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Bradford & Airedale Palliative
Care Managed
Clinical Network
Last few days of life
Symptom Control
Common Symptoms
Pain Agitation Respiratory Secretions Nausea and Vomiting SOB Can be anything Can vary depending on underlying diagnosis
Bradford & Airedale Palliative
Care Managed Clinical Network
Symptom Control Principles
Principles remain the same
Try to diagnose cause and then treat appropriately.
Cause of distress can be difficult to identify LCP documentation is helpful for review
Route of administration usually sc, if starting Syringe Driver usually give stat/loading dose as it is set up
Make sure PRN doses are appropriate/regular review
Bradford & Airedale Palliative
Care Managed Clinical Network
Pain
Not every one has pain Follow algorithm from LCP
Main groups of drugs used
1. Opioid
2. NSAID
Bradford & Airedale Palliative
Care Managed Clinical Network
Opioids
If already on generally convert to a syringe driver.
Morphine Oral to SC divide 24 hr dose by 2(to diamorphine divide by 3)
Oxycodone Oral to SC divide 24 hr dose by 2 Fentanyl / Buprenorhine patches generally
keep on and add morphine or oxycodone to the driver.
Bradford & Airedale Palliative
Care Managed Clinical Network
Opioids continued
PRN
What is the PRN dose if there is 60mg morphine in the Syringe Driver ?
What is the PRN dose for if there is 300mg Oxycodone in the Syringe Driver ?
What is the PRN dose if there is a Fentanyl patch plus 40mg morphine in the Syringe Driver ?
Bradford & Airedale Palliative
Care Managed Clinical Network
Opioids continued
Opioids not always required. Not good for sedation
Watch for toxicity, plucking, hallucinating, myoclonic jerks
May need to reduce dose, give alternative pain relief(NSAID), treat side effects
Bradford & Airedale Palliative
Care Managed Clinical Network
NSAID
Diclofenac supps
Ketorolac. Powerful NSAID but high side effect profile. Risk/Benefit ratio can be justified in last few days of life.
10 to 20mg stat. 30 to 90mg in Syringe Driver
Bradford & Airedale Palliative
Care Managed Clinical Network
Respiratory Secretions
Can be difficult to control distressing to listen too LCP – Buscopan 20mg stat 40 to 120mg in syringe
driver. Other measures. Explanation/positioning/rarely
suction Alternatives. Glycoprronium 200 to 400micrograms
stat 600 to 1200 micrograms/24hrs in syringe driver Hyoscine Hydrobromide 400microgams stat 1,200 tp
2,400 microgams/24hrs in syringe driver
Bradford & Airedale Palliative
Care Managed Clinical Network
Respiratory Secretions
If not settling consider
Stat I/M antibiotic Stat I/M S/C frusemide Midazolam/Morphine Explanation to the family/carers
Bradford & Airedale Palliative
Care Managed Clinical Network
Nausea and Vomiting
LCP Haloperidol 1.5 to 3 mg stat 3 – 5 mg via SDUsually change previous antiemetic to SC via SD
May change drug if not working, which drug depends on likely cause of N/V
Alternatives. Cyclizine/Metoclopramide/Levomepromazine
Less common , Ocreotide/Ondansetron
Bradford & Airedale Palliative
Care Managed Clinical Network
Shortness of Breath
Fear of choking/breathlessness Common with lung ca, end stage copd, heart
failure Often multifactorial, may treat cause Can settle with appropriate
medication/measures May need sedation What to do with the Oxygen
Bradford & Airedale Palliative
Care Managed Clinical Network
Shortness of Breath
s/c opioid morphine(2.5 to 5mg), diamorphine, oxycodone(1.25 to 2.5mg)
s/c anxiolytic midazolam(2.5 to 5mg)
Higher doses if already on background
Syringe Driver typical dose 10mg morphine/10mg Midazolam can be a lot higher
Bradford & Airedale Palliative
Care Managed Clinical Network
Terminal Agitation
Very common 80 to 90% in last week of life Usually multifactorial, possibly reversible
causes include, urine retention, faecal impaction, drug induced, metabolic (hypercalcaemia, uraemia), infection, spiritual, fear/anxiety, intolerable suffering
Often irreversible, therefore need to manage with clear objectives. Explanation to family/carers is essential
Bradford & Airedale Palliative
Care Managed Clinical Network
Terminal Agitation
Midazolam 2,5 to 5mg to 10mg Syringe driver 10 to 100mg/24hrs(20 to 30
usually enough) May add haloperidol, 1.5 to 10mg stat, 3 to
10mg /24hrs Combination usually works
Bradford & Airedale Palliative
Care Managed Clinical Network
Refractory Terminal Agitation
Levomepromazine 25mg stat (12.5mg to 75mg stat)
25 to 300mg/24hrs in syringe driver Phenobarbital. 200mg stat 800 to 2,400mg/24hrs via a syringe driver
Bradford & Airedale
Palliative Care Managed Clinical
Network
Sudden Terminal Events
Haemorrhage, stridor, large PE
High dose Midazolam 10 to 20mg stat (sometimes I/V)
Appropriate dose of Opioid
Bradford & Airedale Palliative
Care Managed Clinical Network
We can only do our best
Not always possible to get perfect symptom control.
‘slowly I learn about the importance of powerlessness. I experience it in my own life and I live with it in my work. The secret is not to be afraid of it, not to run away. The dying know we are not God all they ask is that we do not desert them’ Sheila Cassidy
Bradford & Airedale Palliative
Care Managed Clinical Network
Bradford & Airedale Palliative
Care Managed Clinical NetworkAdvice
Sue Ryder Manorlands Hospice
01535 642308
Marie Curie Hospice
01274 337000
Bradford & Airedale Palliative
Care Managed Clinical Network
www.bradford.nhs.uk/palliativecare