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Anticipatory prescribing

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Presentation on theme: "Anticipatory prescribing"— Presentation transcript:

1 Anticipatory prescribing
Dr Jason Ward Consultant in Palliative Medicine, Mid Yorkshire NSH Trust , & Honorary Senior Lecturer, University of Leeds

2 Factors important for a good death
Control of symptoms Preparation for death Opportunity for closure or "sense of completion" of the life Good relationship with healthcare professionals Steinhauser KE 2000

3 Symptoms on the last 48 hours
Sweating Confusion Pain Urinary dysfunction Breathlessness Death rattle Nausea and vomiting Restlessness/agitation Jerking/plucking/twitching

4 Death rattle Prevalence 41-92% patients
Most common with lung or cerebral primaries Median duration of onset 23 hours

5 Death rattle How do relatives interpret it?
Awful/horrible/terrible Nothing/expected Relief/sign of dying Wee B et al 2006

6 Management of death rattle
Non drug management Discuss with family/carers Re-position Drug - hyoscine butylbromide (buscopan) 20mg sc stat 60-120mg/24hrs Bennett M 2002

7 Pain Cancer Cancer treatment Debility e.g. immobility
Concurrent problems e.g. osteoarthritis

8 Analgesics (1) Paracetamol NSAIDs Liquid, suppository
No subcut preparation NSAIDs Diclofenac PR 100mg od

9 Analgesics (2) Diamorphine Morphine sulphate
Divide total daily dose of oral morphine by 3 = total daily dose of subcut diamorphine Opioid naïve 2.5mg sc PRN 5-10mg/24hrs Morphine sulphate Divide total daily dose of oral morphine by 2 Opioid naïve 2.5mg sc PRN

10 Transdermal analgesia
Name Drug Apply Lowest dose Oral morphine Equivalent 24 hours Durogesic D-Trans Fentanyl 3 days 25mcg -90mg Transtec Buprenorphine 35mcg 30-60mg BuTrans 7 days 5mcg 5-10mg


12 The dying patient with a patch
Continue current patch strength and replace every 72 hours Supplement with diamorphine prn and/ or syringe driver ‘Rule of 5’ Fentanyl 25mcg/5= 5mg diamorphine prn

13 Restlessness Agitation/restlessness Confusion/delirium Vs
Disorientated Hallucinations Sleep-wake reversal Plucking

14 General Management Reverse the ‘easily’ reversible Explanation
Full bladder, position, pain Explanation Environment Family

15 Agitation Benzodiazapine Midazolam
Useful alone if fear/anxiety is the only feature Midazolam 2.5-5mg stat Repeat every 60mins if needed 10mg-60mg/24 hrs

16 Confusion/delirium Haloperidol Levomepromazine
3-5mg stat sc repeated as necessary Generally mg/24hrs Levomepromazine Sedating anti-psychotic 25mg-50mg stat Infusion mg/24 hrs

17 Breathlessness Fan, open window Breathlessness/cough/tachypnoea
Diamorphine Opioid naïve 2.5mg stat, 5-10mg/24hrs Or increase dose by 1/3rd Breathlessness/anxiety Midazolam 2.5 mg stat, 10-30mg /24hrs

18 ‘Terminal’ nausea Persistent or intermittent
Small vomits, ‘possets’, retching Chemical cause Hypercalcaemia Uraemia Jaundice Infection

19 Anti-emetics Cyclizine May precipitate with hyoscine butylbromide
50mg stat 150mg/24hrs, May precipitate with hyoscine butylbromide Avoid saline May cause irritation

20 INJ HYOSCINE BUTYLBROMIDE 20mg / ml 5 x 1ml amps as dir
EXAMPLE INJ CYCLIZINE 50mg / ml 5 X 1ML amps as dir INJ HYOSCINE BUTYLBROMIDE 20mg / ml 5 x 1ml amps as dir INJ MIDAZOLAM 5mg / ml 5 x 2ml INJ DIAMORPHINE 5mg 5 ( five ) x 5mg (five milligram) WATER FOR INJECTION 10 X 10mls amps

21 To foresee and take care of in advance

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