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

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Presentation on theme: "Anticipatory prescribing Dr Jason Ward Consultant in Palliative Medicine, Mid Yorkshire NSH Trust, & Honorary Senior Lecturer, University of Leeds."— 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 Control of symptoms Preparation for death Preparation for death Opportunity for closure or "sense of completion" of the life Opportunity for closure or "sense of completion" of the life Good relationship with healthcare professionals 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 Prevalence 41-92% patients Most common with lung or cerebral primaries Most common with lung or cerebral primaries Median duration of onset 23 hours Median duration of onset 23 hours

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

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

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

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

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

10 Transdermal analgesia NameDrugApply Lowest dose Oral morphine Equivalent 24 hours Durogesic D-Trans Fentanyl 3 days 25mcg-90mg TranstecBuprenorphine 35mcg30-60mg BuTransBuprenorphine 7 days 5mcg5-10mg

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

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

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

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

16 Confusion/delirium Haloperidol Haloperidol 3-5mg stat sc repeated as necessary 3-5mg stat sc repeated as necessary Generally 5 - 10mg/24hrs Generally 5 - 10mg/24hrs Levomepromazine Levomepromazine Sedating anti-psychotic Sedating anti-psychotic 25mg-50mg stat 25mg-50mg stat Infusion 50-300mg/24 hrs Infusion 50-300mg/24 hrs

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

18 ‘Terminal’ nausea Persistent or intermittent Persistent or intermittent Small vomits, ‘possets’, retching Small vomits, ‘possets’, retching Chemical cause HypercalcaemiaUraemiaJaundiceInfection

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

20 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 Costs Costs


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