PRESCRIBING IN THE LAST DAYS OF LIFE

Peter NightingaleMacmillan GP

The Seven C’s Communication Palliative Care Register/MDT

meetings Co-ordination Key person Control of Symptoms Assessment, Treatment

and Patient Centred care Continuity Handover to out-of-hours/protocol.

Information to patients/carers Continued Learning Practice-based

learning/reflection on experiences. Carer Support Practical, Emotional, Bereavement Care of the Dying Liverpool Integrated care

pathway (Dying Phase)

Diagnosing the Terminal Phase BEDBOUND ONLY ABLE TO TAKE SIPS OF FLUID SEMI COMATOSE NO LONGER ABLE TO TAKE ORAL

MEDICATION

2 out of four required for Liverpool Care Pathway

Last Days Of Life- Anticipating and planning for common problems at home 

1. Loss of mobility and ability to transfer safely2. Loss of ability to drink3. Loss of ability to eat4. Pain5. Vomiting6. Dyspnoea7. Excess secretions8. Delerium and agitation

Loss of mobilityUnable to transfer safely Generally safer and more manageable to

nurse in bed Consider loan of hospital bed/monkey

pole/cot sides/commode/urine bottles Assess for pressure area care and

implement appropriate strategy Indwelling urinary catheter/sheath for men

if more acceptable if incontinent/unable to transfer to commode

Bowel care

Methylnaltrexone (relistor) SC methylnaltrexone is approved for use in patients with 'advanced illness'

suffering from opioid-induced constipation despite usual laxative therapy. Constipation is common in advanced disease, even in patients not taking opioids. Thus, so-called 'opioid-induced constipation' is often multifactorial in origin; and methylnaltrexone will normally augment laxatives rather than replace them. It is important that laxative therapy is optimized before using methylnaltrexone.

About 1/2 patients defaecate within 4h of a dose without impairment of analgesia or the development of withdrawal symptoms. Common undesirable effects include abdominal pain, diarrhoea, flatulence, and nausea.

Initially give a single dose on alternate days. If there is no response, a second

dose can be given after 24h, but not more often.

Loss of ability to drink Prepare family and patient for this

happening Explain it is a natural process and may aid

comfort by reducing secretions/gastric secretions and chance of vomiting/urine output

Encourage sips/mouth care In the occasional situation, if still distressed

by thirst consider S/C fluids (N.saline 1l over 12h via a butterfly into anterior abdominal wall or thigh)

What can we conclude? Parenteral hydration in palliative care context:

probably improves mucous membrane hydration status sedation and ?myoclonus

probably worsens peripheral oedema, ascites and pleural effusions

is unlikely to affect delirium and hallucinations agitation bronchial secretions fatigue

can produce a significant placebo effect

Loss of ability to eat Prepare family and patient for this

happening Explain it is a natural process Forcing food may create

discomfort if too weak to swallow/digest

Pain Morphine or Diamorphine SC prn in

proportion to overall opioid requirement

Consider leaving pre drawn-up syringes :possibly leave an indwelling butterfly needle SC

OTFC Fentanyl increasingly considered

Vomiting

Levomepromazine is a useful broadspectrum antiemetic for the end of life. 6.25mg SC

Cyclizine 50mg tds SC or other antiemetic targeted at likely cause

Dyspnoea Common and frightening Morphine/Diamorphine preferably

SC (or sublingual) titrated up as for pain.

Midazolam 2-10mg S.C. or sublingual prn or 5-30mg SC/24h for breathlessness/fear or

Diazepam

Excess respiratory secretions (note Cochrane rev 2008)

Positioning important Antimuscarinics1. Glycopyrronium 2. Hyoscine hydrobromide 0.4mg

sublingual or SC 4h prn or 3. Hyoscine butylbromide 20mg

SC

Delirium and agitation Common at the end of life· Distressing and frightening for everyone involved

Haloperidol 5-30mg/24h/sc and/or midazolam5-60mg/24h(if agitation only)

Changing breathing pattern

Explanation to family "He may appear to stop breathing for a time, then draw another breath"

The Pathway in Today’s Health Care SystemThere must be continuous improvement in the delivery

of health care and the care of the dying patients must improve to the level of the best

(DOH 1998, NHS Cancer Plan 2000)

Patients want to die in the place of their choice and be assured that their carers will be supported throughout their illness and in bereavement

(Commission for health improvement/Audit Commission 2002)

There is a need to describe and transfer best practice in Hospice care into hospital and other care settings

(Bonick 2004)

What Is The LCP and How Does It Work?ICP is a multidisciplinary document which

provides a template for managing patient centred care, it acts as a flow chart for the care being given

It Describes Care It Tracks Care It Monitors Care It Evaluates Care

3 Sections To The LCP

Initial assessment and care Ongoing assessment and care Care after death

Goals Of Patient Care Encompassed By The LCP

Physical Psychological Religious/Spiritual Social

GP’s Involvement

Diagnose that the patient is dying Discontinue oral medication/syringe

driver if required Prescribe 4 core drugs Liaise with nursing staff, relatives

and out of hours/put the pt on pathway

Sign documentation

What Are The Benefits of Using The Pathway?

It organises the process of caring It is multisectoral (community/hospital) Multi-professional/aids communication It can influence ethical decision making Incorporates guidelines, evidence based

practice and clinical effectiveness

Benefits

Outcome focused (clinical supervision) Replaces and reduces documentation Legal record (written or electronic) Variances (allow staff to justify non-

actions) Flexibility (pts can come off the

pathway) Quality of care

PLANNING

NO LONGER ABLE TO TAKE ORAL MEDICATIONS:-

Discontinue unnecessary drugs Review medication required Plan for what medication may be

required

Discontinuing Drugs

Stop Non Essentials e.g. statins

Probably continue diuretics –furosemide can be given subcutaneously

Review steroids

Steroids in Palliative Care Used to improve quality of life

after risk/benefit assessment for:-1. 16mg Dexamethasone in

emergencies2. 12mg for inflammation in brain,

liver or after chemotherapy3. 4mg to temporarily help appetiteBut taper down quickly because of:-

Side effects of steroids Hyperglycaemia Thrush GI bleeding Agitation and restlessness Muscle loss Bed sores Bacterial infection

P A I N

Is patient already taking oral morphine?

Convert to 24hr s/c infusion of DIAMORPHINEFor conversion divide the total daily dose of MORPHINE by 3 ( eg MST 90mg bd orally = DIAMORPHINE 60mg via syringe driver)Make available subcutaneous DIAMORPHINE dose PRN for breakthrough pain PRN dose equals total daily dose divided by 6(eg if DIAMORPHINE 60mg subcutaneous in syringe driver PRN dose equals 10mg subcutaneously)

Make available DIAMORPHINE 2.5mg – 5mg prn s/c

If the patient is still in pain after 12 hours consider increasing the infusion by 30 – 50%

After 24 hours review medication. If2 or more doses required PRN then consider a syringe driver. Starting dose would be the total requirements over the previous 24 hours. The PRN dose may then need to be recalculated

Yes No

TERMINAL RESTLESSNESS & AGITATION

Present Absent

Make availableMIDAZOLAM 2.5mg-5mg s/c 4hrly PRN

Make available MIDAZOLAM 2.5 – 5mg s/c 4hrly PRN

Review the medication after 24hrs

If two or more PRN doses have been required then consider a syringe driver.Starting dose would be the dose required over the previous 24 hours

Review the medication after 24hrs

If two or more PRN doses have beenrequired then consider a syringe driverStarting dose would be the dose required over the previous 24 hours

Continue to give PRN dosage accordingly

RESPIRATORY TRACT SECRETIONS

Present Absent

Glucopyrronium 200 microgram SC stat then 1200mcg over 24 hours Glycopyrronium 200mcg s/c 8 hrly PRN should be made available

Continue to give 200microgram PRN dosage 8 hourly

If two or more doses ofPRN Glycopyrronium required then commence syringe driver s/c over 24 hrs

Increase total 24hr dose to 1.2 mg after 24 hours if symptoms persist

NAUSEA & VOMITING

Present Absent

Levomepromazine 6.25 s/c 8 hrly PRN

Levomepromazine 6.25mg s/c 8rly PRN

Review dosage after 24hrs. If 2 or more PRNdoses required, then consider use of syringedriver. Starting dose 12.5-25mg s/c over 24 hours

NB. If patient is already on an effectiveAntiemetic then switch to parental route and continue

Fentanyl at the end of Life Almost always better to leave the patch

on in the last days of life and add in other drugs via a syringe driver if necessary, because:-

1. Fentanyl reservoir active for up to 17hrs2. Opioid requirements vary greatly at this

time of life, they can decrease due to renal failure or increase due to disease progression

THE SYRINGE DRIVER IN PALLIATIVE MEDICINE

GRASEBY MS26

GREEN FRONTED

RATE = mm/24 hours

INDICATIONS Dysphagia Swallowing difficulties mouth/throat

lesions Intestinal obstruction Severe weakness Nausea & vomiting Poor alimentary absorption Semi comatose/comatose

ADVANTAGES Steady drug levels Avoids repeat injections Loaded once a day Does not limit mobility Can be used to control >1

symptom

DISADVANTAGES

Seen as a panacea

Irritation or swelling can limit absorption-Normal Saline is the preferred diluent unless cyclizine is being used

THE BOOST BUTTON

There is no “lock out” period The dose of analgesia is less than

the prn dose All drugs will be boosted The driver will run out more

quickly

COMMONLY USED DRUGS

Drug Action

Analgesic

Antiemetic

Agitation

Anticonvulsant

Excessive Secretions

Smooth muscle spasm

Steroids

Drug

Morphine/Diamorphine

CyclizineHaloperidolLevomopromazineMetoclopramide

HaloperidolLevomopromazineMidazolam

Midazolam

Hyoscine hydrobromideGlycopyrronium

Hyoscine butylbromide

Dexamethasone

24 Hour Dose

Starting dose 5 – 10mgs

50 – 150mgs1.5 – 5mgs2.5 – 12.5mgs30-60mgs

2.5 – 5mgs6.25 – 25mgs(up to 150mgs)5 – 30mgs

10 – 40mgs

40 – 1200mcgms600 – 1200mcgms

20 – 120mgs

4 – 16mgs

CAUTION

Cyclizine precipitation occurs when mixed with Diamorphine if either one exceeds 20mgs/ml-needs water as diluent

Metoclopramide extrapyramidal reactions can occur with higher doses or if used with Haloperidol

or Levomopromazine

Levomopromazine exessive sedation and skin irritation can occur with higher doses or when used

with other D2 receptor antagonists, eg Haloperidol or Metoclopramide

Dexamethasone should not be mixed with any other drug-very small doses occasionally used for site reactions

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The verification of death

Dr Hong Tseung

Macmillan GP Adviser

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Definitions

verifying death confirming death has actually occurred – 'fact of death'

certifying death written confirmation of cause of death

registering a death formal notification to authorities (Registrar of births and deaths) of fact of death and its cause

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Who does what?

verification of death doctor (GMC registered) registered nurse

certification of death doctor (GMC registered) only must have seen the patient alive in preceding two weeks before death

registration of death by 'the informant' – carer, relative, family member who takes death certificate to the Registrar

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The coroner’s involvement

when the cause of death is not known eg sudden death

when there is a suspicious cause of death eg bullet wounds, knife wounds, strangulation, asphyxiation, overdose, suicide

when no medical practitioner has seen patient alive within the last two weeks before death

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The signs of human life

breathing pulse/heart beat pupil reaction responsiveness

auditory, sensation (pain), reflexes

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The signs of dying (impending death) not always easy to 'diagnose dying' bed-bound comatose/semi-comatose taking sips of fluids only no oral intake irregular breathing (Cheyne Stokes,

shallow)

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What happens when death has occurred? no organs work no brain activity, heart stops, lungs stop,

liver and kidneys stop, muscles stop tissues start to breakdown rigor mortis (several hours later), blood

pools, decomposition

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The signs of death

looks pale (blood pooling) no breathing no pulse no heart sounds pupils fixed and unreactive to light no response to sensory stimuli (eg pain) no reflexes (no brainstem activity)

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What to do

look for skin colour (pink) for chest movement (breathing)

feel for a MAJOR pulse: carotid

listen for breath sounds for heart sounds

test for BOTH pupil reflexes to light

None of the above present? = death confirmed

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Don’t get it wrong

very embarrassing distressing for relatives

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