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Symptom control guidance for last days of life dec 2014

Symptom control in the last days of life
Owner Anne Garry Contributions from Specialist Palliative Care teams in York and Scarborough Jane Crewe, Lynn Ridley and Diabetes team Version 3 Date of issue December 2014 Review date December 2017 Principles of symptom management in last days of life

These principles are applicable to the care of patients who may be dying from any cause
Recognise that death is approaching
Studies have found that dying patients will manifest some or all of the following:
• Profound weakness - usually bedbound • Drowsy or reduced cognition • Diminished intake of food and fluids - only able to take sips of fluid • Difficulty in swallowing medication - no longer able to take tablets
Treatment of symptoms
The prime aim of all treatment at this stage is the control of symptoms current and potential.
• Discontinue any medication which is not essential
• Prescribe medication necessary to control current distressing symptoms
• All patients who may be dying would benefit from having ANTICIPATORY subcutaneous medication
prescribed JUST IN CASE distressing symptoms develop
• All medication needs should be reviewed every 24 hours
• Prn medications may be administered via a Saf -T- intima line
• If two or more doses of prn medication have been required, then consider the use of a syringe driver
for continuous subcutaneous infusion (CSCI)

The most frequently reported symptoms are:-
• Nausea / Vomiting • Excessive secretions / Noisy breathing • Agitation / Restlessness Opioid choice and syringe drivers
Morphine sulphate is the injectable opioid of choice in the majority of patients.
Alternative opioids (when morphine is not tolerated or in patients with severe renal failure e.g. GFR< 30mL /min)
include oxycodone or alfentanil.

Both morphine sulphate and oxycodone are compatible with all the medications that are recommended in the
following guidelines (cyclizine, haloperidol, levomepromazine, hyoscine butylbromide, glycopyrronium,
metoclopramide and midazolam).
Incompatibility may occur when higher doses of oxycodone >150mg are mixed with cyclizine.
Alfentanil is compatible with all the above medications that are recommended, with exception of cyclizine.
Use either water for injection or sodium chloride 0.9 % as the diluent, unless mixing with cyclizine, when
water for injection must be used.
With the introduction of the T34 McKinley syringe drivers use a 20mL syringe as standard and if a
larger volume is required use a 30mL syringe.
For information on the usual doses of drugs used in a syringe driver see inside of back cover.
For guidance on converting between opioids see the coloured opioid conversion chart.
For further information on compatibility in a syringe driver contact:
York Hospital enquiries
Scarborough Hospital enquiries
GP enquiries
York Medicines Information
Scarborough medicine Information Newcastle Medicines Information
01904 725960
01723 385170
0191 2824631
The algorithms will support you in your management of the most frequently reported symptoms Mouth care guidelines
General principles of mouth care
Assess the whole mouth daily. Clean the teeth and tongue using a toothbrush and toothpaste, morning and night. Ensure all toothpaste is rinsed away. Offer mouth care every 3 to 4 hours using a soft toothbrush. Use lip salve for dry lips. Care when using oxygen mask. Note any history of pain, dry mouth, change of taste, medications and respond if required. Document findings

Dry mouth
Consider discontinuing contributing factors, e.g. If required, consider humidifying oxygen. Implement general mouth care principles. Offer fluids hourly if appropriate. Consider topical saliva substitutes, e.g. Saliva Orthana spray or Oral Balance gel/ spray. Coated tongue
Implement general mouth care principles. Rinse the mouth after food with water. Encourage fluids as appropriate. If no improvement in 24 hours consider infection as a cause. Pain / mucositis / ulceration
Implement general mouth care principles. Consider analgesia – topical/systemic.
Use soft toothbrush for hygiene.
Consider diluting mouthwash if the patient finds their
use painful.
Seek specialist advice if symptoms continue.
Infection
Rinse mouth 3 times per day with chlorhexidine 0.2% (Corsodyl) or sodium chloride 0.9%. Implement general mouth care principles. Check for thrush and treat with antifungal, if appropriate. e.g. fluconazole or nystatin Pain Control
(Non renal pathway – see next page for patients with renal failure)
Strong opioid
Conversion to s/c morphine over 24 hours
Zomorph/ MST Divide total oral morphine dose by 2 Zomorph 30mg bd = 30mg Morphine sc in 24 hours Standard practice is to leave fentanyl patch on
Fentanyl patch 75 microgram changed every 72 hours patient and continue to change every 3 days.
is approximately equivalent to Top up with sc doses of morphine and review. morphine 270mg oral or 140mg sc over 24 hours. To calculate prn sc morphine dose to
Leave patch on and calculate initial prn sc morphine
supplement patch
a) Work out equivalent 24 hour oral morphine 1/6th of 140mg morphine sc over 24 hours = 25mg
dose for a given patch b) Divide by 2 to get sc 24 hour morphine dose c) Divide by 6 to get sc morphine prn dose
A syringe driver may be required if 2 or more doses used in the past 24 hours. The prn dose can be given every 3 to 4 hours up
E.g. If 2 prn doses are used (2 x 25mg) the syringe
to a maximum of 6 prn doses in 24 hours.
driver would be set up with 50mg morphine sc over 24 A syringe driver may be required if 2 or more prn
Calculate subsequent prn morphine s/c doses
• Add morphine syringe driver dose i.e. 50mg sc with Subsequent breakthrough dose should be equivalence in patch i.e. 140mg morphine sc. calculated from the dose of morphine in the Total equivalent sc morphine dose in 24 hour = syringe driver and the equivalent given by patch. 50mg + 140mg =190mg. • New prn doses would be 1/6th of 190mg = 32mg
(prescribe 30mg for convenience). It is good practice to document calculations in notes and check dose conversions with a colleague.
Consult colourful opioid conversion chart. If unsure please contact the palliative care team for advice
Remember to include prn doses in your calculations
Pain control in renal failure
(Patients with severe renal failure i.e. GFR < 30mL/min use oxycodone or alfentanil)
Strong opioid
Conversion to sc alfentanil over 24 hours
Conversion to sc oxycodone over 24 hours
MST/ Zomorph Divide total daily oral morphine dose by 30 Divide total daily oral morphine by 4 Zomorph 30mg bd= 2mg alfentanil sc over 24 hours Zomorph 30mg bd = 15mg Oxycodone sc 24 hours Divide total oral oxycodone by 15 Divide total oral oxycodone by 2 OxyContin15mg bd =2mg alfentanil sc over 24 hours OxyContin15mg bd =15mg oxycodone sc over 24 Standard practice is to leave fentanyl patch on
Standard practice is to leave fentanyl patch on
microgram/hour patient and continue to change every 3 days.
patient and change to change every 3 days.
Top up with sc prn alfentanil and review.
Top up with sc prn oxycodone and review.
To calculate initial prn sc alfentanil dose to
To calculate initial prn sc oxycodone dose to
supplement patch
supplement patch
• 1/6th of equivalent 24 hour alfentanil sc dose
• 1/6th of equivalent 24 hour oxycodone sc dose
e.g. Fentanyl 75 micrograms is approximately e.g. Fentanyl 75 micrograms is approximately equivalent to 9mg alfentanil sc over 24 hours. equivalent to 70mg oxycodone sc over 24 hours. • 1/6th of equiv 24 hour alfentanil sc dose is • 1/6th of equiv 24 hour oxycodone sc dose is 9mg divide by 6 = 1.5mg
70mg divide by 6 = 10mg
• The prn dose can be given every 2 to 4 hours up • The prn dose can be given every 2 to 4 hours
to a maximum of 6 prn doses in 24 hours.
• A syringe driver may be required if 2 or more prn
• A syringe driver may be required if 2 or more prn
E.g. If 2 prn doses are used (2 x 10mg) the syringe
E.g. If 2 prn doses are used (2 x 1.5mg) the syringe
driver would be set up with 20mg oxycodone over 24 driver would be set up with 3mg alfentanil over 24 Calculate subsequent prn oxycodone sc doses
Calculate subsequent prn alfentanil sc doses
• Add oxycodone syringe driver dose i.e. 20mg sc • Add alfentanil syringe driver dose i.e. 3mg sc with equivalence of oxycodone in patches i.e. with equivalence of alfentanil in patches i.e. 9mg 70mg sc. Total equivalent 24 hour sc alfentanil sc. Total equivalent 24 hour sc alfentanil dose = dose = 20mg + 70mg =90mg. 3mg + 9mg =12mg. • New prn dose would be 1/6th of 90 mg = 15mg
• New prn dose would be 1/6th of 12 mg = 2mg
Prn doses will need increasing as syringe driver
Prn doses will need increasing as syringe driver
requirements increase. requirements increase. It is good practice to document calculations in notes and check dose conversions with a colleague. Consult
colourful opioid conversion chart. If unsure please contact the palliative care team for advice
Remember to include prn doses in your calculations
Respiratory tract secretions
(Remember you cannot clear existing secretions, but you can help stop further production)
HYOSCINE BUTYLBROMIDE (BUSCOPAN) above 60mg in 24 hours may precipitate when mixed with
CYCLIZINE. If problems discontinue cyclizine and switch to levomepromazine.
GLYCOPYRRONIUM may be used as an alternative if hyoscine butylbromide not effective (reduced
doses in renal failure).
HYOSCINE HYDROBROMIDE is not recommended in patients with renal failure because of
excessive drowsiness or paradoxical agitation.
Agitation / Terminal restlessness
Before prescribing have all reversible causes been excluded? e.g. urinary retention
A
g
itation / Terminal restlessness

NB if uncontrolled on a maximum of 60mg midazolam (30mg in renal failure) consider
levomepromazine starting at 6.25mg prn. Further doses may need to be added to the syringe driver.
If symptoms continue contact the Specialist Palliative Care Team.
Dyspnoea (Breathlessness)
Non renal pathway –see next page for patients with renal failure)
Opioids are more useful for patients who are breathless at rest than those who are breathless on exertion
Reference page 368 of PCF4.
Dyspnoea (Breathlessness in renal failure)
(Patients with severe renal failure i.e. GFR < 30mL/min)
Opioids are more useful for patients who are breathless at rest than those who are breathless on exertion
Reference page 368 of PCF4.
D
y
s
p
n
o
e
a
(Breathlessness in renal failure)
Nausea and Vomiting
Additional prescribing information for anticipatory medication
(Usual doses quoted) For choice of opioid consult symptom control in last days of life or palliative care formulary
If your patient has renal failure look at the cautions in red
24 hours sc
Usual max dose
Single dose by
Prescribing Information
syringe driver
injection (SC)
(PRN + SD)
Anti emetic
Centrally acting on vomiting centre. Good for nausea associated with (25mg in patients bowel obstruction or increased with renal/heart/ intracranial pressure Dilute with water Do not use if
renal/heart/liver renal/heart/liver Note Dose reduction may be
patient has two
necessary in renal, cardiac or liver or more of above
failure e.g. 25mg risk factors
dose in elderly/ Good for chemically induced nausea Antiemetic action 1. Prokinetic (accelerates GI transit) 2. Centrally acting on chemo- receptor trigger zone (CTZ), blocking transmission to vomiting centre Broad spectrum antiemetic, works on CTZ and vomiting centre (at Dilute with sodium chloride 0.9% Anti agitation
Sedative/anxiolytic (terminal Always start low agitation). Also anticonvulsant and For major bleeds Start with lower dose & titrate Antipsychotic used for terminal Start with lower Seek help with (25mg to 50mg in agitation (2nd line to midazolam) dose & titrate higher doses Anti secretory
Antisecretory - useful in reducing respiratory tract secretions. Has antispasmodic properties May precipitate when mixed with cyclizine or haloperidol
Less sedating than hyoscine
hydrobromide as does not cross
the blood brain barrier
Antisecretory - useful in reducing respiratory tract secretions 200microgram in 1mL (600microgram in Also has antispasmodic properties Algorithm for an End of Life Diabetes Care Management Strategy is given below:
adapted from End of Life diabetes Care: Clinical care recommendations 2nd edition Last Days of Life Diabetes Care Management
Discuss changing the approach to diabetes management with patient and/ or family if
not already explored. If the patient remains on insulin ensure the diabetes specialist
nurses (DSNs) are involved and agree monitoring strategy.
Diabetes treated with
Diabetes treated with:
• Insulin
• Tablet
• GLP injectable therapy
Stop therapy
Continue on current background
For twice daily mixed insulin:
Stop monitoring
(long acting) insulin or usual
Prescribe once daily morning
blood glucose
insulin if patient requests this,
dose of Isophane Insulin #
with reduction in dose *
at reduced dose *
• Byette (Exenatide)
Check blood glucose once a day at teatime
• Victoza (Liraglutide)
• Lyxumia (Lixisenatide)
•If below 8 mmols/L reduce insulin by 10 to 20%
•If blood glucose above 20 mmols/L
Humulin I
Increase once daily insulin by 10 to 20% to reduce
Insulatard
risk of symptoms of ketosis
Insuman basal
Consider a correction dose of rapid acting insulin
• Novorapid
• Humalog
• Apidra

•Keep tests to a minimum. It may be necessary to perform some tests to ensure
Based on 25% less than
unpleasant symptoms do not occur due to low or high blood glucose.
total previous daily insulin
•It is difficult to identify symptoms due to "hypo" or hyperglycaemia in a dying patient.

•If symptoms are observed it could be due to abnormal blood glucose levels.
•Test urine or blood for glucose if the patient is symptomatic
•Observe for symptoms in previously insulin treated patient where insulin has been
discontinued.
For queries relating to the diabetes flowchart please contact the Diabetes Specialist Nurses
in York: 01904 726510 and
in Scarborough: 01723 342274
For queries relating to palliative care please contact the Palliative Care Team

Source: https://www.yorkhospitals.nhs.uk/document.php?o=1325