Symptom control and caring for the dying patient: palliative care guidelines

Symptom Control and Caring for the Dying Patient:
Palliative Care Guidelines

4th Edition
Produced byKent Palliative Medicine Forum University of Kent Dosage conversion between opioids
Parent eral
Parent eral Transdermal
Ot he r opioids
Higher doses of oxynorm and morphine are t oo large a volume f or SC inje ct ion.
From total daily opioid To get to the equivalent 24 hour total Conve rsions t o and f rom f ent anyl and buprenorphine pat ches should be checke d against manuf act urer's guidance.
N.B. The conversions given in this table are approximate and may need to be adjusted according to responseAdvice from the palliative care teams should be sought at higher dose conversions For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
This booklet is aimed at all health care professionals involved in the care of
patients with incurable, progressive disease who are experiencing unpleasant
symptoms. The interventions and treatments described are initial measures that
all doctors and nurses should be able to start. If the symptoms do not resolve
specialist advice can be obtained from the contacts given at the end of the
Note: Cautions and contra-indications may apply to any of the medications; some
of the indications are outside of the product licence. Please refer to the BNF,
especially the palliative care section near the beginning.
Where a range of doses is given it is generally the case to start at the lower end,
unless specialist advice suggests otherwise. This should be reviewed regularly
and increased if the symptom is not improving.
Syringe driver use
Nausea and vomiting
Gastrointestinal obstruction
Acute confusional states
Checklist for the dying patient
Respiratory secretions at the end of life
Restlessness at the end of life
Patients with heart failure
Patients with end stage renal disease
Diabetes in palliative care
Communication: breaking bad news and CPR discussions
Contact details for hospices and hospital pal iative care teams
Continuous subcutaneous infusion via a syringe driver For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
The management of pain
A holistic approach is necessary when dealing with pain control in terminal
il ness. There may be several factors contributing to the experience of pain such
Psychological fearsThe fears and concerns of the patient.
Social concernsMost patients are part of a wider social network and may have concerns regarding them.
Spiritual distressThe meaning of the illness to the patient which may lead to questions about the meaning of life - “why me?” “what next?”.
• Explain symptoms to patient and carers • Treat the cause of the pain where possible • Use the analgesic ladder at the appropriate step • Clear explanation to the patient and carers Assessment
o Treat reversible causes.
o Carefully exclude conditions requiring intervention such as spinal cord compression, fracture and infection.
• What are the characteristics and severity of the pain? o Assess by the effect on activities of daily living or at rest / sleep.
• What is the type of pain: neuropathic, bone, visceral, etc? • What associated social, psychological, spiritual and physical issues are For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
• All patients require a ful explanation • Most patients require regular analgesia, and may also require specific treatments aimed at underlying causes (e.g. palliative radiotherapy for metastatic bone pain) • Start at an appropriate step of the ladder: STEP 3 Strong opioids e.g. morphine & Weak opioids e.g. co-codamol 30/500 (+/- adjuvant analgesics) The usual starting doses on each step are: • Slow release morphine (e.g. Zomorph capsules or MST tablets) For patients commencing morphine, an as required (“breakthrough”) dose should also be prescribed: • Immediate release morphine (e.g. Oramorph liquid or Sevredol tablets) a dose of a 1/6th of the 24hour morphine dose is appropriate. e.g. a patient taking 90mg BD of slow release morphine is the equivalent of 180mg in 24 hours and so would receive 30mg as breakthrough. See the table on the inside cover which gives the appropriate break through dose of immediate release morphine, which wil need to be increased in line with the regular dose.
• More frequent use of breakthrough analgesia for example more than 3 doses in 24 hours requires review of the regular dose.
If pain is severe then it is good practice to start at step 3 i.e. strong opioids.
Continue to titrate up the morphine dose by up to 30% every 24-48 hours until pain relief is satisfactory or side-effects occur.
Prescribe a laxative and an anti-emetic - see sections on constipation and nausea.
If patients are unable to take by mouth then analgesia should usually be given SC. To make this conversion see the table in the inside front cover. The 24 hour dose by CSCI is given via a syringe driver.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Alternative opioids
Other opioid drugs are available and are sometimes used for palliative care
patients. Morphine remains the first choice, although there may be specific
indications where alternatives are indicated such as renal failure or intolerable
side effects. The table on the inside front cover gives the relative potency of
these medications helping to guide conversions from one opioid to another.
Oxycodone provides an alternative oral opioid to morphine. It has a role if
patients develop intolerable side-effects from morphine.
This may be of use in patients with significant renal impairment. Please contact
the Palliative Care Team for further advice.
Transdermal opioids (Patches)
These should only be used for patients who have stable analgesic requirements.
They are not suitable for acute pain but may be useful for patients who:
• Are unable to comply with regular medication • Experience intolerable side-effects to other opioids • Have significantly impaired renal function Delivery systems used by different patch manufacturers can lead to prescribing confusion. It is now advised that when prescribing opioid patches that the brand name is used.
Patch strengths: 12 micrograms/hr, 25 micrograms/hr, 50 micrograms/hr, 75
micrograms/hr and 100 micrograms/hr. NB patches only require changing every
72 hours.
When the first patch is applied it will take 12-18 hours before maximal analgesia
is achieved. The starting dose should be the appropriate conversion from the
current opioid (see table on the inside front cover). The dose of the patch should
not be increased until it is due to be changed, but an immediate-release opioid
should always be prescribed for breakthrough pain (see chart for appropriate
doses). Also, once a patch is removed, there will continue to be some absorption
of fentanyl from the skin for a further 12-18 hours.
Buprenorphine is now available in a number of formulations which vary in
duration of activity. Butrans is changed weekly and Transtec twice weekly. As
with fentanyl there is a delay in onset of analgesic effect of 12-18 hours after first
application of a patch, and a similar delay for the effect to wear off after patch
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
removal. For further advice on the use of this opioid please contact the Palliative Care Team.
Common side-effects of opioids
Prescribe a regular laxative to prevent constipation. Increase the dose as the
opioid dose increases. See later section on management of constipation for
suggested regimens.
May occur when starting or increasing opioids, therefore prescribe an anti-emetic
for use if necessary –see section on nausea and vomiting.
Dry Mouth
Can occur in about 40% of patients.
Local measures e.g. ice cubes, pineapple chunks
Artificial saliva (e.g. Saliva Orthana spray or oral balance gel)
Check for oral candidiasis and treat appropriately
May occur when opioids are started or the dose is increased, but it is usually
transient and wil reduce over a few days.
Opioid toxicity
Features of opioid toxicity include
It is important to consider other reversible causes such as hypercalcaemia, sepsis, dehydration and the possible role of other medications. Opioid toxicity is particularly associated with renal impairment; please see renal section for details of specific management.
Management of suspected toxicity includes: • Address other possible causes e.g. rehydration • Opioid sparing techniques e.g. non opioid analgesics • Switch opioid e.g. convert to an alternative opioid with a 20-30% dose For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
NB When sedation is required (to address problems of anxiety, restlessness, agitation) it should not be achieved by increasing the opioid dose, instead a more appropriate sedative medication should be prescribed.
Specific pain syndromes
It is helpful to identify the following syndromes which benefit from particular
management strategies:
Bone pain
• NSAIDs e.g. diclofenac (modified release) 75 mg bd or naproxen 500 mg • Palliative radiotherapy – refer to oncology • Bisphosphonates e.g. pamidronate infusion Back pain and spinal cord compression
Increasing or new back pain with any neurological symptoms or signs in
lower limbs or alteration in bowel or bladder function requires urgent
action to exclude spinal cord compression.

Commence dexamethasone 8mg bd
Arrange MRI of whole spine
Refer for urgent oncology or neurosurgical opinion.
Headache from raised intracranial pressure
May present in primary cerebral tumour or cerebral metastases.
Give dexamethasone, starting at 8 mg bd in the morning and at lunchtime as
may cause insomnia if given later in the day. If there is no response within 7
days discontinue the dexamethasone. If patient responds, gradually reduce the
dosage to a maintenance dose.
Consider palliative radiotherapy – refer to oncology.
Bowel colic
• Assess for and manage constipation.
• Hyoscine hydrobromide (Kwells) 300 micrograms SL tds or hyoscine • In bowel obstruction, the oral route is not appropriate for drug administration (see section on intestinal obstruction).
Liver capsule pain
Dexamethasone 4mg - 8 mg od, NSAID and/or paracetamol.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Treat with an appropriate antibiotic.
Neuropathic pain
• Analgesic ladder (see earlier) – pain may be opioid responsive.
o Dexamethasone: 8mg od to relieve nerve compressiono Amitriptyline: Starting dose 10mg - 25mg at night and titrate o Gabapentin: Starting dose is 300mg od (elderly patients 100mg); Neuropathic pain may be difficult to control and advice needed from the Specialist Palliative Care Team.
Interventional procedures for pain
Consider referral to a pain clinic in specific pain syndrome (e.g. coeliac plexus
block for pancreatic pain) or in difficult pain situations when analgesics are not
working and toxicity is a problem.
TENS (Transcutaneous Electrical Nerve Stimulation)
For nerve irritation and localised pain. Consult a physiotherapist.
Use of a syringe driver
The syringe driver is a battery-operated machine designed to deliver drugs via a
continuous subcutaneous infusion (CSCI) over 24 hours.
The main indications are the inability to swallow or absorb drugs due to
• Medical management of intestinal obstruction if surgery is not possible or Drugs commonly used in a syringe driver
A combination of 2-3 drugs can be used to achieve good symptom control.
The syringe driver site, stability of the contents and rate of infusion should be
checked regularly.
Morphine is the most commonly used opioid analgesic used by CSCI in a syringe
driver. Oxycodone can be used in patients intolerant of morphine. Diamorphine
can be used if the volume to be infused is too large.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Calculating doses of morphine, diamorphine and oxycodone via CSCI
• Calculate the 24 hour dose of opioid on the basis of the previous 24 hour opioid requirement (see also table of equivalent doses) • When reviewing dosage, calculate the total dose of opioid received in the previous 24 hours considering any additional doses given for breakthrough pain. • For breakthrough pain, give 1/6th of the 24 hour opioid dose by SC bolus • Opioids are usually combined with other drugs (see below). The drugs should be diluted to an appropriate volume with 0.9% saline (except with cyclizine).
If a patient is unable to take a NSAID by mouth, an equivalent dose of diclofenac
can be given rectally, or by CSCI. Diclofenac should not be combined with other
drugs in the same syringe driver and should be diluted with 0.9% saline, in a
minimum volume of 20 mls.
Transdermal opioids and CSCI
If setting up a CSCI in a patient using transdermal patches, continue to apply the
patch at the appropriate interval rather than convert to a parenteral opioid in the
CSCI. Add any additional opioid required for breakthrough pain to the CSCI.

Usual starting dose range/24hours
Respiratory secretions and bowel colic

Usual starting dose range/24hours
Terminal agitation and restlessness
(NB exclude urinary retention and pain- see later section)
Usual dose
Add in levomepromazine anxious patient.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
If no recent seizures consider need for ongoing prophylaxis.
Use midazolam starting with 20mg over 24hours and increasing as required.
This is necessary in patients who had required anticonvulsants for convulsions
If uncontrolled convulsions despite higher doses (>60mg midazolam) seek
specialist advice.
Management of constipation
• Careful history and clinical assessment, including rectal examination • Minimise contributory factors, especially constipating medication where possible. Constipation is not a contraindication to the prescription of such medication.
• Always prescribe laxatives when commencing opioids.
• Combination regimes of laxatives are more effective; either two medications or a combination product (see below).
• Any risk of bowel obstruction? – Avoid stimulant laxatives if there is any • Volume of oral intake – what is realistic for patient to manage? • Individual laxative indications and contra-indications Give appropriate laxatives regularly and titrate to maintain a comfortable stool.
Rectal intervention may be needed to address existing constipation prior to establishing an effective laxative regime, although in selected patients Macrogol 3350 (Movicol) may be effective for faecal impaction.
For some patients on-going rectal intervention may need to be continued in conjunction with oral laxatives particularly where there are predisposing factors, such as sacral nerve root involvement or spinal cord compression.
Suggested oral laxative regimens
• Co-danthramer capsules or suspension (also “Strong” version available). Should be avoided in the incontinent patient For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Suggested rectal interventions
• Glycerine and bisacodyl suppositories • Phosphate enema alone (no more than three times a week) Nausea and vomiting in palliative care
Nausea and vomiting are common symptoms in pal iative care occurring in over
50% of patients. There is often more than one precipitating factor making
management particularly difficult.
Approach to nausea and vomiting
• Review current medication and discontinue any non-essential precipitating • Remove any other known precipitating factors • Treat reversible causes e.g. hypercalcaemia (see later section) • Prescribe a regular oral anti-emetic.
• If a patient is vomiting then an injection is necessary and if this successful y controls the vomiting it can be followed by regular oral anti-emetics • If the vomiting persists commence CSCI via a syringe driver • NB Reluctance to commence a CSCI is a common reason for unsuccessful management of vomiting.
Causes of nausea and vomiting
• Area postrema (chemoreceptor trigger zone) activity: e.g. biochemical abnormalities (raised calcium or renal failure), drug changes (opioids, cytotoxics, antibiotics, digoxin) or infection.
• Cerebral cortex activity: e.g. anxiety • Emetic pattern generator (vomiting centre): e.g. radiotherapy to head or neck, primary or secondary cerebral tumours • Gastric irritation: e.g. NSAIDs, iron, cytotoxics, radiotherapy • Gastric stasis or compression: e.g. pressure from tumour or ascites or drug induced such as opioids, tricyclic antidepressants, phenothiazines, hyoscine • Gastrointestinal obstruction (see later section) First line medication
• Haloperidol 1.5 mg-3 mg as a single night time dose • Cyclizine 50 mg tds (often combined with haloperidol) • Metoclopramide 10 mg-20 mg tds especially if improved gastric emptying For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Possible adjuvant medication
• Lorazepam 500 micrograms sublingual or po prn may be helpful where • Dexamethasone 4mg - 16 mg/day for raised intracranial pressure.
• Proton pump inhibitors e.g. lansoprazole 30mg for gastric irritation.
Second line medication
• Levomepromazine (5 mg - 25 mg/24 hours) • Higher doses of metoclopramide (up to 120 mg daily).
NB. Theoretically the prokinetic effect of metoclopramide will be lost if prescribed with an anti-muscarinic drug such as tricyclic antidepressants, cyclizine or levomepromazine.
Before moving to 2nd line treatment consider giving a subcutaneous injection and then to a CSCI if necessary.
Management of gastrointestinal (GI) obstruction in
palliative care
Having ruled out constipation as a cause of symptoms, there are three main
approaches to a patient with malignant GI obstruction:
1. Interventional approach with surgery or stenting for patients with:
• isolated lesions and minimal previous surgery 2. Oncological intervention for patients with: • no previous chemotherapy treatment or where effective second line 3. Medical approach will be the case for the majority of patients and can often provide good control of symptoms without use of naso-gastric tubes or intravenous fluids. This may be appropriate initially in patients being considered for oncological intervention.
The medical approach to managing GI obstruction differs according to thepresence or not of colic.
For patients with no colic: • Metoclopramide 30-60 mg/24 hours via CSCI. Sometimes higher doses • Hyoscine butylbromide 60mg - 120mg / 24 hours or glycopyrronium 400 micrograms – 1.2 mg / 24 hours as an antisecretory agent and antispasmodic • Levomepromazine 5mg - 25 mg / 24 hours as an antiemetic For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
• Octreotide 500 micrograms / 24 hours if further anti-secretory effect is All these drugs should be given by CSCI. Infrequent colic may be managed by SL hyoscine hydrobromide(e.g. Kwel s 300 micrograms). Sodium docusate should be given as a softening laxative.
Steroids in GI obstruction
A trial of dexamethasone 8 - 16mg in the morning may be indicated. There is
some evidence for relief of obstruction, but this has to be weighed against the
risk of side effects and in particular the risk of inducing a good appetite to a
patient who is vomiting.
Acute confusional states in palliative care
Characterised by acute onset, altered level of consciousness, fluctuating course
with disorganised thinking, disorientation and inattention
More common in the elderly, physically ill, patients in the terminal stages of their
il ness and patients with an underlying dementia or cerebral primary or secondary
Whilst offering immediate treatment consider reversible causes: recent drug
changes, organ failure, hypoxia, infection, hypercalcaemia, dehydration,
encephalopathy, hypo/hyperglycaemia.
• Offer calm, wel -lit environment, careful explanations, consistent carers • In absence of abnormal behaviour or perception or psychosis: o Reduce anxiety if necessary with lorazepam 500 micrograms - o If continued sedation indicated, midazolam 2.5mg - 10mg SC prn • In the presence of abnormal behaviour or perception or psychosis: o If wishing to avoid excessive sedation give haloperidol 1mg - 5mg SC or 2mg -10mg orally (note subcutaneous : oral potency haloperidol 2:1) o Should sedation be required, use levomepromazine 12.5mg - 50mg / 24 hrs orally or by CSCI. If risk of seizures, combine with midazolam SC to raise threshold (see syringe driver section) • Explain to family/carers the treatment prescribed.
Acute confusion is complex and difficult to manage so early involvement from the Palliative Care Team is recommended.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Hypercalcaemia of malignancy
Occurs in 10-20% of patients with malignant disease (especially breast cancer,
squamous cel carcinoma, smal cell carcinoma, renal cell carcinoma and
myeloma). Often there is a humoral component irrespective of the presence of
bone metastases.
• Often non-specific and include confusion and drowsiness, anorexia, nausea and vomiting, constipation, polyuria and polydipsia,. • Renal failure and coma may result if left untreated. • Symptoms may relate to the rate of rise in calcium but not necessarily to Treatment is based on the corrected serum calcium mmol/l = {[40 – albumin g/l] x0.02} + serum calcium mmol/lThe correction is important as this group of patients often have a low serum albumin.
• Hypercalcaemia is often a poor prognostic sign and so may not be appropriate to try to treat in the last few days of life.
• IV bisphosphonates (pamidronate, zoledronic acid or ibandronate) • Some drugs have a single specified dose. Others recommend a treatment dose dependent on initial albumin corrected plasma calcium concentration. In the latter case it has been suggested that the higher doses should be given irrespective of initial calcium level to increase likelihood of response and prolong duration.
• Dose may need to be adjusted depending on renal function • Drug and dose may need review in refractory hypercalcaemia and advice sought from the palliative care team.
Palliative management of breathlessness
The uncomfortable awareness of breathing is a frightening symptom, and
management of that fear and anxiety is essential. Episodes of hyperventilation
or panic are a common feature.
Assessment includes history, examination and appropriate investigations.
Reversible causes should be treated when possible. Symptomatic management
requires a multidisciplinary approach and includes both non-pharmacological and
pharmacological strategies. The relative contribution of these approaches will
depend on the degree of breathlessness and the patient’s prognosis.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Treat reversible causes where appropriate
E.g. pulmonary embolus; infection; reversible bronchoconstriction; pleural
effusion; anaemia; cardiac failure; superior vena cava obstruction
(dexamethasone, radiotherapy, stent).
Non-pharmacological strategies
• Should be employed in all breathless patients • Explanation and reassurance: e.g. “an awareness of lack of breath, like after exercise, is not in itself dangerous” • Cool draught or fan, loosen tight clothes • Hand pneumonic for controlled breathing: Stop, sigh, shoulders, slow o Position yourself where you are fully supported and comfortableo When a muscle is tense relax it by moving it in the opposite o Take a moment to feel that area become relaxedo Move each part of the body until the whole body feels relaxedo Think about a time or place where you felt relaxedo Take slow even breaths and few minutes to yourself • General adaptation measures e.g. move bed downstairs, sitting to wash, • Consider referral to a specialist palliative care team and physiotherapist. Some centres also run breathlessness clinics.
Pharmacological treatment
• Reduce the sensation of breathlessness (supported by systematic review • Improvements are seen at doses that do not cause respiratory depression. • Starting dose: morphine 2mg - 5 mg PO 4 hourly prn. • If more than 2 doses are needed within a 24 hr period, prescribe morphine regularly and titrate the dose according to response. • In patients already taking regular opioids for pain then increase regular • The appropriate 4 hourly “breakthrough” dose of morphine should be • Alternative opioids can be used for patients who cannot tolerate morphine.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
• Helpful in managing the fear and anxiety associated with dyspnoea. • E.g. lorazepam 500 micrograms-2.5 mg daily or diazepam 2mg - 10 mg • Sublingual lorazepam (Genus brand only) 500 micrograms - 1 mg or oxazepam 10mg – 20mg prn is useful in the management of a respiratory panic attack.
Nebulised saline 0.9%
Helpful for sticky bronchial secretions.
Useful in some patients, but there is no correlation with the degree of hypoxia. It
has no role if saturation is normal.
Parenteral medication
If the patient is unable to take oral medication, then morphine or diamorphine at
the appropriate conversion dose and midazolam can be given by CSCI and prn
(see section on end of life care).
The dying patient
Recognising the dying patient
• Treatable causes for deterioration have been excluded or refused, or treatment deemed inappropriate or ineffective. • The multi-professional team agree that the patient is dying o Patient is bedboundo Patient is semi-consciouso Patient is no longer able to take tabletso Patient is only able to take sips of fluid Commence the Liverpool Care Pathway for the dying if it is being used locally. If not available use the following checklist to guide care Checklist for the dying patient
• Assess medications and discontinue non-essentials o Analgesia e.g. diamorphine or morphine at the appropriate doseo Anti-emetic: e.g. haloperidol 1.5mg - 3mg 4-6 hourly or cyclizine 50mg 6-8 hourly or levomepromazine 5mg -12.5mg prn 6 hourly o Sedative: midazolam 2.5mg - 10mg prn 2-4 hourly For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
o Antimuscarinic for respiratory secretions: glycopyrronium 200 micrograms – 400 micrograms 2-4 hourly or hyoscine butylbromide (Buscopan) 20mg 2-4 hourly • In the community there is a need for anticipatory prescribing of these medications including the 0.9% saline or water for injections. CSCI prescriptions should include an appropriate range to prevent delays in symptom control.
• Consider commencing a CSCI if more than one dose of these medications • Discontinue inappropriate medical interventions, such as blood tests, IVIs, • Discontinue inappropriate nursing interventions such as the monitoring of vital signs and replace with observations concerning symptom control. Ensure that mouth care and bowel and bladder care regimes are in place.
• Assess the patient’s and family’s insight into the situation and give appropriate information. You may need to explain that the patient is dying, the plan of care for the patient and ‘how’ death will occur. • Assess patient’s religious or spiritual needs.
• Ensure Do Not Attempt CPR forms are completed and the decision communicated to all professionals involved. • Handover the condition of the patient to the on-call team or out of hours Respiratory secretions at the end of life
It is important to distinguish terminal secretions from conditions which may
require alternative treatments e.g. ventricular failure or pneumonia.
‘Death rattle is the noisy respiration caused by turbulent air passing through or
over accumulated secretions in the oropharynx or bronchial tree in a patient who
is close to death and unable to clear secretions by coughing and/or swallowing’.
General interventions
• Repositioning of the patient [e.g. supine to lateral] Drug treatment
Treatment should be commenced as soon as symptoms become apparent.
• Glycopyrronium is the preferred drug because: o No central side effects o Potency and efficacy o Longer half life than other anti-muscarinics. o Dose: 200 micrograms – 400 micrograms SC prn and 1.2mg / 24 For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
• Hyoscine butylbromide: 20 mg SC prn and 40mg - 120mg over 24 hours • Hyoscine hydrobromide: 400 micrograms SC prn and 1.2mg – 2.4mg over 24 hours by CSCI. NB Can cause sedation or agitation • Antibiotics (where infected secretions are distressing) • Diuretics (where there is evidence of ventricular failure) • Agents to reduce awareness of the secretions e.g. midazolam • Suctioning usually only has a role in severe cases Restlessness at the end of life
Patients may become agitated in the last few days or hours of life.
May be physical, metabolic or psychological and precise aetiology may be
difficult to identify or investigation of the cause may be inappropriate given the
patient’s poor prognosis. It is, however, important to exclude easily treatable
causes such as:
Drug management of restlessness at the end of life
• 2.5mg - 10mg SC stat and prn 4 hourly • Consider midazolam 10mg - 60mg per 24 hours by CSCI. This can be gradually increased according to response.
• Often useful in situations which fail to respond adequately to midazolam • 25mg - 100mg / 24 hours via CSCI if ongoing sedation required Aim of treatment should be to achieve relief of symptoms without preventing the patient from being able to communicate. On some occasions symptom relief can only be achieved with sedation. If response unsatisfactory, review possible causes and seek specialist palliative care advice For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Symptom control in end stage heart failure
The guidance in this document is pertinent to patients with end stage heart failure
however the following cautions may need to be considered depending on the
patient’s circumstances.
• Be aware that NSAIDS may worsen heart failure.
• Patients with heart failure may also have renal impairment and in such cases appropriate guidance for opioid prescribing in renal impairment should be sought (see later section).
Nausea and vomiting
• Consider toxicity from medication especially digoxin. • Domperidone and metoclopramide are first choice • Cyclizine should be used with caution in severe heart failure as it can result in vasoconstriction and reduced cardiac output.
• Haloperidol and levomepromazine can affect QT interval and reduce blood Breathlessness
Ensure heart failure therapy is optimised including appropriate use of diuretics.
Review doses and route of cardiac medication. If breathlessness persists see
page 22.
Can be due to heart failure or other co-morbidity.
• Avoid ispaghula husk because of fluid requirements • If using macrogols, Idrolax is preferred rather than Movicol due to its lower Miscellaneous
• When using antidepressants – avoid tricyclic antidepressants and Withdrawal of medications and investigations
Symptom control should continue along with active cardiological management as
long as this remains appropriate. However as the patient’s condition deteriorates
and their prognosis is reduced all drug therapy needs to be reviewed, along with
the need for routine tests. In general, continue medications with short term
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
symptomatic benefits and stop those aimed at medium to long term reductions in morbidity or mortality.
Drug rationalisation needs to be tailored to the individual patient situation but the following may provide useful initial guidance. If a patient is known to the heart failure team discussion is suggested as they will have useful information concerning a patient’s symptomatic response to individual medications. • Anti–anginal medication if symptomatic • Antihypertensives (monitor BP initially) • Anti-anginals if no symptoms (monitor for symptom recurrence) Refer to Kent Cardiac Network guidance.
Implantable cadioverter-defibrillator should be de-activated according to local policy.
Symptom management in end stage renal disease
Exact dosing advice depends on estimated glomerular filtration rate (eGFR).
Paracetamol can be used safely
Fentanyl and alfentanil are the opioids least likely to accumulate.
A NSAID may be used in normal doses if pain control is a clear priority over
maintaining existing renal function
Suggested approach
Mild pain
• Fentanyl patch 12 micrograms per hour For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Please refer to dose conversion chart to establish relative potencies of these opioids.
• Carefully titrated doses of fentanyl patch or alfentanil CSCI • Fentanyl via SC injection or transmucosal preparation o Tramadol immediate release 50mg – 100mg 12 hourlyo Morphine immediate release 1.25mg – 5mg po 6-8 hourly o Oxycodone immediate release 1.25mg – 5mg 6-8 hourly Observe carefully for signs of opioid toxicity (see page 9) which will suggest accumulation. Do not use slow release preparations.
Nausea and vomiting
Haloperidol 500 micrograms – 1.5mg SC or 1.5mg - 3mg via CSCI over 24hrs
(may accumulate)
Cyclizine 50mg tds
Levomepromazine 6.25mg SC prn or 6.25mg via CSCI over 24hrs
Opioids and benzodiazepines provide effective symptom relief.
The same precautions apply as per the use of opioids with pain (above).
Benzodiazepines can be used in the same manner as in the breathlessness
section (see page 22)
Respiratory tract secretions
Refer to page 26. There is no difference in the management in renal failure.
Restlessness at the end of life
Midazolam 2.5mg SC prn or after 3 prn doses consider CSCI 5-10mg over
This can be gradually titrated up according to severity of anxiety or agitation.
Chlorpheniramine 4mg tds/qds or promethiazine 25mg bd or 10mg - 20mg tds
The use of topical creams such as Eurax and aqueous cream with menthol.
For more details on end of life care in renal failure please refer For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Diabetes mellitus in palliative care patients, nearing the
end of life
Aim to:
• Prevent short term problems and symptoms rather than longer term • Achieve blood glucose between 7-17 mmol/l.
• Where possible, treat reversible causes of hyperglycaemia such as • Priority is to avoid hypoglycaemia, whilst preventing ketoacidosis and Dietary restrictions are only required if there is no other means to control unpleasant symptoms.
New diabetics with advanced disease
Management depends on prognosis, blood glucose levels and presence or
absence of ketonuria.
Cachectic patients have a poor response to oral hypoglycaemics so consider
insulin early.
Gliclazide 80mg. Titrated up to 160mg BD according to glucose levels and symptoms.
Start long acting insulin 10 units at night increasing dose gradually as required.
>27mmol/l with ketones or significant Type 1 diabetes
Insulin is always required until the last short number of days or hours of life.
Long acting insulin is the most effective approach as the patient’s condition
Anorexia is common. Short acting insulin can be given after eating to prevent
risks of hypoglycaemia if the meal isn’t finished.
Daily blood glucose, decrease insulin appropriately until stable.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Convert to long acting insulin at night either 10 units or 25% of total daily dose if on high doses.
Monitor blood glucose BD until stable.
Consider admission.
Type 2 diabetes on oral agents
Weight loss or decreased
• Avoid metformin or thiazolidinediones such as • Use gliclazide to manage glucose levels and • Adjust dose according to weekly blood glucose.
• Watch for symptoms of hypoglycaemia.
• May be possible to stop oral agents.
• If glucose >17 mmol/l commence long acting insulin 10 units at night and adjust according to symptoms.
• If glucose > 27 mmol/l then admission may be appropriate for more intensive management.
• Stop oral agents, no monitoring of blood Hypoglycaemia
Hypoglycaemia is a significant risk as anorexia develops. It may not respond
well to glucagon and glucose products such as Glucogel should only be given if
swallowing is safe.
Communication at the end of life
In the palliative phase, decisions about treatments and place of care need to be
anticipated and often made in advance to ensure good communication and
understanding of the situation by all those involved in the patient’s care.
Regular discussion with the patient and their carers is essential especially as
death approaches.
Breaking bad news
Professionals are often involved in giving bad news. The steps below may help
in structuring these conversations.
Preparation: Know the details of the patient and their il ness, ask a colleague to
accompany you, think about a suitable environment and check who the patient
wants to have present.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
1. Find out who is who2. Find out what they know already3. Find out how much they want to know4. Warning shot5. Explanation6. Elicit concerns and allow to ventilate emotions and feelings7. Follow up Cardiopulmonary resuscitation (CPR) discussion and decision
Decisions about CPR often cause concern for professionals but are important to
document and communicate to all professionals involved. In the community or for
patients going home from hospital this would include:
In hospital or other care settings, clear processes for decision making and recording should be in place.
Patients must be central in information and decision making however it is not necessary to discuss CPR with patients who do not wish to or who are already aware they are dying. Where CPR is discussed it is important that patients and carers are aware of the very low likelihood of success and what the procedure involves. Where carers only are involved in the discussion it is important that they realise that their role is to inform the process and not to make the final decision as this can result in a burden of guilt.
Where it is clear that attempts at CPR would not restart the heart for any sustained period (for example when the patient is very il or dying) there is no requirement to discuss CPR specifically. Discussion should aim to secure an understanding of the situation, the needs of the patient and how their care will be managed in the future.
Suggested ways to approach CPR discussions
1. Assessing current understanding of condition“Tell me what you understand about how your il ness is progressing’”2. Explore perceptions of the future“How do you see the future going?” 3. Clarify the current situation by suggesting a poor outlook so providing a “We are concerned about your condition, you don’t appear to be getting any better. What do you think?”4. Gain permission to continue to discuss future For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
“We would like to talk about your future care and management, would that be OK?”5. Explanation about probability of dying and the changing focus on managing symptoms explaining that whilst attempting to maintain the situation there are some things that won’t be of benefit “We are concerned you may be dying now and that we need to focus on maintaining your comfort”Or: “Whilst we will try to get you as well as we can there are some procedures that will not help and will probably cause you more suffering; such as CPR / ventilation / artificial nutrition, etc”6. Discussion of likely future events and how they can be managed with a “I would like to talk through some of the things that may happen to you and how we would we manage them? How do you feel about that?”7. Explore feelings and answer any questions“How does this leave you feeling? What questions would you like to ask?”8. Arrange follow up This is meant only as a guide as to how a discussion may be lead. The exact phrases used should be determined by the patient and their responses to previous questions or information.
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Adult specialist palliative care units and teams in Kent
and Medway

Pilgrims Hospice in Ashford
01233 504100
Fax: 01233 504132
William Harvey Hospital Macmillan Palliative Care Team01233 633331 x88352 Fax: 01233 616867 Canterbury
Pilgrims Hospices in Canterbury
01227 459700
Fax: 01227 812606
Kent and Canterbury Hospital Palliative Care Team01227 766877 Bl 238 or Bl 007 Dartford, Gravesham and Swanley
The Lions Ellenor Hospice (In-patients and day therapy)
01474 320007
Fax: 01474 534633
Ellenor Foundation Hospital Support TeamDarent Valley Hospital01322 428293Fax: 01322 428294 The Ellenor Foundation Dartford Community Team (including Ellenor Shining Lights Children’s Team)01322 221315Fax: 01322 626503 The Ellenor Foundation Gravesend Community Team01474 538508Fax: 01474 326260 Hastings
St Michael’s Hospice
01424 445177
Fax: 01424 721255
Conquest Hospital Macmillan Palliative Care Team For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
The Heart of Kent Hospice
01622 792200
Fax: 01622 718920
Maidstone Hospital Macmillan Palliative Care Nurse01622 225024Fax: 01622 225116 Margate
Pilgrims Hospice in Thanet
01843 233920
Fax: 01843 233931
QEQM Hospital Palliative Care Team01843 225544 x65153 x65074Fax: 01843 234529 Medway and Swale
Wisdom Hospice
01634 830456
Fax: 01634 845890
Medway Maritime Hospital Palliative Care Team01634 833807Fax: 01634 833807 Tunbridge Wells
Hospice in the Weald
01892 820500
Fax: 01892 820520
Kent and Sussex Hospital Macmil an Palliative Care Team01892 632346Fax: 01892 632939 Further Reading
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.
Compatibility Guide
Diamorphine &
For further advice please contact your local palliative care team. Advice is available both during and out of office hours.


Ethan frome

CURRICULUM VITAE FRANCESCO SAVERIO ROBUSTELLI DELLA CUNA Maturità Classica , conseguita presso il Liceo Classico Severino Grattoni di Voghera. Laureato in Farmacia presso la Facoltà di Farmacia dell'Università degli Studi di Pavia con la votazione di 103/110, 14/10/1993. Abilitato alla professione di farmacista sostenuto presso l'Università degli Studi di Pavia facoltà di Farma

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