Symptom Management Guidance to be used with Care …



SYMPTOM MANAGEMENT GUIDANCE PALLIATIVE CARE PAIN

For further information, including if CKD 4 or 5, see the Dose Equivalence Guidance Chartpages 7 & 8.

IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE.

RETAINED SECRETIONS

IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE

TERMINAL RESTLESSNESS AND AGITATION

IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE

NAUSEA

IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE

TERMINAL BREATHLESSNESS

IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE. If CKD 4 or 5, see the Dose Equivalence Guidance Chart, page 7 & 8

GUIDELINES FOR CARE OF DIABETES IN PATIENTS IN THE LAST FEW DAYS OF LIFE

Aim of treatment is to avoid symptoms of hyperglycaemia and hypoglycaemia

Practical points:-

1. In Type 2 diabetes insulin and oral agents can usually be stopped in the terminal phase; steroid treated patients may be an exception.

2. Blood glucose monitoring should be kept to the minimum necessary.

3. It is important to ensure clinical deterioration not due to hyperglycaemia or hypoglycaemia before making decisions re management.

4. Regular review of the patient and management plan is necessary, due to difficulties with prognostication of death and varying terminal phase.

5. If death imminent i.e. expected in less than 24 hours it may be appropriate to discontinue all monitoring and insulin, usually after discussion with the family.

6. SEEK SPECIALIST ADVICE EARLY

• Community Diabetes Specialist Nurse

Monday to Friday, in office hours, usually 9am to 5pm

Tel 01629 817878 Mobile 07884415168 or 07900584162

• Out of Hours Ashgate Hospice Tel 01246 568801

Further information also available at

PALLIATIVE CARE DOSE EQUIVALENCE GUIDANCE CHART, Page 7 & 8

| | |

|Morphine |Zomorph or MST 12 hourly |

|4 hourly |po |

|po | |

| | | | |

|Immediate Release Preparations |Slow Release Preparations |Diamorphine Injections |Fentanyl Patches |

|Sevredol tablets 10, 20, 50mg |MXL 30, 60, 90, 120, 150, 200mg |5, 10, 30, 100, 500mg |12, 25, 50, 75, 100mcg/hr |

|Morphine Sulphate liquid |Zomorph 10, 30, 60, 100, 200mg | | |

|10 mg/5ml e.g. Oramorph 100mg/5ml, e.g. Oramorph |MST 5, 10, 15, 30, 60,100, 200mg | | |

|concentrate |Oxycodone MR 5, 10, 15, 20, 40, 60, 80, 120mg e.g. | | |

|Oxycodone capsules 5, 10, 20mg, e.g. Oxynorm |Oxycontin | | |

|Oxycodone liquid 5mg/5ml, 50mg/5ml, e.g. Oxynorm | | | |

| | | | |

| | |Oxycodone Injection |Buprenorphine Patches |

| | |10mg/ml. 20mg/2ml |5, 10, 20mcg/hr (seven day patches) |

| | | |35, 52.5, 70mcg/hr (four day patches) |

References:- Palliative Care Formulary (PCF4). Fourth Edition. ISBN: 978-0-9552547-5-8.

Editors: Robert Twycross Andrew Wilcock

Summary of Product Characteristics:- Oxynorm Injection. Napp Pharmaceuticals, EMC updated 22/06/2013; Oxycodone injection, Wockhardt UK Ltd EMC

Updated 14/01/2011.

British National Formulary (BNF) 65 March-September 13

-----------------------

NO

YES

Is the patient already taking Morphine or other strong opioids?

Continuous S/C Diamorphine

Calculate the 24 hour dose of oral Morphine, divide the total dose by 3, which is the equivalent dose of Diamorphine over 24 hours s/c via syringe driver – e.g. patient on 90mg Zomorph BD = 180mg oral Morphine over 24 hours, which equals 60mg Diamorphine s/c over 24 hour infusion.

Transdermal Fentanyl

If the patient is using Transdermal Fentanyl but now has uncontrolled pain, continue the Fentanyl on current dose, do not increase, and use appropriate dose s/c Diamorphine as required in addition. See Guidelines.

Breakthrough Analgesia

To calculate the breakthrough dose of Diamorphine divide the 24 hour dose of Diamorphine in the syringe driver by 6, e.g. if the patient is receiving 60mg Diamorphine s/c over 24 hours the breakthrough dose of Diamorphine is 10mg s/c prn.

Alternatively

Morphine oral liquid may be used if the patient is taking sips of fluid. To calculate the equivalent oral Morphine breakthrough dose, multiply the s/c breakthrough dose by 3, e.g. s/c Diamorphine 10mg for breakthrough up to hourly = 30mg oral Morphine for breakthrough.

If Diamorphine is unavailable or the patient has previously been on oral Oxycodone, use the same format as above using Oxycodone.

Oral Oxycodone 2mg in 24 hours = Sub Cut : Diamorphine 1.5mg in 24 hours = Oxycodone 1mg in 24 hours

To calculate the subsequent doses of Diamorphine over 24 hours:

Review the doses of prn analgesia given in the previous 24 hour period. If more than one dose has been required, other than to pre-empt during care, (e.g. before a dressing etc.) then consider a 30% to 50% increase in the daily subcutaneous dose. If this is not controlling the pain or doses need escalating on a daily basis, seek specialist advice.

1. Diamorphine 2.5mg stat

2. Diamorphine 10mg/24 hours

via s/c infusion

3. Diamorphine 2.5mg s/c prn

As Required Medication

1. Diamorphine 2.5mg s/c prn

2. Morphine Sulphate 5mg

orally prn

NO

YES

Has the patient got pain?

Absent

Present

1. Explain to relatives that for the patient retained

secretions are not bothersome due to decreased

sensitivity of pharynx.

IF the relatives are concerned or the patient

appears distressed:

2. Hyoscine Butylbromide 20mg s/c stat.

3. Hyoscine Butylbromide 60mg / 24 hours via s/c

Infusion.

4. Hyoscine Butylbromide 20mg s/c hourly prn

- Maximum dose up to 80mg in 24hrs

As required medication

Hyoscine Butylbromide 20mg s/c

- Maximum dose up to 80mg in 24hrs

Absent

Present

1. Exclude Treatable Causes

Pain

Retention of urine or faeces

Hypercalcaemia if it would be appropriate to treat

As Required Medication

Haloperidol 2.5mg s/c prn– up to hourly (maximum including syringe driver dose 15mg in 24hrs)

2b. Anxiety / Dyspnoea

i. Midazolam 2.5mg s/c stat.

ii. Midazolam 10mg / 24 hrs

via s/c infusion.

iii. Midazolam 2.5mg s/c prn– one hourly for maximum of 3 doses, then seek medical advice.

2a. Delirium

i. Haloperidol 2.5mg stat.

ii. Haloperidol 5mg/24 hours

via s/c infusion.

iii. Haloperidol 2.5mg s/c prn

Review in 24 hours

Review Every 24 Hours

Increase the dose of Haloperidol to 10mg / 24 hours via s/c infusion if necessary.

NB: A total dose of 15mg / 24 hours – including stat dose, continuous dose and prn doses should not be exceeded.

Review every 24 hours

Increase the 24 hour dosage according to the total dose of Midazolam given on a prn basis. The dose should not be increased by more than 10mg/day without specialist advice

For persistent nausea switch to:

1. Levomepromazine 6.25mg / via s/c infusion.

2. Levomepromazine 6.25mg prn s/c.

NB: A total of 50mg / 24 hours – including continuous and prn doses – should not be exceeded.

Increase to 10mg / 24 hours s/c if nausea persists

Review in 24 hours

1. Haloperidol 1.5 – 2.5mg s/c stat.

2. Haloperidol 5mg via s/c infusion.

3. Haloperidol 1.5 – 2.5mg s/c prn.

NB: A total of 15mg / 24 hours – including stat doses, continuous s/c doses and prn doses – should not be exceeded.

Prescribe, so available if needed, Haloperidol 1.5 – 2.5mg s/c prn (up to a total of 15mg / 24 hours)

YES

NO

Nausea present

Previously on Anti-Emetic

NO

YES

Convert to s/c as appropriate

Give as soon as possible:

• Diamorphine 2.5mg s/c hourly for Tachypnoea.

• Midazolam 2.5-5mg s/c hourly for distress.

If no relief 30 minutes after first drug, try alternative, repeating if necessary.

YES

NO

Give as soon as possible appropriate prn of:

• Diamorphine s/c (see equivalence chart) for Tachypnoea.

• Midazolam 2.5-5mg s/c if patient distressed

Previously on oral Opioid or Fentanyl patch

Prescribe so available if needed:

• Diamorphine 2.5mg (or if on regular Opioids dose as per equivalence chart) s/c hourly for Tachypnoea.

• Midazolam 2.5-5mg s/c hourly for distress

•

Absent

Present

YES

Convert to s/c pump (or in case of Fentanyl patch add CSCI, do not remove patch) following Guidelines for Pain Management, BUT consider increasing Opioid dose, e.g. give 30-50% more than the recommended equivalent dose (or for Transdermal Fentanyl add 30-50% of the equivalent dose).

Prescribe appropriate prn as for breakthrough pain, e.g.1/6th of total daily dose Diamorphine for Tachypnoea.

Prescribe Midazolam 2.5-5mg s/c hourly prn for distress caused by breathlessness – hourly for a maximum of 3 doses then seek medical advice

Consider adding Midazolam 10mg to s/c pump, particularly if prn dose has helped.

If repeated doses are needed, consider starting syringe driver with combination of Diamorphine and Midazolam. Suggested starting doses are 5mg of each over 24 hours. Remember to use prns as needed.

AIM for patient’s breathing to be calm and effortless

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