INTEGRATED CARE PATHWAY (ICP) FOR THE DYING ADULT

INTEGRATED CARE PATHWAY (ICP) FOR THE DYING ADULT PLEASE INFORM THE PALLIATIVE CARE TEAM ON COMMENCEMENT OF THIS ICP (EXT 8958) ICP Start Date Patient s Name. Ward. Consultant.. Named Specialist Nurse Date of Birth.. Hospital No.... Named Nurse..... Tel No... This Integrated Care Pathway is a guide to treatment. Practitioners are free to exercise their own professional judgement. Any alteration to the practice identified within this ICP must be recorded as a variance on the variance recording sheet at the back of the pathway Instructions for use: All goals are in heavy typeface. Prompts to support the goals are in normal type. During use, if a goal is not achieved (i.e. variance) please record reason/action on the variance recording sheet. All staff documenting in the care pathway must first complete the signature page (pg 2) of the ICP. Please initial responses to all questions/goals. This pathway can be discontinued if patient s condition stipulates (Date...) CRITERIA FOR USING THIS ICP Please start the ICP when the multi-professional team have AGREED that the patient is DYING and fulfils any two of the following criteria: Please tick: Bed bound Comatose or Semi Comatose Only able to take sips of fluids No longer able to take tablets Please consider NFR status. Patient should have underlying, life threatening and incurable illness. Reversible measures for current deterioration in condition should be considered. Reference: Ellershaw J & Wilkinson S Eds. Care for the Dying: A Pathway to Excellence. Oxford University Press: Oxford, 2003 Ref: J414 1 CM4436

All personnel completing the care pathway please sign & initial below (each member of staff needs to do this once only) Name (print) Full signature Initials Professional title Date 2

Name:... Unit no: Date/Time commenced:... Section 1 Diagnosis & Demographics Initial assessment Goals 1 to 3 to be completed by Doctor PRIMARY DIAGNOSIS: SECONDARY DIAGNOSIS: Physical condition Comfort measures Unable to swallow Yes No Aware Yes No Nausea Yes No Conscious Yes No Vomiting Yes No UTI problems Yes No Constipated Yes No Catheterised Yes No Confused Yes No Respiratory tract secretions Yes No Agitation Yes No Dyspnoea Yes No Restless Yes No Pain Yes No Distressed Yes No Other (e.g. oedema, itch) Yes No Goal 1: Current medication assessed and non essentials discontinued Yes No Appropriate oral drugs converted to subcutaneous route and syringe driver commenced if appropriate (see attached algorithms) Inappropriate medication discontinued. Goal 2: PRN subcutaneous medication written up from list below as per protocol (See algorithms at back of LCP for guidance) Pain Analgesia Yes No Agitation Sedative Yes No Respiratory tract secretions Anticholinergic Yes No Nausea & vomiting Anti-emetic Yes No Dyspnoea Anxiolytic / Muscle relaxant Yes No Goal 3: Discontinue inappropriate interventions Blood test Yes No N/A Antibiotics Yes No N/A I.V. fluids/medications Yes No N/A Not for cardiopulmonary resuscitation recorded Yes No (Please record below & complete Trust Yellow Resusitation Status Form)... Deactivate cardiac defibrillator (ICD) Yes No N/A Contact patient s Cardiologist Refer to local policy and procedures Doctor s signature:... Date:... Goal 3a: Decisions to discontinue inappropriate nursing interventions taken Yes No Routine turning regime reposition for comfort only consider pressure relieving mattress & appropriate assessments re skin integrity. Discontinue EWS If BM monitoring in place reduce frequency as appropriate e.g. once daily Goal 3b: Syringe driver set up within 4 hours of doctor s order Yes No N/A Nurse signature:... Date:... Time:... 3

Section 1 Initial assessment - Continued Psychological/ insight Goal 4: Ability to communicate in English assessed as adequate a) Patient Yes No Comatose b) Family/other Yes No Goal 5: Insight into condition assessed Aware of diagnosis a) Patient Yes No Comatose b) Family/other Yes No Recognition of dying c) Patient Yes No Comatose d) Family/other Yes No Religious/ Spiritual support Goal 6: Religious/spiritual needs assessed a) with Patient Yes No Comatose b) with Family/other Yes No Patient/other may be anxious for self/others Consider specific cultural needs Consider support of Chaplaincy Team Religious Tradition identified, if yes specify: Yes No N/A.. Support of Chaplaincy Team offered Yes No In-house support Tel/bleep no: Name: Date/time: External support Tel/bleep no: Name: Date/time: Comments (Special needs now, at time of impending death, at death & after death identified) Communication with family/other Goal 7: Identify how family/other are to be informed of patient s impending death Yes No At any time Not at night-time Staying overnight at Hospital First contact name:... Relationship to patient:... Tel no:... Second contact:... Tel no:... Goal 8: Family/other given hospital information:- Yes No Facilities leaflet is available to address: Car parking; Accommodation; Beverage facilities; Payphones; Washrooms & toilet facilities on the ward; Visiting times; Any other relevant information. C o m m u n i c a t i o n w i t h p r i m a r y h e a l t h c a r e t e a m Goal 9: G.P. Practice is aware of patient s condition G.P. Practice to be contacted if unaware patient is dying, message can be left with the receptionist Yes No Summary Goal 10: Plan of care explained & discussed with: a) Patient Yes No Comatose b) Family/other Yes No Goal 11: Family/other express understanding of planned care Yes No Family/other aware of the aims of planned care, ie; focusing on comfort, dignity and good symptom control If you have charted No against any goal so far, please complete the variance sheet. Health Professional signature:... Title:... Date:... 4

Codes (please enter in columns) A= Achieved V=Variance (not a signature) Section 2 Patient problem/focus 04:00 08:00 12:00 16:00 20:00 24:00 Ongoing assessment Pain Goal A: Patient is pain free Verbalised by patient if conscious Pain free on movement Appears peaceful Consider need for positional change Agitation Goal B: Patient is not agitated Patient does not display signs of delirium, terminal anguish, restlessness (thrashing, plucking, twitching) Exclude retention of urine as cause Consider need for positional change Respiratory tract secretions Goal C: Excessive secretions are not a problem Medication to be given as soon as symptoms arise Consider need for positional change Symptom discussed with family/other Nausea & vomiting Goal D: Patient does not feel nauseous or vomit Patient verbalises if conscious Dyspnoea Goa E: Breathlessness is not distressing for patient Patient verbalises if conscious. Consider need for positional change. Other symptoms (e.g. oedema, itch)... Treatment/procedures Mouth care Goal F: Mouth is moist and clean Mouth care assessment at least 4 hourly Frequency of mouth care depends on individual need Family/other involved in care given Micturition difficulties Goal G: Patient is comfortable Urinary catheter if in retention Urinary catheter or pads, if general weakness creates incontinence Medication (If medication not required please record as N/A) Goal: All medication is given safely & accurately If syringe driver in progress check at least 4 hourly and complete syringe driver monitoring chart Signature Repeat this page 24 hrly. Spare copies on Ward If you have charted V against any goal so far, please complete variance sheet on the back page Name:... Unit no:... Date:... 5

Codes (please enter in columns) A= Achieved V=Variance 08:00 20:00 Mobility/Pressure area care Bowel care Psychological/ Insight support Goal H: Patient is comfortable and in a safe environment Clinical assessment of: Skin integrity Need for positional change Need for special mattress Personal hygiene, bed bath, eye care needs Goal I: Patient is not agitated or distressed due to constipation or diarrhoea Patient Goal J: Patient becomes aware of the situation as appropriate Patient is informed of procedures Touch, verbal communication is continued Family/other Goal K: Family/other are prepared for the patient s imminent death with the aim of achieving peace of mind and acceptance Check understanding of nominated family/others / younger adults / children Check understanding of other family/others not present at initial assessment Ensure recognition that patient is dying & of the measures taken to maintain comfort Chaplaincy Team support offered Religious/ Spiritual support Care of the family /others Goal L: Appropriate religious/spiritual support has been given Patient/other may be anxious for self/others Support of Chaplaincy Team may be helpful Consider cultural needs Goal M: T h e needs of those attending the patient are accommodated Consider health needs & social support. Ensure awareness of ward facilities Health Professional Signature Early:... Late:..... Night:... Multidisciplinary progress notes Name:... Unit no:... Date:... 6

Codes (please enter in columns) A= Achieved V=Variance (not a signature) Section 2 Patient problem/focus 04:00 08:00 12:00 16:00 20:00 24:00 Ongoing assessment Pain Goal A: Patient is pain free Verbalised by patient if conscious Pain free on movement Appears peaceful Consider need for positional change Agitation Goal B: Patient is not agitated Patient does not display signs of delirium, terminal anguish, restlessness (thrashing, plucking, twitching) Exclude retention of urine as cause Consider need for positional change Respiratory tract secretions Goal C: Excessive secretions are not a problem Medication to be given as soon as symptoms arise Consider need for positional change Symptom discussed with family/other Nausea & vomiting Goal D: Patient does not feel nauseous or vomit Patient verbalises if conscious Dyspnoea Goal E: Breathlessness is not distressing for patient Patient verbalises if conscious. Consider need for positional change. Other symptoms (e.g. oedema, itch)... Treatment/procedures Mouth care Goal F: Mouth is moist and clean Mouth care assessment at least 4 hourly Frequency of mouth care depends on individual need Family/other involved in care given Micturition difficulties Goal G: Patient is comfortable Urinary catheter if in retention Urinary catheter or pads, if general weakness creates incontinence Medication (If medication not required please record as N/A) Goal H: All medication is given safely & accurately If syringe driver in progress check at least 4 hourly and complete monitoring sheet Signature Repeat this page 24 hrly. Spare copies on Ward If you have charted V against any goal so far, please complete variance sheet on the back page Name:... Unit no:... Date:... 7

Codes (please enter in columns) A= Achieved V=Variance 08:00 20:00 Mobility/Pressure area care Bowel care Psychological/ Insight support Goal I: Patient is comfortable and in a safe environment Clinical assessment of: Skin integrity Need for positional change Need for special mattress Personal hygiene, bed bath, eye care needs Goal J: Patient is not agitated or distressed due to constipation or dia r r h o e a Patient Goal K: Patient becomes aware of the situation as appropriate Patient is informed of procedures Touch, verbal communication is continued Family/other Goal L: Family/other are prepared for the patient s imminent death with the aim of achieving peace of mind and acceptance Check understanding of nominated family/others / younger adults / children Check understanding of other family/others not present at initial assessment Ensure recognition that patient is dying & of the measures taken to maintain comfort Chaplaincy Team support offered Religious/ Spiritual support Care of the family /others Goal M: Appropriate religious/spiritual support has been given Patient/other may be anxious for self/others Support of Chaplaincy Team may be helpful Consider cultural needs Goal N: The needs of those attending the patient are accommodated Consider health needs & social support. Ensure awareness of ward facilities Health Professional Signature Early:... Late:..... Night:... Multidisciplinary progress notes Name:... Unit no:... Date:... 8

Codes (please enter in columns) A= Achieved V=Variance (not a signature) Section 2 Patient problem/focus 04:00 08:00 12:00 16:00 20:00 24:00 Ongoing assessment Pain Goal A: Patient is pain free Verbalised by patient if conscious Pain free on movement Appears peaceful Consider need for positional change Agitation Goal B: Patient is not agitated Patient does not display signs of delirium, terminal anguish, restlessness (thrashing, plucking, twitching) Exclude retention of urine as cause Consider need for positional change Respiratory tract secretions Goal C: Excessive secretions are not a problem Medication to be given as soon as symptoms arise Consider need for positional change Symptom discussed with family/other Nausea & vomiting Goal D: Patient does not feel nauseous or vomit Patient verbalises if conscious Dyspnoea Goal E: Breathlessness is not distressing for patient Patient verbalises if conscious. Consider need for positional change. Other symptoms (e.g. oedema, itch)... Treatment/procedures Mouth care Goal F: Mouth is moist and clean Mouth care assessment at least 4 hourly Frequency of mouth care depends on individual need Family/other involved in care given Micturition difficulties Goal G: Patient is comfortable Urinary catheter if in retention Urinary catheter or pads, if general weakness creates incontinence Medication (If medication not required please record as N/A) Goal H: All medication is given safely & accurately If syringe driver in progress check at least 4 and complete monitoring sheet Signature Repeat this page 24 hrly. Spare copies on Ward If you have charted V against any goal so far, please complete variance sheet on the back page 9

Name:... Unit no:... Date:... Codes (please enter in columns) A= Achieved V=Variance 08:00 20:00 Mobility/Pressure area care Bowel care Psychological/ Insight support Goal I: Patient is comfortable and in a safe environment Clinical assessment of: Skin integrity Need for positional change Need for special mattress Personal hygiene, bed bath, eye care needs Goal J: Patient is not agitated or distressed due to constipation or diarrhoea Patient Goal K: Patient becomes aware of the situation as appropriate Patient is informed of procedures Touch, verbal communication is continued Family/other Goal L: Family/other are prepared for the patient s imminent death with the aim of achieving peace of mind and acceptance Check understanding of nominated family/others / younger adults / children Check understanding of other family/others not present at initial assessment Ensure recognition that patient is dying & of the measures taken to maintain comfort Chaplaincy Team support offered Religious/ Spiritual support Care of the family /others Goal M: Appropriate religious/spiritual support has been given Patient/other may be anxious for self/others Support of Chaplaincy Team may be helpful Consider cultural needs Goal N: The needs of those attending the patient are accommodated Consider health needs & social support. Ensure awareness of ward facilities Health Professional Signature Early:... Late:..... Night:... Multidisciplinary progress notes 10

SECTION 3 Care after death Patients Surname First name Hosp No: Date of death: Time of death: Persons present: Verification of Death by (please print) Time: Pupils fixed and dilated Yes Breathing absent Yes Pulse absent Yes Heart sounds absent Yes Signature Care after death Goal 12: Healthcare Professionals Contacted: GP Practice telephoned re: patient s death Yes No Palliative Care Team informed (X8958) Yes No Chaplaincy Team if required Yes No Goal 13: Last offices guidleines followed according to hospital policy Carry out specific religious / spiritual / cultural needs - requests Goal 14: Procedure following death discussed or carried out Check for the following: Explain mortuary viewing as appropriate Post mortem discussed as appropriate. Input patients death on hospital computer Yes No Yes No Goal 15: Family/other given information on hospital procedures Yes No Information given to family/other Relatives/other informed to ring Bereavement Office to make an appointment to collect death certificate Goal 16:Hospital policy followed for patient s valuables & belongings Belongings and valuables are signed for by identified person Property packed for collection. Valuables listed and stored safely Goal 17: Necessary documentation & advice is given to the appropriate person Hospitals When someone dies booklet given to family/other Goal 18:Bereavement leaflet given Information leaflet on grieving given to family/other Yes No Yes No Yes No If you have charted No against any goal so far, please complete the variance sheet at the back of the pathway before signing below Health Professional signature:... Date:... 11

Name:... Unit no:... NHS no:... Variance analysis What Variance occurred & why? Action Taken Outcome Goal:- Goal:- Goal:- Goal:- Goal:- 12

Name:... Unit no:... NHS no:... Variance analysis What Variance occurred & why? Action Taken Outcome Goal:- Goal:- Goal:- Goal:- Goal:- 13

THE PATIENT IN PAIN (and unable to swallow) HAS NOT PREVIOUSLY TAKEN OPIOIDS REGULAR S/C MORPHINE Administer 4 hourly morphine 2.5-5mgs s/c and prn doses until syringe driver commenced (i.e. when response to PRN assessed) IS ALREADY T AKING REGULAR ORAL MORPHINE AND IS NOT WEARING A FENTANYL TRANSDERMAL PATCH (If taking other opioids e.g. oxycodone, hydromorphone, please contact Specialist Palliative Care Team)* REGULAR S/C MORPHINE To calculate the s/c morphine dose, divide the prn oral morphine dose by 2. Administer 4 hourly s/c morphine and prn doses as indicated until s yr inge driver commenced. IS WEARING A FENTANYL TRANSDERMAL PATCH CONTINUE FENTANYL PATCH. Administer s/c morphine prn as indicated below until continuous morphine commenced CONTINUOUS S/C MORPHINE Use Table One in Appendix One. The CSCI dose increases the analgesia the patient is receiving by 33% (equivalent to two PRN doses). CONTINUOUS S/C MORPHINE (CSCI) Morphine 10-20mg via syringe driver over 24 hours or guided by morphine requirement prior to commencement of continuous subcutaneous infusion CONTINUOUS S/C MORPHINE To calculate the equivalent dose of morphine s/c over 24 hours via syringe driver, divide the total 24 hour dose of oral morphine by 2. PRN S/C MORPHINE To calculate the new prn dose of morphine divide the 24 hour dose of morphine in the syringe driver by 6. Example: patient receiving 60mg of morphine s/c over 24 hours, the prn dose of morphine should be 10mg s/c PRN. PRN S/C MORPHINE** Use Table One in Appendix One. The PRN dose is calculated by dividing the amount of morphine in the syringe driver by 6 (a) and adding this to the breakthrough dose for the fentanyl patch (b). Example: if the patient is wearing a 100 microgram/hour patch and has 60mg morphine s/c over 24 hours, the prn dose of morphine should be 40mg a = 10 b = 30 Table Two in Appendix One is used to calculate the breakthrough dose for fentanyl patches and for adjusting subsequent doses (See below) TO CALCULATE THE SUBSEQUENT DOSES OF MORPHINE OVER 24 HOURS Add the dose of morphine in the syringe driver to any morphine given on a prn basis over the previous 24 hours. Recalculate the prn dose as a sixth of the new 24 hour dose. Example: if the patient has 60mg of morphine s/c over 24 hours and has received 3 doses of 10mg s/c, the required dose of morphine will be 90mg s/c over the next 24 hours and 15mg morphine s/c prn. If a fentanyl patch is also being worn then the prn morphine dose will be recalculated as in the above box** IF SYMPTOMS PERSIST REQUEST MEDICAL REVIEW AND CONTACT SPECIALIST PALLIATIVE CARE TEAM* Specialist Palliative Care Team Urgent Pager 07659509075 (9am 5pm weekdays) Although the use of drugs outside their licence is recognised practice in palliative care, the prescribing doctor takes personal responsibility for the prescription. Information for this algorithm is taken from the CMMC Pain & Symptom Control Guidelines 2004. Algorithm amended August 2008.

THE PAIN CONTROLLED PATIENT (and unable to swallow) HAS NOT PREVIOUSLY TAKEN OPIOIDS IS ALREADY T AKING REGULAR ORAL MORPHINE AND IS NOT WEARING A FENTANYL T R AN SDERMAL PATCH (if taking other opioids e.g. oxycodone, hydromorphone, please contact your Specialist Palliative CareTeam)* IS WEARING A FENTANYL TRANSDERMAL PATCH REGULAR S/C MORPHINE To calculate the s/c morphine dose, divide the prn oral morphine dose by 2. Administer 4 hourly s/c morphine until syringe driver commenced. CONTINUE FENTANYL PATCH PRESCRIBE PRN S/C MORPHINE Morphine 2.5-5mg s/c prn CONTINUOUS S/C MORPHINE To calculate the equivalent dose of morphine s/c over 24 hours via syringe driver, divide the total 24 hour dose of oral morphine by 2. Example: patient on 90mg morphine sulphate m/r bd = 180mg morphine sulphate m/r over 24 hours. Divided by 2 = 90mg morphine via syringe driver over 24 hours PRESCRIBE PRN S/C MORPHINE Fentanyl 25 = 7.5mg s/c morphine prn Fentanyl 50 = 15mg s/c morphine prn Fentanyl 75 = 20 25mg s/c morphine prn Fentanyl 100 = 30mg s/c morphine prn (See Table Two in Appendix One) IF PRN MORPHINE REQUIRED THEN MOVE TO APPROPRIATE PART OF THE PATIENT IN PAIN ALGORITHM Specialist Palliative Care Team Urgent Pager 07659509075 (9am 5pm weekdays) Although the use of drugs outside their licence is recognised practice in palliative care, the prescribing doctor takes personal responsibility for the prescription. Information for this algorithm is taken from the CMMC Pain & Symptom Control Guidelines 2004. Algorithm amended August 2008.

ARE RESPIRATORY TRACT SECRETIONS PRESENT? YES NO Give s/c bolus injection of glycopyrronium 200mcg (0.2mg) and repeat 6 hourly until syringe driver commenced PRESCRIBE PRN MEDICATION Glycopyrronium 200mcg (0.2mg) s/c 6 hourly PRN COMMENCE A CONTINUOUS S/C INFUSION AT EARLIEST OPPORTUNITY Glycopyrronium 600mcg (0.6mg) over 24 hours IF RESPIRATORY TRACT SECRETIONS PERSIST OVER THE NEXT 24 HOURS INCREASE DOSE TO: NOTE The BNF lists this antimuscarinic drug as glycopyrronium bromide. Ampoules are labelled as glycopyrrolate and boxes are labelled as both glycopyrronium bromide and glycopyrrolate Glycopyrronium 1.2mg over 24 hours IF SYMPTOMS PERSIST REQUEST MEDICAL REVIEW AND CONTACT SPECIALIST PALLIAT IVE CARE TEAM* Specialist Palliative Care Team Urgent Pager 07659509075 (9am 5pm weekdays) Although the use of drugs outside their licence is recognised practice in palliative care, the prescribing doctor takes personal responsibility for the prescription. Information for this algorithm is taken from the CMMC Pain & Symptom Control Guidelines 2004. Algorithm amended August 2008.

IS THE PATIENT EXPERIENCING TERMINAL RESTLESSNESS & AGITATION? YES NO Midazolam 2.5 5mg s/c prn until syringe driver commenced If 2.5mg ineffective after 30minutes, give 5mgs. If second dose ineffective after a further 30 minutes (total 1 hour) seek Medical Review and contact Specialist Palliative Care Team (who may advise that the prn dose is increased ) * PRN medication Midazolam 2.5 5mg s/c prn COMMENCE A CONTINUOUS S/C INFUSION (CSCI) With dose guided by prn requirements of midazolam prior to starting syringe driver If requiring 2.5 mg prn give 15mg via CSCI over 24 hours If requiring 5mg prn give 30mg via CSCI over 24 hours If requiring 10 mg prn give 60mg via CSCI over 24 hours To calculate the subsequent doses of midazolam Add the dose of midazolam in the s yr inge driver to any midazolam given on a prn basis over 24 hours Increase the prn dose of midazolam accordingly IF SYMPTOMS PERSIST REQUEST MEDICAL REVIEW AND CONTACT SPECIALIST PALLIATIVE CARE TEAM* Specialist Palliative Care Team Urgent Pager 07659509075 (9am 5pm weekdays) Although the use of drugs outside their licence is recognised practice in palliative care, the prescribing doctor takes personal responsibility for the prescription. Information for this algorithm is taken from the CMMC Pain & Symptom Control Guidelines 2004. Algorithm amended August 2008.

THE PATIENT IS BREATHLESS GENERAL MEASURES Explanation Companionship Fan/open window Oxygen Reposition IS THERE A REVERSIBLE CAUSE THAT C AN BE TREATED WITHOUT INVASIVE/AGGRESSIVE INTERVENTION? YES Treat the cause e.g. nebulised bronchodilators for bronchospasm, diuretics for distressing dyspnoea due to heart failure NO Symptomatic treatment to relieve distress First line treatment - opioids: If no previous opioid commence morphine 2.5-5mg s/c prn If previous opioid, increase dose by 30% and if agitated add midazolam 2.5 5mgs s/c prn. After 2 or more prn doses assess need for syringe driver / seek medical advice and contact Specialist Palliative Care Team* If still symptomatic, to relieve distress IF SYMPTOMS PERSIST REQUEST MEDICAL REVIEW AND CONTACT SPECIALIST PALLIATIVE CARE TEAM* Specialist Palliative Care Team Urgent Pager 07659509075 (9am 5pm weekdays) Although the use of drugs outside their licence is recognised practice in palliative care, the prescribing doctor takes personal responsibility for the prescription. Information for this algorithm is taken from the CMMC Pain & Symptom Control Guidelines 2004. Algorithm amended August 2008.

IS THE PATIENT EXPERIENCING NAUSEA AND VOMITING? YES NO IS THE PATIENT EXPERIENCING BOWEL OBSTRUCTION? PRN MEDICAT I ON Levomepromazine (methotrimeprazine) 6.25-12.5mg s/c 4 hourly PRN NO YES WAS THE SYMPTOM PREVIOUSLY CONTROLLED ON A PROKINETIC ANTI-EMETIC? i.e. METOCLOPRAMIDE OR DOMPERIDONE YES NO CONTACT THE MEDICAL STAFF/ SPECIALIST PALLIATIVE CARE TEAM* Give s/c bolus injection of metoclopramide 10mg Commence a continuous s/c infusion metoclopramide 30 90 mg over 24 hours Give s/c bolus injection of levomepromazine 6.25mg (methotrimeprazine) Commence a continuous s/c infusion levomepromazine (methotrimeprazine) 12.5-25mg over 24 hours IF SYMPTOMS PERSIST REQUEST MEDICAL REVIEW AND CONTACT SPECIALIST PALLIAT IVE CARE TEAM* Specialist Palliative Care Team Urgent Pager 07659509075 (9am 5pm weekdays) Although the use of drugs outside their licence is recognised practice in palliative care, the prescribing doctor takes personal responsibility for the prescription. Information for this algorithm is taken from the CMMC Pain & Symptom Control Guidelines 2004. Algorithm amended August 2008.

Appendix One: Tables for patients wearing fentanyl patches and unable to swallow Use Table One to find the dose of morphine to put in the s/c syringe driver over 24 hours in addition to the fentanyl patch. Prescribe appropriate PRN dose for breakthrough. For patients on other doses e.g. fentanyl 37 micrograms/hr patch add together the doses for the two patches (12 micrograms/hr and 25 micrograms/hr) 10mg amd 15mg = 25mg for CSCI and 5mg and 10mg = 15mg for PRN dose. Table One: Patient in pain wearing a fentanyl patch and now requiring continuous subcutaneous infusion (CSCI) morphine Fentanyl patch dose (micrograms/hr) Morphine 24hr CSCI Morphine PRN s/c 12 7.5 10mg 5mg 25 15mg 10mg 50 30mg 20mg 75 45mg 30mg 100 60mg 40mg 125 75mg 50mg 150 90mg 60mg 175 100mg 70mg (2 sites) 200 120mg 80mg (2 sites) 225 140mg 90mg (2 sites) 250 150mg 100mg (2 sites) 275 160mg 110mg (2 sites) 300 180mg 120mg (2 sites) Use Table Two to prescribe the PRN dose of morphine for patients on fentanyl patches and to calculate PRN dose for patients on a fentanyl patch requiring CSCI morphine Table Two: Pain controlled patient wearing a fentanyl patch who requires `breakthrough with parenteral (subcutaneous) morphine Fentanyl patch dose (micrograms/hr) Morphine PRN s/c 12 2.5 5mg 25 7.5mg 50 15mg 75 20 25mg 100 30mg 125 35 40mg 150 45mg 175 50mg 200 60mg 225 70mg (2 sites) 250 75mg (2 sites) 275 80mg (2 sites) 300 90mg (2 sites) References 1. CMMC 2004. Palliative care: Pain and symptom control guidelines 2. CMMC 2005. Palliative Care Guidance on the Diamorphine Shortage.