COVID
-19 EOLC Sym
ptom m
anagement guidance 2 April 2020
Guidance for the M
anagement of
Symptom
s in Adults in the Last D
ays of Lifeprofessionals on m
anaging comm
only experienced sym
ptoms at the end of life.
Updated Jan 2018 Peter Arm
strong & D
r Kiran Kaur on behalf of the
Public Health
Agency
COVID
-19: Symptom
Managem
ent in Last D
ays of Life (For use in Secondary and Prim
ary Care Se!ngs)
(April 2020)
CORONAVIR
US
COVID
-19 EOLC Sym
ptom m
anagement guidance 2 April 2020
COVID
-19: Symptom
Managem
ent in Last Days of Life (2 April 2020)
This guidance is a supplement to the RPM
G “G
uidance for the Managem
ent of Symptom
s in Adults in the Last Days of life” w
hich should s!ll be used as a reference. h"p://w
ww
.professionalpallia!vehub.com/sites/default/files/RPM
G%
20End%20of%
20Life%20G
uidance%202018.pdf
This guidance has been developed given the extreme challenges that m
ay arise as a result of COVID
-19 pandemic. It is specifically for use in
pa!ents in the last days of life and is applicable in both Secondary and Primary care se!
ngs.
The subcutaneous route of medica!on adm
inistra!on remains the preferred route as pa!ents w
ill o$en have difficulty or be unable to sw
allow
in the last days of life. If there are issues with drug availability, please refer to 3rd line op!ons - these should only be considered as a last resort
where all other op!ons have been exhausted.
Please seek advice from the local H
ospital Specialist Pallia!ve Care team or H
ospice if needed:
Belfast HSC Trust
028 9615 1900
Northern H
SC Trust
028 9442 4000
South Eastern HSC Trust
028 4483 8388 ext 2222
Southern HSC Trust
028 3026 7711
Western H
SC Trust (North Sector )
028 7134 5171 (Altnagelvin Hospital Sw
itchboard)
Western H
SC Trust (South Sector)
028 6638 2000 (SW
AH)
STAFF SHO
ULD
BE AWARE TH
AT THIS GU
IDAN
CE IS SUBJECT TO
CHAN
GE AS DEVELO
PMEN
TS OCCU
R. CHECK FO
R UPD
ATES ON
THE
PALLIATIVE CARE IN PARTN
ERSHIP W
EBSITE: ww
w.pcip.hscni.net
COVID
-19 EOLC Sym
ptom m
anagement guidance 2 April 2020
For pa"ents who are seriously ill w
ith Covid-19, honest and sensi"ve conversa"ons about goals of care and treatment escala"on planning
should be ini"ated as early as possible.
Ac"on
Consider
Establish a clear ceiling of care at admission
DN
ACPR discussions Review
route of administra!on of m
edicines for symptom
control - con!nue oral if tolerated and prescribe PRN
SC alterna!ves as appropriate U
sual SC medicines are not available or cannot be adm
inistered
Consider stopping regular observa!ons and inverven!ons including BM
s and fluids An!cipatory Prescribing
Consider mouth care
Ra!onalise all medicines
A"end to the social, psychological and spiritual care of the pa!ent
See 3rd line medicine choices
Ra!onalise diabetes treatment and BM
monitoring in line w
ith diabetes U
K End-of- Life-Care; h"ps://ww
w.diabetes.org.uk/
resources-s3/2018-03/EoL_Guidance_2018_Final.pdf
Consider stopping parenteral fluids
Ensure an!cipatory medica!on is prescribed for all pa!ents - please
prescribe oral and SC op!ons as appropriate
Consider regular Biotene Gel four !m
es a day
Avoid mouthw
ashes
Consider stopping non-cri!cal medicines and if necessary, review
ing the route of adm
inistra!on for cri!cal medicines e.g. an!-epilep!cs,
Parkinson’s medica!on
COVID
-19 EOLC Sym
ptom m
anagement guidance 2 April 2020
General points•
In all cases consider posi!oning and other non-pharmacological m
easures. Seek physio advice if required.
• For pa!ents already on opioid m
edica!ons adjust the breakthrough dose to one sixth of the pa!ent’s regular total opioid dose.
• For all sym
ptoms, consider star"ng at low
er end of ranges given, especially in pa"ents who are opioid-naïve, elderly or have a low
BM
I, and !tra!ng up rapidly as needed (usually 30-50% every 12 hours, using clinical judgem
ent. Reassess symptom
s if pa!ent is not
responding).
• For pa!ents w
ho are very symptom
a!c or distressed, consider star!ng higher doses in the range and !tra!ng up rapidly if needed. The
pa!ents m
ay benefit from a dose range being prescribed to allow
nursing staff more flexibility eg M
orphine Sulfate 2mg-5m
g SC PRN (TW
O
m
g to FIVE mg) for pain or dyspnoea 2 hourly to a m
aximum
of 30mg/24hrs PRN
.
• A shorter dose interval eg 1-2 hourly PRN
with a clear m
aximum
permissible dose in 24hrs m
ay also allow flexibility
• The pa!ents m
ay deteriorate very quickly and may require com
bina!ons of 2 or 3 SC PRNs at one !m
e eg if SOB/agitated and having
secre!ons - consider giving the pa!ent Morphine Sulfate SC for SO
B; Midazolam
SC for anxiety and a SC an!secretory.
• Consider using a subcutaneous line to allow
for stat dosing, par!cularly if repeated stat doses are required for symptom
s. Consider using a
‘Saf-T-In!ma’ for this purpose at end of life.
• U
nless stated these drugs are compa!ble in a CSCI w
ith 0.9% Sodium
Chloride. Up to 4 drugs can be added to a CSCI.
• FO
R LOW
VOLU
ME O
RAL DRU
GS GIVEN e.g. 0.5m
l, ENSU
RE 1 ML SYRIN
GES ARE AVAILABLE FOR CARER / PATIEN
TS.
COVID
-19 EOLC Sym
ptom m
anagement guidance 2 April 2020
Injectable op"on
Non-
injectable Alterna"ve
Dyspnoea/Pain/Cough
Consider reversible causes and treat if appropriate. Consider posi"oning; relaxa"on techniques; reduce room tem
perature; cool cloth for face; psychological support. Avoid all fans. Consider cough hygiene (‘Catch it/ Bin it/ Kill it’) and m
easures eg oral fluids/cough remedies/
humidified air.
For pa"ents already on opioid medica"ons adjust the breakthrough dose to one sixth of the pa"ent’s regular total opioid dose.
1st line – Ini"a"on of therapy
eGFR>45M
orphine Sulfate injec!on 2mg-5m
g every 2-4 hours PRN by SC Inj
eGFR15-45O
xycodone injec!on 1mg-2m
g every 2-4 hours PRN by SC Inj
eGFR<15or concern re opioid toxicityO
xycodone injec!on 1mg every 2-4 hours PRN
by SC Inj and Contact Specialist Pallia!ve Care Team
for advice
eGFR>45M
orphine Sulfate Oral Solu!on (O
ramorph
®) 5mg every 2-4 hours PRN
eGFR15-45Shortec®
Oral Solu!on 1m
g-2mg every 2-4 hours PRN
eGFR<15Shortec
® Oral Solu!on 1m
g-2mg every 2-4 hours PRN
and Contact Specialist Pallia!ve Care Team
for advice
2nd line – Alterna"ve or progression of symptom
s
eGFR>45M
orphine Sulfate injec!on 10mg +/-M
idazolam 10m
gover 24 hours via CSCI (Con!nuous Sub-Cutaneous Infusion) and con!nue PRN
SC Inj for breakthrough
eGFR15-45O
xycodone injec!on 5mg +/-M
idazolam 10m
gover 24 hours via CSCI and con!nue PRN
SC Inj for breakthrough
eGFR<15or concern re opioid toxicityO
xycodone injec!on 1mg every 2-4 hours PRN
by SC InjConsider Alfentanil 1m
g +/- Midazolam
5mg-10m
g over 24hrs via CSCIContact Specialist Pallia!ve Care Team
for advice
Use available short-ac!ng opioid eg O
ramorph
® or Shortec® at
equivalent dose, regularly every 4 hours and 2hourly PRN.
Consider use of long-ac!ng opioid at appropriate star!ng dose according to previous opioid use eg M
ST® BD
while con!nuing
Oram
orph® PRN
OR Longtec
® BD w
hile con!nuing Shortec® PRN
. See Regional O
pioid Conversion Guidance
h"p://ww
w.professionalpallia!vehub.com
/resource-centre/northern-ireland-guidelines-conver!ng-doses-opioid-analgesics-adult-use-2018
Please exercise cau!on if prescribing long-ac!ng opioid medica!on
in pa!ents with renal im
pairment.
For use in Secondary and Primary Care
COVID
-19 EOLC Sym
ptom m
anagement guidance 2 April 2020
Injectable op"on
Non-injectable
Alterna"ve
Injectable op"on
Non-injectable
Alterna"ve
Midazolam
injec!on 2mg-5m
g every 2 hours PRN by SC Inj
And either H
aloperidol 0.5mg-1m
g every 2 hours PRN by SC Inj
OR
Levomeprom
azine 5mg-10m
g every 4 hours PRN by SC Inj
Lorazepam sublingual tablets 0.5-1m
g every 4 hours PRN (M
ax 4mg/24
hours) (Suitable brands – Genus, Teva, Lexon or M
ylan)O
RD
iazepam 2m
g-5mg every 4 hours PRN
Glycopyrronium
injec!on 200 microgram
s every 4 hours PRN by SC Inj
and/orG
lycopyrronium injec!on 600-1200 m
icrograms over 24 hours by CSCI
(Max dose 1200 m
icrograms in 24 hours)
OR
Hyoscine Butylbrom
ide injec!on 20mg every 4 hours PRN
by SC InjAnd/O
rH
yoscine Butylbromide injec!on 60-120m
g over 24 hours by CSCI
Hyoscine H
ydrobromide sublingual tablets (Kw
ells®)
300 microgram
s every 6 hours PRN (M
ax 3 doses/24 hours)
Midazolam
10mg over 24 hours via CSCI
And add eitherLevom
epromazine 10-25m
g O
R H
aloperidol 3-5mgand con!nue PRN
SC Inj for breakthrough
Haloperidol 0.5-1m
g every 4-6 hours PRNO
RLevom
epromazine tablets 6m
g-12mg every 4-6 hours PRN
(Max TD
S)(25m
g tablets can be used and split to appropriate dose and dissolved in w
ater if 6mg tablets are unavailable)
Hyoscine H
ydrobromide injec!on 400 m
icrograms every 4 hours PRN
by SC Injand/orH
yoscine Hydrobrom
ide injec!on 1200-2400 microgram
s over 24 hours by CSCI
NB: First line choice of an!secretory m
ay be affected by availability of m
edica!ons.
Hyoscine H
ydrobromide 1m
g Patch (Scopoderm®
) every 72 hours
Delirium
/Agita"on/ Anxiety Consider reversible causes and treat if appropriate. eg: superadded infec"on; drugs; urinary reten"on; dehydra"on; cons"pa"on; hypoxia. Consider usual non-pharm
acological approaches.
Respiratory Secre"ons Consider reposi"oning on side or sem
i-prone posi"on; reassurance of family that secre"ons are not likely to be causing the pa"ent
discomfort.
COVID
-19 EOLC Sym
ptom m
anagement guidance 2 April 2020
Can use IV Paracetamol if cannula in situ
Dose according to w
eight:>50kg 1g Q
DS or every 4-6 hours PRN
<50kg 15mg/kg Q
DS or every 4-6 hours PRN
Paracetamol O
ral tablets 1g QD
S or every 4-6 hours PRN
Also consider cooling the face using a cool cloth and Oral fluids if able.
Avoid all fans
NSAID
s are NO
T recomm
ended in COVID
-19 but may be an op"on
at end of life where there is diffi
cult to control pyrexia and limited
alterna"vesConsider:Parecoxib injec!on 20m
g BD PRN
by SC Inj or 40-80mg over 24 hours by
CSCI(Parecoxib should not be m
ixed in syringe pump w
ith any other medicine)
Paracetamol Suppositories 1g Q
DS or every 4-6 hours PRN
And/Or
Diclofenac Suppositories 50-100m
g every 8 hours PRN (M
ax 150mg/24
hours)
Injectable op"on
Non-injectable
Alterna"ve
Pyrexia Consider cool cloth for face; oral fluids if able. Avoid all fans.
COVID
-19 EOLC Sym
ptom m
anagement guidance 2 April 2020
3rd line medicine choices
To be used only if 1st and 2
nd line choices are not suitable or not available. These are considered less well established prac"ce.
Exercise cau"on when prescribing as m
ay lead to an increased risk of adverse events.N
ote: Transdermal prepara"ons m
ay be absorbed more rapidly in pyrexic pa"ents
Product
Prescribing details
Dyspnoea/Pain
Buprenorphine Patch* – BuTec®
10-20 m
icrogram/hour every 7 days (N
B Equivalent to 20-50mg O
ral Morphine/24 hours)
Fentanyl Patch* – Mezolar M
atrix®
12-25 m
icrogram/hour every 72 hours (N
B Equivalent to 30-90mg O
ral Morphine/24 hours)
Oram
orph® CO
NCEN
TRATED 20m
g/ml O
ral Solu!on
10mg every 4 hours via buccal route PRN
(NB 0.5m
l volume – high risk of overdose if inaccurate m
easure)Shortec®
CON
CENTRATED
10mg/m
l Oral Solu!on
5m
g every 4 hours via buccal route PRN (N
B 0.5ml volum
e – high risk of overdose if inaccurate measure)
Agita"on/Anxiety/Delirium
Epistatus® Buccal Solu!on O
R
5-10m
g every 4 hours PRN via buccal adm
inistra!onBuccolam
®Prefilled Syringes (in the absence of the above being available, m
idazolam
solu!on for injec!on can be administered via buccal m
ucosa)
Diazepam
Enema
5-10m
g OD
PRN via rectum
Olanzapine O
rodispersible tablets
5-10mg O
D (Can increase to 20m
g/day as required)Risperidone tablets
500 m
icrograms BD
regularly or PRN
If CSCI not available but DN
able to administer SC injec"on:
Consider Haloperidol 1-3m
g sc daily or
Levom
epromazine 10m
g sc od /bd
Respiratory Secre"onsIf CSCI not available but D
N able to adm
inister SC injec"on: Consider H
yoscine Butylbromide 40m
g SC BD O
R
G
lycopyrronium 400m
cg BD or TID
Atropine 1% Eye D
rops
Sublingually 1-2 drops every 6-8 hours PRN
*Note topical opioid patches w
ill take 24-48 hours to establish efficacy in m
ost pa!ents and PRN opioids/alterna!ve strategies w
ill need to be used in mean!m
e.
COVID
-19 EOLC Sym
ptom m
anagement guidance 2 April 2020
CORONAVIR
US
This guidance has been prepared by the Regional Pallia"ve M
edicine Group (RPMG) in N
orthern Ireland w
ith input from the N
I Specialist Pallia"ve Care Pharm
acy Group and supported by the Pallia"ve Care in Partnership Program
me.
WA
SH
HA
ND
SK
EE
P D
ISTA
NC
ES
TAY
HO
ME
Prescribing Opioid A
nalgesicsM
orphine is the first line choice of strong opioid in non-specialist settings.
*In severe renal impairm
ent or dialysis patients, buprenorphine, fentanyl or alfentanil m
ay be the preferred opioid.
Prescribe oral, transdermal and transm
ucosal opioids by brand nam
e and injections generically.
Remem
ber to ensure you are clear on the duration of action w
hen prescribing branded products:
• Short-acting preparations e.g. O
ramorph
®, Sevredol ®, Shortec
®, Oxynorm
® or Palladone
® approximately 4 hours.
• Long-acting preparations e.g. M
ST®,
Longtec®, O
xyContin
® or Palladone® SR
approximately 12 hours.
• O
pioid patches e.g. Mezolar ®, D
urogesic®,
replace every 3 days. Butec®, BuTrans
®, replace every 7 days. Transtec
® replace twice
weekly (every 3 or 4 days).
Northern Ireland guidelines on converting
doses of opioid analgesics for adult use 2018
Disclaim
er: Conversion ratios vary and these are an approxim
ate guide only. They m
ay differ from other published
conversions but have been chosen to reflect best evidence and safety. U
sers are advised to m
onitor patients carefully for pain and side effects. Responsibility for the use of these recom
mendations lies w
ith the healthcare professional(s) m
anaging each patient. Seek specialist palliative care advice w
hen necessary, especially at higher doses.
ReferencesBritish N
ational Formulary 74 (Septem
ber 2017)Palliative C
are Formulary 5th Edition (2014)
Palliative Adult N
etwork G
uidelines (PAN
G) 2016.
ww
w.book.pallcare.info
Health and Social C
are Board NI Form
ulary http://niformulary.hscni.net
Royal College of A
naesthetists. Opioids A
ware: A
resource for patients and healthcare professionals. w
ww
.rcoa.ac.uk/faculty-of-pain-m
edicine/opioids-aware
National Patient Safety A
gency. 2008. Reducing dosing errors with
opioid medicines. N
PSA/2008/RRR005
Electronic Medicines C
ompendium
2017. Summ
ary of Product C
haracteristics Tapentadol. Personal com
munication. G
runenthal June 2017
Developed w
ith input from the H
ealth and Social Care Board Pharmacy and M
edicines M
anagement Team
January 2018. For review January 2021
• Ensure you are fam
iliar with the follow
ing characteristics of that medicine and
formulation: usual starting dose, frequency of adm
inistration, standard dosing increments,
symptom
s of overdose, comm
on side effects.
• C
onfirm the m
ost recent opioid dose, formulation, frequency of adm
inistration and any other analgesic m
edicines prescribed for the patient.
• Ensure w
here a dose increase is intended, the calculated dose is safe for the patient (e.g. generally by a third but not norm
ally more than 50%
higher than the previous dose). U
se caution in higher doses.
• W
hen making a planned opioid sw
itch, if there is no stated opioid equivalent, usual practice is to convert to the oral m
orphine equivalent and then to the chosen opioid.
• C
onsider reduced doses in elderly, cachectic and debilitated patients. In renal or significant hepatic im
pairment, seek further advice.*
• W
hen switching opioids it is recom
mended that a 25 - 50%
reduction of the calculated dose of the new
opioid should occur. This is to allow for cross tolerance, w
here tolerance to a currently adm
inistered opioid may not extend com
pletely to other opioids. The new
regimen m
ay need to be increased or decreased accordingly. Monitor patients closely,
especially at higher doses.
• The addition of adjuvant analgesia m
ay require reduction of the opioid dose.•
Before prescribing opioids or increasing doses:
• All patients should be m
ade aware of the potential risks, side-effects and potency of
opioids. Patient information available at http://niform
ulary.hscni.net
• W
hen considering prescribing opioids for persistent non-malignant pain, m
edication w
ill achieve a 30-50% pain reduction at best. The risk of harm
increases substantially above daily doses of oral m
orphine sulfate 120mg (or equivalent), w
ithout significant benefit. Suitable pain self m
anagement should also be explored w
ww
.paintoolkit.org
• Transderm
al Opioid Conversion
• Transdermal patches are N
OT appropriate w
hen rapid titration of opioids is required e.g. acute pain. U
se in stable pain. • O
n first applying or increasing patch, systemic therapeutic levels are not reached for at
least 12 hours. Doses should not be changed m
ore regularly than every 48 hours.
• On rem
oval of an opioid patch a reservoir of the drug remains under the skin w
ith levels falling by 50%
(half-life) approximately every 18 to 24 hours.
• For inform
ation on initiating, changing or stopping transdermal opioids refer to
Palliative Adult N
etwork G
uidelines ww
w.book.pallcare.info
Health and Social Care
in Northern Ireland
Breakth
rou
gh
An
algesia in
Palliative C
areIn palliative care the standard dose of a strong opioid for breakthrough pain is usually one-sixth of the regular 24 hour dose, repeated every 4 to 6 hours as required.
The BNF prescribing in palliative care guidance
also supports use (outside the product licence) every 2 to 4 hours as required (up to hourly m
ay be needed if pain is severe or in the last days of life).
14
In persistent non-malignant pain, patients
should not routinely require breakthrough analgesia except prior to events likely to cause pain e.g. dressing changes.
Buprenorphine Patch e.g. Butec®, BuTrans
® Replace patch EV
ERY 7 D
AY
S
Patch strength(m
icrograms per hr)
Oral dose over 24 hours (m
g)
Morphine
Tramadol
Codeine/
Dihydrocodeine
5 microgram
s/hr~10 - 12
~100~120m
g/day
10 microgram
s/hr~20 - 24
~200~240m
g/day
20 microgram
s/hr ~40 - 48
~400
Oral M
orphine to Oral O
xycodone – Divide by 2
E.g. 30mg O
ral Morphine = 15m
g Oral O
xycodone
Oral M
orphine to Oral H
ydromorphone – D
ivide by 7.5 E.g. 30m
g Oral M
orphine = 4mg O
ral Hydrom
orphone
Oral Tapentadol ‡ to O
ral Morphine – D
ivide by 2.5 E.g. 50m
g Oral Tapentadol = 20m
g Oral M
orphine
Oral Tapentadol ‡ to O
ral Oxycodone – D
ivide by 5 E.g. 50m
g Oral Tapentadol = 10m
g Oral O
xycodone
Oral Tram
adol ‡ to Oral M
orphine – D
ivide by 10 E.g. 100 m
g Oral Tram
adol = 10 mg O
ral Morphine
Oral Tram
adol ‡ to Oral Tapentadol ‡ – D
ivide by 4E.g. 200m
g Oral Tram
adol modified release = 50m
g Oral Tapentadol
modified release
Oral Codeine / D
ihydrocodeine to Oral M
orphine – Divide by 10
E.g. 240 mg O
ral Codeine / D
ihydrocodeine = 24 mg O
ral Morphine
Oral M
orphine to Subcutaneous (SC) Diam
orphine – Divide by 3
E.g. 30 mg O
ral Morphine = 10 m
g SC D
iamorphine
Oral M
orphine to SC Morphine – D
ivide by 2 E.g. 30 m
g Oral M
orphine = 15 mg SC
Morphine
Oral M
orphine to SC Alfentanil – D
ivide by 30 E.g. 30 m
g Oral M
orphine = 1 mg SC
Alfentanil
Oral O
xycodone to SC Oxycodone – D
ivide by 2 E.g. 10 m
g Oral O
xycodone = 5 mg SC
Oxycodone
Oral H
ydromorphone to SC H
ydromorphone – D
ivide by 2 E.g. 4 m
g Oral H
ydromorphone = 2 m
g SC H
ydromorphone
PO (O
ral) to PO
PO (O
ral) to SC (Subcutaneous)SC (Subcutaneous) to SC
SC Diam
orphine to SC Alfentanil – D
ivide by 10E.g. 10 m
g SC D
iamorphine = 1 m
g SC A
lfentanil
SC Morphine to SC D
iamorphine – D
ivide by 1.5 E.g. 15 m
g SC M
orphine = 10 mg SC
Diam
orphine
SC Morphine to SC O
xycodone – D
ivide by 2E.g. 20 m
g SC M
orphine = 10 mg SC
Oxycodone
Note this m
ay differ from other available conversions
SC Morphine to SC A
lfentanil – Divide by 15
E.g. 15mg SC
Morphine = 1m
g SC A
lfentanil
Buprenorphine Patch e.g. Transtec®
PatchReplace patch TW
ICE WEEK
LY (every 3 or 4 days)
Transtec®
Patch (microgram
s/hr)24 hour O
ral M
orphine Dose
35 microgram
s/hr~ 63 - 97m
g
52.5 microgram
s/hr~ 95 - 145m
g
The doses below are not recom
mended for persistent non-
malignant pain
70 microgram
s/hr~ 126 - 193m
g
140 microgram
s/hr~ 252 - 386m
g
Fentanyl Patch e.g. Mezolar
®, D
urogesic®
Replace patch every 3 days
Fentanyl Patch (m
icrogram/hr)
Equivalent 24 hourly Oral
Morphine D
ose (mg)
1230-59
2560-89
3790-119
50120-149
The doses below are not recom
mended for
persistent non-malignant pain.
62150-179
75180-239
100240-299
125300-359
150360-419
175420-479
200480-539
225540-599
250600-659
275660-719
300720-779
Transdermal to O
ral
Transdermal to O
ral
32
Specialist Palliative Care only. Oral M
orphine to SC Fentanyl D
ivide by 150 e.g. 15mg O
ral Morphine = 100 m
icrograms SC
Fentanyl
‡Analgesia only partly opioid-m
ediated. Potential for increased opioid-related side effects w
hen switching
to other opioids.
Approxim
ate equivalent doses of opioid analgesics for adult use Read page1 before using these equivalence tables
The following medicines are stocked by all network pharmacies DRUG STOCK DRUG STOCK
Alfentanil 1mg/2ml Injection 1 x 10 Lorazepam 1mg Tablets (Brands
Genus, Teva, Mylan, Lexon) NEW
1 x 28
Cyclizine 50mg/ml Injection 2 x 5 Metoclopramide 10mg/2ml Injection 1 x 10
Cyclizine 50mg Tablets NEW 1 x 100 Metoclopramide 10mg Tablets NEW 2 x 28
Dexamethasone 3.3mg/ml Injection 1 x 10 Midazolam 10mg/2ml Injection 2 x 10
Diamorphine 5mg Injection 1 x 5 Midazolam Buccal Solution (Epistatus®)
10mg/ml NEW
1 x 5ml
Diamorphine 10mg Injection 2 x 5 Morphine Sulfate (Oramorph®)
10mg/5ml Solution VOLUME
INCREASED
3x100ml and 1x300ml
Diamorphine 30mg Injection 2 x 5 Morphine Sulfate 10mg/ml Injection 1 x 10
Diamorphine 100mg Injection 1 x 5 Morphine Sulfate 30mg/ml Injection 1 x 10
Diazepam 2mg Tablets NEW 1 x 28 Ondansetron 4mg/2ml Injection 1 x 5
Diazepam Oral 10mg/5ml
Suspension/Solution NEW
2 x 200ml Ondansetron Orodispersible Films 4mg
NEW
1 x 10
Furosemide 50mg/5mls Injection 1 x 10 Oxycodone 5mg/5ml Syrup 1 x 250ml
Glycopyrronium 200micrograms/ml Injection
1 x 10 Oxycodone 10mg/1ml Injection 2 x 5
Haloperidol 5mg/ml Injection 1 x 10 Oxycodone 20mg/2ml Injection 2 x 5
Haloperidol Caps or Tabs 500mcg
NEW
3 x 28 Oxycodone 50mg/1ml Injection 1 x 5
Haloperidol Oral Solution 5mg/5ml
NEW
1 x 100ml Oxygen Cylinders and one giving set 2 x Size AF
Hyoscine Butylbromide 20mg/ml (Buscopan®) Injection
1 x 10 Paracetamol 500mg Tablets NEW 100
Hyoscine Hydrobromide 400micrograms/ml Injection
1 x 10 Paracetamol Soluble Tablets 500mg
NEW
100
Hyoscine Hydrobromide (Kwells®)
Sublingual Tablets 300mcg NEW
2 x 12 Paracetamol Suppositories 500mg
NEW
2 x 10
Hyoscine Hydrobromide Patch 1mg
(Scopoderm®) NEW
1 x 2 Paracetamol Suspension/Solution
250mg/5ml NEW
2x 500ml
Levomepromazine 25mg/ml Injection
1 x 10 Prochlorperazine Buccal Tablets 3mg
NEW
1 x 50
Levomepromazine 6mg Tablets 1 x 28 Sodium Chloride 0.9% 10ml Injection 1 x 10
Levomepromazine 25mg Tablets (if
6mg unavailable) NEW
1 x 28 Water for Injection 10ml
2 x 10
Information correct as of April 2020. For review January 2022.
Community Pharmacy Palliative Care
Network Information for Healthcare Professionals 2020
Palliative care is provided by all community pharmacies and patients and carers
should always be encouraged to use their regular pharmacy to obtain medicines. If
they cannot supply a medication within the required timeframe, contact a network
pharmacy.
Network pharmacies are spread throughout Northern Ireland and aim to increase
access to community pharmacy palliative care services. They can supply medicines
from the palliative stock list (see back page) or be contacted for advice.
Please note:
Outside normal working hours, local arrangements for the supply of
medicines may exist. Contact your local GP Out of Hours Centre.
‘Anticipatory prescribing’ for patients approaching end of life ensures
medicines are available to relieve symptoms as soon as they occur. This can
greatly improve patient comfort and prevent delays accessing medicines.
Information on symptom control at the end of life is available at:
http://niformulary.hscni.net/Formulary/Adult/PalliativeCare
Prescribe sufficient quantities of medicines to cover weekends and out of hours. Prescriptions for controlled drugs must meet the legal requirements:
Drug name, form, strength, dose and frequency.
Total quantity in words and figures, prescriber’s signature
e.g. Morphine Sulfate injection 5mg to be given subcutaneously every four hours
when required for breakthrough pain. Supply Ten (10) x 10mg/ml injection
Southern Area
Armagh
McKeevers Chemists,
33-37 Ogle Street
Mon-Fri 9am-6.00pm
Sat 9am-5.30pm
Tel. 3752 2685
Lurgan
McKeagney Chemist,
10 Edward Street
Mon-Fri 9am-6pm, Sat
9am-5.30pm
Tel. 3832 2295
Aughnacloy
Aughnacloy Pharmacy
67-69 Moore Street
Mon-Sat 9am-6pm
Tel. 8555 7943
Moy
Gordons Chemists,
1 Killyman Street
Mon-Fri 9am-6pm, Sat
9.00am-5.30pm
Tel. 8778 4248
Banbridge
Clear Pharmacy,
19-21 Bridge Street
Mon-Sat 9am - 5.30pm
Thur 9.00am - 5.00pm
Tel. 4066 2622
Newry
Cherrymount
Healthcare Ltd, 5 John
Mitchel Place
Mon-Fri 9am-6pm
Sat 9am-5.30pm
Tel. 3026 2606
Crossmaglen
Health Centre
Pharmacy McCormick
Place
Mon-Fri 9am-1pm and
2pm-5.30pm
Tel. 3086 8314
Portadown
Hamill’s Pharmacy
17 Thomas Street
Mon-Fri 9am-6 pm, Sat
9am-1pm
Tel. 3835 2471
Stock list also available from the following pharmacies with extended opening hours:
Dungannon Boots Pharmacy, Oaks Centre, Mon-Wed 9am-5.30pm, Thurs-Fri 9am-9pm, Sat 9am-
5.30pm, Sun 1pm-6pm. Tel. 8772 6626
Craigavon Boots Pharmacy, Rushmere Shopping Centre, Mon-Fri 8.45am-9pm, Sat 8.45am-6pm,
Sun 1pm-6pm Tel. 3834 6885
Newry Medical Hall, The Quays Centre. Mon-Tues 9am-6pm, Wed-Fri 9am-9pm, Sat 9am-6pm,
Sun 1pm-6pm Tel. 3083 3781
Western Area
Belleek
McGuinness
Pharmacy, 4 Main
Street
Mon-Sat 9.30am-6pm
Tel. 6865 8218
Limavady
Gormley Medicare Ltd,
171 Irish Green Street
Mon-Sat 9am-5.30pm
Tel. 7772 2508
Castlederg
Corrys Chemist
11-12 The Diamond
Mon-Fri 9am-6pm, Sat
9am-5.30pm
Tel. 8167 1974
Lisnaskea
Armstrongs Pharmacy,
119 Main Street
Mon-Sat 9am-6pm
Tel. 6772 1231
Derry
Murphy's Chemist,
165 Spencer Road
Mon-Sat 9am-9pm,
Sun 12.30pm-1.30pm
Tel. 7131 1720
Omagh
Kelly’s Chemist
41 High Street
Mon-Sat 9am-6pm
(Wed to 5.30pm)
Tel. 8224 2030
Derry
Medicare Pharmacy,
43 Great James Street
Mon-Fri 9.15am–
6.15pm
Tel. 7126 7004
Strabane
Medicare Pharmacy,
340a Ballycolman
Estate
Mon-Fri 9am-6pm,
Tel. 7138 2252
Enniskillen
Erne Pharmacy, 12
Church Street
Mon-Fri 9am-6pm, Sat
9am-5.30pm
Tel. 6632 2291
Stock list also available from the following pharmacies with extended opening hours:
Derry Whitehouse Pharmacy, 65 Buncrana Road, Mon-Thurs 9am-6pm, Fri 9am-9pm, Sat 9am-
6pm Tel. 7136 7191
Omagh Boots Pharmacy, 43-47 High Street, Mon-Thurs 8.45am-5.45pm, Fri 8.45am-9pm, Sat 9am-
5.45pm, Sun 1pm-5pm Tel. 8224 5455
Belfast & South Eastern Areas
Belfast
Gordons Chemists 13 Greenway, Cregagh Road
Mon-Fri 9am-6pm Sat 9am-5.30pm Tel. 9040 1023
Downpatrick Gordons Chemists 37 Market Street
Mon-Sat 9am-5.30pm Tel. 4461 2014
Belfast
Crossin Chemist 267 Antrim Road
Mon-Fri 9am-6pm Sat 9.30-5.30 Tel. 9035 1084
Holywood
Sweeney’s Pharmacy 52 High Street
Mon-Sat 9am-5.30pm Tel. 9042 2222
Belfast
McCoubrey Chemists 154 Cavehill Road
Mon-Fri 9am-6pm Sat 9am-1pm Tel. 9039 1169
Kircubbin McKeevers Chemists 40 Main Street
Mon-Sat 9am- 5.45pm Tel. 4273 8235
Belfast
Dohertys Pharmacy 115-117 Andersonstown Rd
Mon-Fri 9am-6pm Sat 9am-5.30pm Tel. 9061 3832
Lisburn
Boots Pharmacy 57-59 Bow Street
Mon-Wed 9am-5.30. Thurs 9am-9pm, Fri-Sat 9am-6pm. Sun 1pm- 5pm Tel. 9266 2193
Belfast
McMullans Pharmacy 165 Lisburn Road
Mon-Sat 9am- 5.30pm Tel. 9038 1882
Newcastle Gordons Chemists 16 Railway Street
Mon-Fri 9am-6pm Sat 9am-5.30pm Tel. 4372 2724
Bangor
Gordons Chemists 110 Abbey Street
Mon-Fri 9am-6pm. Sat 9am-1pm and 2pm- 5.30pm Tel. 9127 0408
Newtownards Boots Pharmacy 104-108 Frances St
Mon-Fri 9am-9pm Sat 9am-6pm Tel. 9182 3700
Stock list also available from the following pharmacies with extended opening hours
Newtownards Boots Pharmacy, Ards Shopping Centre.
Mon-Fri 9am-9pm, Sat 9am-5.30pm, Sun 1pm-5.30pm Tel. 9181 1297
Northern Area
Antrim Clear Pharmacy, The Health Centre
Mon-Fri 9am-6pm Tel. 9446 3495
Draperstown O’Kane’s Pharmacy, 6 Tobermore Road
Mon-Fri 9am-6pm, Sat 9am-5.30pm Tel. 7962 8209
Ballycastle McMullan’s Pharmacy, 63 Castle Street
Mon-Sat 9am-6pm Tel. 2076 3135
Larne
Larne Chemists The Health Centre
Mon-Fri 9am-6pm, Sun 1-2 pm Tel. 2826 0696
Ballymoney Mathewson’s Pharmacy 51-53 Queen Street
Mon & Thurs 8.30am- 7pm, Tues, Wed, Fri & Sat 8.30-6pm Tel. 2766 4600
Sat 9am-5.30pm, Sun 2-5pm from McFarlane’s Pharmacy 86-88 Main Street, Larne Tel. 2826 0768
Magherafelt O’Briens Pharmacy, 5 Broad Street
Mon-Sat 9am-6pm Tel. 7963 3333
Coleraine
Boots Pharmacy,
Asda Shopping Centre, Ring Road
Mon- Fri 9am-9pm, Sat 9am-5.30pm, Sun 1pm- 6pm Tel. 7032 1596
Randalstown Randalstown Pharmacy, Medical Centre, 5 Neillsbrook Road
Mon-Fri 8.30-6pm. Tel. 9447 2245
Sat 9am-5.30pm operating from 46/48 High St, Randalstown Tel. 9447 2751
Carrickfergus Carrickfergus Chemists, The Health Centre
Stewartstown
F P Kelly,
12 The Square
Mon-Fri 9am-6pm, Sat 9am-1pm Tel. 8773 8241
Mon- Fri 8.45am - 8pm Tel. 93365111
Stock list also available from the following pharmacies with extended opening hours
Ballymena LLoyds Pharmacy (in Sainsburys), Braidwater
Retail Park, Mon-Fri 8am-10pm Sat 8am-8pm Sun 1-6pm
Tel. 2565 3420
Newtownabbey Boots Pharmacy, Abbeycentre,
Mon-Fri 9am-9pm, Sat 9am-6pm, Sun 1pm-6pm Tel. 9036 5910
Consider
Discussions about goals of care
COVID-19 Outbreak
Talking to patients and those close to them about prognosis, ceilings of treatment and possible end of life care is often challenging but, in the current COVID-19 outbreak, such conversations with the population described may become even more difficult, as health professionals may have to triage patients, often in emergency or urgent situations, and prioritise certain interventions and ceilings of treatment.
Background
The UK population is ageing and many more people are living with chronic illness and multiple comorbidities. A third of patients admitted unexpectedly to hospital (rising to 80% in those living in 24-hour care) are in the last year of their lives. Despite such facts, few have ever had discussions about ceilings of treatment or resuscitation. Such conversations, which constitute advance care planning, are useful during normal times, but even more so during the COVID-19 outbreak. Open, honest discussions regarding ceilings of treatment and overall goals of care are not only essential to ensure that those with significant potential to recover receive appropriate care, but also that those who are very unlikely to survive also receive appropriate, end of life care. Such decisions may have to be made when health professionals have not had the opportunity to get to know their patient as well as they would usually like, or may involve discussion with those close to the patient over the telephone or via internet-based communication facilities. While this is less than ideal, honest conversations are often what patients and those close to them actually want. While palliative, end of life and bereavement care professionals cannot take over responsibility for this aspect of care and have the conversations for you, they should be able to support, advise and provide follow up care.
don’t make things more complicated than they need to be; use a framework such as SPIKES: o Setting / situation
read clinical records, ensure privacy, no interruptions
o Perception what do they know already?; no assumptions
o Invitation how much do they want to know?
o Knowledge explain the situation; avoid jargon; take it slow
o Empathy even if busy, show that you care
o Summary / strategy summarise what you’ve said; explain next steps
should ceilings of treatment conversations include ethical issues, for example where escalation to Level 3 care is thought not to be appropriate due to frailty, comorbidity or other reasons, health professionals should be prepared for anger / upset / questions o these are usually not aimed directly at you,
but you may have to absorb these emotions and react professionally, even if they are upsetting / difficult at the time
o patients or those close to them may request a ‘second opinion’ – this should be facilitated wherever possible
be honest and clear o don’t use jargon; use words patients and
those close to them will understand o sit down; take time; measured pace and tone;
use silences to allow people to process information
o avoid using phrases such as “very poorly” on their own – is the patient “sick enough that they may die”? If they are – say it
Source: COVID-19 and Palliative, End of Life and Bereavement Care (27 March 2020) https://apmonline.org/
Grievingin exceptional
timesWhat is Grief?A death in your family or in your circle of friends is always difficult. You may feelshocked, upset, tearful or distressed. You may find it difficult to concentrate andto realise what has happened. You may be angry or frightened. Theseexperiences are particularly confusing and intense in the early days and weeksof a bereavement. In Ireland, we have a long tradition of coming together in the days after a death.We all understand the rituals that happen around a death, and they oftenprovide comfort. These may involve a wake, a funeral, a burial or cremation.There may be a gathering or meal after the funeral and later, a month’s mind. People have found arranging a funeral, meeting with family and friends to behelpful. We share stories and memories about the person who died. We laughand we cry. We pay tribute to the person who died through our mourning. The Covid-19 pandemic has changed the traditional ways we mark our grief. For themoment, it is not possible to come together and to gather in one location. It isnot possible to have a large funeral. It may not be possible to receive thecompany of those who wish to offer condolences. However, we can support ourselves and each other in different ways.
20TH MARCH 2020 - VER 1 The Irish Hospice Foundation Care & Inform Series
Try not to become emotionally isolated. Even if people cannot visit you, allowthem to offer their condolences and support in different ways; you mayreceive texts, emails and messages through social media as well as phonecalls. Try to allow yourself to feel and react in a way that is natural to you. Wesometimes say that ‘grief is the price we pay for love’, and there is no doubtbut it is painful. Keep conversations going with the people who are closest to you, yourfamily or close circle of friends. Even if those closest to you are not physically near, reach out to them andmake sure to telephone someone each day. Having ‘conversations’ through WhatsApp or through Facebook can meanthere is a regular flow of communication through the day. They can remindyou that people are thinking about you. Remember to eat and to keep hydrated. Your body has needs and grief ishard work. Keeping some routine can be helpful and mealtimes play an important partin this. So too, does bed-time and getting-up time. Try to stick to yournormal routine as much as possible. Try getting out in the garden, if possible. If there are children in your family, check-in with them often. Answer theirquestions honestly. Don’t ‘fob them off’. There are some useful resourcesbelow. Children may appear sad and happy in the space of minutes. It can belikened to jumping in an out of the puddles. Let children set their own pace. Try to limit how much news and social media you consume – when you arefeeling very sad, regular news can be distressing.
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Remember: In grief you can only do the best you can, try to be tolerant
and kind to yourself.
Ten ways to support yourselfwhen you are grieving
www.bereaved.ie#IHFsupportingyou #Covid19Ireland
To help a grieving friend, think about how you might send your condolences
– write a card, complete an online condolence such as on RIP.ie, send a text
or telephone. You might share photos or drop food and little gifts at a
person’s door to offer comfort.
Reach out, make yourself available not just in the short term but in the weeks
and months to come.
Ask your friend how they are doing, ask what might help, listen carefully.
Offer practical help, for example with meals, shopping etc.
Offer to help with technology, for example with setting up video calls, What’s
App or other ways of keeping in touch.
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Five ways to help others who aregrieving
Call Message Write Conference
www.bereaved.ie#IHFsupportingyou #Covid19Ireland
Bereaved.ie |www.bereaved.ie
What’s Your Grief |https://whatsyourgrief.com/mental-health-and-
coronavirus/
HSE minding your mental health| https://www2.hse.ie/wellbeing/mental-
health/minding-your-mental-health-during-the-coronavirus-outbreak.html
Department of Education and Skills |https://www.education.ie/en/The-
Department/Announcements/talking-to-children-and-young-people-about-
covid-19-coronavirus-advice-for-parents-and-schools.pdf
Irish Childhood Bereavement Network|
https://www.childhoodbereavement.ie
If you have questions or worries about Covid-19 listen to the advice of the
professionals as offered through the HSE. https://www2.hse.ie/coronavirus/
You might find it useful to look at bereavement websites or resources or videos.
Some useful websites and resources include;
Talking to children about Corona virus|https://krisepsykologi.no/what-can-we-
say-to-children-about-coronavirus/
Useful Resources
This leaflet is brought to you by The Irish Hospice FoundationIf you would like to support us you can do so online at www.hospicefoundation.ie
www.bereaved.ie#IHFsupportingyou #Covid19Ireland