Last few days of life

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Last few days of life

• Symptom Control

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Common Symptoms

• Pain
• Agitation
• Respiratory Secretions
• Nausea and Vomiting
• SOB
• Can be anything
• Can vary depending on underlying diagnosis

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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

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Pain

• Not every one has pain
• Follow algorithm from LCP
• Main groups of drugs used
• Opioid
• NSAID

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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.

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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 ?

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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

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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

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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

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Respiratory Secretions

• If not settling consider
• Stat I/M antibiotic
• Stat I/M S/C frusemide
• Midazolam/Morphine
• Explanation to the family/carers

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Nausea and Vomiting

• LCP Haloperidol 1.5 to 3 mg stat
• 3 5 mg via SD
• Usually 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/Levomeproma
  zine
• Less common , Ocreotide/Ondansetron

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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

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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

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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

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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

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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

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Sudden Terminal Events

• Haemorrhage, stridor, large PE
• High dose Midazolam 10 to 20mg stat (sometimes
  I/V)
• Appropriate dose of Opioid

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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

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Advice
Sue Ryder Manorlands Hospice 01535 642308 Marie
Curie Hospice 01274 337000
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www.bradford.nhs.uk/palliativecare