palliative care guide v3 - 2019€¦ · web viewbefore using this guidance always ensure you are...

BEFORE USING THIS GUIDANCE ALWAYS ENSURE YOU ARE USING THE MOST UP TO DATE VERSION

Palliative Care for Adults – Guidance for Primary CareThis guidance contains suggested advice for the management and treatment of adult

palliative care patients. It applies to Islington primary care practitioners (GPs and practice nurses). It will also be relevant to practice-based and community pharmacists

in assisting with patient education and suitable treatments.

Comments on this document should be sent to the Medicines Management Team (MMT), by email to [email protected]

The information contained in this document is not suitable to be shared with patients / public or non NHS Organisations.

Not to be used or reproduced for commercial or marketing purposes.

This document is produced to inform and review local decision making using the best available evidence at the time of publication. The information in this document may be superseded in due course. Every care has been taken in the

compilation and publication of this document, however, neither the Medicines Management Team nor Islington CCG will be held responsible for any loss, damage, or inconvenience caused as a result of any inaccuracy or error within these

pages. Islington CCG is not responsible for the content or availability of any external sites to which it may include links. Please be aware that this information is correct at the time of the search and Islington CCG is under no obligation to

inform you if the situation changes in the future. The information provided is the property of Islington CCG and is subject to Intellectual Property and Database Rights.

The information contained in this guideline is issued on the understanding that it is accurate based on the resources at the time of issue. For further information please refer to the Summary of Product Characteristics

(SPC) or contact a member of the MMT.

The information in this document is a broad guideline only; it does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in

consultation with the patient and/or guardian or carer. Treatment of an individual patient should always be modified according to need & circumstances, and may involve a multidisciplinary approach.

Islington CCG does not restrict assessment, treatment, therapy, or care on the basis of age, disability, race, religion or belief, gender, sexual orientation, gender reassignment, pregnancy and maternity or marriage and

civil partnership or any other irrelevant consideration.


1 SUMMARY This guidance contains suggested advice for the management and treatment of adult palliative care patients being managed in primary care. It applies to Islington CCG primary care practitioners (GPs and practice nurses). It will also be relevant to practice-based and community pharmacists in assisting with patient education and suitable treatments.

2 RESPONSIBLE PERSON: Head of Medicines Management

3 ACCOUNTABLE DIRECTOR: Director of Quality and Clinical Effectiveness

4 APPLIES TO: NHS Islington Clinical Commissioning Group (CCG) primary care practitioners and prescribers

5 GROUPS/ INDIVIDUALS WHO HAVE OVERSEEN THE DEVELOPMENT OF THIS GUIDANCE:

Camden Medicines Management Team,Camden, Haringey and Islington Palliative Care Working Group including: Community Palliative Care Teams, Consultants, Specialist Nurses, Clinical Pharmacists, Hospice Clinical Teams, GP Clinical Leads for Palliative and End of Life Care, and Prescribing Advisers.

6 GROUPS WHICH WERE CONSULTED AND HAVE GIVEN APPROVAL:

Camden Medicines Management Committee (CMMC)Islinton Medicines Optmisation Committee (IMOG)

7 EQUALITY IMPACT ANALYSIS COMPLETED:

Guidance Screened

Date March 2019

Template completed

Date March 2019

8 RATIFYING COMMITTEE(S) & DATE OF FINAL APPROVAL:

Islington Medicines Management Committee (CMMC)2008, 2014, 03/10/2018

9 VERSION: 3

10 AVAILABLE ON: Intranet Website

11 RELATED DOCUMENTS: Camden Prescribing Recommendations (CPR)

12 DISSEMINATED TO: To be placed on IslingtonGPs Website and distributed via Prescribing Matters newsletter to Islington prescribers and clinicians.

13 DATE OF IMPLEMENTATION: 2008, updated 2014, updated 2018

14 DATE OF NEXT FORMAL REVIEW: December 2021

DOCUMENT CONTROL

Date Version Action Amendments2008 1 Guidance first

implemented

Agreed by CMMC 10/01/2008

N/A

2014 2 Guidance reviewed and updated


Principles of pain control section added Assessment and measurement of pain added Treatment guidance for pain – flow chart added Conversion table for opioids added Use of a syringe driver section expanded and

updated2018 3 Guidance reviewed and General Principles section added

This information is a broad guideline only. Treatment of an individual patient should always be modified according to need & circumstances, and may involve a multidisciplinary approach

Palliative Care for Adults – Guidance for Primary Care v3 of 21


Date Version Action Amendmentsupdated.


Factors affecting pain tolerance removed Treatment guidance for pain – flow chart

amended Opioid dose conversion tables changed. Management of nausea and vomiting section

expanded and dose information amended Lactulose removed from laxative

recommendations Symptom control in last days of life section -

general advice added Use of a syringe driver section moved to

appendices New section on hydration and oral nutritional

support added to appendices Useful contacts section updated

This guideline is an update of the 2014 guideline and was reviewed with input from CCG representatives and local specialists from Camden, Islington and Haringey teams.Adapted from the original The Pocket Guide for Palliative Care 2004. For clinical queries relating to this guideline please contact the local CCG medicines management team or local specialist team.




Palliative Care for Adults - Guidance for Primary Care

These principles are intended for guidance and do not cover all aspects of an individual patient’s care. They reflect commonly accepted practice in palliative medicine. Further advice should be sought from the

specialist palliative care team where required. The use of some medicines may be unlicensed or off-label – this may relate to dose, route or indication. In such instances, clinicians should refer to MHRA and GMC

guidance on the prescribing of unlicensed/off-label medicines.

Contents

General Principles p4 Symptom Control in the Last Days of Life p13Pain Control p5 Useful Contacts p15Management of Toxicity to Opioids p10 References p16Nausea and Vomiting p10 Appendix I – Use of a Syringe Driver p17Constipation p12 Appendix II - Hydration and Nutritional Support p20

GENERAL PRINCIPLES The purpose of this document is to provide guidance to primary care clinicians in

managing and treating adult palliative care patients within primary care. It is aimed at non-specialists and covers the most common issues presenting in palliative care patients. This guidance is intended for use in addition to seeking patient specific advice from the specialist palliative care team as needed.

Healthcare professionals caring for adults at the end of life need to take into consideration the person's current mental capacity to communicate and actively participate in their end of life care, including giving consent. Where possible involve patients AND their carers in prescribing decisions. The principles outlined in NICE guidance (NG31) for communication and shared decision making should be followed.

Where appropriate, anticipate what medicines may be needed for end of life symptom control so that if required, these can be given without unnecessary delay and prevent inappropriate admission to hospital. The decision to prescribe medication for use in the future should always be based on a risk/benefit analysis. Reasons for not providing anticipatory medicines include risk of drug diversion or misuse.

The use of medicines off-label, or use of unlicensed medicines, may be more common in palliative care than other specialities. The use of a licensed medicine should be considered first. If it is deemed necessary to prescribe off-label, the available evidence and cost-effective product choice should be considered. Unlicensed medicines should only be used where the clinician is satisfied there is not an alternative, suitably licensed medicine that would meet the patient’s needs and that there is sufficient evidence base and/or experience of using the medicine. Clinicians should refer to MHRA and GMC guidance on the prescribing of unlicensed/off-label medicines. Specialist palliative care advice can also be sought.

Where relevant, prescribing guidance and medication choices approved via the North Central London Joint Formulary Committee should be followed: https://www.ncl-mon.nhs.uk/

Specialist palliative care teams can be contacted for advice and guidance at any stage. This includes telephone advice. Recommendations made by specialist palliative care teams may sometimes differ from those specified in this guidance. In this scenario, prescribing and treatment recommendations will be discussed with the primary care prescriber and agreement sought before transfer of clinical and prescribing responsibility occurs.

Specialist palliative care guidance such as the Palliative Care Adult Network Guidelines (PANG) is available. These may provide additional information. The information contained overleaf should be referred to in the first instance.



http://book.pallcare.info/index.php

https://www.ncl-mon.nhs.uk/

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices/prescribing-unlicensed-medicines

https://www.gov.uk/drug-safety-update/off-label-or-unlicensed-use-of-medicines-prescribers-responsibilities

https://www.nice.org.uk/guidance/ng31/chapter/Recommendations#communication




Effective Communication is Imperative for Effective Symptom Control

PRINCIPLES OF PAIN CONTROL

Assess : Prior to treatment an accurate assessment should be made to determine the cause (consider if reversible), type and severity of the pain and its effect on the patient.

Assess All Pains and treat accordingly. Patients with cancer may develop other pains, which could be related to treatment, debility or other unrelated causes.

Consider Total Pain: The physical, emotional, social, and spiritual dimensions of distress all affect a patient’s perception of pain.

Discuss and Explain symptoms and treatments (pharmacological and non-pharmacological) to patient and carer.

With Continuous Pain Prescribe Continuous Analgesia, never just as required (prn). Use the WHO Pain Ladder in choosing appropriate analgesia. If strong opioids are required, discuss and resolve any concerns about strong opioids, including

concerns about addiction and overdose. All patients/carers should be provided with a patient information leaflet.

Start with immediate release oral morphine every 4 hours. If higher frequency use is anticipated in an individual case, contact specialist palliative care team for advice.

The patient does not need to be specifically woken to take a dose during the night. In some cases, it may be appropriate to start with a 12 hour release oral morphine preparation.

This should be started at low dose and titrated accordingly. Use low doses and titrate the dose slowly, especially if the patient is frail, elderly or has renal

impairment. Breakthrough pain : If only prescribed immediate release morphine, give additional prn doses for

breakthrough pain at the same dose as the regular 4 hourly dose. If on sustained release opioid, prescribe additional immediate release opioid for episodes of

breakthrough pain. This is given 4 hourly prn at one-sixth of the total daily dose of opioid (ask the patient/carer to keep a record of usage). Use this record of all morphine administered in 24 hours to calculate dose increases in the sustained release opioid.

Patients should be appropriately counselled on how to take breakthrough opioids. If more than 2 doses of breakthrough analgesia are required in 24 hours, the patient should be advised to contact a healthcare professional (GP, district nurse or community palliative care team).

Constipation occurs with all opioids. Laxatives are usually needed (see page 12). Nausea should be treated with an appropriate anti-emetic (see page 10). Review frequently to optimise analgesia as soon as possible. Pain can be managed in the

majority of patients. If pain is not controlled, review assessment. Specialist advice should be sought promptly especially if pain has not responded to treatment,

dose of opioid has increased rapidly but patient is still in pain, there are episodes of severe acute pain or pain is worse on movement.

Consider renal and hepatic function. Dose adjustment or alternative medication choices may be required. Seek specialist advice.

IF UNCERTAIN PLEASE CONTACT A SPECIALIST TEAM FOR ADVICE. see useful contact numbers on page 15




ASSESSMENT AND MEASUREMENT OF PAIN

COMMON TYPES OF PAIN

Type of Pain Description ManagementVISCERAL / SOFT

TISSUEConstant dull pain,

poorly localisedUsually opioid responsive

BONE PAIN Usually well localised,worse on movement,

local tenderness

Partly opioid responsiveGenerally NSAID and paracetamol

responsiveRadiotherapy may help if metastases are

present at the site of pain

NEUROPATHIC PAIN Often described as burning, stabbing, shooting or ‘pins and

needles’

May be partially opioid responsive. Likely to require an adjunctive analgesic e.g. tricyclic

antidepressant or anticonvulsant

MEASURING PAINThe patient should be the prime assessor of his or her pain.Measuring using the scales below* creates some objectivity between one review and the next.

* Turk DC and Okifuji A. Lancet 1999;353:1784 -1788

In addition to, or as a minimum, grade pain as per the Gold Standards Framework PACA tool (Patient and Carer assessment tool SCR3):

GSF PACA score Pain level0 Pain absent1 Pain present, not affecting daily life2 Pain present, moderate effect on daily life3 Pain present, daily life dominated by symptom



http://www.goldstandardsframework.org.uk/cd-content/uploads/files/Library%2C%20Tools%20%26%20resources/SCR3%20PACA%20Assessment.pdf


TREATMENT GUIDANCE FOR PAIN


NON-OPIOIDSParacetamol or NSAIDs (e.g.

ibuprofen or naproxen)

WEAK OPIOIDSe.g. codeine

Max. dose in 24 hours – 60mg qdsEnsure dose is titrated and optimised

before considering strong opioid

STRONG OPIOIDS(1st line - immediate release morphine)

e.g. morphine sulphate oral solution 10mg/5mL Dose conversion

10mg oral codeine ≡1mg oral morphineLower initial doses are recommended in opioid naïve patients e.g.

2.5mg oral morphine 4 hourlyIncrease dose by 30-50% each day if necessary to achieve pain

control. Use a record of the total amount of immediate release morphine

taken in 24 hours to inform dose increases. If pain remains uncontrolled consult with specialist.

Lower doses and increased dosing intervals should be used in elderly/renal impairment (seek specialist advice). Seek

specialist advice in moderate to severe liver impairment

ANTICIPATE CONSTIPATIONA stimulant and faecal softener

laxative is recommended (see

table on page 12)

1st LINE SLOW RELEASE MORPHINE Use 12 hour release preparation ONLY

Calculate 12 hourly dose by adding up total amount of immediate release morphine taken over the last 24 hours

and divide by 2.New breakthrough dose (4 hourly immediate release

dose) will be one-sixth of the total daily dose.

For all patients on regular strong opioids, always prescribe an immediate release opioid to be used when required for breakthrough pain. A maximum total daily dose of 120mg morphine (or equivalent) should not be exceeded without specialist advice.

Ask the patient to keep a record of how much breakthrough medication they have needed. If more than 2 doses of breakthrough analgesia are required in a 24 hour period, seek specialist advice and review pain management.

Fentanyl patches and oral oxycodone should be prescribed by brand name. Pain crisis – sudden change in pain that is severe, uncontrolled and causing distress despite regular analgesia is a

medical emergency – seek specialist advice. For management of opioid toxicity see guidance on page 10. If considering changing from an opioid to alternative analgesia or vice versa, discuss with specialist palliative care team.

Pain controlled on regular dose.Convert to equivalent dose of slow release opioid

if not already prescribed.

Start with slow release morphine preparation (12 hour release) instead of immediate release if appropriate

Continue laxative Consider anti-

emetic Ensure

patient/carer is counselled on regular and breakthrough medication to avoid confusion

If pain remains uncontrolled refer to specialist

Refer to page 9 for approximate conversion doses between opioids

Co-prescribing of weak and strong opioids is NOT recommended – stop any weak opioid

before initiating a strong opioid

AD

JUVA

NT A

NA

LGESIC

SA

djuvant drugs e.g. tricyclic antidepressants, anticonvulsants may be added at any stage.

Assess and continue if of benefit

2nd LINE STRONG OPIOIDSIf there are unacceptable side effects from morphine

(e.g. excessive drowsiness, constipation or itching) or significant renal impairment, then use of 2nd line opioid

may be considered.

Refer to guidance on page 8 and SEEK SPECIALIST ADVICE

WHO Step 1Mild painNon-opioid

analgesics +/- adjuvant

WHO Step 2Moderate

painWeak opioid + non-opioid +/-

adjuvant

WHO Step 3

Moderate to severe pain

Strong opioid + non-opioid+/- adjuvant

Steps on the WHO Pain

Ladder

https://www.who.int/cancer/palliative/painladder/en/

https://www.who.int/cancer/palliative/painladder/en/


USE OF SECOND LINE STRONG OPIOIDS

The table below outlines the place in treatment for fentanyl patches and oral oxycodone:

FENTANYL PATCHES ORAL OXYCODONEConsider if:

There is an established swallowing difficulty, persistent nausea and vomiting, GI blockage or severe renal impairment where dose adjustment with morphine is not feasible.

There are unacceptable side effects from morphine. The patient is not tolerating oral medication.

Not suitable for patients with unstable or rapidly changing pain. Opioid naïve patients should be commenced on oral or parenteral opioids and the dose titrated until pain is controlled before converting to fentanyl patches.Fentanyl is less constipating than morphine, hence there may be a need to reduce the dose of laxatives following a change from morphine to fentanyl.

Consider if: Analgesia is inadequate with morphine despite

dose optimisation (this may include circumstances in which opioid rotation is being considered); or

Dose optimisation of morphine is limited by persistent adverse effects.

Fentanyl patches are available as matrix and reservoir patches. The two patch formulations have different medication release characteristics and are not interchangeable. Examples of matrix patches include Durogesic DTRANS®, Fencino®, Matrifen®, Mezolar® Matrix, and Opiodur®. Examples of reservoir patches include: Fentalis Reservoir® and Tilofyl®.

Fentanyl patches should be prescribed by brand name to ensure patients remain on the same preparation and a cost-effective preparation is supplied. Refer to Islington Medicnes Optimisation Scheme 2019/20 for preferred brands.

Prescribe by brand name (e.g. Shortec®) to ensure patient receives cost-effective product and same product each time.

Patches are changed every 72 hours (3 days). If more than one patch is needed, apply the patches at the same time to avoid confusion.

Oxycodone is available as modified release (12 hourly) and immediate release preparations.

Patients should be counselled to remove old patches and use a new area of clean, dry, hairless skin for each patch change.

Heat/pyrexia increases the rate of fentanyl absorption and can cause toxicity. Ensure pyrexic patients are monitored for adverse events and counsel all patients to avoid exposing the application site to external heat e.g. radiators, hot water bottles. See MHRA Drug Safety Update .

Patients should be counselled appropriately on the differences between the preparations to avoid confusion regarding which is for regular dosing and which is for breakthrough pain.

If dose needs to be increased, increase patch dose by 12 – 25 micrograms/hour, also consider the use of prn/breakthrough analgesia. Frail or elderly patients may need lower doses and slower titration. Improved analgesic effect may take up to 12-24 hours. Leave a minimum interval of 48 hours between dose increases. Significant blood levels of fentanyl will persist for up to 24 hours after removal of the patch.

There should be a clear reason for changing to oxycodone and for ongoing prescribing. If, after an adequate trial of oxycodone, no benefit has been achieved, consider changing back to morphine or alternative analgesia.

Renal impairment: No initial dose reduction is needed in renal impairment but monitor for signs of accumulation.

Liver impairment: Dose reduction may be needed in severe liver impairment.

Renal impairment: Reduced clearance in mild to moderate renal impairment so initiate at low dose, titrate slowly and monitor. Consider dose reduction and increased time between doses if required. Ideally, avoid modified release preparations and restrict to prn use only.

Avoid if eGFR less than 20 mL/minute/1.73 m 2 without specialist advice.

Liver impairment: Clearance of oxycodone is reduced in moderate to severe liver impairment; do not use without specialist advice.

Ensure immediate release opioid (e.g. morphine/oxycodone) is available for breakthrough pain at an appropriate dose.

The 12 micrograms/hour strength patch is only licensed for dose titration but may be used for patients requiring a lower starting dose (unlicensed).

Ensure immediate release oxycodone is available for breakthrough pain. Ensure the patient/carer is aware of when and at what dose to use the immediate release and modified release preparations.



Oral morphine is the first line choice where a strong opioid is required. A second line choice should be used for moderate to severe opioid responsive pain where oral morphine is not suitable. Specialist advice should be sought before changing treatment and to discuss alternatives.Pain crisis – sudden change in pain that is severe, uncontrolled and causing distress despite regular analgesia, is a medical emergency – seek specialist advice..

https://www.gov.uk/drug-safety-update/transdermal-fentanyl-patches-life-threatening-and-fatal-opioid-toxicity-from-accidental-exposure-particularly-in-children

https://gps.camdenccg.nhs.uk/medicines-management/camden-prescribing-recommendations-cpr


If considering changing to an alternative opioid seek specialist advice first.




Medicine Route of Administration

Dose equivalent to 10mg oral morphine

Dose conversion ratio TO oral morphine

Morphine IM, IV, SC 5mg 1:2Codeine oral 100mg 10:1Dihydrocodeine oral 100mg 10:1Tramadol oral 100mg 10:1Oxycodone oral 5mg 1:2 (some evidence for ratio of 1:1.5)

Oxycodone SC, IV 2.5mg (approx) 1:4 (some evidence for ratio of 1:2 -1:4) Diamorphine SC, IV 3mg 1:3

24 hour dose of oral morphine (mg)

Equivalent 72 hour fentanyl patch (micrograms/hour)

Breakthrough dose of oral morphine (mg)**

30 - 60 12 5 -1060 - 90 25 10 -1590 - 150 37 15 - 20150 - 210 50 30210 - 270 62 35270 - 330 75 40 - 50330 - 490 100 60

Conversion ratios vary and these figures are a guide only, specialist palliative care teams may use alternative conversion ratios.

Fentanyl equivalences in this table are for patients on well-tolerated opioid therapy for long periods; for patients who are opioid-naïve or who have been stable on oral morphine or other immediate release opioid for only several weeks, seek specialist advice. Fentanyl patches should not be prescribed for opioid-naïve patients without specialist advice due to the risk of opioid toxicity.

The 24 hour doses of oral morphine listed above are considered to be approximately equivalent to the fentanyl patches shown. However, when changing opioids due to possible opioid-induced hyperalgesia, reduce the calculated equivalent dose of the new opioid by 25% - 50%.

** Dose for breakthrough pain is 1/10th (one-tenth) to 1/6th (one-sixth) of the regular 24 hour morphine dose, repeated 4 hourly as required.

Adapted from UCLH Palliative Care Quick Reference Guide (published July 2018).

Transdermal preparations of fentanyl are not suitable for acute pain or in patients whose analgesic requirements are changing rapidly because the long time to steady state prevents rapid titration of the dose.

Prescribers should ensure that they are familiar with the correct use of transdermal preparations (inappropriate use has caused fatalities). Immediate-release oral morphine can be given for breakthrough pain.

Following patch initiation or dose change, patients should be reassessed frequently for efficacy and adverse effects.



CONVERTING TO OR FROM ORAL MORPHINE TO ALTERNATIVE OPIOIDS - DOSE CONVERSIONS

The doses listed in the table

above are approxima

te equivalent

doses only.

Where no direct dose

conversion

information is

available, dose

equivalents have been

estimated via

indirect conversio

n. Patients

should be carefully

monitored after any change in medicatio

n and dose

titration may be

required. Seek

specialist advice.

FENTANYL PATCH – APPROXIMATE EQUIVALENT MO


MANAGEMENT OF TOXICITY TO OPIOIDS

There is a wide variation in the dose of opioid that causes symptoms of toxicity. Be aware this can also occur if the level of pain has reduced significantly e.g. after radiotherapy used to manage bone metastases as opioid requirements may decrease post treatment.

Common warning signs of opioid toxicity or overdose

Increasing/persistent drowsiness (exclude other causes) New onset or worsening confusion Muscle twitching/myoclonus/jerking Vivid dreams/hallucinations Agitation Respiratory depression (overdose/severe toxicity). Respiratory rate of <12bpm is a medical

emergency. Stop opioid and seek urgent medical attention. Coma (overdose/severe toxicity)

Management of toxicity

Mild toxicity: Consider decreasing the opioid dose by a third and closely monitor the patient Check renal function Ensure patient is well hydrated (if appropriate) Contact specialist palliative care team for advice regarding ongoing management Consider advance care plan and admitting patient Change syringe driver medications/dose on specialist advice

Moderate to severe toxicity: Seek specialist advice immediately Call an ambulance if medical emergency

NAUSEA AND VOMITING1. GENERAL MEASURES

Consider potentially reversible factors and treat these if possible and appropriate (correction may not be indicated for some of these if the patient is imminently dying). Causes include:

Medicines Cough Severe pain Uraemia Anxiety Infection Hypercalcaemia Bowel obstruction Raised intracranial

pressure Constipation Ascites

In palliative care patients, especially those with advanced cancer, nausea and vomiting is often multifactorial and all causes should be investigated. Drugs should be given as a stat dose and then regularly, NOT as required, and by an appropriate route. If absorption may be compromised give anti-emetics by continuous subcutaneous infusion (CSCI) in a syringe driver. The management of all patients with refractory nausea and vomiting should be discussed with the specialist palliative care team. If appropriate, consider non-drug measures e.g. psychological measures for anxiety, and dietary advice. Evidence for alternative therapies such as acupuncture, acupressure, and ginger is limited.



Be careful not to confuse a patient who is dying with someone who is experiencing opioid toxicity, be clear on the diagnosis. If in doubt, seek specialist advice.


2. MANAGEMENT

Choice of medication is based on likely cause, side effect profile and route of administration as well as patients’ condition/prognosis.

Cause First Line Second Line

For gastritis or gastric stasis use a prokinetic anti-emetic (provided the patient is not in bowel obstruction).

Metoclopramide 10 - 20mg PO/SC tds (for doses above 10mg tds, seek specialist advice; caution in those at risk of extrapyramidal side effects e.g. Parkinson’s disease; note MHRA advice regarding neurological effects) or

Domperidone 10mg PO tds (note MHRA advice regarding cardiac risk, max 30mg daily). Extrapyramidal side-effects rare with domperidone.

Also consider use of an antacid or proton pump inhibitor (PPI)

Levomepromazine 6.25 -12.5mg (i.e. ¼ - ½ of 25mg tablet) PO nocte (up to max 12.5mg bd) (avoid when at risk of seizure e.g. brain metastases, epilepsy) or

5 - 25mg CSCI in 24 hours. Max. 25mg in 24 hours (avoid when at risk of seizure)

Drowsiness with doses greater than 12.5mg in 24 hours may limit titration

NB: Levomepromazine 25mg PO equivalent to 12.5mg SC

For most chemical causes of vomiting (e.g. opioids, hypercalcaemia, uraemia) use a centrally acting anti-emetic

Haloperidol 0.5 - 1mg PO/SC nocte/bd or2.5mg CSCI in 24 hours (both unlicensed).

(dose may be titrated up as needed to a maximum of 10mg in 24 hours - seek specialist advice)

Levomepromazine 6.25 -12.5mg (i.e. ¼ - ½ of 25mg tablet) PO nocte (up to max 12.5mg bd) or

5 - 25mg CSCI in 24 hours. Max. 25mg in 24 hours (avoid when at risk of seizure)


Raised intra-cranial pressure, motion sickness

Cyclizine 50mg PO/SC tds or 150mg CSCI in 24 hours


5 - 25mg CSCI in 24 hours. Max. 25mg in 24 hours (avoid when at risk of seizure).


Cause not clear Cyclizine 50mg PO/SC tds or Metoclopramide 10 - 20mg

PO/SC tds (for doses above 10mg tds, seek specialist advice, note MHRA advice regarding neurological effects) or

Haloperidol 0.5 - 1mg PO/SC nocte/bd (dose may be titrated up as needed to a maximum of 10mg in 24 hours – seek specialist advice)


5 - 25mg CSCI in 24 hours. Max. 25mg in 24 hours (avoid when at risk of seizure).


For resistant nausea and vomiting due to chemotherapy and/or radiotherapy

Consult oncology team

Use metoclopramide, levomepromazine and haloperidol with caution in those at risk of extrapyramidal side-effects. These individually may enhance the extrapyramidal effects of other drugs such as antipsychotics. Domperidone is the anti-emetic of choice in Parkinson’s disease as extrapyramidal side-effects are rare with domperidone.

The overall safety profile of domperidone, and in particular its cardiac risk and potential interactions with other medications, should be taken into account if there is a clinical need to use it at doses or durations greater than those authorised. This should not be done without specialist advice. See MHRA advice.

Review efficacy of anti-emetic medication every 24 hours until control achieved. If underlying cause is resolved, review and discontinue anti-emetic medication.



https://www.gov.uk/drug-safety-update/domperidone-risks-of-cardiac-side-effects

https://www.gov.uk/drug-safety-update/metoclopramide-risk-of-neurological-adverse-effects

http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON418518




Avoid combining medications with similar mode of action or side-effect profile. Do not combine prokinetics with anticholinergics e.g. oxybutynin, tolterodine. If nausea and vomiting are not controlled with oral anti-emetics, review the patient’s regular oral

medications and consider conversion to alternative route in order to maintain absorption e.g. to fentanyl patches or syringe driver.

Advise patient/carer on good mouth care and on avoiding any nausea triggers e.g. strong smells Refer to local specialist palliative care team if causes such as bowel obstruction or raised

intracranial pressure are suspected.

CONSTIPATION Regularly enquire about constipation. Consider potentially reversible causes of constipation e.g. poor oral intake, opioids, dehydration,

abdominal masses/ ascites etc. Patients should be advised to maintain an adequate fluid intake. Daily laxatives are necessary for almost all patients on strong opioids (unless already liable to

diarrhoea or there is a contra-indication). Most patients will need a softener and a stimulant. A stepwise approach to laxative therapy should be adopted – prescribe regular laxative treatment,

titrate treatment and optimise before adding or changing treatment. Regularly review and optimise treatment. Check adherence to treatment before increasing dose or changing treatment. Increase doses as necessary every 1-2 days. Rectal measures may still be required e.g. glycerol

suppositories.

For patients experiencing abdominal pain, investigate and treat cause before considering titration of opioid dose to treat this.

ROUTINE LAXATIVES

Softener – takes 24 - 36 hours to actDocusate sodium 100mg capsules

Initially 100mg PO bd Max 200mg tds

Softener at lower doses and mild stimulant at higher doses. Mostly a faecal softener.

Osmotic laxative – may take 1 - 3 days to have an effectMacrogol oral powder

Initially 1 - 3 sachets PO dailyMax 8 sachets PO daily for 1 - 3 days for faecal impaction

1 sachet administered with 125ml water is isotonic. It is important to ensure sachet is administered in the correct volume of liquid. For use in faecal impaction refer to current edition of the BNF.A large volume of liquid may be difficult to take for some patients e.g. frail.

Stimulant – avoid in intestinal obstruction. Takes 6 - 12 hours to act (suppositories act within 10 - 30 minutes)Glycerol suppositories

4g suppository PR prn Moisten with water before use.

Bisacodyl 5mg tablets or 10mg suppositories

5 -10mg PO nocte 10mg PR daily

Mostly acts on large bowel. Can cause abdominal cramps.

Senna tablets or liquid

1 - 4 tablets (7.5mg - 30mg) PO nocte or 7.5mg/5mL syrup (5 –20mL) PO nocte

Can cause abdominal cramps.

Co-danthramer and co-danthrusate are options for severe constipation in palliative care patients ONLY as potentially carcinogenic. Seek advice from a specialist before initiating and refer to full prescribing information for dosage information.




SYMPTOM CONTROL IN LAST DAYS OF LIFE

Several resources are available to support care in the last days of life. For example, the Central and North West London (CNWL) NHS Foundation Trust’s ‘Supporting Excellent Care in the Last Days of Life’ guidance documents and the ‘One Chance to Get it Right’ document by the Leadership Alliance for the Care of Dying People, June 2014. A copy of the CNWL ‘Supporting Excellent Care in the Last Days of Life’ documents should usually be kept in the patient’s home, so that visiting healthcare professionals and those important to the patient are able to access it. Advice can also be obtained from the specialist palliative care teams.

Recognising when a person may be in the last days of lifeThe possibility that a person may die within the next few hours/days must be recognised and communicated clearly, having ensured that reversible causes have been excluded. An appropriate clinician caring for the patient at home, in conjunction with support from other multidisciplinary team members, should offer the patient dedicated time to have a compassionate and sensitive discussion, answering any questions that they may have, to the extent that the patient wishes to talk about such matters. If possible, the patient should be consulted regarding who they wish to have in attendance for this conversation. If the patient is unconscious or lacks capacity for these decisions, communication with those known to be closest to the patient is crucial.

Care in the last days of life Document the details of the conversation had with the patient/carer regarding the last days of life. Consider the person’s mental capacity to communicate and actively participate in their end of life care

and shared decision making. Provide individualised care. Ensure hydration is maintained and route of hydration is offered appropriately according to individual

needs and desires. Consider non-pharmacological methods of symptom management where appropriate e.g. repositioning

to manage pain or the use of fans to minimise the impact of breathlessness. Review current medications and stop those which are not providing symptomatic benefit or that may

cause harm. This should be done in discussion and in agreement with the patient and/or carer. Seek specialist advice if required.

Use an individualised approach to prescribing anticipatory medicines for people who are likely to need symptom control in the last days of life. Indications, route of administration and dose should be specified. Document an individualised care plan.

Consider the following medications for use in the dying person Oral or transdermal medication (where applicable) should be considered in patients who remain able to

take these medications safely and effectively, and it remains their wish to do so. For those patients who require pharmacotherapy for symptom control, and the injectable route is

appropriate and desired , the document: Improving the Quality of Care in the Last Days of Life: A practical guide to getting medications right published by NHS London Clinical Networks may be consulted for additional information on medications which may be considered for use in the dying person. The CNWL ‘Individual Assessment and Care Plan for Care in the Last Days of Life’, a copy of which should available in the patient’s home, also contains useful information on medicines that can be used for symptom control in the last days of life. Please use the care plan in conjunction with the rest of the information in this guideline.

Consider any contraindications for individual patients and consult specialist palliative care team if in doubt. Seek advice from the palliative care team if the patient has renal or liver impairment, or is at risk of seizures or extrapyramidal side-effects e.g. patients with Parkinson’s disease.



http://www.londonscn.nhs.uk/publication/improving-the-quality-of-care-in-the-last-days-of-life/


https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/323188/One_chance_to_get_it_right.pdf


SHORTNESS OF BREATHKEY POINTS

Very frightening for patient Is it appropriate to treat underlying cause? e.g. congestive cardiac failure (CCF). Seek specialist

advice if in doubt Are there reversible causes that can be treated? e.g. pulmonary embolism, infection, pleural

effusion etc. Check oxygen saturation

SYMPTOM CONTROL Visualised reminder charts can be used to remind patient in crisis Physical measures e.g. open windows, fan, keep face cool Refer to physio for relaxation techniques Where appropriate – bronchodilators (via spacer), antibiotics, steroids, diuretics, oxygen (ONLY if

hypoxic). Oxygen must be specialist initiated and clinically appropriate. Consider low dose immediate release oral morphine e.g. 1- 2.5mg morphine liquid PO 4 hourly

and/or prn. If the patient is already on morphine for pain control, use the existing immediate-release breakthrough analgesic dose for the relief of breathlessness.

Benzodiazepines may help in the relief of anxiety associated with breathlessness (no evidence that benzodiazepines directly relieve breathlessness). Consider lorazepam 0.5 – 1mg PO/sublingual prn (maximum 4mg in 24 hours; maximum 2mg in 24 hours if frail/elderly)

BRONCHIAL SECRETIONS KEY POINTS

Consider if these are due to a treatable underlying cause e.g. heart failure General management measures include repositioning to lateral position, avoid over hydration,

addressing family distress

SYMPTOM CONTROL Hyoscine butylbromide, hyoscine hydrobromide or glycopyrronium bromide SC injections can be

given. Give stat dose and review response after 60 mins, if effective, prn or regular doses via SC syringe driver can be given. Consult specialist palliative care team. Also see syringe driver section (Appendix 1)

AGITATIONKEY POINTS

Ensure calm and comfortable environment Treat reversible causes

o Paino Urinary retentiono Constipation

May still be appropriate to use sedation even if reversible causes are present

SYMPTOM CONTROL Subcutaneous stat administration or CSCI (continuous subcutaneous infusion) via a syringe

driver over 24 hours may be needed

1st line Lorazepam (if patient conscious) 0.5 - 1mg PO or sublingually 4 - 6 hourly prn (max 4mg daily) or Midazolam. Use 2.5 - 5mg SC hourly prn or 10 - 60mg over 24 hours in syringe driver (Discuss

with specialist palliative care team if requiring greater than 40mg in 24 hours)

2nd line Levomepromazine – avoid if risk of seizure Sedative and anti-emetic Use 12.5 - 100mg of levomepromazine over 24 hours in syringe driver for

restlessness/sedation. For doses above 100mg/24 hours, seek specialist advice. Higher doses for sedation only

Lower doses (5 - 25mg over 24 hours) are used for anti-emetic purposes




USEFUL CONTACTS - LOCAL SPECIALIST PALLIATIVE CARE TEAMS If you wish to discuss how to manage the palliative care needs of a patient with a specialist palliative care service, contact details of the local specialist palliative care teams are given below.

Local community specialist palliative care teamsReferral form available at http://www.londonscn.nhs.uk/networks/others/end-of-life-care/

Area Team base Office hours Out of hours

Islington Camden and Islington ELiPSe team, St. Pancras Hospital, 5th Floor South Wing, 4 St. Pancras WayLondon NW1 0PE

Mon - Fri: 9am – 5pmTel: 020 3317 5777

Email: [email protected]

Tel: 020 3456 7890 – This is the University College London Hospital (UCLH) switchboard. Please ask for the Palliative Care on-call team to be bleeped. A member of the team will ring back.

South Camden

Mon - Fri: 9am – 5pmTel: 020 3317 5777Email: [email protected]

North Camden

Royal Free Hospital Mon - Fri: 9am – 5pmTel: 020 7830 2905Email:[email protected] t

Tel: 020 3758 2000 – This is Royal Free Hospital switchboard Please ask them to air-call the Palliative Care Nurse.(9am - 5pm on weekends)

Haringey North London Hospice Mon - Fri: 9am – 5pmTel: 020 8343 8841

Mobile: 07957588273 (Mon – Fri:5pm – 9am; and on weekends)

City and Hackney

St Joseph’s Hospice Mon - Fri: 8am – 9pm Tel: 020 8525 6060First Contact Team Tel: 0300 303 0400

Tel: 0300 303 0400 (available 24 hours)

District Nursing TeamsArea/Team Contact Number Out of hours

CAMDEN District Nursing TeamsBelsize Priory (West Camden Locality Team)

020 3317 5705 (Mon – Fri, 9am – 5pm) Twilight mobile number : 07711015850(weekdays between 5pm – 9am and on weekends 24 hours)

Gospel Oak(North Camden Locality Team)

020 3317 5915 (Mon – Fri, 9am – 5pm)

Hunter Street(South Camden Locality Team)

020 3317 2309 (Mon – Fri, 9am – 5pm)

ISLINGTON & Haringey District Nursing TeamWhittington Health 24 hour District Nurse Messaging Service (For patients already known to DN team)

020 7288 3555 020 7288 3555

New referrals (Whittington Health District Nursing team)

Haringey: 020 316 1600 (Mon - Fri, 10am – 4pm)Islington: 0203 316 1111 (Mon – Fri, 10am – 4pm)

City and Hackney District Nursing Team ( will only see patients who reside in Hackney)City and Hackney District Nursing Team

020 7683 4144 (Mon – Fri, 8am – 8pm) 020 7683 4144 (Sat/Sun/ Bank Holidays, 9am – 5pm)

Pharmacy ServicesIslington Pharmacies (Palliative Care Medicines Scheme) for Islington patients only: Clan Pharmacy. 150 Upper Street. N1 1RA Tel: 020 7359 7595 Dev’s Chemist (Atchem Ltd). 110 Seven Sisters Road. N7 6AE Tel: 020 7607 3081*Islington is expected to have a new service in which pharmacies will be able to provide a 24/7 service for palliative care patients. The pharmacies that will be providing this service are yet to be confirmed.*Camden 100 hour pharmacies Baban Pharmacy, 34 Chalton Street, NW1 1JB. Tel: 020 7388 9989 (Mon–Fri 7am – midnight; Sat 12am - 3pm) IPSA Pharmacy, 7 Harben Parade, Finchley Road, Hampstead. NW3 6JP. Tel: 020 7449 9490 (Mon-Sat 8:30am – 11pm ; Sun

9am – 10pm) Pharmacy Republic, 100 Fleet Road. NW3 2QX . Tel: 0207 485 2240 (Mon –Sat 8am – 11pm ; Sun 10am – 8pm) Warman-Freed Pharmacy, 45 Golders Green Road. NW11 8EL . Tel: 0208 455 4351(8:30am – midnight 7 days a week)Haringey Pharmacies providing on demand medicines for end of life care and other specialist medicines Boots the Chemist Unit A2, Tottenham Hale Retail Park, N15 4QD. Tel: 0208 801 7243 (Mon – Sat 9am – 7pm; Sun 11am – 5pm ) Hornsey Central Pharmacy, 151 Park Rd, Crouch End, N8 8JD Tel: 020 3074 2700 (Mon – Sat 7am –10pm; Sun 9am – 7pm) Philips Chemist, 193 Lordship Lane, Tottenham, N17 6XF Tel: 020 8808 4040 (Mon – Fri 9am – 6:30pm; Sat 9am -5:30pm) Pharmacy Express, 214 High Road, London, N22 8HH. Tel: 020 8888 1669 (Mon – Fri 9am - 6:30pm; Sat 9am – 1pm)



tel:020

mailto:[email protected]



http://www.londonscn.nhs.uk/networks/others/end-of-life-care/


REFERENCES

1. National Institute for Health and Care Excellence (NICE). Care of dying adults in the last days of life. NICE guideline [NG31] Published date: December 2015. Available via https://www.nice.org.uk/guidance/ng31 (Last accessed December 2018)

2. National Institute for Health and Care Excellence (NICE). Palliative care for adults: strong opioids for pain relief. Clinical guideline [CG140] Published date: May 2012. Last updated: August 2016. Available via https://www.nice.org.uk/guidance/cg140 (Last accessed December 2018)

3. Palliative Care Adult Network Guidelines (PANG) 2018. http://book.pallcare.info/ (Last accessed December 2018)

4. NHS Scotland. Scottish Palliative Care Guidelines. https://www.palliativecareguidelines.scot.nhs.uk/ (Last accessed December 2018)

5. Palliative Care Formulary (PCF) online. Available via www.medicinescomplete.com (Last accessed February 2019)

6. Leadership Alliance for Care of Dying People. One chance to get it right. June 2014. Available via https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/323188/One_chance_to_get_it_right.pdf (Last accessed December 2018)

7. NHS London Clinical Networks. Improving the quality of care in the last days of life. Available via http://www.londonscn.nhs.uk/publication/improving-the-quality-of-care-in-the-last-days-of-life/ (Last accessed December 2018)

8. British National Formulary (BNF) online. Accessed via https://bnf.nice.org.uk/ 9. UCLH Palliative Care Quick Reference Guide. July 2018. (Authored by Dr Sarah Yardley and Dr Julia

Bichard)10. Macmillian Cancer Support. Macmillian Durham Cachexia Pack. www.learnzone.org.uk (Last Accessed

12th March 2019)11. General Medical Council. Ethical Guidance: Prescribing unlicensed medicines. Accessed via

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices/prescribing-unlicensed-medicines (Last accessed 12th April 2019)

12. Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update: Off-label or unlicensed use of medicines: prescribers’ responsibilities. Published 11 December 2014. Accessed via https://www.gov.uk/drug-safety-update/off-label-or-unlicensed-use-of-medicines-prescribers-responsibilities

PRESCRIBING ABBREVIATIONSRoutes of Administration Abbreviation Times of Administration AbbreviationOral PO Twice a day bdSubcutaneous SC Three times a day tdsIntravenous IV Four times a day qdsIntramuscular IM Immediately statRectal PR As required/as needed prnContinuous Subcutaneous Infusion CSCI At night nocte







http://www.learnzone.org.uk/

https://bnf.nice.org.uk/




http://www.medicinescomplete.com/

https://www.palliativecareguidelines.scot.nhs.uk/

http://book.pallcare.info/

https://www.nice.org.uk/guidance/cg140

https://www.nice.org.uk/guidance/ng31


APPENDICES

APPENDIX I - USE OF A SYRINGE DRIVER

A syringe driver is an alternative route of administration where other routes are not viable. Medication is delivered by continuous subcutaneous infusion (CSCI).

Indications include: persistent nausea and vomiting, dysphagia, intestinal obstruction or poor intestinal absorption, coma, or patient too weak to take oral medications.

Obtain advice from the local specialist palliative care team regarding the need for a syringe driver, medications, doses etc. If there is no specialist palliative care support available, a GP could initiate and write a prescription for treatment including completing a syringe driver prescription sheet.

Try to anticipate the need for a syringe driver and prescribe in advance so that drugs and paperwork are all correct and present when the drugs are needed and can be sourced within working hours. Most pharmacies can obtain palliative care drugs within 24 hours and should be able to inform you if there is any likely delay.

Engage district nurse (DN) service to set up and monitor syringe driver. A syringe driver prescription/authorisation sheet will need to be completed and given to the DN or left with the patient for the DN to action.

It is common practice to administer two to three different drugs in the same infusion device. A maximum of four drugs can be administered via a syringe driver (if compatible), this should be undertaken ONLY on specialist palliative care team advice.

Water for injection (WFI) is the usual diluent, however compatibility should be checked as some drugs are less compatible with WFI in comparison to sodium chloride 0.9% e.g. ondansetron. Clinicians are reminded to prescribe the diluent e.g. WFI in addition to the other drugs required for administration via the syringe driver.

The use of most opioids via continuous subcutaneous infusion is unlicensed. Before setting up a syringe driver, it is important to explain its use to the patient and their family. It is

important that the syringe driver is not seen just as the last resort but as an effective method of relieving certain symptoms by injection.

Ensure compatibilities of medications in the syringe driver have been checked prior to prescribing (see section on Syringe Driver Drug Compatibility). Check with the specialist palliative care team if required.

Refer to table on page 9 for approximate dose conversions between opioidsNote: Morphine injection is available in different strengths (e.g. 10mg/ml, 30mg/ml). Care needs to be taken when prescribing, preparing and administering, to ensure patient receives the correct dose. Seek specialist advice.

SYMPTOM DRUGS GUIDELINES TO DOSAGE VIA SYRINGE DRIVERPain Morphine sulphate If opioid naïve start at 10mg in 24

hours. For all medications: No ceiling limit. Titrate cautiously. Do not titrate above 120mg morphine daily (or equivalent) without specialist advice

Oxycodone Do not use in opioid naive patients unless under specialist advice. Calculate 24 hour dose from patients previous opioid dose

Colic Hyoscine butylbromide 60 - 120mg in 24 hours (For higher doses, seek specialist advice)Bronchial secretions Hyoscine hydrobromide 1200 - 2400 micrograms in 24 hours. Confusion limits use.

Hyoscine butylbromide 60 -120mg in 24 hours

Glycopyrronium bromide 600 – 1200 micrograms in 24 hoursNausea and vomiting Metoclopramide 30 - 100mg in 24 hours (Doses > 30mg in 24 hours only on

specialist advice)Cyclizine (only use WFI) 150mg in 24 hours

Nausea and vomiting/restlessness

Levomepromazine

(avoid if risk of fitting)5 - 25mg in 24 hours (for nausea/vomiting) 12.5 -100mg in 24 hours (for restlessness/sedation) – For doses above 100mg/24 hours seek specialist advice.Higher doses for sedation only

Nausea and vomiting Haloperidol(caution in epilepsy, may lower seizure threshold)

2.5 - 10mg in 24 hoursDoses greater than 8mg/day risk of extrapyramidal effects

Terminal anxiety and agitation, anti-convulsant

Midazolam 10 - 60mg in 24 hours (Discuss with specialist palliative care team if requiring greater than 40mg /24 hours)

LESS COMMONLY USED DRUGS – SPECIALIST INITIATED




Dexamethasone (If possible, should be administered as sole drug in syringe driver. Seek specialist advice if site irritation occurs)

Alfentanil Ketorolac (bone pain)

CME Medical T34 Syringe Pump (previously called McKinley T34 syringe pump)

There is only one type of syringe driver in use across North Central London – this is the CME Medical T34 syringe pump.

The volume in the syringe will infuse over 24 hours. Refer to local guidance or consult with specialist palliative care team or district nurses for

advice on equipment, setting up and administration of syringe pump. The infusion line should be checked at each visit/regularly for signs of redness, induration,

crystallisation of the infusing solution, leakage. For advice on managing injection site reactions, seek advice from the palliative care team. A syringe driver prescription/authorisation chart should be completed for medicines to be administered

via the pump. This can be accessed via community nurses or palliative care teams. Compatibility of medications to be mixed in a syringe driver should be checked. Seek advice from the

palliative care team.




Syringe Driver Drug Compatibility

Drug combinations may be compatible only at certain concentrations, therefore the concentration of each drug in the syringe should be compared with compatibility data, not the dose. Syringe driver drug compatibility can be checked using reference sources such as the Palliative Care Adult Network Guidelines (PANG Guidelines), the BNF and the Palliative Care Formulary (PCF). Advice on syringe driver drug compatibility can also be obtained from the specialist palliative care team.

Check the solution in the syringe regularly for precipitation and/ or discoloration and discard the contents if this happens.

Some drugs are irritant if administered by the SC route and therefore should not be used in a syringe pump. These include diazepam, chlorpromazine, and prochlorperazine.

A maximum of four drugs can be administered via a syringe driver (if compatible) – this should be undertaken ONLY on specialist palliative care team advice.

Care should be taken when mixing more than two drugs in a syringe and in ensuring that the diluent is compatible with each of the drugs.

The following points are useful to consider when mixing drugs in a syringe pump, especially if compatibility data is lacking: Drugs with a similar pH are more likely to be compatible. Examples of drug combinations that are NOT compatible include: cyclizine and hyoscine

butylbromide; dexamethasone and glycopyrronium. Most of the drugs commonly used in syringe pumps are acidic in solution, therefore more alkaline

medications e.g. dexamethasone, furosemide, ketorolac could cause compatibility problems if added. A second syringe pump should be considered to administer these drugs.

Exposure of the syringe mixture to extremes of temperature and light can affect stability and should be avoided where possible.

In general, drugs tend to be more stable in lower concentrations in solution. Therefore, a larger syringe with more diluent may be required where possible. If this is not possible the drugs may need to be separated and administered using more than one syringe. Seek specialist advice.

Drugs with long duration of action can alternatively be given equally well as a bolus SC or intravenous injection once or twice daily, for example dexamethasone and levomepromazine. This avoids the need to add to a syringe mixture that may affect stability.

Skin irritation around the needle site, poor symptom control or an unexpected loss of symptom control may be the result of drugs becoming unstable when mixed together. Frequent checks of the syringe pump contents for precipitation or discoloration as well as the patient’s condition is essential.



https://bnf.nice.org.uk/

https://book.pallcare.info/

https://book.pallcare.info/


APPENDIX II - HYDRATION AND ORAL NUTRITIONAL SUPPORT IN PALLIATIVE CARE PATIENTS

Maintaining hydrationEnsure hydration is maintained in palliative care patients and the route of hydration is offered appropriately according to individual needs and desires. For patients considered to be in the last days of life, principles and approach to hydration should be considered and offered in line with NICE Clinical guideline 31 – Care of dying adults in the last days of life.

The use of subcutaneous fluids for hydration in the last days of life should always be discussed with the specialist palliative care team prior to initiation.

Palliative care and oral nutritional supplements (ONS) Loss of appetite is a complex phenomenon that affects both patients and carers. Be aware of the potential tensions that may arise between patients and carers concerning a patient’s loss of appetite. This is likely to become more significant through the palliative stages and patients and carers may require support with adjusting and coping.

Principles of care: The patient should always remain the focus of care. Carers should be supported in consideration of the

environment, social setting, food portion size, smell and presentation and their impact on appetite. Use of ONS in palliative care should be assessed on an individual basis. Appropriateness of ONS will be

dependent upon the patient’s health and their treatment plan. Emphasis should always be on the enjoyment of nourishing food and drinks and maximising quality of life.

Management of palliative patients can be divided into three stages: early palliative care, late palliative care, and the last days of life. Care aims will change through these stages.

If ONS is required, consider seeking specialist advice and refer to local guidelines for preferred product choice.

Treatment with ONS should be regularly reviewed.

Nutritional management in early palliative care In early palliative care, patients may have months or years to live and may be undergoing palliative

treatment to improve quality of life. Screening and assessment for nutritional needs should be undertaken, using local nutrition support

pathways and guidance, as early intervention could improve the patient’s response to treatment and potentially reduce complications.

When prescribing nutrition supplements, consider whether a patient is likely to consistently manage two doses of ONS per day as, if not, they are unlikely to derive any significant benefit to well-being or nutritional status from the prescription.

Nutritional management in late palliative care In late palliative care, the patient may be experiencing increased symptoms such as pain, nausea and

reduced appetite. The nutritional content of the meal is no longer of prime importance and patients should be encouraged

to eat and drink the foods they enjoy. The main aim is to maximize quality of life including comfort, symptom relief and enjoyment of food. Aggressive feeding is unlikely to be appropriate especially as this can cause discomfort, as well as distress and anxiety to the patient, family and carers.

The goal of nutritional management should not be weight gain or reversal of malnutrition, but quality of life.

Nutrition screening, weighing and initiating prescribing of ONS at this stage is not recommended. Prescribing ONS for the sake of ‘doing something’ when other dietary advice has failed would not generally be recommended.

Nutritional management in the last days of life In the last days of life, the patient is likely to be bed-bound, very weak and drowsy with little desire for

food or fluid. The aim of nutritional support should be to provide comfort for the patient and offer mouth care and sips

of fluid or mouthfuls of food as desired.

Adapted from the Macmillan Durham Cachexia Pack 2007



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