MMG035 Symptom Management Guidelines for a Person thought to be in the Last Few Days and Hours of Life

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Muriel Blake
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MMG035 Symptom Management Guidelines for a Person thought to be in the Last Few Days and Hours of Life The following pages are guidelines for the management of common symptoms for a person thought to

1 MMG035 Symptom Management Guidelines for a Person thought to be in the Last Few Days and Hours of Life The following pages are guidelines for the management of common symptoms for a person thought to be in the last few days and hours of life. They are based on a review of the Palliative Adult Network Guidelines (2011) 1, Palliative Care Formulary (2011) 2 and clinical consensus from rthamptonshire Specialist Palliative Care Service. These guidelines do not replace clinical judgement. Full explanation and negotiation with the patient and their important others is essential. The prescriber must consider the following points when prescribing, as well as: - other medication, age, frailty, renal impairment and co-morbidities. 1. Consider how symptoms can be improved without using drugs: - Are there any underlying causes that need to be managed? For example - urinary retention can cause agitation. Are drugs the best treatment? For example - would changing the patient s position help noisy respiratory secretions? 2. Assume that the oral route will not be possible, if not immediately, then in the near future. 3. Anticipatory prescribing for symptoms that commonly develop in the last few days and hours of life will ensure that there is no delay in responding to a symptom as it occurs. 4. Symptoms can change frequently and rapidly. Regular assessment of the patient and review of the effect of interventions is crucial. 5. Medications given by a (s/c) infusion via a syringe pump take approximately 6 hours to reach a therapeutic level. If the patient is symptomatic at the time the infusion is commenced an appropriate as (PRN) dose of medication should also be administered. 6. Medication should be prescribed via the route. This ensures that the drug is absorbed and it is a route of administration that is possible in the majority of settings; please refer to your organisation s policy for the use of syringe pumps. 7. If the patient was previously taking opioid medication other than morphine, then their original opioid would be the drug of choice for a infusion via a syringe pump; seek specialist advice for dose conversions before prescribing. 8. If the patient was previously prescribed a fentanyl or buprenorphine patch, the patch should be continued. If increasing pain develops and their background opioid dose needs to be increased, a infusion via a syringe pump can be added; seek specialist advice before prescribing. If symptoms are not adequately controlled or side effects are intolerable contact Cynthia Spencer Hospice (01604) or Cransley Hospice (01536) Watson M, et al (2011). Palliative Adult Network Guidelines United Kingdom. Max Watson. 3 rd Ed. 2. Twycross R & Wilcock A (2014). Palliative Care Formulary United Kingdom. palliativedrugs.com 5 th Ed. Approved by NHFT Medicines Management Committee September 2014 Reviewed December 2016 Review Jan 2019 MMG035 NHFT End of Life Medication Guidelines (Jan17-Jan19) Page 1 of 7

2 The Management of Pain with MORPHINE in the Last Few Days of Life Is the patient in pain? Is the patient prescribed regular Is the patient prescribed regular Prescribe in anticipation of the symptom developing: Morphine If symptom develops follow guidelines as for a patient who has pain To convert a patient from oral morphine to a infusion of morphine, divide the total daily dose of oral morphine by 2 [e.g. If a patient is taking 60mg oral morphine daily, (e.g. Zomorph, MST or Morphgesic 30mg 12hourly) start a infusion of 30mg morphine via syringe pump over 24 hours] Prescribe PRN morphine at one sixth of the 24 hour dose as [e.g. A patient prescribed a infusion of 30mg morphine via syringe pump over 24 hours requires 5mg morphine PRN by injection] If two or more breakthrough doses of morphine have been given in a 24 hour period, increase the total daily dose in the syringe pump by the equivalent amount and recalculate the new breakthrough dose of morphine as described above Prescribe morphine After 24 hours, review medication If two or more PRN doses have been given, consider a syringe pump Assuming absorption is not impaired, the current morphine dose is insufficient to control symptoms To convert from oral morphine to a infusion of morphine, divide the total daily dose of oral morphine by 2 and then increase this dose by 30%; this will result in an appropriate increase in analgesic [e.g. 60mg oral morphine over 24 hours (Zomorph, MST or Morphgesic 30mg 12hourly) converts to a infusion of 40mg morphine via a syringe pump over 24 hours] Prescribe PRN morphine at one sixth of the 24 hour dose as [e.g. A patient prescribed a infusion of 30mg morphine via syringe pump over 24 hours requires 5mg morphine by injection] Give a stat dose of morphine (one sixth of the total daily dose) whilst the syringe pump is being set up Patients who have not taken an opioid before should be prescribed haloperidol 1.5mg PRN as an anti-emetic In patients who are uncomfortable because of stiffness and those not previously on opioids consider rectal or diclofenac ( 50mg - 100mg PRN max 150mgs 24hrs) Although the appropriate dose of morphine is not weight related lower starting doses (i.e. 2.5mg stat ) should be used in patients that are elderly, cachectic or have dementia. Those patients with renal impairment should also start at the lower dose in a range Morphine is the medication of first choice. For patients on very high doses (>500mg/24hr ) diamorphine might be : seek specialist advice To convert oral morphine to diamorphine, divide the oral morphine dose by 3 MMG035 NHFT End of Life Medication Guidelines (Jan17-Jan19) Page 2 of 7 If symptoms are not adequately controlled or side effects are intolerable contact Cynthia

3 The Management of Pain with DIAMORPHINE in the Last Few Days of Life Is the patient in pain? NB: Morphine is the medication of first choice Is the patient prescribed regular Is the patient prescribed regular Prescribe in anticipation of the symptom developing: Diamorphine If symptom develops, follow guidelines as for a patient who has pain To convert a patient from oral morphine to a infusion of diamorphine, divide the total daily dose of oral morphine by 3 [e.g. If a patient is taking 60mg oral morphine daily, (e.g. Zomorph, MST or Morphgesic 30 mg 12 hourly) start a infusion of 20 mg diamorphine via syringe pump over 24 hours] Prescribe PRN diamorphine at one sixth of the 24 hour dose of diamorphine as [e.g. A patient prescribed a infusion of 20 mg diamorphine via syringe pump over 24 hours requires 3mg diamorphine by injection] If two or more breakthrough doses of diamorphine have been given in a 24 hour period, increase the total daily dose in the syringe pump by the equivalent amount and recalculate the new breakthrough dose of diamorphine as described above. Prescribe diamorphine After 24 hours, review medication If two or more PRN doses have been given, consider a syringe pump Assuming absorption is not impaired, the current oral morphine dose is insufficient to control symptoms To convert to a infusion of diamorphine divide the total daily dose of oral morphine by 3 and then increase this dose by 30%; this will result in an appropriate increase in analgesic [e.g. 60mg oral morphine over 24 hours (Zomorph, MST, or Morphgesic 30mg 12hourly) converts to a infusion of 25mg diamorphine via a syringe pump over 24 hours] Prescribe PRN diamorphine at one sixth of the 24 hour dose of diamorphine as [e.g. A patient prescribed a infusion of 20mg diamorphine via syringe pump over 24 hours requires 3mg diamorphine by injection] Give a stat dose of diamorphine (one sixth of the total daily dose) whilst the syringe pump is being set up Patients who have not taken an opioid before should be prescribed haloperidol 1.5mg PRN as an anti-emetic In patients who are uncomfortable because of stiffness and those not previously on opioids consider rectal or diclofenac (50mg - 100mg PRN max 150mgs 24hrs) Morphine is the medication of first choice: See Management of Pain with Morphine in the Last Few Days flow chart Although the appropriate dose of diamorphine is not weight related lower starting doses (i.e. 2.5mg stat ) should be used in patients that are elderly, cachectic or have dementia. Those patients with renal impairment should also start at the lower dose in a range.

4 The Management of Restlessness and Agitation in the Last Few Days of Life Is the patient restless or agitated? A human presence often helps to calm agitated patients Prescribe in anticipation of the symptom developing: Midazolam If symptom develops, follow guidelines for a patient who is restless or agitated Consider underlying causes and resolve where possible: Uncontrolled pain Full bladder Full rectum Dyspnoea Anxiety and fear If the patient s distress cannot otherwise be relieved Where anguish and anxiety are predominant: Give midazolam 2.5-5mg stat and as by injection (this may need to be repeated after 30 minutes) If two or more doses have been given in 24 hours, consider starting a infusion of 10mg midazolam via a syringe pump over 24 hours The infusion dose may need to be increased gradually to midazolam 30mg via syringe pump over 24 hours Where delirium and psychotic features are predominant (e.g. hallucinations, confusion): Give haloperidol 1.5mg stat and 0.5 1mg haloperidol as by injection up to a maximum total daily dose of 10mg. Consider giving haloperidol via a infusion over 24 hours Consider a infusion of haloperidol 3mg and midazolam 10mg via a syringe pump over 24 hours if Levomepromazine mg stat by injection is an alternative to haloperidol. Consider a infusion of 50mg via syringe pump over 24 hours if

5 The Management of Nausea and Vomiting in the Last Few Days of Life Is patient already on an effective antiemetic? Is nausea or vomiting present? Prescribe this antiemetic As infusion over 24hr As PRN dosing Prescribe in anticipation of the symptom developing: Haloperidol 0.5 1mg by injection as If symptom develops, follow guidelines as for a patient who is nauseated or vomiting Give haloperidol 0.5 1mg by Review after 24 hours. If two or more PRN doses of haloperidol have been given, consider starting a infusion of haloperidol 3mg via a syringe pump over 24 hours Maximum total daily dose of haloperidol should not exceed 10mg Alternative antiemetic: Stop haloperidol and prescribe levomepromazine 6.25mg by (or a infusion of mg levomepromazine via a syringe pump over 24 hours)

6 The Management of Respiratory Tract Secretions in the Last Few Days of Life isy respiratory tract secretions can be a normal part of dying Consider whether they are troublesome or need treating at all Changing the patient s position is the first step of management Does the patient have troublesome respiratory tract secretions? Consider: Patient positioning Stopping I.V. or fluids or PEG feed Prescribe in anticipation of the symptom developing: Glycopyrronium 200micrograms by, up to every four hours If symptoms develop, follow guidelines as for a patient who has respiratory tract secretions Give glycopyrronium 400 micrograms by soon as symptom arises and as, up to every four hours If two or more doses of glycopyrronium have been given and are effective, consider starting a infusion of 800micrograms glycopyrronium via syringe pump over 24 hours Review after 24 hours If symptoms persist, increase the total daily dose to a maximum of 1.2mg glycopyrronium over 24 hours In a VERY SMALL number of patients, suction may be helpful This is a difficult symptom to treat and drugs may not be effective - remember to reassure relatives and friends Hyoscine hydrobromide is an alternative but is sedative and frequently causes confusion (400micrograms stat and up to 2.4 mg over 24 hours)

7 The Management of Dyspnoea in the Last Few Days of Life Does the patient complain of breathlessness? Prescribe in anticipation of the symptom developing: Morphine injection, as and Midazolam 2.5mg by If breathlessness develops, follow guidelines as for a patient who is breathless First considerations: Reposition the patient, e.g. sit up in bed Calm and reassure patient and carers by touch, talking and explanation Keep air moving across the face e.g. open the window, use a fan or try oxygen Is the patient taking regular Give morphine injection. If not sufficiently effective give 2.5mg midazolam by injection. Doses can be repeated every 30 minutes as. Specialist advice should be sought if symptoms persist (e.g. after 3 PRN doses in quick succession) After 24 hours, review medication If two or more PRN doses, consider a syringe pump Assuming absorption is not impaired, the current morphine dose is insufficient to control symptoms To convert a patient from oral morphine to a infusion of morphine divide the total daily dose of oral morphine by 2, and then increase the dose by 30%; this will result in an appropriate increase in the amount of opiate being given Give PRN morphine at one sixth of the 24 hour dose. See The Management of Pain with Morphine in the Last Few Days of Life If not sufficiently effective give 2.5mg midazolam by injection Review after 24 hours. If two or more doses of midazolam have been given, consider starting a infusion of 5-10mg midazolam over 24 hours via a syringe pump Patients who have not taken an opiate before should be prescribed haloperidol 1.5mg PRN as an anti-emetic. Morphine is used for relief of the sensation of dyspnoea; midazolam is used for the relief of anxiety associated with dyspnoea To convert oral morphine to diamorphine, divide the oral morphine dose by 3

Symptom Management Guidelines for End of Life Care

Symptom Management Guidelines for End of Life Care The following pages are guidelines for the management of common symptoms in the last few days of life. General principles: 1. Consider how symptoms can