Last few days of life

1. Last few days of life Symptom Control

2. Bradford & Airedale Palliative Care Managed Clinical Network Common Symptoms • Pain • Agitation • Respiratory Secretions • Nausea and Vomiting • SOB • Can be anything • Can vary depending on underlying diagnosis

3. 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

4. Bradford & Airedale Palliative Care Managed Clinical Network Pain • Not every one has pain • Follow algorithm from LCP • Main groups of drugs used • Opioid • NSAID

5. 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.

6. 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 ?

7. 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

8. 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

9. 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

10. 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

11. Bradford & Airedale Palliative Care Managed Clinical Network Nausea and Vomiting • LCP Haloperidol 1.5 to 3 mg stat 3 – 5 mg via SD Usually 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

21. Bradford & Airedale Palliative Care Managed Clinical Network Advice Sue Ryder Manorlands Hospice 01535 642308 Marie Curie Hospice 01274 337000

22. Bradford & Airedale Palliative Care Managed Clinical Network www.bradford.nhs.uk/palliativecare