N.B. If your patient is (or is suspected of being) COVID-19 positive, see the End of Life Guidance when a Person is Imminently Dying from COVID-19 Lung Disease for information on symptom management.
When all reversible causes for the patient's deterioration have been considered, the multidisciplinary team agrees the patient is dying and change 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".
If discharge home is being considered, prompt and careful planning is needed. See the Rapid Discharge Guidance for Patients who are in the Last Days or Weeks of Life.
In all patients anticipatory medicines should be prescribed in the 'when required' section of the kardex. See table 1 for details.
oral morphine 30mg ≈ SC morphine 15mg ≈ SC diamorphine 10mg
oral oxycodone 15mg ≈ SC oxycodone 7mg–8mg
If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review.
If already controlled with an oral anti-emetic, 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 anti-emetics include:
For anti-emetic 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 QT Prolongation article at www.ggcmedicines.org.uk.
Reduce risk by avoiding fluid overload; review any assisted hydration or nutrition (IV or SC fluids, feeding) if symptoms develop. Suction may also exacerbate secretions.
First-line agent is hyoscine butylbromide SC 20mg hourly as required (up to 120mg/ 24 hours). See table 1c 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.
Guideline reviewed: August 2022
Page last updated: January 2023