GPAtlas🧭 When to suspect
Cough is one of the most common and exhausting symptoms in advanced illness, reported as very distressing by around a quarter of people in their last year of life. It may be dry and non-productive, productive of sputum, barking, or – where there is recurrent laryngeal nerve involvement – a prolonged, low, bovine cough. The character of the cough, and crucially whether the patient can still clear secretions effectively, determine the entire management strategy.
It is rarely a symptom in isolation. Look for the underlying cause – lung cancer or metastases, malignant pleural effusion, heart failure, or end-stage respiratory disease – and for treatable contributors such as chest infection, gastro-oesophageal reflux disease (GORD), bronchospasm, or an angiotensin-converting enzyme (ACE) inhibitor. Treatment-related causes (chemotherapy, radiotherapy-induced pneumonitis) and aspiration should also be considered. Coughing itself can cause muscle and rib pain, vomiting, syncope, urinary incontinence and broken sleep.
| Cough type | Primary aim | First-line approach |
|---|---|---|
| Dry / non-productive | Suppress the cough | Demulcent, then antitussive ladder (simple linctus → codeine → low-dose morphine) |
| Productive, effective cough | Help clear secretions | Nebulised 0.9% saline, physiotherapy, carbocisteine; avoid suppressing |
| Productive, dying & too weak to clear | Dry secretions for comfort | Reposition + antimuscarinic (e.g. hyoscine butylbromide) |
Source: Scottish Palliative Care Guidelines · Association for Palliative Medicine
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