Symptom Control

Symptom Control in last days of life

Care in the last days of life should involve care of both the patient who is dying and their loved ones. Attention should be paid to individual needs, and support given to meet those needs as far as possible. The Scottish Government has set out four principles which should be followed when providing care
to dying patients:

Informative, timely and sensitive communication is an essential component of each individual person's care

Each individual person's physical, psychological, social and spiritual needs are recognised and addressed as far as is possible

Significant decisions about a person's care, including diagnosing dying, are made on the basis of multidisciplinary discussion

Consideration is given to the wellbeing of relatives or carers attending the person

All who are thought to be dying should be allowed to eat and drink as tolerated. As part of the dying process, there will come a time when it is difficult to manage oral food and fluids, and this should be sensitively discussed with patient and loved ones. If there is uncertainty about the appropriateness of artificial nutrition and hydration, seek advice from the Specialist Palliative Care Team.
Medication should be adjusted in line with goals of care agreed. Often oral medication will be difficult to manage regularly, and consideration given as to whether to stop or continue medication via a different route.
Regular medication for symptom relief should be continued via subcutaneous route using a syringe driver after careful explanation. Syringe drivers should not be routinely started – only if there is an indication.

Hypo-thyroidism

Opiate toxicity

Steroid withdrawal

Infection

Acute kidney injury

Hyper- calcaemia

Dehydration

Hypo- / hyper- glycaemia

Unable to take Parkinson's meds

There is detailed guidance in literature, and in the SPCG, on how to approach end of life conversations and management. Sensitive exploration and explanation of the situation are important. All treatment should be given in line with capacity legislation, and any previously documented wishes should be taken into account. Consideration should be given to whether there are reversible causes for deterioration, and whether or not treatment is appropriate in discussion with the patient and their loved ones. Some possible reversible causes are listed above

Anticipatory Prescribing

Patients who are in the last days of life should have ready access to medication to relieve any symptoms they may encounter during the dying process. When medication is prescribed, there should be an administration record completed to allow nurses to give medication if needed, without trying to find a doctor to prescribe the drugs. This allows timely administration of medication.
For all symptoms, non-drug treatment should also be considered.
Suggested medication is in the table below. All should be given as needed, with minimum intervals indicated:

*The doses here assume that the patient is opiate naïve. If already taking opiates regularly, follow guidance under pain control to calculate PRN dosing.

If you are in an area that uses “HEPMA” electronic prescribing, enter “palliative care” in the protocol box and these drugs will appear.

Indication	Drug	Dose (SC)	Minimum Frequency
Pain – no renal impairment*	Morphine	2mg	Hourly
Pain – renal impairment*	Oxycodone	1mg	Hourly
Nausea / vomiting	Levomepromazine	5mg (If too sedating reduce dose to 2.5mg or switch to haloperidol)	Four hourly
Agitation	Midazolam	2mg	Hourly
Agitation not responding to midazolam / with psychotic symptoms	Levomepromazine	5 to 10mg	Four hourly
Breathlessness	Opiate or midazolam as above	-	Hourly
Respiratory secretions	Hyoscine butylbromide	20mg	Four hourly

Pain

The cause of pain should be elucidated and managed if possible. For example, re-positioning may help to relieve pressure on the site of pain.
Pain assessment is described in other texts and guidelines, but general indications of pain in someone who is dying and unable to speak are grimacing, groaning and stiffness or resistance to movement. These can also be due to anxiety, so clinical judgement is important. When administering opiates for pain relief, response to treatment should be documented to allow good ongoing symptom management.
Patients already on regular opiate analgesia should have this converted to a
24 hour syringe driver – see syringe driver section.
Patients should be prescribed either:
• the starting dose of opiate prn (2mg morphine sulphate if no renal impairment / 1mg oxycodone if renal impairment / lower if type 2 respiratory failure – suggest seek specialist advice in this situation).
• If 2 or more doses given in 24 hours, consider starting a syringe driver.
• OR 1/6 total dose prn if on a background analgesic (use conversion charts above if needed).

The background dose is adjusted by the sum of the prn doses used in the previous 24 hours.

Patient taking 30mg morphine sulphate MR, PO, bd. Unable to swallow and thought to be dying. 30mg PO BD = 60mg total over 24 hours 60mg PO = 30mg SC Therefore syringe driver commenced with 30mg morphine sulphate over 24 hrs SC and regular

The same patient uses 2 x 5mg SC morphine over the next 24 hours. The syringe driver is re calculated: (2 x 5mg) + 30mg = 40mg over 24 hours SC via syringe driver. The breakthrough is also recalculated: 40mg divided by 6 = approx 7mg SC prn. If a patient uses three or more breakthroughs in 24 hours, then further increases should be

Nausea and Vomiting

If patient taking a regular PO antiemetic, and it is effective, this should be converted to SC over 24 hours via a syringe driver. Usually the same total dose PO is given SC for antiemetics.
Treat new nausea and vomiting with a long acting, broad spectrum antiemetic either as a once daily bolus or in a syringe driver over 24 hours: levomepromazine 5mg OD SC is recommended locally. Maximum dose for nausea is 37.5mg levomepromazine over 24 hours.

Patient taking metoclopramide 10mg, tds PO. Unable to swallow, and thought to be dying. Stop PO doses and prescribe 30mg over 24 hours SC via syringe driver, and 10mg SC, PRN 6 hourly.

Unless taking metoclopramide, patients should be prescribed PRN levomepromazine 5mg, 4 hourly PRN for nausea and vomiting.

Patient taking haloperidol 1mg, BD, PO. Unable to swallow, and thought to be dying. Stop PO doses and prescribe 2mg haloperidol over 24 hours SC via

If unsure, contact the specialist team. If bowel obstruction known or suspected, discuss with the specialist team.

Restlessness and Agitation

Unfortunately, some people get restless and agitated during the last days of life. Non-drug treatments should be used, but medication should also be readily and available and used if necessary. Non-drug treatments include looking at the environment (noise, lighting, fans), skilled
practitioners providing reassurance and calm,
aromatherapy, orientation using familiar sounds (music,
voices) and objects. Some people find touch comforting,
others seem to find touch irritating. In this case, it can be
difficult for loved ones as they may feel rejected. Careful
explanation is important.
Most people want a calm, peaceful death, and if
restlessness and agitation is not responding to treatments
quickly, then discuss with the specialist palliative care
team. There can also be concern that sedation leads to an
inevitable death, so it is important to carefully explain the
reasons for using sedatives.
As before, detailed pharmacology and guidance is available
in PCF6 / SPCG / BNF.

Urinary retention

Constipation, esp. faecal impaction

Drug side effects

High calcium

Hypoxia

Agitation

Primary / secondary brain disease

Renal / hepatic impairment

Spiritual distress

Probable causes of agitation in the dying phase are listed above

Some can be fairly easily corrected (eg) urinary retention / faecal impaction. Others may not be possible to correct, and symptom management is key.

Medical management is outlined in the table across:

Benzodiazepines (lorazepam and midazolam) are particularly helpful if someone is very anxious. If psychotic features predominate, haloperidol and levomepromazine may be more helpful. Some people may need combination treatment.
Occasionally people need much larger doses and alternative medication. In this circumstance, seek specialist advice from palliative medicine.

Drug	Oral PRN (start with lowest dose)	SC PRN (start with lowest dose)	SC Syringe Driver over 24 hours*
Lorazepam	0.5-1mg, 4 hourly	-	-
Midazolam	-	2.5-5mg	10-20mg
Haloperidol	1.5-2.5mg	1-2.5mg	5-10mg
Levomepromazine	6-12.5mg	5-10mg	12.5-25mg

*These are starting doses if needed for someone who is very distressed. It is helpful to have given at least one SC PRN dose prior to starting the syringe driver to get an idea of how what dose is likely to be needed over 24 hours.

Breathlessness

Breathlessness in the last days of life can be multifactorial, and at any stage is often accompanied by anxiety. In the last days and hours of life, it may be difficult for patients to practice breathing exercises, but if
possible these should be used, along with psychological support.
Oxygen may improve breathlessness if a patient is hypoxic, but not if oxygen saturations are normal. If considering adjusting oxygen for patients with COPD, discuss with respiratory first, particularly if known type 2 respiratory failure. Hand held fans may be helpful, over nose and cheeks.
If a patient is already taking regular oral benzodiazepines or opiates for breathlessness, these should be converted to a syringe driver with midazolam, or continue clonazepam if already taking. Opiates should be converted as for pain. For enzodiazepines, approximate equivalent doses are shown below (from PCF):

Approximate equivalent dose of 2.5mg SC midazolam
Chlordiazepoxide 12.5mg PO	Nitrazepam 5mg PO
Clonazepam 250mcg PO / SC	Temazepam 10mg PO
Lorazepam 500mcg PO	Diazepam 5mg PO

Starting doses of opiates and benzodiazepines are as for pain / agitation respectively.

Respiratory Secretions

Respiratory secretions are a normal part of the dying process. They can be difficult to control once they develop, and drugs do not always work. If they do develop, anticholinergics may be used.
About 1/3 patients respond well to drug treatments, 1/3 partially respond, and 1/3 don’t respond. It doesn’t matter which anticholinergic is used, they are all equally effective.
Positioning can be more effective than medicine, for example lying on their side, or up to 45 degrees.
Once secretions are audible, in most cases it is worth putting the full dose in a CSCI, with a bolus dose to start. An alternative is to put 50% of the maximum, with 3 prn doses / 24 hours for breakthrough. Caution should be used where anticholinergic effects could be problematic (eg) acute glaucoma / tachyarrythmias (see BNF / PCF for list of side effects).

Hyoscine butylbromide and glycopyrronium do not cross the blood brain barrier. Hyoscine hydrobromide does, and can cause sedation or agitation and delirium. If possible, it should be avoided in the elderly and people with renal impairment. Therefore, hyoscine butylbromide is recommended locally. Hyoscine butylbromide is incompatible with cyclizine. All anticholinergics antagonise the prokinetic effects of metoclopramide. Seek specialist advice if needed.

Drug	Dose over 24 hours in syringe driver SC	Breakthrough dose	Interval between dosing	Maximum total dose in 24 hours
Hyoscine butylbromide	60-120mg	20mg	4 hours	160mg
Glycopyrronium	600-1200mcg	200mcg	4 hours	1200mcg
Hyoscine hydrobromide	1200- 2000mcg (locally 2400mcg used for severe problems)	200-400mcg	4 hours	2400mcg

Haemorrhage - see the Emergency guideline

Generally haemorrhage should be managed in the usual way, applying pressure and addressing the cause if possible. If there is catastrophic haemorrhage (eg) from a tumour eroding a large blood vessel, the most important thing is to remain calm and stay with the patient, as death will be in minutes. If there is an additional member of staff present 10mg midazolam can be administered IM. Dark towels are less alarming than pale ones.