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Anticipatory prescribing

Anticipatory prescribing. Dr Jason Ward Consultant in Palliative Medicine, Mid Yorkshire NSH Trust , & Honorary Senior Lecturer, University of Leeds. Factors important for a good death. Control of symptoms Preparation for death

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Anticipatory prescribing

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  1. Anticipatory prescribing Dr Jason Ward Consultant in Palliative Medicine, Mid Yorkshire NSH Trust , & Honorary Senior Lecturer, University of Leeds

  2. Factors important for a good death • Control of symptoms • Preparation for death • Opportunity for closure or "sense of completion" of the life • Good relationship with healthcare professionals Steinhauser KE 2000

  3. Symptoms on the last 48 hours

  4. Death rattle • Prevalence 41-92% patients • Most common with lung or cerebral primaries • Median duration of onset 23 hours

  5. Death rattle How do relatives interpret it? • Awful/horrible/terrible • Nothing/expected • Relief/sign of dying Wee B et al 2006

  6. Management of death rattle • Non drug management • Discuss with family/carers • Re-position • Drug - hyoscine butylbromide (buscopan) • 20mg sc stat • 60-120mg/24hrs Bennett M 2002

  7. Pain • Cancer • Cancer treatment • Debility e.g. immobility • Concurrent problems e.g. osteoarthritis

  8. Analgesics (1) • Paracetamol • Liquid, suppository • No subcut preparation • NSAIDs • Diclofenac PR 100mg od

  9. Analgesics (2) • Diamorphine • Divide total daily dose of oral morphine by 3 = total daily dose of subcut diamorphine • Opioid naïve • 2.5mg sc PRN • 5-10mg/24hrs • Morphine sulphate • Divide total daily dose of oral morphine by 2 • Opioid naïve 2.5mg sc PRN

  10. Transdermal analgesia

  11. The dying patient with a patch • Continue current patch strength and replace every 72 hours • Supplement with diamorphine prn and/ or syringe driver • ‘Rule of 5’ • Fentanyl 25mcg/5= 5mg diamorphine prn

  12. Restlessness • Agitation/restlessness Vs • Confusion/delirium • Disorientated • Hallucinations • Sleep-wake reversal • Plucking

  13. General Management • Reverse the ‘easily’ reversible • Full bladder, position, pain • Explanation • Environment • Family

  14. Agitation • Benzodiazapine • Useful alone if fear/anxiety is the only feature • Midazolam • 2.5-5mg stat • Repeat every 60mins if needed • 10mg-60mg/24 hrs

  15. Confusion/delirium • Haloperidol • 3-5mg stat sc repeated as necessary • Generally 5 - 10mg/24hrs • Levomepromazine • Sedating anti-psychotic • 25mg-50mg stat • Infusion 50-300mg/24 hrs

  16. Breathlessness • Fan, open window • Breathlessness/cough/tachypnoea • Diamorphine • Opioid naïve 2.5mg stat, 5-10mg/24hrs • Or increase dose by 1/3rd • Breathlessness/anxiety • Midazolam • 2.5 mg stat, 10-30mg /24hrs

  17. ‘Terminal’ nausea • Persistent or intermittent • Small vomits, ‘possets’, retching Chemical cause Hypercalcaemia Uraemia Jaundice Infection

  18. Anti-emetics • Cyclizine • 50mg stat • 150mg/24hrs, • May precipitate with hyoscine butylbromide • Avoid saline • May cause irritation

  19. EXAMPLE INJ CYCLIZINE 50mg / ml 5 X 1ML amps as dir INJ HYOSCINE BUTYLBROMIDE 20mg / ml 5 x 1ml amps as dir INJ MIDAZOLAM 5mg / ml 5 x 2ml INJ DIAMORPHINE 5mg 5 ( five ) x 5mg (five milligram) WATER FOR INJECTION 10 X 10mls amps

  20. To foresee and take care of in advance • Costs

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