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CG29 | VERSION 1.0 1/24

© South Western Ambulance Service NHS Foundation Trust 2014

1. Introduction1.1 This palliative care guideline aims to provide guidance on managing patients

who require palliative care at the end of their lives. Palliative care has been described as the active holistic care of patients with advanced, progressive illnesses1, with an approach that focuses on quality of life for patients and families facing the problems associated with the care of cancer patients, but is also increasingly applied to the care of others with end-stage conditions motor neurone disease, renal failure and heart failure.2

1.2 To provide palliative or end of life care requires all staff to look at the patient and family as a whole, and to work towards relief of pain and other symptoms. Team working plays a vital part if safe and compassionate care is to be achieved at the end of life.

1.3 This guideline aims to cover: ▲ Common palliative care symptoms; ▲ Prescribing in palliative care; ▲ Gold Standards Framework; ▲ Mental Capacity Act and Best Interests; ▲ Advance Care Planning and Advance Decisions to Refuse Treatment; ▲ Resuscitation decision tools; ▲ A holistic approach.

Guideline ID CG29

Version 1.0

Title Palliative Care Guideline

Approved by Clinical Effectiveness Group

Date Issued 01/10/2014

Review Date 31/09/2017

Directorate Medical

Authorised Staff Ambulance Care Assistant Paramedic (non-ECP) Emergency Care Assistant Nurse (non-ECP) Student Paramedic ECP Advanced Technician Doctor

Clinical Publication Category

Guidance (Green) - Deviation permissible; Apply clinical judgement



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1.4 The ambulance service plays a crucial role in the delivery of high quality care at the end of life, and in enabling people to achieve what they would consider a good death. This was recognised in the Department of Health’s End of Life Care Strategy (2008).3

2. Issues2.1 Pain 2.1.1 Pain occurs in up to 70% of patients with advanced cancer and about 65% of

patients dying of non-malignant disease.4

2.1.2 Always try to diagnose the cause of the pain prior to treatment. Take a detailed history of the pain(s) and make a full assessment including:

▲ Physical effects or manifestations; ▲ Functional impact of pain; ▲ Psychosocial factors; ▲ Spiritual aspects.

2.1.3 Given the subjective nature of pain, the patient is central to pain assessment. Regular monitoring with visual analogue, numerical or verbal rating scales can allow treatment to be modified promptly where pain is inadequately controlled. Self-assessment should be used wherever possible, including in patients with cognitive impairment. Only substitute with observational pain rating when a patient cannot complete self-assessment.5

2.1.4 The analgesic ladder approach is the basis for administering all types of pain relief, but careful choice of appropriate adjuvant drugs will increase the chance of effective palliation.

▲ Step One - mild Pain, non-opioid; ▲ Step Two - moderate pain, weak opioid +/- non-opioid; ▲ Step Three - severe pain, strong opioid +/- non-opioid.

2.1.5 Non Opioids - Careful consideration must be given to the choice of analgesia. Non-opioids such as paracetamol and NSAIDS have particular advantages in that they have very few side effects. NSAIDS are useful for bone pain that is often poorly controlled by opioids. The main side effect is gastrointestinal bleeding.

2.1.6 Weak Opioids - These are used when non-opioids are ineffective. They include codeine phosphate and are often used in combination with paracetamol. Emergency Care Practitioners carry a wider range of analgesic options so consider referral to them for administration of weak opioids.



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2.1.7 Strong Opioids - Morphine remains the first-line strong opioid of choice and oral morphine forms the backbone of first-line therapy. It is important to titrate any strong opioids to the patient’s response. Elderly patients are likely to need a lower or less frequent dose, especially if they have renal or hepatic impairment.

2.1.8 Once pain relief is at a satisfactory and stable level, consideration must be given to the onward management and maintenance of the pain, and any breakthrough pain that may be experienced. Referral to the patient’s GP, or to the local palliative care team, should be considered .

2.2 Breathlessness2.2.1 Breathlessness can be very distressing for patients, and occurs in about a third

of all patients receiving palliative care, in up to three-quarters of patients with advanced cancer and in over a half of patients with end-stage chronic obstructive pulmonary disease (COPD), heart failure and renal failure.

2.2.2 The causes of breathlessness in end of life patients can be categorized by those that are reversible and those that are irreversible.

2.2.3 Reversible causes: ▲ Infection; ▲ Pulmonary embolism; ▲ Pleural effusion; ▲ Ascites.

2.2.4 Irreversible causes: ▲ Malignant infiltration of lungs; ▲ Fibrosis of lungs; ▲ Lung congestion.

2.2.5 A history and examination of the patient with breathlessness, will help determine the cause. The degree of intervention desired by the patient will vary and management decisions should be made with them and their families. Discussing possible eventualities can help patients make important, informed decisions about their future care such as the need for emergency hospital admissions, use of artificial ventilation and aggressive treatment of infections.



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2.2.6 Some management options for breathlessness include: ▲ Positioning; ▲ Use of fan; ▲ Nebulised saline; ▲ Opiates (oral or SC); ▲ Benzodiazepines.

2.2.7 If the patient is felt to be in the terminal phase of their life, then the use of anticipatory prescribing medicines may be appropriate. Please refer to the anticipatory prescribing section of this document for more information.

2.3 Nausea and Vomiting2.3.1 Nausea and vomiting is a common symptom in palliative patients occurring in

30% of end-stage renal failure patients, at least 17% of heart failure patients, and at least 6% of cancer patients. An understanding of the likely causes of these symptoms is required for accurate assessment and treatment, resulting in better symptom control.2

2.3.2 Possible causes of nausea and vomiting include: ▲ Irritation or stretching of the meninges by intracranial tumour; ▲ Pelvic or abdominal tumour; ▲ Bowel obstruction; ▲ Gastric stasis; ▲ Chemically/metabolically induced e.g. hypercalcaemia; ▲ Anxiety related; ▲ Motion sickness.

2.3.3 Anti-emetics can be delivered via a syringe driver (Trust clinicians are not authorised to set up or alter syringe drivers) or given as stat doses via the subcutaneous or intramuscular routes. Please refer to the anticipatory prescribing section for more detail around the medicines used.

2.4 Excessive Respiratory Secretions2.4.1 This is another common symptom in end of life care, and is commonly termed

the ‘death rattle’. It is often more distressing for the family than for the patient. Hyoscine hydrobromide or glycopyrronium are often used in this scenario.2



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3. Palliative Care Emergencies3.1 The most common conditions that constitute a palliative care emergency are

spinal cord compression, superior vena cava obstruction (SVCO) and neutropenic sepsis. These conditions which are generally a consequence of advancing disease can be controlled for many months but need to be regarded as emergencies in order to avoid severe permanent damage and to maintain the patients quality of life for as long as possible.

3.2 Malignant Spinal Cord Compression (MSCC)3.2.1 Malignant spinal cord compression (MSCC) is the compression of the spinal cord

or nerve roots in the cauda equina by a malignant process. It is a major cause of morbidity in cancer and its presentation needs to be considered an emergency normally needing urgent treatment.

3.2.2 It occurs in up to 5% of all patients diagnosed with cancer and pain is usually the earliest presenting sign in MSCC, often being present many weeks before diagnosis.

3.2.3 MSCC is more common in certain cancers including breast, lung or prostate and those with lymphoma or myeloma. Spinal cord compression is a medical emergency, as early diagnosis and treatment can prevent irreversible spinal cord injury, therefore emergency referral is essential.

3.2.4 Refer to CG30 spinal care and immobilisation for examination, management and signs and symptoms of SCI.

3.3 Neutropenic Sepsis3.3.1 Neutropenic sepsis is a potentially fatal complication of some cancer treatments

such as chemotherapy. Mortality rates as high as 21% have been reported in adults. Neutropenic sepsis occurs when a patient develops a low neutrophil count as a result of the cancer therapy, which increases their risk of developing severe infections. Cancer patients can become neutropenic and not develop severe infections or sepsis. However many do develop this serious complication; suspect neutropenic sepsis in patients having cancer treatment who become unwell.



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3.3.2 Any of the following features could indicate that a neutropenic patient has an infection, and is at risk of Septicaemia:

▲ Tachypnoea; ▲ Tachycardia; ▲ Hypotension; ▲ Temperature greater than 38°C; ▲ Chest pain; ▲ Shivering episodes; ▲ Flu-like symptoms; ▲ Gum or nose bleeds; ▲ Vomiting; ▲ Diarrhoea (or four or more bowel movements in a 24 hour period); ▲ Bruising; ▲ Catheter site infections (Please note that neutropenic patients are unable to

produce the pus normally associated with skin infections.

3.3.3 A neutronpenic patient at risk of septic shock can look deceptively well and can deteriorate rapidly. A high index of suspicion is necessary, particularly if a patient who has recently undergone chemotherapy has an increased temperature.

3.3.4 Neutropenic sepsis should be managed in the same way as any other septic patient (refer to trust Clinical Guideline 19). Neutropenic sepsis is a medical emergency and all patients should be transported to the nearest Emergency Department with an ATMIST pre-alert.

3.4 Superior Vena Cava obstruction (SVCO) 3.4.1 SVCO is the partial or complete obstruction of blood flow through the superior

vena cava into the right atrium and occurs in 3-8% of patients with Cancer. SVCO is an obstructive emergency that may occur as the result of progression of a malignancy or may be the diagnostic symptom.

3.4.2 The obstruction may be the consequence of compression, invasion, thrombosis or fibrosis and causes severe reduction in the venous return from the head, neck and upper extremities. Because of the venous obstruction and compression, intravenous pressure increases and collateral circulation develops.



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3.4.3 Signs and Symptoms: ▲ Venous distension in neck and chest; ▲ Facial oedema; ▲ Plethora – dilation of superficial blood vessels; ▲ Proptosis (bulging of the eye); ▲ Stridor; ▲ Oedema of arms; ▲ Neck and facial swelling (especially eyes); ▲ Cough; ▲ Dyspnoea; ▲ Pressure symptoms, head fullness/ headache; ▲ Hoarseness; ▲ Nasal congestion / epistaxis; ▲ Haemoptysis.

3.4.4 In most patients symptoms are uncomfortable rather than life-threatening, however in severe or rapid cases, where collateral circulation has not had time to develop, symptoms may be immediately life-threatening.

4. Anticipatory Prescribing4.1 Good palliative prescribing is important but drugs are rarely the whole answer

for the relief of pain and other symptoms. Always consider the psychological, social and spiritual needs of the person. The use of nondrug measures is as important as medication in relieving suffering.2

4.2 Patients with a terminal illness often experience new or worsening symptoms for which they require urgent medication. It is essential that these patients and the healthcare professionals looking after them, have swift access to the medicines that can help them immediately, if their condition deteriorates or symptoms occur suddenly, at any time of the day or night, as is common in terminal illness.

4.3 Anticipatory medication should be implemented where the patient’s physical condition has been assessed by a qualified health professional as deteriorating or unstable, and the patient is on the Gold Standards Register and the Electronic Palliative Care Co-ordination System (EPPCS an electronic end of life register).



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4.4 ‘Just In Case’ bags or boxes (JICB) contain a supply of medication that may well not be needed, but is kept in the patients home just in case they need them. Sometimes it can be difficult to get these drugs in a hurry, especially at night or at weekends, so it is very helpful to have them ready just in case. Further guidance on the administration of such medicines by ambulance clinicians is provided in Appendix 1.

4.5 The JICB will usually be prescribed by the patient’s GP, and reviewed regularly by the GP and community nursing team.

4.6 Common anticipatory medicines include: ▲ Diamorphine – to relieve pain or shortness of breath; ▲ Levomepromazine/Metaclopramide – to relieve sickness; ▲ Hyoscine Hydrobromide – to relieve for secretions in the chest; ▲ Midazolam – to relieve restlessness or distress; ▲ Haloperidol – to relieve hallucinations and restlessness;

Please see Appendix 1 for more information on these medicines and the situations in which they are used.

5. Mental Capacity Act/Best Interests 5.1 Please refer to Clinical Guideline (CG28) - Mental Health and Mental Capacity

Guideline for further information.

6. Advance Care Planning 6.1 Advance care planning (ACP) is a voluntary process of discussion about

future care between an individual and their care providers, irrespective of discipline. If the individual wishes, their family and friends may be included. It is recommended that any discussions are documented, regularly reviewed, and communicated to key persons involved in their care.7

6.2 For individuals with capacity, it is their current wishes about their care which need to be considered. Under the Mental Capacity Act 2005,6 individuals can continue to anticipate future decision making about their care or treatment should they lack capacity. In this context, the outcome of ACP may be the completion of a statement of wishes and preferences, or if referring to refusal of specific treatment, may lead onto an advanced decision to refuse treatment.6.

6.3 A statement of wishes and preferences is not legally binding. However, it does have legal standing and must be taken into account when making a judgment in a person’s best interests. Careful account needs to be taken of the relevance of statements of wishes and preferences when making best interest decisions.6



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7. Advance Decision to Refuse Treatment7.1 An Advance Decision to Refuse Treatment is a document in which a patient

specifies certain treatments that they would not wish to receive. If an Advance Decision to Refuse Treatment has been made, it is a legally binding document if it can be shown to be valid and applicable to the current circumstances. If it relates to life sustaining treatment (e.g. a wish not to be resuscitated), it must be a written document, which is signed and witnessed.

7.2 Advanced Directives (Living Wills) and Advance Care Plans (ACP) may contain a DNAR instruction. As a DNAR decision is a refusal of treatment, this is called an Advanced Decision to Refuse Treatment (ADRT).

7.3 In England and Wales, ADRTs are covered by the Mental Capacity Act 2005.6 The Act confirms that an advance decision refusing CPR will be valid and legally binding if:

▲ The patient was 18 years old or over and had capacity when the decision was made;

▲ The decision is in writing, signed and witnessed; ▲ It includes a statement that the advance decision is to apply even if the

patient’s life is at risk; ▲ The circumstances that have arisen match those envisaged in the advance

decision e.g. not a reversible cause.

7.4 Healthcare professionals will be protected from liability if they: ▲ Stop or withhold treatment because they reasonably believe that an advance

decision exists, and that it is valid and applicable; ▲ Treat a person because, having taken all practical and appropriate steps to

find out if the person has made an Advance Decision to Refuse Treatment, they do not know or are not satisfied that a valid and applicable advance decision exists.



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8. Resuscitation Decision Tools 8.1 There are occasions when resuscitation may not be considered appropriate for a

patient. Trust clinicians have a legal, ethical and moral obligation to ensure that the decision not to attempt resuscitation has been made with the patient and/or the patients family and the multidisciplinary team caring for the patient, to ensure the patient’s best interests are being served. A number of forms exist across the Trust that inform clinicians of these advanced wishes including:

▲ ‘Do not attempt resuscitation’; ▲ ‘Allow a natural death’; ▲ Treatment Escalation Plan’.

8.2 If a healthcare professional considers that CPR has no realistic prospect of success, then they may decide it is not to be attempted or offered. In these circumstances, this decision is made by the healthcare team and is not an Advance Decision to Refuse Treatment made by the patient.

8.3 If no explicit decision has been made in advance regarding CPR, and the wishes of the patient are unknown, clinicians should commence resuscitation in the event of cardio-respiratory arrest where resuscitation is indicated by Clinical Guideline CG07 - Cardiac Arrest.

8.4 Obtaining information about Advance Directives (Living Wills) and DNARs can take time. While information is being obtained resuscitation should commence; any delay may adversely affect a patient who needs resuscitation.

8.5 Resuscitation should not be commenced if a formal DNAR order is in place. This can either be communicated verbally by a Doctor, Senior Nurse or other healthcare professional (provided that it is also documented on the patient record), or in writing (usually a letter or specific form), signed by a doctor. DNAR decisions are now available to clinicians through Adastra, which is accessed by the Clinical Supervisors within the Clinical Hub, to inform decisions on resuscitation.

8.6 The decision to resuscitate should relate to the condition for which the DNAR order is in force; resuscitation should not be withheld for coincidental conditions. A DNAR decision does not override clinical judgement in the event of a reversible cause of the patient’s cardio-respiratory arrest e.g. patient choking.

8.7 When transporting any patient from hospital, it is important to check with a senior member of staff whether the patient has a valid DNAR, Advance Directive (Living Will) or ADRT.



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8.8 Ambulance Care Assistants must only transport patients with a DNAR if the patient is completely stable and is not expected to deteriorate en-route (e.g. patients attending routine appointments). If the patient deteriorates unexpectedly, they should contact the Clinical Hub urgently or call 999. Please refer to the Flow Chart on ACA Transportation of Patients (Appendix 2).

8.9 In the community, DNAR decisions may be found in patient-held documentation such as the Gold Standard Framework, as well as through Adastra as previously mentioned.

8.10 Staff must satisfy themselves that a valid and applicable DNAR, Advanced Directive or living will exists and should respect the wishes stated in such a document. This document can be a photocopy of the original. However, if staff have genuine doubts, and are therefore not satisfied about the existence, validity or applicability of the ADRT, resuscitation should be provided without delay in accordance with this policy.

8.11 Should a competent and coherent adult patient who you believe to have capacity, express their wishes not to be resuscitated to a member of Trust staff, and subsequently collapse without withdrawing this request, then resuscitation should not commence.

9. Gold Standards Framework 9.1 In primary care, the Gold Standards Framework aims to improve the quality

of palliative care by focusing on the organisation of care of dying patients. Symptom control forms one of seven key tasks of the framework (the others being communication, co-ordination, continuity, continued learning, carer support and care of the dying).



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10. A Holistic Approach10.1 Fostering Hopefulness One of the surprising things that research has shown over the past twenty

years is that patients and families can remain hopeful right up to the end of life in certain circumstances. If the patient’s physical comfort is maintained, if caring relationships are demonstrated and if the patient and family feel valued as individuals, then hope may be fostered.8 Similarly enabling the patient and family to retain an element of choice and control has been found to be helpful. These are all integral to the role of all health care staff, but it is perhaps useful to be reminded of their positive effect on how patients, family and friends feel. The presence, or indeed absence, of these may profoundly influence the rest of the patient journey and, for families, may have an impact on into bereavement.

10.2 Supporting Families As noted at the beginning, individual patients and families will respond

differently to different situations.8 For most patients and families, the palliative care and end of life phase of illness is one of many losses – for example, for patients it may be the loss of health, loss of job, loss of role and indeed loss of a future.9 By the time they are reaching the end of life, the patient and family may have travelled a long journey with the illness. That needs to be kept in mind if staff are to understand patient and family emotions and behaviour. Some people cope or adjust to illness by confronting it, while others avoid thinking about it. Some express their emotions, while others actively try to seek information and address issues.10 In particular it is important, when supporting family members around or at the time of death, to remember that they may experience and express a whole range of complex emotions, such as shock, anger, sadness, disbelief, or perhaps even relief. No assumptions can be made. It is also important to balance the need to be present and supportive without being intrusive.



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11. References1. Suportive and Palliative care: the Manual, NICE, 2004. Available online: http://

guidance.nice.org.uk/CSGSP/Guidance/pdf/English [Accessed 18th March 2013]2. Palliative Care, Patient UK. Available online: http://www.patient.co.uk [Accessed

14th March2013]3. End of Life Care Strategy - promoting high quality care for all adults, 2008.

Department of Health. Available online: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_086345.pdf [Accessed 17th March 2013]

4. Colvin, L., Forbes, K. and Fallon, M. 2006. ABC of palliative care: difficult pain. British Medical Journal 332 (7549), 1081-1083.

5. Control of pain in adults with cancer, Scottish Intercollegiate Guidelines Network, SIGN, 2008. Available online: http://www.sign.ac.uk/pdf/SIGN106.pdf [Accessed 14th March 2013]

6. Mental Capacity Act, 2007. Available online: http://www.legislation.gov.uk/ukpga/2005/9/contents [Accessed 18th March 2013]

7. Gold Standards Framework. Available online: www.goldstandardsframework.nhs.uk [Accessed 20th March]

8. Cooper, J., Cooper, D.B. 2006. Hope and coping strategies. In: Cooper, J. ed. Stepping into palliative care 1: relationships and responses. Abingdon: Radcliffe

9. Mitchell, G., Murray, J., Hynson, J. 2008. Understanding the whole person: life limiting disease across the life cycle. In: Mitchell, G. ed. Palliative Care: a patient centred approach. Abingdon, Radcliffe.

10. Parkes, C.M., Relf, M., Couldrick, A. 1996. Counselling in Terminal Care and Bereavement. Leicester: BPS Books.



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Appendix 1 - Just in Case MedicinesMore and more palliative/end of life patients are being cared for at home in their final days. Many of these will have medications in bags or boxes, known as anticipatory care or sometimes “Just In case” (JIC) boxes. They contain medications to assist in palliative care crises to reduce pain, suffering, anxiety and unnecessary admission to an ED.

Ambulance clinicians may well be called to palliative patients suffering a crisis. They may administer these drugs under the following conditions:

▲ There is an accompanying Patient Specific medication chart, signed by an independent prescriber (GP, Specialist or Nurse Independent Prescriber).

▲ They are confident and competent in administering the drug. ▲ They are aware of each drug’s indication, usual dose, side effects, signs of

overdose and treatment for OD. This document will look at common causes of palliative crises, along with the drugs that will most likely be prescribed in the JIC box for the treatment of each. It is hoped that this document will inform ambulance clinicians and thus increase their competence and confidence, allowing them to actively participate in palliative care treatment if called.

This document only covers the injectable ‘as needed’ medications. It does not include syringe drivers or their medications. These devices should not be touched by ambulance staff whilst the patient is alive. Refer to Clinical SOP M09 if called to a patient with a syringe driver who has died.

Common Palliative CrisisThe most common calls for palliative crisis are:

▲ Pain. ▲ Nausea and Vomiting. ▲ Breathlessness. ▲ Excess secretions. ▲ Restlessness/agitation.

Consider other possible causes before using the PRN meds. Is the patient restless/agitated/in pain due to constipation? Or a blocked catheter? Can the breathlessness be treated with simple positioning? Consider the patient holistically.



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The medication chartThe medication administration and prescribing charts can be found either within the JIC box, or in the palliative care folder.

Drugs used in the Anticipatory Care settingThe following table identifies the drugs that are commonly found in these boxes. They may be known as anticipatory, Just in Case or most likely “As needed” or PRN meds (from Latin; Pro Re Nata, meaning “as and when” or “As needed”). Start at the lower end of the range stated on the chart and titrate to response without exceeding the maximum dose. Only administer via the prescribed route. Most PRN drugs are written up as a subcutaneous (SC) dose, sometimes IM but generally NOT Intravenously.



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Cause of Palliative crisis

Drug commonly used

Information on administration

Pain (usually ‘breakthrough pain’)

Morphine, Diamorphine or oxycodone

Usual starting dose 2.5 to 5mg SC, in the opiate naive. This may well have been increased by a prescriber if the patient has already been on any opiates for some time. If already on opioids then breakthrough pain is generally treated as an extra 1/6th of the patient’s regular subcut dose (worked out as the prescribed drug’s equivalency to an oral morphine dose, see below). Again, start at the lower end of the prescribed range and titrate to response. Effects should normally be seen in 15-20 minutes.

CAUTION: OPIOID TOXICITYAlways ask about the doses of opioid drugs that have been administered in the previous 24 hrs and remain alert to the possibility of opioid toxicity.

Ambulance clinicians should already be aware of the actions and side effects of opiates, signs of OD and treatment of OD with naloxone. NB In palliative care opioid toxicity may present as subtle agitation, seeing shadows at the periphery of the visual field, vivid dreams, visual and auditory hallucinations, confusion, and myoclonic jerks. Agitated confusion may be interpreted as uncontrolled pain and further opioids given. A vicious cycle then follows, in which the patient is given sedation and may become dehydrated, resulting in the accumulation of opioid metabolites and further toxicity.

Management Naloxone if acute OD following JRCALC guidance. If more subtle symptoms present, management may also include reducing the dose of opioid, ensuring adequate hydration, and treating the agitation with haloperidol (1.5-3 mg orally or subcutaneously, repeated hourly as needed). Subsequent increases in opioid dose may be tolerated. Seek urgent advice if this is suspected.



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Pain (usually ‘breakthrough pain’)

Morphine, Diamorphine or oxycodone

Please note: There are many opiates in use for palliative patients (which they may be on prior to the breakthrough episode) and their administration varies. These range from oral to transdermal patches. See fig 3 below on the different opiate equivalencies. (Refer also to “reducing errors with opiates” as found in the Morphine PGD). Clinicians are also strongly advised to complete the learning package on opiates here: http://www.mhra.gov.uk/ConferencesLearningCentre/LearningCentre/Medicineslearningmodules/Reducingmedicinerisk/Opioidslearningmodule/index.h

Table of relative potencies of oral and subcutaneous opioid analgesicsThis table provides only an approximate guide to opioid equivalents, because comprehensive data are lacking. Doses always need to be re-titrated after achange of opioid. Breakthrough dose is normally up to 1/6th total daily dose

Drug and route of administration

Dose ratio of oral morphine

Approximate dose equivalents (examples) in mg

Oral codeine 10 - 12300 - 360

- -

Oral tramadol 7 - 10200 - 300

- -

Oral morphine 1 30 90 240

Subcutaneous morphine 1 / 2 15 45 120

Subcutaneous diamorphine 1 / 3 10 30 80

Oral oxycodone 1 / 2 15 45 120

Subcutaneous oxycodone 1 / 3 10 30 80

Oral hydromorphone 1 / 7.5 4 12 32

Subcutaneous hydromorphone 1 / 15 2 6 16

Subcutaneous alfentanil 1 / 30 1 3 8



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Table of Approximate Equivalents of Patches and prn Opioid Doses

Oral morphine (total mg/24 hrs) 30 60 120 180 240

Transdermal fentanyl (microgram/hr)

12 25 37 50 75

Transdermal buprenorphine (microgram/hr)

20 - 35 35 70 105 140

Oral morphine for breakthrough (mg)

5 10 20 30 40

sc diamorphine for breakthrough (mg)

2.5 2.5 - 5 5 - 7.5 10 15

sc morphine for breakthrough (mg)

2.5 5 10 15 20

Nausea and Vomiting

Cyclizine Usual starting dose 50mg sc, 8 hourly. Can take up to 2 hours for maximum effect and lasts for 4 hours. Cyclizine is a histamine H1 receptor antagonist of the piperazine class which is characterised by a low incidence of drowsiness. It possesses anticholinergic and antiemetic properties. The exact mechanism by which Cyclizine can prevent or suppress both nausea and vomiting from various causes is unknown.

Unwanted effects are due to it’s anticholinergic properties and include blurred vision, dry mouth, dizziness. Signs of toxic overdose are increased dry mouth, nose and throat, blurred vision, tachycardia and urinary retention. Central nervous system effects include drowsiness, dizziness, incoordination, ataxia, weakness, hyperexcitability, disorientation, impaired judgement, hallucinations, hyperkinesia, extrapyramidal motor disturbances, convulsions, hyperpyrexia and respiratory depression.

Treatment of overdose may include gastric lavage and respiratory support, bear in mind the palliative state of the patient and seek urgent advice.



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Nausea and vomiting

Levomepromazine (may be referred to as Nozinan).

Usual starting dose 6.25mg sc PRN. Levomepromazine resembles chlorpromazine and promethazine in the pattern of its pharmacology. It possesses anti-emetic, antihistamine and anti-adrenaline activity and exhibits a strong sedative effect. It reaches peak effects at approximately two hours.

Symptoms of Levomepromazine overdosage include drowsiness or loss of consciousness, hypotension, tachycardia, ECG changes, ventricular arrhythmias and hypothermia. Severe extrapyramidal dyskinesias may occur. Bear in mind the palliative state of the patient and seek urgent advice.

Haloperidol Usually a dose of 2.5-5 mg SC, PRN. Haloperidol is a member of the butyrophenone class of neuroleptic drugs. It has antiemetic and also antipsychotic/ antianxiety effects, which have been well demonstrated; Although the precise mechanism of action has not been elucidated, antagonism of dopamine-mediated synaptic neurotransmission appears to be an important action of haloperidol and may be the primary action through which the antipsychotic and extrapyramidal neurologic effects are mediated.

Signs of overdose are extensions of its pharmacological actions; most commonly severe extrapyramidal symptoms, also hypotension and psychic indifference with a transition to sleep. The risk of ventricular arrhythmias possibly associated with QT-prolongation should be considered. The patient may appear comatose with respiratory depression and hypotension which could be severe enough to produce a shock-like state.



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Nausea and vomiting

Haloperidol Paradoxically hypertension rather than hypotension may occur. Convulsions may also occur. As the patient may well be at end of life, it may be difficult to ascertain if these are end of life symptoms or those associated with OD. Bear in mind the state of the patient prior to administration, and seek urgent advice if uncertain.

Restlessness and Agitation

Midazolam Midazolam is the drug of choice. Usual dose is 2.5-5mg SC, PRN. Effects are usually seen within 30 minutes. Midazolam is a benzodiazepine, thus its effects are a sedative and sleep-inducing effect of pronounced intensity. It also exerts an anxiolytic, an anticonvulsant and a muscle-relaxant effect.

Overdose: Like other benzodiazepines, midazolam commonly causes drowsiness, ataxia, dysarthria and nystagmus. Overdose of midazolam is seldom life threatening if the drug is taken alone, but may lead to areflexia, apnoea, hypotension, cardiorespiratory depression and in rare cases to coma. Coma, if it occurs, usually lasts a few hours but it may be more protracted and cyclical, particularly in elderly patients. Benzodiazepine respiratory depressant effects are more serious in patients with respiratory disease.

As before, it may be difficult to ascertain if these are normal End of life symptoms or those associated with OD. Bear in mind the state of the patient prior to administration, and seek urgent advice if uncertain.

Breathlessness See opiate / Midazolam

The drug treatment for breathlessness is generally one of the opiates as above, followed by Midazolam if required. Doses are as already described. Be guided by the direction in the prescribing chart.



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Excess respiratory tract secretions

Hyoscine Hydrobromide

Usual dose 400 mcg SC, PRN. Effects usually seen within 30 minutes. Hyoscine is an anticholinergic drug which inhibits the muscarinic actions of acetylcholine at post-ganglionic parasympathetic neuroeffector sites including smooth muscle, secretory glands and CNS sites. Small doses effectively inhibit salivary and bronchial secretions and sweating and provide a degree of amnesia. Hyoscine is a more powerful suppressor of salivation than atropine and usually slows rather than increases heart rate.

Signs of overdosage include dilated pupils, tachycardia, rapid respiration, hyperpyrexia, restlessness, excitement, delirium and hallucinations. In the unlikely event of overdosage, supportive therapy should be implemented. Bear in mind the palliative state of the patient and seek urgent advice.

Glycopyrronium Usual dose 200 mcg, SC PRN. Effects usually seen within 30 minutes. Glycopyrronium is an antimuscarinic, which reduces secretion from salivary and bronchial glands.

Symptoms of overdosage are peripheral rather than central in nature. The signs will be excessive extensions of its pharmacological action, such as transient bradycardia (followed by tachycardia, palpitations and arrhythmias), urinary urgency and retention, dilatation of the pupils with loss of accommodation, photophobia, dry mouth, flushing and dryness of the skin. Bear in mind the palliative state of the patient and seek urgent advice



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Signs of overdose are extensions of its pharmacological actions; most commonly severe extrapyramidal symptoms, also hypotension and psychic indifference with a transition to sleep. The risk of ventricular arrhythmias possibly associated with QT-prolongation should be considered. The patient may appear comatose with respiratory depression and hypotension which could be sever enough to produce a shock-like state. Paradoxically hypertension rather than hypotension may occur. Convulsions may also occur. As the patient may well be at end of life, it may be difficult to ascertain if these are end of life symptoms or those associated

Required Paperwork After Administration of any DrugThe PCR must be fully completed following Trust policy. The drugs used from the JIC should be listed on PCR and annotated with dose, route and the fact it was from patient’s own stock. The administration chart (See fig 1 ) MUST also be filled out so that the specialist palliative team or GP can see what drugs have been used, and can also decide if an increase in meds is required, or a syringe driver needs addition or alteration. There are also some self explanatory pages at the back of the chart, which should be filled in and signed to show the use of a certain controlled drug, and thus the current stock level.

It is good practice to also ensure that the patient’s own GP is informed, either by direct surgery contact, or if out-of-hours, via the SPoA line.

Further Advice and GuidanceIt is recognised that palliative crises can be very traumatic for all involved, including the attending clinician. Do not feel alone, even if it is 0300 hours. There will be several options available to get further clinical management advice. If the patient has a JIC box and care folder then there will be hospice/palliative care advice numbers listed here. You can also access the patient’s own GP or OOH GP (remember to inform UCS call taker that this is an urgent palliative call). There is also the option of accessing the Senior clinical advisor on call (see SOP C15).

http://intranet.swast.nhs.uk/SWASFT%20instructions/SWASFT%20SOPs/SOP%20C15%20Senior%20Clinical%20Advisor%20On-Call.pdf

ECPs have experience and training in Palliative care and should also be approached for advice, and can also provide backup at scene. Contact 999 dispatch and request the nearest ECP to either phone or attend, and give the required priority.



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Recommended ReadingWessex Palliative Care Handbook 2010: http://www.weld-hospice.org.uk/Resources/Weldmar/PDFs/Help%20for%20professionals/PCHandbook7thEditionOct2010.pdf

Palliative Care Learning Zone:http://intranet.swast.nhs.uk/palliative-care-learning-zone.htm

Reducing errors in opiate doses:http://intranet.swast.nhs.uk/Downloads/SWASFT%20downloads/Clinical/ReducingDosingErrorswithOpioidMedicines.pdf

Electronic Medicines Compendium (With full summaries of product characteristics)http://www.medicines.org.uk/emc/



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