SYMPTOM MANAGEMENT GUIDANCE FOR PATIENTS RECEIVING PALLIATIVE CARE AT ROYAL DERBY HOSPITAL

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1 SYMPTOM MANAGEMENT GUIDANCE FOR PATIENTS RECEIVING PALLIATIVE CARE AT ROYAL DERBY HOSPITAL If a patient is believed to be approaching the end of their life, medication should be prescribed in anticipation of common symptoms that are known to cause distress at this time. Doses suggested in the Palliative Care order set are for guidance only; if a patient is already on opiates or sedatives, different dosing regimes may be appropriate. Please contact the Hospital Palliative Care Team if you require further advice. For further information regarding prescribing at the end of life, please refer to the Derbyshire Handbook of Priorities for Care, available within the Derbyshire End of Life Toolkit (via Toolkit link on FLO). For more detailed information regarding specific symptoms at the end of life, please refer to the following: Nausea and vomiting Constipation Agitation Breathlessness Approximate opiate dose conversions Syringe driver combinations available at DHFT (November 2014) For more information about treating diabetes in patients who are believed to be dying please refer to the following:

2 Assess for possible causes, for example: Nausea & Vomiting Drug induced, chemo, NSAIDs, antibiotics Gastric outlet obstruction, large volume vomits Constipation Intestinal obstruction, distended abdomen, colicky abdominal pain Infection Metabolic, hypercalcaemia, renal failure Raised intracranial pressure Anxiety Treat the cause if appropriate. Indication Drug Oral dose Subcutaneous Also consider.. infusion/24hrs Drug induced Haloperidol 0.5 3mg od 3 5mg Stop offending drug, PPI Gastric outlet obstruction Metoclopramide 10mg tds 30 75mg Obstruction without colic Domperidone 10mg tds Metoclopramide 10mg tds 30 75mg Dexamethasone Obstruction with colic Cyclizine +/- Haloperidol +/- 50mg tds 1.5 3mg od 150mg 3 5mg Dexamethasone Metabolic Hyoscine Haloperidol 20mg tds 1.5 3mg od mg 3 5mg Raised Intracranial pressure Levomepromazine mg mg Cyclizine 50mg tds 150mg Dexamethasone If unable to tolerate oral medication can give medication as SC PRNs (EXCEPT Domperidone)

3 Constipation Prevention better than cure! Think laxative when prescribing opioids Oral laxatives (doses divided per day according to response) Maximise dose of laxative before switching to an alternative Drug Starting dose Maintenance Maximum dose dose Stimulants Senna (tablets or liquid) 7.5mg mg mg or Bisocodyl 5 mg 5-10mg 20mg plus Softeners Docusate 100mg mg 500mg or Lactulose 10ml 20 40ml 30-60ml or Movicol/Laxido 1 sachet 1 3 sachets 8 sachets in faecal impaction Rectal intervention based on PR examination Rectal findings Agent Reason Soft faeces Firm faeces Hard faeces Microlax enema or Bisacodyl suppository Glycerine suppository followed by Bisacodyl suppository or microlax enema 2 Glycerine suppositories left in for 1 hour then phosphate enema Stimulate evacuation Soften then stimulate Soften then stimulate

4 Assess for possible causes, for example: Urinary retention Faecal impaction Increased pain Infection Hypoxia Treat the cause if appropriate. Agitation Indication Drug Dose Drug toxicity Metabolic upset Altered sensorium Hallucinations Haloperidol PO 1-5 3mg SC 1 5mg bolus CSCI mg / 24hrs Anxiety & Distress Risk of seizure Alternative or additional sedation Nausea Altered sensorium and anxiety Midazolam Levomepromazine Combine Haloperidol and Midazolam SC mg bolus CSCI mg / 24hrs PO mg up to qds SC mg bolus 4 hourly CSCI mg / 24hrs

5 Assess for possible causes, for example: Infection COPD PE Superior vena caval obstruction Pleural effusion Ascites Anaemia Cardiac failure Anxiety Treat the cause if appropriate. Breathlessness Morphine If opioid naïve, oramorph 2.5 5mg four hourly If on opioids, increase the dose of opioid Terminal breathlessness, if opioid naïve, cscidiamorphine 5 10mg/24hours or convert existing morphine dose to diamorphine Benzodiazepines if there is an element of anxiety and panic to breathlessness Diazepam 2mg bd increasing to 5mg bd Lorazepam 0.5 1mg used sublingually for panic attacks/acute breathlessness Midazolam 2.5 5mg PRN sc or 5 10mg csci/24hours Also consider position of patient, fan, relaxation

6 Approximate dose conversions ratios: PO to PO Opiate dose conversions Conversion and Ratio Calculation Example Codeine PO to morphine PO 10:1 Divide 24h codeine dose by 10 Codeine 240mg/24h PO morphine 24mg/24h PO Tramadol PO to morphine PO 10:1 Divide 24h tramadol dose by 10 Tramadol 400mg/24h PO morphine 40 mg/24h PO Morphine PO to oxycodone PO 2:1 Divide 24h morphine dose by 2 Morphine 30mg/24h PO oxycodone 15mg/24h PO Approximate dose conversions ratios: PO to SC Conversion and Ratio Calculation Example Morphine PO to diamorphine SC 3:1 Divide 24h morphine dose by 3 Morphine 30mg/24h PO diamorphine 10mg/24h SC Morphine PO to morphine SC 2:1 Divide 24h morphine dose by 2 Morphine 30mg/24h PO 15mg/24h SC Oxycodone PO to oxycodone SC 2:1 Divide 24h oxycodone dose by 2 Oxycodone 30mg/24h PO oxycodone 15mg/24h SC Fentanyl and buprenorphine transdermal (TD) patches Patches are contraindicated in patients with acute pain which requires rapid titration. An analgesic effect may take > 12h. Patients on patches will still require p.r.n. medication. See table below: Morphine PO MorphineSC DiamorphineSC Fentanyl patch (3 day patch) mg/24h p.r.n. mg mg/24h p.r.n. mg mg/24h p.r.n. mg microgram/h a a. for combinations of Fentanyl patches, add the p.r.n. doses together, e.g microgram/h patches = mg morphine SC = 35mg morphine SC, but can round up to 40mg or down to 30mg for convenience. Comparative doses of morphine/diamorphine and TD buprenorphine (based on PO morphine: TD buprenorphine dose ratio 100:1) Morphine PO MorphineSC DiamorphineSC Buprenorphine patch mg/24h p.r.n. mg mg/24h p.r.n. mg mg/24h p.r.n. mg Microgram/h BuTrans(7 day patch) 12 2 a a Transtec(4 day patch) b a. at these doses, p.r.n. codeine (30-60mg) or tramadol (50mg) may suffice. b. for combinations of patches, add the p.r.n. doses together, e.g microgram/h patches = mg morphine SC = 25mg morphine SC but can round up to 30 mg or down to 20mg for convenience.

7 All syringes are made up to 15ml Syringe Driver Combinations Single drug DRUG EXPIRY STORAGE LIMITS Cyclizine 7 days Diamorphine days if prepared in a licensed unit Haloperidol 7 days Hyoscine 7 days Levomepromazine 7 days Metoclopramide 3 days Fridge Max 75mg in 15ml Midazolam 7 days Octreotide 4 days Fridge Oxycodone 7 days 15mg to 150mg in 15ml 2 Drug combinations Cyclizine + Haloperidol 24 hrs Cyclizine max 150mg Haloperidol 4.5mg Diamorphine + Cyclizine 24 hrs/ 7 days Cyclizine max 100mg with Diamorphine 301mg-1.5g (7d) Cyclizine max 150mg with Diamorphine up to 150mg (7d) Cyclizine max 150mg with Diamorphine mg (24hrs) Diamorphine + Haloperidol 24 hrs/ 7 days Haloperidol max 10mg with Diamorphine up to 1.5g (7d) Haloperidol max 10mg with Diamorphine up to 2g (24hrs) Diamorphine + Hyoscine Diamorphine + Levomepromazine 7 days 7 days Protect from light until administered to patients Diamorphine + Metoclopramide 72hrs Fridge Diamorphine + Midazolam 7 days Midazolam max 75mg with Diamorphine up to 500mg

8 Diamorphine + Octreotide 96hrs Fridge Haloperidol + Hyoscine 24hrs Haloperidol + Midazolam 24hrs Haloperidol max 7.5mg with Midazolam up to 60mg Levomepromazine + Hyoscine 24hrs Protect from light until administered to patients Midazolam + Hyoscine 24hrs Midazolam + Octreotide 24hrs Oxycodone + Cyclizine 24hrs Cyclizine max 45mg with Oxycodone mg Oxycodone + Haloperidol 24hrs Haloperidol up to 7.5mg with Oxycodone mg Oxycodone + Hyoscine butylbromide Oxycodone + Levomepromazine 24hrs Hyoscine butylbromide up to 35mg with Oxycodone mg 24hrs Levomepromazine mg with Oxycodone mg. Protect from light until administered to patient Oxycodone + Metoclopramide 24hrs Metoclopramide up to 35mg with Oxycodone mg Oxycodone + Midazolam 24hrs Midazolam up to 35mg with Oxycodone mg 3 Drug Combinations Diamorphine + Cyclizine + Haloperidol Diamorphine + Haloperidol + Hyoscine Diamorphine + Haloperidol + Midazolam Diamorphine + Hyoscine + Levomepromazine 24hrs Diamorphine up to 750mg Cyclizine up to 150mg Haloperidol up to 20mg 24hrs 24hrs Diamorphine up to 1g Haloperidol up to 7.5mg Midazolam up to 60mg 24hrs Protect from light until administered to patient Diamorphine + Hyoscine + Midazolam Diamorphine + Midazolam + Octreotide 24hrs 24hrs