End of Life Symptoms

Prescribing information:  for managing common end of life symptoms

Based on palliAGED - 'Prescribing and care in the terminal phase' 
 
For: Anxiety and emotional distress
Anticipatory prescribing:

• Midazolam - 2.5mg - 5mg SC every 2 hours PRN (non-PBS) (can be used in a syringe driver)
  or
• CLONazepam 0.25mg - 0.5mg oral or SC every 4 hours PRN (PBS) (cannot be used in a syringe driver)

Continuing management of anxiety and emotional distress:

• Calculate previous benzodiazepine doses, including PRN doses, and convert to a SC alternative given regularly over 24 hours, using either BD CLONazepam or a continuous SC infusion of midazolam
• Continue to administer additonal PRN doses as required

For anxiety and emotional distress which is not controlled by these measures seek palliative care advice.

For: Delirium which is causing distress
Anticipatory prescribing:

• Haloperidol - 0.5mg - 1mg SC twice a day PRN (PBS)

Continuing management of delirium which is causing distress:

• Give haloperidol regularly over 24 hours, either as a BD dose or in a continuous SC infusion
• Consider adding midazolam or CLONazepam if agitation persists
• Continue to administer additional PRN doses of haloperidol and / or benzodiazepine as required

For delirium which is not controlled by these measures seek palliative care advice.

For: Excessive secretions
Anticipatory prescribing:

• Hyoscine BUTYLbromide (Buscopan®) - 20mg SC every 2 - 4 hours PRN (PBS - palliative care listing)

Continuing management of excessive secretions:

• Give hyoscine BUTYLbromide (Buscopan®) regularly every 2 - 4 hours or as a continuous SC infusion of the previous 24 hour dose
• Continue to administer additional PRN doses as required

For excessive secretions which are not controlled by these measures seek palliative care advice.

For:  Nausea and vomiting
Anticipatory prescribing:

• Metoclopramide - 10mg SC three times a day PRN (PBS)
  or
• Haloperidol 0.5mg SC twice a day PRN (PBS)

Continuing management of nausea and vomiting:

• Give metoclopramide regularly SC three times a day or as a continuous SC infusion of 30 - 40mg 
  or
• Give haloperidol regularly twice a day or as a continuous SC infusion of 1 - 2 mg
• Continue to administer additional PRN doses as required

For nausea and vomiting which is not controlled by these measures seek palliative care advice.

For: Pain
Anticipatory prescribing:

• Morphine - 2.5mg to 5mg SC every 2 hours PRN (PBS)
  or
• Hydromorphone 0.5 - 1mg SC every 2 hours PRN (PBS)
  or
• Fentanyl 25 micrograms - 50 micrograms SC every 2 hours PRN (non-PBS)

Continuing management of pain:

• If an opioid patch is in situ consider continuing patch at same dose and ordering an opioid PRN dose SC for breakthrough pain 
  or
• Convert the patient’s previous oral and / or transdermal opioids (including all opioids that are being used) to an equivalent subcutaneous dose. Give either as a continuous subcutaneous infusion via a syringe driver over 24 hours, or divided as regular boluses every four  hours. See EviQ Opioid calculator for opioid conversions.
• Administer additional PRN doses of opioid as required
• For patients who are on regular opioids the PRN dose (or breakthrough dose) is proportional to their regular dose. Calculate it as:
• PRN dose ~ 10% of total daily SC opioid dose every 2 hours.

For pain which is not controlled by these measures seek palliative care advice.

For: Shortness of breath
Anticipatory prescribing:

• Morphine 1.25 - 2.5 mg SC every 2 hours PRN (PBS)

Continuing management of shortness of breath:

• Calculate the PRN opioid dose used in the previous 24 hours and give as either a continuous subcutaneous infusion over 24 hours in a syringe driver, or divided as regular subcutaneous doses every 4 hours
• If  already receiving opioids for pain, and the patient is distressed by shortness of breath, titrate up current regular opioid dose by 30%
• Administer additional PRN doses of the person’s regular opioid as required - for either pain or shortness of breath

For shortness of breath which is not controlled by these measures seek palliative care advice.

From: palliAGED Smartphone apps

• Ambulance plan NSW Government
• Brochure from PCA - About the process of dying
• palliAGED smartphone app
• Planning for a home death (Helping GPs Plan for an Expected Home Death – The Checklist)
• Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents: A Resource for General Practitioners (260kb pdf)
• Considerations for a Home Death Canadian Virtual Hospice

• Syringe Drivers
• Sharing Care (Model Letter)