PRESCRIBING IN THE LAST DAYS OF LIFE

1. PRESCRIBING IN THE LAST DAYS OF LIFE Peter Nightingale Macmillan GP

2. The Seven C’s • Communication Palliative Care Register/MDT meetings • Co-ordination Key person • Control of Symptoms Assessment, Treatment and Patient Centred care • Continuity Handover to out-of-hours/protocol. Information to patients/carers • Continued Learning Practice-based learning/reflection on experiences. • Carer Support Practical, Emotional, Bereavement • Care of the Dying Liverpool Integrated care pathway (Dying Phase)

3. Diagnosing the Terminal Phase • BEDBOUND • ONLY ABLE TO TAKE SIPS OF FLUID • SEMI COMATOSE • NO LONGER ABLE TO TAKE ORAL MEDICATION • 2 out of four required for Liverpool Care Pathway

4. Last Days Of Life- Anticipating and planning for common problems at home • Loss of mobility and ability to transfer safely • Loss of ability to drink • Loss of ability to eat • Pain • Vomiting • Dyspnoea • Excess secretions • Delerium and agitation

5. Loss of mobilityUnable to transfer safely • Generally safer and more manageable to nurse in bed • Consider loan of hospital bed/monkey pole/cot sides/commode/urine bottles • Assess for pressure area care and implement appropriate strategy • Indwelling urinary catheter/sheath for men if more acceptable if incontinent/unable to transfer to commode • Bowel care

6. Methylnaltrexone (relistor) • SC methylnaltrexone is approved for use in patients with 'advanced illness' suffering from opioid-induced constipation despite usual laxative therapy. Constipation is common in advanced disease, even in patients not taking opioids. Thus, so-called 'opioid-induced constipation' is often multifactorial in origin; and methylnaltrexone will normally augment laxatives rather than replace them. It is important that laxative therapy is optimized before using methylnaltrexone. • About 1/2 patients defaecate within 4h of a dose without impairment of analgesia or the development of withdrawal symptoms. Common undesirable effects include abdominal pain, diarrhoea, flatulence, and nausea. • Initially give a single dose on alternate days. If there is no response, a second dose can be given after 24h, but not more often.

7. Loss of ability to drink • Prepare family and patient for this happening • Explain it is a natural process and may aid comfort by reducing secretions/gastric secretions and chance of vomiting/urine output • Encourage sips/mouth care • In the occasional situation, if still distressed by thirst consider S/C fluids (N.saline 1l over 12h via a butterfly into anterior abdominal wall or thigh)

9. What can we conclude? • Parenteral hydration in palliative care context: • probably improves • mucous membrane hydration status • sedation and ?myoclonus • probably worsens • peripheral oedema, ascites and pleural effusions • is unlikely to affect • delirium and hallucinations • agitation • bronchial secretions • fatigue • can produce a significant placebo effect

10. Loss of ability to eat • Prepare family and patient for this happening • Explain it is a natural process • Forcing food may create discomfort if too weak to swallow/digest

11. Pain • Morphine or Diamorphine SC prn in proportion to overall opioid requirement • Consider leaving pre drawn-up syringes :possibly leave an indwelling butterfly needle SC • OTFC Fentanyl increasingly considered

12. Vomiting • Levomepromazine is a useful broadspectrum antiemetic for the end of life. 6.25mg SC • Cyclizine 50mg tds SC or other antiemetic targeted at likely cause

13. Dyspnoea • Common and frightening • Morphine/Diamorphine preferably SC (or sublingual) titrated up as for pain. • Midazolam 2-10mg S.C. or sublingual prn or 5-30mg SC/24h for breathlessness/fear or • Diazepam

14. Excess respiratory secretions (note Cochrane rev 2008) • Positioning important • Antimuscarinics • Glycopyrronium • Hyoscine hydrobromide 0.4mg sublingual or SC 4h prn or • Hyoscine butylbromide 20mg SC

15. Delirium and agitation • Common at the end of life· Distressing and frightening for everyone involved • Haloperidol 5-30mg/24h/sc and/or midazolam5-60mg/24h(if agitation only)

16. Changing breathing pattern • Explanation to family "He may appear to stop breathing for a time, then draw another breath"

17. The Pathway in Today’s Health Care System There must be continuous improvement in the delivery of health care and the care of the dying patients must improve to the level of the best (DOH 1998, NHS Cancer Plan 2000) Patients want to die in the place of their choice and be assured that their carers will be supported throughout their illness and in bereavement (Commission for health improvement/Audit Commission 2002) There is a need to describe and transfer best practice in Hospice care into hospital and other care settings (Bonick 2004)

18. What Is The LCP and How Does It Work? ICP is a multidisciplinary document which provides a template for managing patient centred care, it acts as a flow chart for the care being given • It Describes Care • It Tracks Care • It Monitors Care • It Evaluates Care

19. 3 Sections To The LCP • Initial assessment and care • Ongoing assessment and care • Care after death

20. Goals Of Patient Care Encompassed By The LCP • Physical • Psychological • Religious/Spiritual • Social

21. GP’s Involvement • Diagnose that the patient is dying • Discontinue oral medication/syringe driver if required • Prescribe 4 core drugs • Liaise with nursing staff, relatives and out of hours/put the pt on pathway • Sign documentation

22. What Are The Benefits of Using The Pathway? • It organises the process of caring • It is multisectoral (community/hospital) • Multi-professional/aids communication • It can influence ethical decision making • Incorporates guidelines, evidence based practice and clinical effectiveness

23. Benefits • Outcome focused (clinical supervision) • Replaces and reduces documentation • Legal record (written or electronic) • Variances (allow staff to justify non-actions) • Flexibility (pts can come off the pathway) • Quality of care

24. PLANNING NO LONGER ABLE TO TAKE ORAL MEDICATIONS:- • Discontinue unnecessary drugs • Review medication required • Plan for what medication may be required

25. Discontinuing Drugs • Stop Non Essentials e.g. statins • Probably continue diuretics –furosemide can be given subcutaneously • Review steroids

26. Steroids in Palliative Care • Used to improve quality of life after risk/benefit assessment for:- • 16mg Dexamethasone in emergencies • 12mg for inflammation in brain, liver or after chemotherapy • 4mg to temporarily help appetite But taper down quickly because of:-

27. Side effects of steroids • Hyperglycaemia • Thrush • GI bleeding • Agitation and restlessness • Muscle loss • Bed sores • Bacterial infection

28. P A I N Is patient already taking oral morphine? Yes No Convert to 24hr s/c infusion of DIAMORPHINE For conversion divide the total daily dose of MORPHINE by 3 ( eg MST 90mg bd orally = DIAMORPHINE 60mg via syringe driver) Make available subcutaneous DIAMORPHINE dose PRN for breakthrough pain PRN dose equals total daily dose divided by 6 (eg if DIAMORPHINE 60mg subcutaneous in syringe driver PRN dose equals 10mg subcutaneously) Make available DIAMORPHINE 2.5mg – 5mg prn s/c After 24 hours review medication. If 2 or more doses required PRN then consider a syringe driver. Starting dose would be the total requirements over the previous 24 hours. The PRN dose may then need to be recalculated If the patient is still in pain after 12 hours consider increasing the infusion by 30 – 50%

29. TERMINAL RESTLESSNESS & AGITATION Present Absent Make available MIDAZOLAM 2.5mg-5mg s/c 4hrly PRN Make available MIDAZOLAM 2.5 – 5mg s/c 4hrly PRN Review the medication after 24hrs If two or more PRN doses have been required then consider a syringe driver. Starting dose would be the dose required over the previous 24 hours Review the medication after 24hrs If two or more PRN doses have been required then consider a syringe driver Starting dose would be the dose required over the previous 24 hours Continue to give PRN dosage accordingly

30. RESPIRATORY TRACT SECRETIONS Present Absent Glucopyrronium 200 microgram SC stat then 1200mcg over 24 hours Glycopyrronium 200mcg s/c 8 hrly PRN should be made available Continue to give 200microgram PRN dosage 8 hourly If two or more doses of PRN Glycopyrronium required then commence syringe driver s/c over 24 hrs Increase total 24hr dose to 1.2 mg after 24 hours if symptoms persist

31. NAUSEA & VOMITING Absent Present Levomepromazine 6.25mg s/c 8rly PRN Levomepromazine 6.25 s/c 8 hrly PRN Review dosage after 24hrs. If 2 or more PRN doses required, then consider use of syringe driver. Starting dose 12.5-25mg s/c over 24 hours NB. If patient is already on an effective Antiemetic then switch to parental route and continue

32. Fentanyl at the end of Life • Almost always better to leave the patch on in the last days of life and add in other drugs via a syringe driver if necessary, because:- • Fentanyl reservoir active for up to 17hrs • Opioid requirements vary greatly at this time of life, they can decrease due to renal failure or increase due to disease progression

33. THE SYRINGE DRIVER IN PALLIATIVE MEDICINE GRASEBY MS26 GREEN FRONTED RATE = mm/24 hours

34. INDICATIONS • Dysphagia • Swallowing difficulties mouth/throat lesions • Intestinal obstruction • Severe weakness • Nausea & vomiting • Poor alimentary absorption • Semi comatose/comatose

35. ADVANTAGES • Steady drug levels • Avoids repeat injections • Loaded once a day • Does not limit mobility • Can be used to control >1 symptom

36. DISADVANTAGES • Seen as a panacea • Irritation or swelling can limit absorption-Normal Saline is the preferred diluent unless cyclizine is being used

37. THE BOOST BUTTON • There is no “lock out” period • The dose of analgesia is less than the prn dose • All drugs will be boosted • The driver will run out more quickly

38. COMMONLY USED DRUGS

39. CAUTION Cyclizine precipitation occurs when mixed with Diamorphine if either one exceeds 20mgs/ml-needs water as diluent Metoclopramide extrapyramidal reactions can occur with higher doses or if used with Haloperidol or Levomopromazine Levomopromazine exessive sedation and skin irritation can occur with higher doses or when used with other D2 receptor antagonists, eg Haloperidol or Metoclopramide Dexamethasone should not be mixed with any other drug-very small doses occasionally used for site reactions

41. The verification of death Dr Hong Tseung Macmillan GP Adviser

42. Definitions • verifying death • confirming death has actually occurred – 'fact of death' • certifying death • written confirmation of cause of death • registering a death • formal notification to authorities (Registrar of births and deaths) of fact of death and its cause

43. Who does what? • verification of death • doctor (GMC registered) • registered nurse • certification of death • doctor (GMC registered) only • must have seen the patient alive in preceding two weeks before death • registration of death • by 'the informant' – carer, relative, family member who takes death certificate to the Registrar

44. The coroner’s involvement • when the cause of death is not known • eg sudden death • when there is a suspicious cause of death • eg bullet wounds, knife wounds, strangulation, asphyxiation, overdose, suicide • when no medical practitioner has seen patient alive within the last two weeks before death

45. The signs of human life • breathing • pulse/heart beat • pupil reaction • responsiveness • auditory, sensation (pain), reflexes

46. The signs of dying (impending death) • not always easy to 'diagnose dying' • bed-bound • comatose/semi-comatose • taking sips of fluids only • no oral intake • irregular breathing (Cheyne Stokes, shallow)

47. What happens when death has occurred? • no organs work • no brain activity, heart stops, lungs stop, liver and kidneys stop, muscles stop • tissues start to breakdown • rigor mortis (several hours later), blood pools, decomposition

48. The signs of death • looks pale (blood pooling) • no breathing • no pulse • no heart sounds • pupils fixed and unreactive to light • no response to sensory stimuli (eg pain) • no reflexes (no brainstem activity)

49. test for BOTH pupil reflexes to light None of the above present? = death confirmed What to do • look • for skin colour (pink) • for chest movement (breathing) • feel • for a MAJOR pulse: carotid • listen • for breath sounds • for heart sounds

50. Don’t get it wrong • very embarrassing • distressing for relatives