GGC Medicines


Adult Therapeutics Handbook

Palliative Care - Last days of life

Palliative Care - Last days of life

When all reversible causes for the patient's deterioration have been considered, the multidisciplinary team agrees the patient is dying and changes the goals of care. Reversible causes to consider include: dehydration, infection, opioid toxicity, renal impairment, hypercalcaemia or delirium. Refer to "Guidance at End of Life (GAEL) for Health Care Professionals".

Management of a dying patient and their family

Plan and document care.

      • Discuss prognosis (patient is dying), goals of care (maintaining comfort) and preferred place of care.
      • If discharge home is possible, prompt and careful planning is needed. Contact GP, district nurse and occupational therapist urgently. Also see the Rapid Discharge Guidance for Patients who are in the Last Days of Life.
      • Clarify resuscitation status; check DNACPR form has been completed (see www.palliativecareggc.org.uk/professional/dnacpr).
      • Reassure the patient and family that full supportive care will continue.
      • Consider discontinuing interventions (including the use of assessment tools) that are of no benefit to the patient.

Hydration

      • Consider discontinuing tube feeding / fluids if respiratory secretions present, if there is a risk of aspiration due to reduced conscious level or at the patient's request. Regular review of nutrition and hydration is essential, discuss with patient / relative / carer / friend the benefits or burdens of artificial hydration / nutrition.
      • Over-hydration contributes to distressing respiratory secretions. Artificial fluids are usually not appropriate, but if indicated can be given subcutaneously.

Symptom control in the last days of life

Anticipatory prescribing

In all patients the following should be prescribed in the 'when required' section of the kardex. See table 1 below for details.

Table 1: Anticipatory subcutaneous medications - initial dose suggestions

Symptom Initial dose suggestion

Pain

  • If patient is receiving oral morphine or on a step 2 analgesic (including co-codamol 30/500mg or equivalent) an appropriate SC breakthrough dose of morphine should be available (1/6th to 1/10th of 24 hour equivalent dose).
  • If opioid naive, consider morphine 2mg SC hourly as required (max 6 doses in 24 hours)

Nausea and vomiting

  • If patient is receiving an oral anti-emetic and this is effective, then that drug should be available for SC use.
  • If patient is not on an anti-emetic, consider levomepromazine 2.5mg (TWO point FIVE milligrams) SC 8 hourly as required. N.B. Levomepromazine can prolong QT interval. See note relating to haloperidol and QT below. 

Agitation / restlessness

Prescribe *midazolam 2mg SC hourly as required (max 6 doses in 24 hours)

Breathlessness (dyspnoea)

  • If patient is receiving oral morphine or a step 2 analgesic (including co-codamol 30/500 or equivalent) an appropriate SC breakthrough dose of morphine should be available (1/6th to 1/10th of 24 hours equivalent dose).
  • If opioid naive, consider morphine 2mg SC hourly as required (max 6 doses in 24 hours)
  • It patient is breathless and anxious, consider the use of lorazepam 500micrograms sublingually 4-6 hourly (if able to take) or midazolam 2mg SC hourly as required (max 6 doses in 24 hours).

Respiratory secretions

Prescribe hyoscine butylbromide 20mg SC hourly as required (max 6 doses in 24 hours).

If the patient is reaching maximum dose of any anticipatory medicines then seek advice from the Palliative Care Team.

*Midazolam 10mg/ 2ml ampoules should be prescribed as other strengths are not used in palliative care.

Management of symptoms present in last days of life

Pain

      • Non-opioid analgesics: Paracetamol or diclofenac (liquid / dispersible / rectal preparations). NSAID benefits may outweigh risks in a dying patient; can help bone, joint, pressure sore, inflammatory pain.
      • Opioid analgesics: convert any regular oral morphine or oxycodone to a 24 hour SC infusion – see Opioid Conversion Flowchart below.
      • For breakthrough pain, prescribe dose hourly as required by:
        • Calculating 1/6th to 1/10th of the 24 hour dose of any regular oral or SC opioid.
        • If not on regular opioid, prescribe morphine SC 2mg hourly as required, maximum 6 doses in 24 hours.
      • Continue fentanyl patches in dying patients and refer to National Guidelines - Fentanyl Patches
      • For patients with stage 4-5 chronic kidney disease, see National Guidelines - Renal Disease in Last Days of Life.

Agitation / delirium

      • Anxiety / distress – midazolam SC 2mg hourly as required and titrate upwards as required.
      • Confusion / delirium – haloperidol SC 2mg once or twice daily (see note regarding QT below before prescribing).
      • Established terminal delirium / distress (note: lower dose as suggested above should be tried before progressing to the following higher dose:

 

Nausea / Vomiting

If already controlled with an oral antiemetic, use the same drug as a SC infusion, see National Guidelines - Nausea and Vomiting. Treat new nausea / vomiting with a long-acting anti-emetic given by SC injection or give a suitable anti-emetic as a SC infusion in a syringe pump. Long-acting antiemetics include:

      • Levomepromazine SC 2.5mg (TWO point FIVE milligrams) 8 hourly when required. N.B. Levomepromazine can prolong QT interval. See note relating to haloperidol and QT below.
      • Haloperidol SC 1 mg 12 hourly or 2 mg once daily (see note below before prescribing).

For antiemetic doses in SC infusion see National Guidelines - Syringe Pumps. For persistent vomiting, a nasogastric tube may be considered if the medication is ineffective. Contact the Palliative Care Team for advice.

N.B. Haloperidol can prolong QT interval and contraindications include: patients with prolonged QTc interval and in combination with other drugs that prolong QT interval. Where possible modifiable risk factors for QT interval prolongation should be minimised e.g. discontinue other drugs known to prolong QT interval. There may be certain circumstances when haloperidol may be used despite contraindications (e.g. distressed individual with an incurable condition at the end of life). Seek senior advice before prescribing. 

A list of drugs which prolong QT interval can be found at http://crediblemeds.org and further information can also be found in Medicines Update Extra (MUE 08) Drug Induced Prolongation article at www.ggcmedicines.org.uk. 

Respiratory tract secretions

Avoid fluid overload; assess fluid balance, stop IV/SC fluids and tube feeding. Changing patient's position may help. Intermittent SC injections often work well or medications can be given as SC infusions.

First-line: hyoscine butylbromide SC 20mg, hourly as required (up to 120mg/ 24 hours). See here for more guidance on the use of anticholinergics in a syringe pump. 

For information on management of other symptoms in the patient's last days of life, see National Guidelines - Care in the Last Days of Life

 

Content last updated October 2018