Recognising dying and pro-active prescribing – keeping patients at

home Dr Andrew Tysoe-Calnon

Lead Consultant

Principles of a good death • To know when death is coming, and to understand what can be expected. • To be able to retain control of what happens. • To be afforded dignity and privacy. • To have control over pain relief and other symptom control. • To have choice and control over where death occurs (at home or

elsewhere). • To have access to information and expertise of whatever kind is

necessary. • To have access to any spiritual or emotional support required. • To have control over who is present and who shares the end. • To be able to issue advance directives which ensure wishes are respected. • To have time to say goodbye • To be able to leave when it is time to go, and not to have life prolonged

pointlessly. “The Future of Health and Care of Older People” Debate of the Age Health and Care Study Group

What prevents a good death at home?

• Poorly controlled symptoms • Oral medications burden • Lack of equipment • Lack of injectable drugs when you need them • Lack of authorisations to use injectable drugs

at home • Fear/anxiety of patient and/or carers • Inappropriate resuscitation • Unfinished business/unable to say goodbye • Involvement of coroners/police • Wills/finances not sorted out

How to achieve a good death at home

• Assess if patient has any complex symptoms that requires input from the local palliative care team

• Ensure DN’s are involved • Continue drugs for symptom control so think about

route • Put DNACPR orders in place • Prescribe injectables • Syringe driver and prn pink charts written and in the

house • Spiritual care • Advice from solicitors • Visit every 14 days

When to do anticipatory prescribing?

• If you think a patient is approaching the end of life then it is good practice to do a pink chart covering the most likely potential symptoms

• This may be within the last few weeks of life but a stable patient can also rapidly deteriorate

• Try to anticipate emergencies that may arise and plan for them e.g. haemorrhage, seizures, stridor

• However, it is prudent for patients who develop a new diagnosis of for eg: brain metastases who may have or be at risk of seizures to have an anticipatory chart for seizure control.

• Think about bank holidays, Christmas etc

• Becoming much weaker • Bed bound • Drinking sips only • Struggling to take oral medications • Semi-conscious/unconscious • May see plucking/restlessness • Apnoeas • Often if a patient is deteriorating over days

then they will have a prognosis of days

Recognising dying

Anticipatory Prescribing at the End of Life

• Anticipatory prescribing forms a key part of good pro-active End of Life Care and should be initiated as the patient enters the last few weeks of life.

• Ensure that in the last days or hours of life there is no delay in responding to symptoms

• Administer medication if and when needed, but no more than is required to relieve symptoms

• Review all medication including doses and frequency • Commence a syringe pump if several prns required in

24 hours. Not all dying patients require a continuous subcutaneous infusion

• Contact the Specialist Palliative Care Team if symptoms persist

Pain at the end of life

• Think about cause or if new pain consider urinary retention, fracture, constipation, acute bleed, anxiety

• If you think it is a fracture consider if appropriate to send to hospital or advise for bed rest and analgesia

• Follow the anticipatory guidance • Morphine remains the gold standard • Oxycodone is double the strength of morphine

Guidance - Pain

• If opioid naive, Morphine Sulphate 5-30mg sc over 24 hours in syringe pump with 2.5 – 5mg sc prn

• If already on analgesic patch, continue patch add in sc morphine sulphate as required

• If already on oral morphine, divide 24 hr oral dose by 2 to calculate 24 hr syringe pump dose. If on other oral opioids, use conversion chart to calculate dose

• In renal failure, seek Specialist Palliative Care advice on Alfentanil use

• Think about cause • Unless specific cause then I would usually

go for haloperidol as this covers most situations

• Don’t use tiny doses such as 1.5mg in a SD as this will be too small for most patients

• Guidance has starting doses, patients may need more, so titrate up

Nausea and vomiting

Guidance - Nausea and vomiting

• Haloperidol 3-5mg sc over 24 hr with 1.5mg sc prn

• Brain tumour/mets Cyclizine 150mg sc over 24hr with 50mg sc prn

• Poor gut motility, Metoclopramide 30-60mg sc over 24hr

Agitation/restlessness

• Can occur in late stages • ? Cause – physical - pain, retention,

metabolic etc or psychological - are there unmet spiritual needs or not come to terms with events in their lives

• Distresses family • Distresses staff • Distresses patient

Agitation/restlessness

• Treat with sedation • Give continuously in syringe driver as irreversible event • Use Midazolam first line up to 60-100mg • If midazolam fails then see specialist advice • Levomepromazine second line (high dose) 50-300mg • Use phenobarbital as third line drug • Midazolam and Levomepromazine can cause paradoxical agitation (rare) • If starting levomepromazine or phenobarbital do not stop the midazolam as patient

may have a benzodiazepine withdrawal • Encourage family to remain calm, to stroke and talk to the patient

Guidance- Agitation/restlessness

• Midazolam 10-40mg sc over 24 hours with 2.5-5mg sc prn

Respiratory secretions

• From secretions in the pharynx • ‘Death rattle’ • Patient can’t expectorate • Usually in last couple of days or hours • Patients are usually unaware and not

distressed • Carers often are distressed • Reassure carers

Respiratory secretions

• Treat early as once secretions are formed very difficult to treat

• Use re-positioning to help and drain • Can use glycopyrronium if conscious or unconscious • Other drugs are hyoscine hydrobromide 0.4-0.6mg prn

if unconscious, or hyoscine butylbromide (buscopan) 20mg prn if conscious

• Can suction but can be unpleasant if patient not fully unconscious, so do as last resort – hard to do at home

• Maximum doses for glycopyrronium and hyoscine hydrobromide in a SD is 2.4mg

• Glycopyrronium 0.6-1.2mg sc over 24 hours with 0.2-0.4mg sc prn

• Maximum 2.4mg in 24 hours

Guidance- Respiratory secretions

Dyspnoea at the end of life

• Can be very distressing • Can induce panic attacks • Consider oxygen • Someone to stay with the patient • Positioning • Use nebulisers, benzodiazepines, opioids

to control symptoms • May need SD with opioid and midazolam

to control symptom

• If opioid naive, Morphine sulphate 5-30mg sc over 24 hours with 2.5 - 5mg sc prn. Concurrent Midazolam recommended.

Guidance- Dyspnoea

Seizures

• Can occur with primary cerebral tumours or metastases or in epileptics

• Likely to occur if steroids or anti-epileptics stopped because can’t swallow

• Can give steroids s/c once daily to replace oral at half the dose

• Use midazolam in syringe driver starting at 30mg if patient can’t manage to swallow oral anti-epileptics

• Remember, levomepromazine can decrease the threshold for fits

• Midazolam 30-90mg over 24 hours with 10-20mg sc prn

• Start if patient fitting or unable to take oral anti epileptic drugs

Guidance- Seizures

Intestinal Obstruction

• Will likely need to use several drugs in the syringe driver

• Anti-emetic • Opioid • Anti-spasmodic – titrate quickly 60-120-

180-240mg • Can go up as far as 480mg buscopan

• Hyoscine butylbromide (Buscopan) • 60-240mg over 24 hours with 20mg sc prn

Guidance- Intestinal Obstruction

Prescribing advice

• Suggestions for the initial prescription for injectables:

• Morphine sulphate 10mg/2ml x 10 amps (30mg/ml if on larger doses)

• Haloperidol 5mg/ml x 10 amps • Midazolam 10mg/2ml x 10 amps • Glycopyrronium 600mcg/3ml x 10 amps • Remember to prescribe water for injection

10mls x 10amps

Other injectables

• Oxycodone 10mg/ml or 10mg/2ml. For large doses, 50mg/ml available if greater concentration required to fit in syringe pump but much more expensive

• Hyoscine butylbromide (Buscopan) 20mg/ml for bowel obstruction

• Hyoscine hydrobromide 600mcg/ml – alternative to Glycopyrronium

Indications for using a syringe driver

• Unable to swallow • Not absorbing oral medications eg: bowel obstruction • Vomiting • To avoid lots of separate prn subcut injections when

symptoms uncontrolled • If titration is proving difficult • Agitation • However, not everyone dying will need a driver

What goes in the driver?

• Convert oral opioid to injectable for SD • Continue anti-emetics • For terminal agitation or distress use sedation • Treat secretions • Can use up to 4 drugs in driver • Not all drugs are compatible with each other • Some mix with saline instead of water • Sometimes small doses of dexamethasone are needed

in the driver to prevent site reactions • Consider how much sub cut fat they have

Frequency of prns

• Unless drug has to be given at specific intervals I write all drugs as hourly

• My justification - if patient has severe symptom then writing 4-6hourly for a prn means they will have to wait that length of time in pain, SOB, agitated before they can be given another injection

• This is not acceptable

Titration of SD’s

• Patient has range 40-80mg morphine over 24 hours in SD

• If patient currently has 60mg of morphine in the SD and has used another 60mg in prn stats in the past 24 hours there is little point in only increasing the SD to 70 or 80mg within the current allowed range.

• Chart needs to be re-written with larger range eg: 100-200mg

• You may start at 100, 120 or 160mg depending on circumstances

Midazolam

• When midazolam is prescribed on the pink chart you can write underneath give 10mg in emergency

• This allows a DN/paramedic to administer midazolam in different emergency situations eg: seizures, large bleeds, severe agitation

Steroids

• Some patients may be on high dose oral steroids or may have been on steroids for a long time

• In this case you may worsen symptom control by stopping them by potentially increasing pain, causing seizures, increasing agitation

• Consider giving half the oral dose as a once daily injection

• Injectable steroids come in different strengths: • dexamethasone 4mg/ml stopping • dexamethasone 3.3mg/ml equivalent to 4mg – USE

THIS • dexamethasone 3.8mg/ml equivalent to 5mg

Concerns over abuse of drugs

• Drugs once collected from a chemist are the property of the patient

• It is the families responsibility to return them to a chemist after death

• All CD’s in the house should be logged by the DN’s who keep count of the number and batch numbers

• If a patient is a known drug user then the primary care team can manage the amount of drugs going into the house

• In some circumstances another arrangement may be made

• Don’t allow concerns over abuse to prevent appropriate prescribing, they may well need larger doses – seek specialist advice

How can the hospice help to ensure a good death?

• Home care team – CNS specialist advice • Crisis support team – care in last 2 weeks of

life, don’t have to be under our other services, can provide 24 hour care

• Respite care – daytime few hours or occasional night at home to give carers a rest

• In-patient unit • OOH service for advice – always CNS on call

and consultant on call • Consultant advice – open door

Consultant mobile numbers

Andrew Tysoe-Calnon 07968 481081

Siva Subramaniam

07918 561058

Any questions?

for families facing terminal illness