bradford & airedale palliative care managed clinical network last few days of life symptom...

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


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



Pain

Not every one has pain Follow algorithm from LCP

Main groups of drugs used

1. Opioid

2. NSAID



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.



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 ?



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



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



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



Respiratory Secretions

If not settling consider

Stat I/M antibiotic Stat I/M S/C frusemide Midazolam/Morphine Explanation to the family/carers



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



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



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



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



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



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



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




Care Managed Clinical NetworkAdvice

Sue Ryder Manorlands Hospice

01535 642308

Marie Curie Hospice

01274 337000



www.bradford.nhs.uk/palliativecare

bradford & airedale palliative care managed clinical network last few days of life symptom...

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