (284 participants, 14 Australian services.) View source
  7. 26 Ekström M, Ferreira D, Chang S, et al. Effect of regular, low-dose, extended-release morphine on chronic breathlessness in chronic obstructive pulmonary disease: the BEAMS randomized clinical trial. JAMA. 2022;328:2022–32. (160 participants, 20 Australian centres.) View source
  8. 27 End of Life Law in Australia, Queensland University of Technology. Palliative care: the law on medication to relieve pain and symptoms (doctrine of double effect; Criminal Code (Qld) s 282A). (Accessed October 2026; page undated.) View source
  9. 28 Queensland Health. Care plan for the dying person: family and carer distress in the last days of life (fact sheet). (Undated; cites 2024 guidance.) View source

See every source cited across the palliative and end-of-life care section →

Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at October 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment. It is not legal advice. Evidence, Australian regulatory requirements and state laws on advance care planning, substitute decision-making and voluntary assisted dying change — always confirm current advice with the treating GP, the state health department or a lawyer.

This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.

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