Symptom Management Guidelines for End of Life Care

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Ferdinand Baker
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1 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 be improved without using drugs 2. Common symptoms at the end of life are pain, agitation, nausea and vomiting, breathlessness, and respiratory secretions. Anticipatory prescribing for these symptoms will ensure that there is no delay in responding to the symptom when it occurs. 3. Assume that the oral route will not be possible, if not immediately, then in the near future and prescribe medications via the subcutaneous route pre-emptively. 4. Use water for injection as a diluent unless otherwise stated. 5. The prn dose of morphine is 1/6 of the total daily dose of morphine. 6. Where a patient already has FENTANYL or BUPRERPHINE patches in situ, do not remove. Replace patch as required. Contact the Specialist Palliative Care Team for further guidance. 7. If the dying patient has renal failure, dementia or Parkinson s disease, contact the Specialist Palliative Care Team for further guidance. 8. Symptoms can change frequently and rapidly. Regular assessment of the patient and reviewing the effect of interventions is crucial. Developed by the End of Life Care Medicines Group, April Review date April 2014.

2 1 THE MANAGEMENT OF PAIN WITH MORPHINE IN THE LAST FEW DAYS OF LIFE Is the patient in pain? Is the patient prescribed regular MORPHINE? Is the patient prescribed regular MORPHINE? Prescribe in anticipation of the symptom developing: MORPHINE 2.5 mg by subcutaneous injection, as required 1 hourly. To convert a patient from oral morphine to a subcutaneous infusion of morphine, divide the total 24 hour amount of morphine by 2 i.e. if a patient is taking 60mg oral morphine (e.g. MST 30mg bd) then start a subcutaneous infusion of 30mg morphine over 24 hours. Prescribe prn MORPHINE at one sixth of the 24 hour dose as required i.e. a patient prescribed a subcutaneous infusion of 30mg MORPHINE over 24 hours requires 5mg of MORPHINE subcutaneously as required 1 hourly. Prescribe in anticipation of the symptom developing: MORPHINE 2.5 mg by subcutaneous injection as required 1 hourly. If two or more prn doses have been given, consider a syringe driver The current morphine dose is insufficient to control symptoms To convert a patient from oral MORPHINE to a subcutaneous infusion of MORPHINE, divide the total 24 hour amount of MORPHINE by 2 and then increase this dose by 30% i.e. If a patient is taking 60mg oral MORPHINE (e.g. MST 30mg bd) then start a subcutaneous infusion of 40mg MORPHINE over 24 hours. Prescribe prn MORPHINE at one sixth of the 24 hour dose as required i.e. a patient prescribed a subcutaneous infusion of 40mg MORPHINE over 24 hours requires 5mg-10mg of MORPHINE subcutaneously 1 hourly as required.

3 2 THE MANAGEMENT OF BREATHLESSNESS IN THE LAST FEW DAYS OF LIFE Does the patient complain of breathlessness? Reposition the patient, e.g. sit up in bed Improve air circulation i.e. fan therapy, open windows Breathlessness persists Prescribe in anticipation of the symptom developing: MORPHINE 2.5 mg by subcutaneous injection 1 hourly as required and MIDAZOLAM 2.5 mg by subcutaneous injection as required 1 hourly Give MORPHINE 2.5mg subcutaneous 1 hourly when required (If already on opiates, give appropriate breakthrough dose) After 24 hours, review the total quantity of medication given S/C for dyspnoea. If two or more doses have been given consider starting a syringe driver that delivers the same quantity of medication over a 24-hour period. If not sufficiently effective, give MIDAZOLAM 2.5mg subcutaneously 1 hourly as required Supportive information MORPHINE is used for the relief of the sensation of dyspnoea; MIDAZOLAM is used for the anxiety associated with dyspnoea To convert oral morphine to subcutaneous MORPHINE divide the oral dose by 2 Give PRN MORPHINE at one sixth of the 24 hour dose

4 3 THE MANAGEMENT OF NAUSEA AND VOMITING IN THE LAST FEW DAYS OF LIFE Is the patient already on an effective antiemetic? Prescribe this antiemetic as a subcutaneous infusion over 24 hours Does the patient have nausea or vomiting? Prescribe in anticipation of the symptom developing/ getting worse: HALOPERIDOL 1 milligram by subcutaneous injection up to 2 hourly as required Give HALOPERIDOL 1mg by subcutaneous injection as required 2 hourly Review after 24 hours. If two or more prn doses of HALOPERIDOL have been given, consider starting a subcutaneous infusion of HALOPERIDOL 3mg via a syringe driver over 24 hours. Maximum total 24 hour dose of HALOPERIDOL should not exceed 10mg Supportive information: Alternative antiemetic: stop haloperidol and prescribe LEVOMEPROMAZINE 6.25mg by subcutaneous injection as required (or a subcutaneous infusion of mg of LEVOMEPROMAZINE over 24 hours). THE MANAGEMENT OF RESTLESSNESS AND AGITATION IN THE LAST FEW DAYS OF LIFE

5 4 THE MANAGEMENT OF RESTLESSNESS AND AGITATION IN THE LAST FEW DAYS OF LIFE Is the patient restless or agitated? Prescribe in anticipation of the symptom developing MIDAZOLAM milligrams by subcutaneous injection as required 1 hourly If the patient s distress cannot be otherwise relieved: Consider underlying causes, such as: Uncontrolled pain Full bladder Full rectum Dyspnoea Anxiety and fear Resolve where possible. Where anguish and anxiety are predominant: Give MIDAZOLAM 2.5 5mg as required by subcutaneous injection up to one hourly. If two or more doses have been given in 24 hours, consider starting a subcutaneous infusion of MIDAZOLAM 5 10mg over 24 hours The subcutaneous infusion dose may need to be increased gradually up to MIDAZOLAM 30mg via syringe driver over 24 hours Where delirium and psychotic features are predominant (e.g. hallucinations, confusion) Give HALOPERIDOL 3mg and then 1.5 3mg HALOPERIDOL as required by subcutaneous injection four hourly (The maximum total daily dose should be 10mg). If two or more doses THE have MANAGEMENT been given, consider OF RESPIRATORY starting a syringe TRACT driver SECRETIONS that delivers the IN same THE quantity LAST FEW of medication DAYS OF over LIFE the next 24-hour period. LEVOMEPROMAZINE THE 12.5mg MANAGEMENT 4-hourly by subcutaneous OF RESPIRATORY injection is an alternative TRACT SECRETIONS to HALOPERIDOL IN THE if symptoms LAST FEW persist, DAYS contact OF LIFE. the specialist palliative care team. RESPIRATORY SECRETIONS

6 5 THE MANAGEMENT OF RESPIRATORY TRACT SECRETIONS IN THE LAST FEW DAYS OF LIFE Noisy respiratory tract secretions can be a normal part of dying as fluid pools in the oropharynx Consider whether they are troublesome or need treating at all; most patients are unaware of secretions Does the patient have troublesome respiratory tract secretions? Prescribe in anticipation of the symptom developing: GLYCOPYRRONIUM 200 micrograms by subcutaneous injection up to every 4 hours Consider: Patient positioning and regular mouth care Give GLYCOPYRRONIUM 200 micrograms by subcutaneous injection as soon as symptom arises and as required, up to every 4 hours. If two or more doses of GLYCOPYRRONIUM have been given and are effective, consider starting a subcutaneous infusion of 600 micrograms GLYCOPYRRONIUM via a syringe driver 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

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

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