Palliative Care
in Dumfries and Galloway
Staff Area
Guidelines
The Scottish Palliative Care Guidelines, published by HIS, can be accessed here. Please note that each Scottish guideline has a pdf tab at the top of the webpage, so this can be downloaded and printed for those who wish to have hard copies of a particular section.
Click on each link below to take you to the relevant page. You can advance to the section you wish here: Palliative Care Emergencies, Symptom Control, Syringe Drivers, and Care in the Last Days of Life and After Death.
Palliative Care Emergencies
Emergencies in Palliative Care are situations where there is a necessity for urgent treatment to avoid a reduced quality of life for the person affected, such as Metastatic Spinal Cord Compression (MSCC), or where the presentation is potentially life threatening. For some patients, this emergency may be occurring on a background of significant deterioration where the prognosis is thought to be poor whatever is done. Careful and speedy consideration has to be made about the appropriateness of giving such treatments – if an anticipatory care plan is in place this should be referred to, and the implications of treating or not treating carefully discussed with the patient or their proxy, in line with the Adults with Incapacity Act.
For people with cancer, close involvement with their site specific CNS is important, and the CNSs can link with the patient’s oncologists. For people with life limiting conditions other than cancer there may also be a CNS or other professional involved who knows the patient well and can guide you as to their wishes and preferences, and previous treatments.
The Specialist Palliative Care Team, including the on-call consultant team overnight, would be happy to assist in the management of patients presenting with the following problems. Early referral for severe distress is particularly recommended.
Click on each link below to take you to the relevant guideline as per the Scottish Palliative Care Guidelines (SPCG) and local information. Some of the medications recommended are used off-license or have QT prolonging effects – please see the relevant SPCG for more information.
For Covid-19 specific guidance, click here.
Symptom Control
Below are links to guidelines some are direct links to the Scottish Palliative Care Guidelines, others are our local guidance, including opiate conversion tables.
Syringe Drivers (Continuous subcutaneous infusions)
A syringe driver is the device used to deliver continuous subcutaneous infusions (CSCI) in palliative care. It is a portable device, and so can be used in community as well as inpatient settings. It is used when the oral route is not possible – this may be early in the course of someone’s illness, for example if the person has problems with vomiting or intestinal absorption is impaired. It is commonly used as a convenient route to deliver medication for symptom relief when someone is dying. Usually when a person is dying, they become increasingly drowsy and lose their ability to swallow, and so parenteral administration of medication is required.
When starting a syringe driver, the reason for using the device should be carefully and sensitively explained to patients, or if the patient doesn’t have capacity their POA, guardian or NOK. Be aware that for many people the use of syringe drivers is synonymous with death and dying – if not being used in the last days of life, make sure that the patient and their loved ones understand this. Some people incorrectly believe that the reason for using a syringe driver is to hasten death – again reassure people that this is not the case. Patients should be offered the Marie Curie leaflet below. If the patient is at home and has access to the internet, it can be found in the patient section of this website, and via this link: Marie Curie “having a syringe driver“.
HIS guidelines on T34 syringe pumps can be found here. If you are not familiar with syringe drivers, the video below is short and helps explain what they are and what to look out for.
Top tips for syringe driver use
Indications for a syringe driver: persistent nausea and vomiting, dysphagia, bowel obstruction or intestinal failure to absorb medication, coma or patient preference.
3 drugs are generally the maximum number of medications to be mixed in a syringe driver. However, 4 drugs may be used if this is under instruction of specialists, or using the standard drugs in last days of life (an opiate, midazolam, levomepromazine or haloperidol, and hyoscine butylbromide or hyoscine hydrobromide).
Water for injections is used except with ketamine and ketorolac where 0.9% saline should be used. Consider 0.9% saline with granisetron, hydromorphone, octreotide and ondansetron if site problems develop.
Site of Syringe Driver
Anterior chest wall, anterolateral upper arms, supra- or inter-scapular area, abdomen or upper thighs are all reasonable sites depending on the characteristics of the individual patient. Avoid oedematous areas or scar tissue, breast tissue, broken or inflamed skin, bony prominences and joints.
Starting a Syringe Driver when patient already on background medications orally…
Stopping a Syringe Driver and converting to oral medications…
Care in the Last Days of Life
Broad guidance, and medication advice can be found here.
We have locally developed protocols for medication in the last days of life. In inpatient settings with Hepma, anticipatory medications can be prescribed as a protocol on Hepma, with pre-populated bundles for standard medications, medications for patients with renal impairment, and those with hepatic impairment. For other areas the anticipatory medication chart can be used, and the GPs can use the synonyms on EMIS.
We are also implementing the “SWAN” initiative to try to improve care in the last days of life in and inpatient setting. Find out more information here.
Care After Death
Guidance on “last offices” has been developed by Nurse Consultants in Palliative Care in England, and their guidance can be found here. Broadly, this is similar to Scotland, although in Scotland the legal system is different. Referrals are made to the Procurator Fiscal rather than the Coroner, and there are differences in completing the MCCD (Medical Certificate of Cause of Death). Of note, time of death is the time the person died, not the time the death was verified. The CMO’s guidance on completing the MCCD can be found here. Offer families the booklet “What should I do after someone has died”. There is also an online version what to do after a death. You may wish to signpost people to this website and the bereavement section.