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 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.

Anticipatory prescribing

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

Management of symptoms present in last days of life

Pain

• Paracetamol (PR dose) or diclofenac (as SC) for pain or high temperature.
• The benefits of non-steroidal anti-inflammatory drugs (NSAIDs) may outweigh the risks in a dying patient and can help bone, joint, pressure sore and inflammatory pain. 
• If prescribed regular oral opioids and the oral route is no longer reliable, convert the total 24 hour oral morphine or oxycodone dose to a 24 hour SC infusion, for example:

• For opioid dose conversions, refer to Choosing and Changing Opioids or seek advice.
• Fentanyl patches should be continued in dying patients, refer to Fentanyl Patches information sheet.
• For a patient with stage 4-5 acute or chronic kidney disease, refer to Renal Disease in Last Days of Life guideline.
• Breakthrough analgesia should be prescribed hourly, as required:
  • 1/6^th to 1/10^th of the 24 hour dose of any regular oral or SC opioid.
  • If not on any regular opioid, prescribe morphine SC 2mg hourly.

  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.

Agitation / delirium

• Intermittent anxiety / distress – midazolam SC 2mg, repeated at hourly intervals as needed. 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.
• Persistent anxiety / distress -
  • Midazolam SC 10mg–20mg over 24 hours in a syringe pump + midazolam SC 2mg–5mg hourly as required.
  • Levomepromazine may need to be used in addition to midazolam under specialist advice.
    • Use lower doses if not used previously and in frail elderly for example: levomepromazine SC 2.5mg-5mg as required 2 hourly.
    • Higher doses may be needed for persistent distress or delirium.
    • Levomepromazine can cause sedation, hypotension and prolong QT interval (see note below). Use with caution.

Nausea / Vomiting

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:

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

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. 

Respiratory tract secretions

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