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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