Older patients at the end of life often present with multiple geriatric syndromes and comorbidities, resulting in complex symptom profiles and a high risk of medication-related harm. These challenges not only compromise quality of life at the end of life but also complicate clinical decision-making. Currently, there is a lack of systematic, age-specific guidelines for medication management of symptoms in older palliative care patients in China. This guideline is developed in accordance with the standards of the grading of recommendations, assessment, development, and evaluations (GRADE) system and the reporting items for practice guidelines in healthcare (RIGHT). It addresses 15 symptoms, including pain, dyspnea, and cough in elderly palliative care patients, resulting in 67 recommendations. Based on the best available evidence, an expert panel conducted structured discussions and formulated recommendations. This guideline aims to identify and recommend appropriate pharmacological treatments for common and refractory symptoms in older palliative care patients, and to provide guidance for healthcare professionals on safe, rational, and standardized medication use.