Guidelines for prescribing in the last few days of life

Prescribe PRN for ALL patients except in cases of known allergy: Analgesia (see below) Midazolam 2.5mg 5mg sc prn (muscle relaxant and anxiolytic) Haloperidol 0.5mg 1.5mg sc/po max 10mg/24hours (antiemetic and anxiolytic) Buscopan 20mg prn max 180mg/24 hours (for respiratory secretions)

ANALGESIA For full prescribing guidelines see Morphine, Oxycodone and Fentanyl guidelines. Most patients require at least low dose opioid analgesia for discomfort in the terminal phase If the patient was previously on any oral analgesia they should be started on an equivalent dose of the drug in a syringe driver. (see appropriate guidelines for conversion doses) If the patient is taking analgesia via a patch (Fentanyl, Buprenorphine) leave the patch on and add a syringe driver with any extra analgesia required (Contact the Palliative Care Team) If the patient is opioid nave (i.e. they were not previously taking any opioid analgesia) the normal starting dose of analgesia in a syringe driver is Morphine Sulphate 10mg/24hours

AGITATION Consider potentially reversible causes: Pain, nausea, urinary retention, full rectum, cerebral irritation, or side effects of medication (especially steroids) Medication: 1st line-Midazolam 10-30mg sc/24hours via syringe driver PLUS 2.5mg-5mg sc prn 2nd line-Haloperidol 3-10mg sc/24 hours via syringe driver PLUS 1.5mg-3mg sc prn

RESPIRATORY SECRETIONS This is noisy, moist breathing resulting from pooling of secretions in the patients upper airways/oropharynx. Management: The noise is often distressing for the patients family reassure them that the secretions are not distressing the patient. Try repositioning the patient. Prescribe Hyoscine Butylbromide (Buscopan) 20mg prn (effective in 50% of patients). If secretions do not resolve, start Buscopan 40mg sc/24hours in a syringe driver. The dose can be increased to max 180mg in 24 hours as needed.

SEIZURES Patients on a regular anticonvulsant who are no longer able to take it orally MUST be commenced on a syringe driver with Midazolam 20mg sc/24 hours (max 60mg) If a dying patient continues to fit despite Midazolam 60mg add Phenobarbitol. Give a loading dose of 200-1000mg iv at a rate of 50mg/min until fitting stops, then use 6001600mg sc/24 hours via syringe driver.

Authors H Western, F Fieldhouse August 2007. Review August 2009 Palliative Care Guidelines

References: 1. Ellershaw, J. & Murphy, D (n.d) Liverpool care pathway for the dying: version 11.[online] Liverpool: Marie Curie Palliative Care Institute. Available from: http://www.mcpcil.org.uk/liverpool_care_pathway [Acessed 24th May 2007] 2. Hughes, A; Wilcock, A; Corcoran, R; Lucas, V. & King, A. (2000) Audit of three antimuscarinic drugs for managing retained secretions. Palliative medicine, 14 (3) p. 221222. 3. Watson, M.S. (2005) Oxford handbook of palliative care. Oxford: Oxford University Press.

Authors H Western, F Fieldhouse August 2007. Review August 2009 Palliative Care Guidelines