PRESCRIBING IN THE LAST DAYS OF LIFE
Peter NightingaleMacmillan GP
The Seven C’s Communication Palliative Care Register/MDT
meetings Co-ordination Key person Control of Symptoms Assessment, Treatment
and Patient Centred care Continuity Handover to out-of-hours/protocol.
Information to patients/carers Continued Learning Practice-based
learning/reflection on experiences. Carer Support Practical, Emotional, Bereavement Care of the Dying Liverpool Integrated care
pathway (Dying Phase)
Diagnosing the Terminal Phase BEDBOUND ONLY ABLE TO TAKE SIPS OF FLUID SEMI COMATOSE NO LONGER ABLE TO TAKE ORAL
MEDICATION
2 out of four required for Liverpool Care Pathway
Last Days Of Life- Anticipating and planning for common problems at home
1. Loss of mobility and ability to transfer safely2. Loss of ability to drink3. Loss of ability to eat4. Pain5. Vomiting6. Dyspnoea7. Excess secretions8. Delerium and agitation
Loss of mobilityUnable to transfer safely Generally safer and more manageable to
nurse in bed Consider loan of hospital bed/monkey
pole/cot sides/commode/urine bottles Assess for pressure area care and
implement appropriate strategy Indwelling urinary catheter/sheath for men
if more acceptable if incontinent/unable to transfer to commode
Bowel care
Methylnaltrexone (relistor) SC methylnaltrexone is approved for use in patients with 'advanced illness'
suffering from opioid-induced constipation despite usual laxative therapy. Constipation is common in advanced disease, even in patients not taking opioids. Thus, so-called 'opioid-induced constipation' is often multifactorial in origin; and methylnaltrexone will normally augment laxatives rather than replace them. It is important that laxative therapy is optimized before using methylnaltrexone.
About 1/2 patients defaecate within 4h of a dose without impairment of analgesia or the development of withdrawal symptoms. Common undesirable effects include abdominal pain, diarrhoea, flatulence, and nausea.
Initially give a single dose on alternate days. If there is no response, a second
dose can be given after 24h, but not more often.
Loss of ability to drink Prepare family and patient for this
happening Explain it is a natural process and may aid
comfort by reducing secretions/gastric secretions and chance of vomiting/urine output
Encourage sips/mouth care In the occasional situation, if still distressed
by thirst consider S/C fluids (N.saline 1l over 12h via a butterfly into anterior abdominal wall or thigh)
What can we conclude? Parenteral hydration in palliative care context:
probably improves mucous membrane hydration status sedation and ?myoclonus
probably worsens peripheral oedema, ascites and pleural effusions
is unlikely to affect delirium and hallucinations agitation bronchial secretions fatigue
can produce a significant placebo effect
Loss of ability to eat Prepare family and patient for this
happening Explain it is a natural process Forcing food may create
discomfort if too weak to swallow/digest
Pain Morphine or Diamorphine SC prn in
proportion to overall opioid requirement
Consider leaving pre drawn-up syringes :possibly leave an indwelling butterfly needle SC
OTFC Fentanyl increasingly considered
Vomiting
Levomepromazine is a useful broadspectrum antiemetic for the end of life. 6.25mg SC
Cyclizine 50mg tds SC or other antiemetic targeted at likely cause
Dyspnoea Common and frightening Morphine/Diamorphine preferably
SC (or sublingual) titrated up as for pain.
Midazolam 2-10mg S.C. or sublingual prn or 5-30mg SC/24h for breathlessness/fear or
Diazepam
Excess respiratory secretions (note Cochrane rev 2008)
Positioning important Antimuscarinics1. Glycopyrronium 2. Hyoscine hydrobromide 0.4mg
sublingual or SC 4h prn or 3. Hyoscine butylbromide 20mg
SC
Delirium and agitation Common at the end of life· Distressing and frightening for everyone involved
Haloperidol 5-30mg/24h/sc and/or midazolam5-60mg/24h(if agitation only)
Changing breathing pattern
Explanation to family "He may appear to stop breathing for a time, then draw another breath"
The Pathway in Today’s Health Care SystemThere must be continuous improvement in the delivery
of health care and the care of the dying patients must improve to the level of the best
(DOH 1998, NHS Cancer Plan 2000)
Patients want to die in the place of their choice and be assured that their carers will be supported throughout their illness and in bereavement
(Commission for health improvement/Audit Commission 2002)
There is a need to describe and transfer best practice in Hospice care into hospital and other care settings
(Bonick 2004)
What Is The LCP and How Does It Work?ICP is a multidisciplinary document which
provides a template for managing patient centred care, it acts as a flow chart for the care being given
It Describes Care It Tracks Care It Monitors Care It Evaluates Care
3 Sections To The LCP
Initial assessment and care Ongoing assessment and care Care after death
Goals Of Patient Care Encompassed By The LCP
Physical Psychological Religious/Spiritual Social
GP’s Involvement
Diagnose that the patient is dying Discontinue oral medication/syringe
driver if required Prescribe 4 core drugs Liaise with nursing staff, relatives
and out of hours/put the pt on pathway
Sign documentation
What Are The Benefits of Using The Pathway?
It organises the process of caring It is multisectoral (community/hospital) Multi-professional/aids communication It can influence ethical decision making Incorporates guidelines, evidence based
practice and clinical effectiveness
Benefits
Outcome focused (clinical supervision) Replaces and reduces documentation Legal record (written or electronic) Variances (allow staff to justify non-
actions) Flexibility (pts can come off the
pathway) Quality of care
PLANNING
NO LONGER ABLE TO TAKE ORAL MEDICATIONS:-
Discontinue unnecessary drugs Review medication required Plan for what medication may be
required
Discontinuing Drugs
Stop Non Essentials e.g. statins
Probably continue diuretics –furosemide can be given subcutaneously
Review steroids
Steroids in Palliative Care Used to improve quality of life
after risk/benefit assessment for:-1. 16mg Dexamethasone in
emergencies2. 12mg for inflammation in brain,
liver or after chemotherapy3. 4mg to temporarily help appetiteBut taper down quickly because of:-
Side effects of steroids Hyperglycaemia Thrush GI bleeding Agitation and restlessness Muscle loss Bed sores Bacterial infection
P A I N
Is patient already taking oral morphine?
Convert to 24hr s/c infusion of DIAMORPHINEFor conversion divide the total daily dose of MORPHINE by 3 ( eg MST 90mg bd orally = DIAMORPHINE 60mg via syringe driver)Make available subcutaneous DIAMORPHINE dose PRN for breakthrough pain PRN dose equals total daily dose divided by 6(eg if DIAMORPHINE 60mg subcutaneous in syringe driver PRN dose equals 10mg subcutaneously)
Make available DIAMORPHINE 2.5mg – 5mg prn s/c
If the patient is still in pain after 12 hours consider increasing the infusion by 30 – 50%
After 24 hours review medication. If2 or more doses required PRN then consider a syringe driver. Starting dose would be the total requirements over the previous 24 hours. The PRN dose may then need to be recalculated
Yes No
TERMINAL RESTLESSNESS & AGITATION
Present Absent
Make availableMIDAZOLAM 2.5mg-5mg s/c 4hrly PRN
Make available MIDAZOLAM 2.5 – 5mg s/c 4hrly PRN
Review the medication after 24hrs
If two or more PRN doses have been required then consider a syringe driver.Starting dose would be the dose required over the previous 24 hours
Review the medication after 24hrs
If two or more PRN doses have beenrequired then consider a syringe driverStarting dose would be the dose required over the previous 24 hours
Continue to give PRN dosage accordingly
RESPIRATORY TRACT SECRETIONS
Present Absent
Glucopyrronium 200 microgram SC stat then 1200mcg over 24 hours Glycopyrronium 200mcg s/c 8 hrly PRN should be made available
Continue to give 200microgram PRN dosage 8 hourly
If two or more doses ofPRN Glycopyrronium required then commence syringe driver s/c over 24 hrs
Increase total 24hr dose to 1.2 mg after 24 hours if symptoms persist
NAUSEA & VOMITING
Present Absent
Levomepromazine 6.25 s/c 8 hrly PRN
Levomepromazine 6.25mg s/c 8rly PRN
Review dosage after 24hrs. If 2 or more PRNdoses required, then consider use of syringedriver. Starting dose 12.5-25mg s/c over 24 hours
NB. If patient is already on an effectiveAntiemetic then switch to parental route and continue
Fentanyl at the end of Life Almost always better to leave the patch
on in the last days of life and add in other drugs via a syringe driver if necessary, because:-
1. Fentanyl reservoir active for up to 17hrs2. Opioid requirements vary greatly at this
time of life, they can decrease due to renal failure or increase due to disease progression
THE SYRINGE DRIVER IN PALLIATIVE MEDICINE
GRASEBY MS26
GREEN FRONTED
RATE = mm/24 hours
INDICATIONS Dysphagia Swallowing difficulties mouth/throat
lesions Intestinal obstruction Severe weakness Nausea & vomiting Poor alimentary absorption Semi comatose/comatose
ADVANTAGES Steady drug levels Avoids repeat injections Loaded once a day Does not limit mobility Can be used to control >1
symptom
DISADVANTAGES
Seen as a panacea
Irritation or swelling can limit absorption-Normal Saline is the preferred diluent unless cyclizine is being used
THE BOOST BUTTON
There is no “lock out” period The dose of analgesia is less than
the prn dose All drugs will be boosted The driver will run out more
quickly
COMMONLY USED DRUGS
Drug Action
Analgesic
Antiemetic
Agitation
Anticonvulsant
Excessive Secretions
Smooth muscle spasm
Steroids
Drug
Morphine/Diamorphine
CyclizineHaloperidolLevomopromazineMetoclopramide
HaloperidolLevomopromazineMidazolam
Midazolam
Hyoscine hydrobromideGlycopyrronium
Hyoscine butylbromide
Dexamethasone
24 Hour Dose
Starting dose 5 – 10mgs
50 – 150mgs1.5 – 5mgs2.5 – 12.5mgs30-60mgs
2.5 – 5mgs6.25 – 25mgs(up to 150mgs)5 – 30mgs
10 – 40mgs
40 – 1200mcgms600 – 1200mcgms
20 – 120mgs
4 – 16mgs
CAUTION
Cyclizine precipitation occurs when mixed with Diamorphine if either one exceeds 20mgs/ml-needs water as diluent
Metoclopramide extrapyramidal reactions can occur with higher doses or if used with Haloperidol
or Levomopromazine
Levomopromazine exessive sedation and skin irritation can occur with higher doses or when used
with other D2 receptor antagonists, eg Haloperidol or Metoclopramide
Dexamethasone should not be mixed with any other drug-very small doses occasionally used for site reactions
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The verification of death
Dr Hong Tseung
Macmillan GP Adviser
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Definitions
verifying death confirming death has actually occurred – 'fact of death'
certifying death written confirmation of cause of death
registering a death formal notification to authorities (Registrar of births and deaths) of fact of death and its cause
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Who does what?
verification of death doctor (GMC registered) registered nurse
certification of death doctor (GMC registered) only must have seen the patient alive in preceding two weeks before death
registration of death by 'the informant' – carer, relative, family member who takes death certificate to the Registrar
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The coroner’s involvement
when the cause of death is not known eg sudden death
when there is a suspicious cause of death eg bullet wounds, knife wounds, strangulation, asphyxiation, overdose, suicide
when no medical practitioner has seen patient alive within the last two weeks before death
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The signs of human life
breathing pulse/heart beat pupil reaction responsiveness
auditory, sensation (pain), reflexes
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The signs of dying (impending death) not always easy to 'diagnose dying' bed-bound comatose/semi-comatose taking sips of fluids only no oral intake irregular breathing (Cheyne Stokes,
shallow)
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What happens when death has occurred? no organs work no brain activity, heart stops, lungs stop,
liver and kidneys stop, muscles stop tissues start to breakdown rigor mortis (several hours later), blood
pools, decomposition
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The signs of death
looks pale (blood pooling) no breathing no pulse no heart sounds pupils fixed and unreactive to light no response to sensory stimuli (eg pain) no reflexes (no brainstem activity)
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What to do
look for skin colour (pink) for chest movement (breathing)
feel for a MAJOR pulse: carotid
listen for breath sounds for heart sounds
test for BOTH pupil reflexes to light
None of the above present? = death confirmed
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Don’t get it wrong
very embarrassing distressing for relatives
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