SYMPTOM MANAGEMENT GUIDELINES FOR SUPPORTING …
SYMPTOM MANAGEMENT GUIDANCE TO BE USED WITH CARE PATHWAY FOR THE LAST DAYS OF LIFE
PAIN
For further information see the additional conversion sheet attached.
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE.
RETAINED SECRETIONS
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
TERMINAL RESTLESSNESS AND AGITATION
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
NAUSEA
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
TERMINAL BREATHLESSNESS
ANTICIPATORY PRESCRIBING
Patients who are dying may develop new symptoms over the course of the terminal phase.
To avoid delays in responding to these symptoms all patients should be prescribed the following PRN medication in anticipation:
| | | | |
|Drug |Dose / Route / Frequency |Use | |
| | | | |
| | | | |
| | | | |
| | | |For further information, see individual symptom guidance |
| | | | |
| | | | |
|Diamorphine |See guidance for appropriate dose s/c four hourly |Pain | |
| | |Breathlessness | |
| | | | |
|Haloperidol |1 – 2.5mg s/c four hourly |Nausea and vomiting | |
| | |Confusion / hallucinations | |
| | | | |
|Midazolam |2.5 – 5mg s/c two hourly |Breathlessness | |
| | |Anxiety / distress | |
| | | | |
|Hyoscine Butylbromide |20mg s/c one hourly. Maximum 80mg in 24 hours |Respiratory secretions | |
Suggested doses are for the “average” patient. Doses may need reducing for patients with:
• End stage heart failure;
• Renal or Liver failure; and
• In the frail elderly,
e.g. to Diamorphine 1mg, Midazolam 1mg)
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
PALLIATIVE CARE DOSE CONVERSION CHART
| | | | |
|Morphine |Zomorph or MST b.d. |MXL o.d. |Oxynorm |
|4 hourly | | |4 hourly |
| | | | |
| | |Oxynorm Injection |Buprenorphine Patches |
| | |10mg/ml. 20mg/2ml |35, 52.5, 70mcg/hr |
| | |
|Breakthrough analgesia, dose of Opioid should be ONE SIXTH of the total daily dose (dose over 24 hours). This is the |These doses are only approximate and the dose may need to be adjusted accordingly to responses. |
|same as the four hourly dose. | |
-----------------------
NO
YES
Is the patient already taking Morphine or other strong opioids?
Continuous S/C Diamorphine
Calculate the 24 hour dose of oral Morphine, divide the total dose by 3, which is the equivalent dose of Diamorphine over 24 hours s/c via syringe driver – e.g. patient on 90mg Zomorph BD = 180mg oral Morphine over 24 hours, which equals 60mg Diamorphine s/c over 24 hour infusion.
Transdermal Fentanyl
If the patient is using Transdermal Fentanyl but now has uncontrolled pain, continue the Fentanyl and use appropriate dose s/c Diamorphine as required in addition. See Guidelines.
Breakthrough Analgesia
To calculate the breakthrough dose of Diamorphine divide the 24 hour dose of Diamorphine in the syringe driver by 6, e.g. if the patient is receiving 60mg Diamorphine s/c over 24 hours the breakthrough dose of Diamorphine is 10mg s/c prn.
Alternatively
Morphine oral liquid may be used if the patient is taking sips of fluid. To calculate the equivalent oral Morphine breakthrough dose, multiply the s/c breakthrough dose by 3, e.g. s/c Diamorphine 10mg for breakthrough up to hourly = 30mg oral Morphine for breakthrough.
If Diamorphine is unavailable or the patient has previously been on oral Oxycodone, use the same format as above using Oxycodone.
Oral Oxycodone 1.5mg in 24 hours = Sub Cut : Diamorphine 1mg in 24 hours = Oxycodone 1mg in 24 hours
To calculate the subsequent doses of Diamorphine over 24 hours:
Review the doses of prn analgesia given in the previous 24 hour period. If more than one dose has been required, other than to pre-empt during care, (e.g. before a dressing etc.) then consider a 30% to 50% increase in the daily subcutaneous dose. If this is not controlling the pain or doses need escalating on a daily basis, seek specialist advice.
1. Diamorphine 2.5mg stat
2. Diamorphine 10mg/24 hours
via s/c infusion
3. Diamorphine 2.5mg s/c prn
As Required Medication
1. Diamorphine 2.5mg s/c prn
2. Morphine Sulphate 5mg
orally prn
NO
YES
Has the patient got pain?
Absent
Present
As required medication
Hyoscine Butylbromide 20mg s/c
1. Explain to relatives that for the patient retained
secretions are not bothersome due to decreased
sensitivity of pharynx.
IF the relatives are concerned or the patient
appears distressed:
2. Hyoscine Butylbromide 20mg s/c stat.
3. Hyoscine Butylbromide 60mg / 24 hours via s/c
Infusion.
4. Hyoscine Butylbromide 20mg s/c hourly prn
Absent
Present
1. Exclude Treatable Causes
Pain
Retention of urine or faeces
Hypercalcaemia if it would be appropriate to treat
As Required Medication
Haloperidol 2.5mg s/c p.r.n.
2b. Anxiety / Dyspnoea
i. Midazolam 2.5mg s/c stat.
ii. Midazolam 10mg / 24 hrs
via s/c infusion.
iii. Midazolam 2.5mg s/c prn
2a. Delirium
i. Haloperidol 2.5mg stat.
ii. Haloperidol 5mg/24 hours
via s/c infusion.
iii. Haloperidol 2.5mg s/c prn
Review in 24 hours
Review every 24 hours
Increase the 24 hour dosage according to the total dose of Midazolam given on a prn basis. The dose should not be increased by more than 10mg/day without specialist advice
Review Every 24 Hours
Increase the dose of Haloperidol to 10mg / 24 hours via s/c infusion if necessary.
NB: A total dose of 15mg / 24 hours – including stat dose, continuous dose and prn doses should not be exceeded.
For persistent nausea switch to:
1. Levomepromazine 6.25mg / via s/c infusion.
2. Levomepromazine 6.25mg prn s/c.
NB: A total of 50mg / 24 hours – including continuous and prn doses – should not be exceeded.
Increase to 10mg / 24 hours s/c if nausea persists
Review in 24 hours
1. Haloperidol 1.5 – 2.5mg s/c stat.
2. Haloperidol 5mg via s/c infusion.
3. Haloperidol 1.5 – 2.5mg s/c prn.
NB: A total of 15mg / 24 hours – including stat doses, continuous s/c doses and prn doses – should not be exceeded.
Prescribe, so available if needed, Haloperidol 1.5 – 2.5mg s/c prn (up to a total of 15mg / 24 hours)
YES
NO
Nausea present
Previously on Anti-Emetic
NO
YES
Convert to s/c as appropriate
If repeated doses are needed, consider starting syringe driver with combination of Diamorphine and Midazolam. Suggested starting doses are 5mg of each over 24 hours. Remember to use prns as needed.
AIM for patient’s breathing to be calm and effortless
Convert to s/c pump (or in case of Fentanyl patch add CSCI, do not remove patch) following Guidelines for Pain Management, BUT consider increasing Opioid dose, e.g. give 30-50% more than the recommended equivalent dose (or for Transdermal Fentanyl add 30-50% of the equivalent dose).
Prescribe appropriate prn as for breakthrough pain, e.g.1/6th of total daily dose Diamorphine for Tachypnoea.
Prescribe Midazolam 2.5-5mg s/c hourly prn for distress caused by breathlessness.
Consider adding Midazolam 10mg to s/c pump, particularly if prn dose has helped.
Give as soon as possible:
• Diamorphine 2.5mg s/c hourly for Tachypnoea.
• Midazolam 2.5-5mg s/c hourly for distress.
If no relief 30 minutes after first drug, try alternative, repeating if necessary.
YES
NO
Give as soon as possible appropriate prn of:
• Diamorphine s/c see equivalence chart for Tachypnoea.
• Midazolam 2.5-5mg s/c if patient distressed
Previously on oral Opioid or Fentanyl patch
Prescribe so available if needed:
• Diamorphine 2.5mg (or if on regular Opiods dose as per equivalence chart) s/c hourly for Tachypnoea.
• Midazolam 2.5-5mg s/c hourly for distress
Absent
Present
YES
GFR > 30
NO
Refer to National Guidelines for Patients with Renal Failure
(Consider discussion with Specialist Palliative care team)
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