Palliative Care - Symptoms

Encourage good oral hygiene with regular sips of water before considering saliva replacement.

Therapeutic choice: Saliva replacement gel e.g. BioXtra^® gel or Biotène Oralbalance^® – use as required. See palliative care mouth care guidance at www.palliativecareguidelines.scot.nhs.uk.

Reduce risk by avoiding fluid overload; review any assisted hydration or nutrition if symptoms develop. Suction may also exacerbate secretions. Changing the patient's position, for example, head down or lateral position may help.

Hyoscine butylbromide* is first-line as it is a less sedating alternative to hyoscine hydrobromide. Be aware that conscious patients may be troubled by dry mouth on these medications; refer to palliative care mouth care guidance at www.palliativecareguidelines.scot.nhs.uk.

Hyoscine butylbromide* SC bolus 20mg hourly as required (max 120mg/day)

See Last Days of Life guideline for the management of respiratory secretion at end of life. Seek advice from local Palliative Care team if therapeutic options and doses are maximised.

*Hyoscine butylbromide (Buscopan^®) injection: risk of serious adverse effect in patients with underlying cardiac disease (MHRA Drug Safety Update 2017).

Assess for cause and reverse as appropriate.

Refer to palliative care guidelines and seek advice from local Palliative Care team for further advice.

Therapeutic choice:

• Haloperidol* (first choice) - start at 500micrograms oral or SC. Repeat after 2 hours, if necessary. Maintenance treatment may be needed if cause cannot be reversed; use lowest effective dose 500micrograms - 3mg oral, or SC 2mg once daily.
• Benzodiazepines (second choice) - used in alcohol withdrawal, sedative and antidepressant withdrawal, preferred in Parkinson's disease. Choices include:
  • Lorazepam oral or sublingual 500micrograms - 1mg 6 hourly
  • Midazolam SC 2mg - 5mg 1 to 2 hourly
  • Diazepam oral or via rectal 5mg 8 to 12 hourly.

For terminal delirium, refer to Last Days of Life guideline.

*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 where possible. 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, limited or no reversible causes of agitation and distress). Seek senior advice before prescribing. A list of drugs that can prolong QT interval can be found at http://crediblemeds.org and further information can also be found in the Medicines Update Extra (MUE 08) Drug Induced QT Prolongation article available at www.ggcmedicines.org.uk. 

Use guidelines to identify possible causes and suitable treatments (see www.palliativecareguidelines.scot.nhs.uk).

Prescribe anti-emetics regularly until symptoms controlled. 

If vomiting regularly, switch to SC route, ideally administer via syringe pump over 24 hours.

Avoid pharmacologically antagonistic combinations e.g. cyclizine and metoclopramide.

Metoclopramide: use with caution in young, especially female patients, because of risk of extrapyramidal side effects.

For therapeutic options, see the nausea and vomiting guidance at www.palliativecareguidelines.scot.nhs.uk. 

In intractable nausea and vomiting, oral prochlorperazine can be used second-line. Prescribe either the buccal preparation 3mg - 6mg twice daily, or the oral preparation 5mg - 10mg two to three times daily.

Prophylactic antiemetics may be necessary (when opioid initiated and/or opioid dose increased). Prescribe:

• Metoclopramide oral 10mg three times daily or
• Haloperidol - start at lowest possible dose e.g. 500micrograms and give once or twice daily. Maximum 1.5mg twice daily. See guidance above regarding QT prolongation. 

• If patient is receiving oral morphine or 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 hours equivalent dose).
• If opioid naïve, consider morphine SC 2mg two hourly as required. If more than 6 doses are required in 24 hours, seek advice or review.
• If patient is breathless and anxious, consider the use of lorazepam sublingual 500micrograms (half a scored 1mg tablet) or midazolam SC 2mg given 4 to 6 hourly as required.

See Breathlessness section at www.palliativecareguidelines.scot.nhs.uk