Changes

September 2026 — reviewed. A literature search was conducted in July 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring including consolidation of the Assessment section into one node, to improve clarity and navigation. The recommendations have been updated in line with current evidence in the literature. The prescribing information about Pholcodine Linctus BP has been removed following its withdrawal from the UK market, and has been replaced with information about Simple Linctus BP. The recommendation to use weak opioids such as codeine for dry cough has been removed in line with evidence in the literature. Various web links to patient and carer information have been added to the topic.

Update

Goals

To support primary healthcare professionals to:

• Assess a person with cough in a palliative care setting.
• Make a diagnosis and treat the underlying cause of the cough in the palliative care setting, if clinically possible and appropriate.
• Provide symptom relief for cough in the terminal phase of illness and last days of life.
• Advise on sources of information and support for the person, family members, and/or carers.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

End of life care for adults

• Adults who are likely to be approaching the end of their life are identified using a systematic approach.
• Adults approaching the end of their life have opportunities to discuss advance care planning.
• Adults approaching the end of their life receive care that is coordinated between health and social care practitioners within and across different services and organisations.
• Adults approaching the end of their life and their carers have access to support 24 hours a day, 7 days a week.
• Carers providing end of life care to people at home are supported to access local services that can provide assistance.

[NICE, 2021a]

Decision-making and mental capacity

• People aged 16 and over who may lack capacity to make decisions are supported with decision-making in a way that reflects their individual circumstances and meets their particular needs.
• People aged 16 and over at risk of losing capacity to make decisions, and those with fluctuating capacity, are given the opportunity to discuss advance care planning at each health and social care review.
• People aged 16 and over who are assessed as lacking capacity to make a particular decision at the time that decision needs to be made, have a clear record of the reasons why they lack capacity and the practicable steps taken to support them.
• People aged 16 and over who lack capacity to make a particular decision at the time that decision needs to be made have their wishes, feelings, values and beliefs accounted for in best interests decisions.

[NICE, 2020]

What is it?

• Cough is a forced propulsive manoeuvre and defensive reflex that occurs in response to stimulation of irritant afferent vagal nerve and C-fibre receptors that are found in the airways [Twycross, 2021].
  • Receptors respond to mechanical stimuli (such as foreign body, mucus, reflux of gastric contents) and/or chemical stimuli (such as smoke, noxious gases), together with inflammatory and immunological mediators. Stimulation of the receptors can cause cough, bronchoconstriction, and/or mucus secretion, depending on which receptors are stimulated [Twycross, 2021].
• The process of coughing comprises three phases [Chan, 2015] [HIS, 2025]:
  • The inspiratory phase with lengthening of expiratory muscles.
  • The compression phase with build-up of intrathoracic pressure against a closed glottis.
  • The expiratory phase where air is expelled at high velocity together with dynamic compression of the airways, producing the characteristic 'cough' sound.
• The cough reflex has the main protective function of helping to clear the central airways of foreign material, secretions, sputum, or pus [Chan, 2015] [Twycross, 2021].
  • Higher centre input from the brain allows cough to be voluntarily induced or suppressed [Twycross, 2021].

How common is it?

The prevalence of cough in people with cancer varies according to the primary type of cancer, the stage of disease, and treatment(s).

• Expert opinion states that the prevalence of cough in people with cancer is 50–80%, and it is highest in people with lung cancer [Twycross, 2021].
• Expert opinion in another palliative care textbook cites study evidence that cough is present in 43% of people with undifferentiated cancer at the start of treatment, and in more than 65% of people with lung cancer at the time of diagnosis [Chan, 2015].

What are the causes?

There is a wide range of possible underlying causes and mechanisms of cough in advanced disease in the palliative care setting.

• Direct causes due to cancer
  • Endobronchial tumour within the central airways (due to airway infiltration, distortion, and/or obstruction).
  • Infiltration of lung parenchyma (due to airway distortion and/or obstruction).
  • Pleural disease such as mesothelioma.
  • Lymphangitis carcinomatosa (the diffuse infiltration of lymphatics of the lungs by cancer cells).
• Indirect causes due to complications of cancer or treatment
  • Pleural effusion.
  • Aspiration (due to bulbar muscle weakness, neuromuscular incoordination, or gastro-oesophageal reflux, for example). See the CKS topic on Dyspepsia - proven GORD for more information.
  • Pericardial effusion.
  • Radiation-induced pneumonitis or lung fibrosis.
  • Chemotherapy-induced lung fibrosis (for example, bleomycin, methotrexate, and cyclophosphamide).
  • Pneumonia. See the CKS topic on Chest infections - adult for more information.
  • Tracheo-oesophageal fistula.
  • Superior vena cava syndrome.
  • Metastatic spread.
• Non-malignant causes
  • Upper airway cough syndrome (post-nasal drip).  See the CKS topic on Cough for more information.
  • Asthma. See the CKS topic on Asthma for more information.
  • Chronic obstructive pulmonary disease. See the CKS topic on Chronic obstructive pulmonary disease for more information.
  • Bronchiectasis.
  • Interstitial lung disease/lung fibrosis.
  • Gastro-oesophageal reflux disease. See the CKS topic on Dyspepsia - proven GORD for more information.
  • Heart failure. See the CKS topic on Heart failure - chronic for more information.
  • Pneumonia/infection/aspiration. See the CKS topic on Chest infections - adult for more information.
  • Pulmonary embolism. See the CKS topic on Pulmonary embolism for more information.
  • Drugs (such as angiotensin-converting enzyme [ACE]-inhibitors, beta-blockers, nitrofurantoin).
  • Sarcoidosis.
  • Neurodegenerative disease, such as motor neurone disease or amyotrophic lateral sclerosis (causing excess saliva production).

  [Chan, 2015; Twycross, 2021; HIS, 2025]

What are the complications?

• Cough may be pathological when it is ineffective (dry or unproductive), and the person is unable to clear the central airways of foreign material, secretions, or pus, leading to a risk of pneumonia and infection [Twycross, 2021].
  • Ineffective cough may be due to various factors, such as [Chan, 2015; Twycross, 2021]:
    • Muscle — general debility, weakness of respiratory or abdominal muscles, neurological deficit, and decreased level of consciousness.
    • Airway — non-compressible airway (due to tumour or stent insertion, for example), vocal cord paralysis.
    • Mucus — reduction of water content of mucus increasing mucus tenacity (due to dehydration, drug adverse effects, or respiratory infection, for example).
    • Mucociliary — impaired mucociliary function (due to smoking or chronic obstructive pulmonary disease, for example).
• Cough can negatively impact a person's quality of life, due to [Chan, 2015; Pan, 2020; Twycross, 2021; HIS, 2025]:
  • Reduced quality of life:
    • Sleep disturbance, exhaustion, and fatigue.
    • Anxiety, fear of choking, panic, and embarrassment.
    • Impact on social activities and risk of social isolation.
    • Impact on conversation, communication, and eating.
  • Physical complications:
    • Haemodynamic changes (such as arrhythmias and hypotension). See the CKS topic on Palpitations for more information.
    • Ruptured blood vessels causing nosebleeds, haemoptysis, or conjunctival haemorrhage. See the CKS topic on Epistaxis (nosebleeds) for more information.
    • Stress urinary incontinence. See the CKS topic on Incontinence - urinary, in women for more information.
    • Hernia. See the CKS topic on Scrotal pain and swelling for more information.
    • Headache. See the CKS topic on Headache - assessment for more information.
    • Syncope. See the CKS topic on Blackouts and syncope for more information.
    • Pneumothorax and rib fractures.
    • Vomiting. See the CKS topic on Palliative care - nausea and vomiting for more information.
    • Muscular pain. See the CKS topic on Sprains and strains for more information.

How should I assess a person with cough in a palliative care setting?

If a person presents with cough in a palliative care setting:

• Ask about:
  • Clinical features of the cough, including severity, time of onset, duration of episodes, pattern and character of cough (wet or dry), progression or change over time, precipitating and exacerbating factors, and relieving factors. A 'cough diary' may provide an objective record of cough symptoms.
    
    • Dry cough, persisting over weeks — may be due to an underlying cancer. See the CKS topic on Lung and pleural cancers - recognition and referral for more information.
    • Dry barking cough that is short-lived — may be due to pharyngitis, tracheobronchitis, pneumonia. See the CKS topics on Chest infections - adult and Sore throat - acute for more information.
    • Harsh, hoarse 'croup' sounding cough — may be due to laryngitis.
    • Prolonged, low 'bovine' cough — may be due to left recurrent laryngeal nerve palsy from intrathoracic compression or disease (for example, lung cancer and hilar lymph nodes), which causes abductor paralysis of the vocal cords.
    • Hard, metallic-sounding 'brassy' cough — may be due to tracheal compression from intrathoracic lesions, lymph nodes, or superior vena cava syndrome (may be associated with wheeze or stridor).
    • Wet cough — secretions moving in the major airways (these may or may not be expectorated).
    • Coughing or choking with food or after a meal — aspiration from gastro-oesophageal or pharyngeal disease. See the CKS topic on Dyspepsia - proven GORD for more information.
    • Wheezy cough — may be due to airflow obstruction associated with asthma or chronic obstructive pulmonary disease (COPD), for example. See the CKS topics on Asthma and Chronic obstructive pulmonary disease for more information.
  • Any associated symptoms, such as:
    • Nasal discharge — may be caused by upper respiratory infection and/or sinus disease. See the CKS topics on Common cold and Sinusitis for more information.
    • Sputum — purulent (thick, yellow, or green may suggest infection); frothy (may suggest heart failure or rarely alveolar cell cancer); non-infected (jelly-like, white, or clear).
    • Haemoptysis and/or pleuritic pain — due to tumour, tumour erosion, or pulmonary embolism. See the CKS topics on Lung and pleural cancers - recognition and referral and Pulmonary embolism for more information.
    • Breathlessness, insomnia, and fatigue. See the CKS topic on Palliative care - breathlessness for more information.
    • Stridor —  may be due to tracheal compression from intrathoracic lesions or superior vena cava syndrome. See the CKS topic on Palliative care - breathlessness for more information.
  • Any comorbidities or clinical features suggesting an underlying cause or contributing factor, such as gastro-oesophageal reflux, or uncontrolled pain reducing cough effectiveness.
  • Any associated psychological symptoms such as anxiety, panic, fear of choking, or depression.
  • Smoking and occupational history including asbestos exposure.
  • Any potentially causative medications, such as angiotensin-converting enzyme (ACE)-inhibitors, beta-blockers, nitrofurantoin.
  • The person's social situation and impact on daily functioning and quality of life, including self-image, role, conversation and communication, eating, vomiting and choking, continence, and sleep.
  • The person's emotional response, level of distress, and coping strategies/support network.
• Examine the person, depending on the stage of disease and estimated prognosis, to assess severity and underlying cause, if possible and appropriate.
  • Ear, nose, and throat examination — to assess for signs of pharyngitis, sinus disease, or upper airway cough syndrome, for example. See the CKS topic on Cough, Sinusitis, and Sore throat - acute for more information.
  • Respiratory examination including oxygen saturation level using pulse oximetry, respiratory rate, and effort. Assess for:
    • The effectiveness of cough — whether it is powerful enough to expectorate secretions.
    • The character of cough — dry, wet, productive, or non-productive.
    • Decreased chest wall movement — may suggest lung collapse, pleural effusion, and respiratory muscle weakness.
    • Percussion note — dullness may suggest lung collapse, stony dullness may suggest pleural effusion.
    • Breath sounds — bronchial breath sounds may suggest lung consolidation. See the CKS topic on Chest infections - adult for more information.
    • Wheeze/stridor — may suggest endobronchial tumour, superior vena cava syndrome, asthma, or chronic obstructive pulmonary disease. See the CKS topics on Asthma and Chronic obstructive pulmonary disease for more information.
    • Crepitations — may suggest exudate in the bronchioles due to infection and/or heart failure. See the CKS topics on Chest infections - adult and Heart failure - chronic for more information.
    • Breathlessness. See the CKS topic on Palliative care - breathlessness for more information on assessment.
  • Cardiovascular examination including pulse rate, rhythm, and signs of heart failure. See the CKS topic on Heart failure - chronic for more information.
• Arrange investigations in primary care, depending on the person's stage of disease and estimated prognosis, any likely underlying cause, the relative benefits and risks of investigation(s), and the person's wishes, such as:
  
  • N-terminal pro-B-type natriuretic peptide level (NT-pro-BNP) blood test to assess for heart failure. See the CKS topic on Heart failure - chronic for more information.
  • Sputum culture and sensitivity if suspected infection. See the CKS topics on Chest infections - adult and Cough for more information.
  • Chest X-ray to assess for lung disease such as pneumonia, pleural effusion, and heart failure. See the CKS topics on Chest infections - adult and Heart failure - chronic for more information.
  • Spirometry to assess for asthma or chronic obstructive pulmonary disease. See the CKS topics on Asthma and Chronic obstructive pulmonary disease for more information.

Scenario: Known cause of cough

From age 16 years onwards.

Scenario: Symptomatic treatment

From age 16 years onwards.

Scenario: End of life care

From age 16 years onwards.

Morphine

• Morphine may be used for symptom relief of a distressing dry cough in a palliative care setting (off-label indication).
  • The initial starting dose of morphine depends on the person's age, comorbidities, and previous exposure to opioids. The dose should be titrated in the same way as when used for pain relief. See the CKS topic on Palliative care - pain for more detailed information.
  • Contraindications for oral morphine include acute respiratory depression and risk of paralytic ileus.
  • Use morphine with caution (consider reducing dose) in people who are frail and elderly, with hepatic and renal impairment, hypotension, hypothyroidism, convulsive disorders, and obstructive bowel disorders.
• If using 4-hourly morphine:
  • After 1–2 days, calculate the total dose given over 24 hours, and use this to recalculate the 4-hourly dose. The new 4-hourly and 'as required' dose is one-tenth to one-sixth of the new total daily dose.
  • Repeat this process every 1–2 days until the cough is controlled.
  • Once a stable dose has been reached, this can be converted to once- or twice-daily modified-release morphine if preferred.
• If already taking morphine for pain relief:
  • Use an 'as required' dose of morphine to relieve cough. If this 'as required' dose provides cough relief, either increase the regular daily dose by 30–50% every 2–3 days until symptoms are controlled or adverse effects prevent further dose increases, or continue to use additional morphine as required.
  • If the total daily dose is increased, the 'as required' dose will also need to be recalculated. If an 'as required' dose of morphine does not relieve cough, do not continue to increase the morphine dose.
• Advise about and manage possible adverse effects of morphine:
  • Arrhythmias; confusion; constipation; dizziness; drowsiness; dry mouth; euphoric mood; flushing; hallucination; headache; hyperhidrosis; hypotension (with high doses); miosis; nausea (more common on initiation); palpitations; respiratory depression (with high doses); skin reactions; urinary retention; vertigo; visual impairment; vomiting (more common on initiation); and withdrawal syndrome.
    
    • Some drowsiness is common at the start of treatment or after dose increases, and people should be warned to take care with daily activities. In most people, drowsiness resolves within a few days. Persistent drowsiness may be managed by a morphine dose reduction.
  • Uncommon adverse effects include agitation; bronchospasm; ileus; mood altered; myoclonus; peripheral oedema; pulmonary oedema; sensation abnormal; syncope; and taste altered.

[HIS, 2025; BNF, 2026]

Mucolytics

• Carbocisteine may be used as a mucolytic to help expectoration if there is a distressing wet cough.
  • Initially prescribe 2.25 g daily in 3 divided doses, then reduced to 1.5 g daily in 2–4 divided doses, the dose may be reduced if symptoms improve.
• Do not prescribe carbocisteine if a person has active peptic ulceration.
• Prescribe carbocisteine with caution if a person has a history of peptic ulceration, as the drug may disrupt the gastric mucosal barrier.
• Possible adverse effects of carbocisteine include gastrointestinal haemorrhage, skin reactions, Stevens-Johnson syndrome, and vomiting.

[BNF, 2026]

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of palliative care - cough.

Search dates

March 2021 - September 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Palliative Care/, exp Terminal Care/, exp Terminally Ill/, palliat$.tw., (terminal adj care).tw., (palliative or terminal$ or end of life).tw., (advanced adj disease).tw.
• exp Cough/, cough$.tw.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
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Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
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Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

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Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.