1. Symptom Control in the Last 48hrs
Dr Bisharat El Khoury
Consultant in Palliative Medicine NUH

2. Objectives Recognise patient is dying Planning end of life care-MDT
Symptom management
Psychological and emotional support
Patient and family/ carers
Each other

6. How do you recognise a patient is dying?

7. Recognising Death Profoundly weak Bed bound Very limited oral intake
Drowsy/ semi-comatose
Confused/ agitated
Unable to swallow medication

8. Planning End of Life Care
Wishes of family/ coping at home
Planning for crisis – Anticipatory Prescribing
Drug administration and prns
Discuss 999/ resuscitation
DNACPR

9. Main Aims of Treatment STOP unnecessary drugs
STOP unnecessary intervention i.e. BP, pulse
Manage symptoms
Psychological support
Patient
Carers/ family
Yourself

10. Management
Continue to assess bladder, bowels

11. Indications for Using a Syringe Driver
Essential meds if unable to take oral
Semi-comatose
Vomiting, swallowing difficulties
Confused/ agitated

12. Symptoms Pain Nausea & Vomiting Terminal agitation Breathlessness
Death rattle
Haemorrhage

13. Pain Assess cause i.e. urinary retention Route of medication
Ensure breakthrough analgesia available

14. Pain – If Not On Opioids
Provide prn morphine 2.5-5mg sc up to 1hrly if needed
Review after 24hrs – if 2+ doses start syringe driver

15. Pain-if On Opioids
Convert 24hr PO morphine to 24hr CSCI morphine – divide by 2
Convert 24hr PO morphine to 24hr CSCI diamorphine – divide by 3
Convert 24hr PO oxynorm to 24hr CSCI oxycodone – divide by 2
Continue to give prn pain relief if needed (1/6 of total)

16. Pain
Do not start Fentanyl patches
Provide prn analgesia

17. Fentanyl and Equivalent Doses Compared to Oral Morphine 1:100
Fentanyl patches
mcg/72hrs
Morphine po
Mg/24hrs 12 30 25 60 50
120 75
180
100
240

18. Fentanyl Patches in the Terminal Phase
Leave patch on, continue to change every 72hrs
Give doses of sub cut morphine for breakthrough pain
If 2+ prns needed/ 24hrs give morphine by CSCI starting with sum of prn doses in last 24hrs

19. Renal Impairment e GFR < 30ml/min Stage 4/5 Chronic Kidney Disease
There is no exact equivalence between opioids

20. Anticipatory Medication Renal Impairment - Pain
Use smaller doses of opioids the patient is on ie 1/2mg oxycodone/ morphine po/sc
Better to be familiar with the opioid
Opioids of choice are Alfentanil and Fentanyl

21. Renal Impairment – Pain if not on regular opioid
Alfentanil 100micrograms or Fentanyl 25micrograms prn
If needing prns consider syringe driver with Alfentanil 500mcg or Fentanyl 100mcg

22. Alfentanil 1mg Alfentanil subcut is equivalent to 30mg oral morphine
Hepatic metabolism inactive metabolites excreted in urine
Rapid onset of action and used in procedure related pain
Ensure prn dose

23. Fentanyl 1mg Fentanyl is equivalent to 150mg oral morphine
Can use trans mucosal Fentanyl products earlier
Fentanyl patch continue and use prns
Ensure prn doses available

26. A 51-year-old woman with a history of hypertension and chronic constipation presented with abdominal pain of 2 weeks' duration
A 51-year-old woman with a history of hypertension and chronic constipation presented with abdominal pain of 2 weeks' duration. The pain was continuous, worsened with eating, was associated with nausea, and radiated to her back. She reported no vomiting, fever, diarrhea, or weight loss, and her vital signs were normal. Her abdomen was distended, diffusely tender on palpation, and tympanic on percussion on the upper half and dull on the lower half. Bowel sounds were missing on the left side, and a large mass was palpated in that area. Laboratory evaluation was unremarkable. Computed tomography (CT) showed massive dilatation of the stomach, and gas was seen distally on a CT scan. More than 4 liters of fluid was drained from the patient's stomach during the first 24 hours. Upper gastrointestinal endoscopy showed no evidence of peptic ulcer disease or cancer but did show hypertrophic pyloric stenosis. She underwent endoscopic balloon dilation of the pyloric sphincter, with immediate symptomatic relief and resolution of gastric dilatation. Within a few days, the patient returned to a normal diet, and 20 months later, she continued to do well.

27. Nausea & Vomiting
Nausea - unpleasant feeling of need to vomit, often with autonomic symptoms
Retching - rhythmic laboured movements of diaphragm and abdominal muscles
Vomiting- forceful expulsion of gastric contents

28. Common causes of N&V - cancer

29. Correct The Correctable
Cough - antitussive
Gastritis - antacid
Gastric irritant drugs - ie NSAID ? Stop
Constipation - laxative
Raised ICP - corticosteroid
Hypercalcaemia - zometa

30. N & V End of Life If cause known and previous antiemetics working
Continue and give parenterally

31. N & V End of Life
If cause unknown or unrelieved by previous antiemetics
Use levomepromazine broad spectrum
Start mg po/sc o.n. and prn
Can be given prn up to 1 hourly if needed
If 2+ doses use CSCI

32. Nausea & Vomiting Give regularly and reassess
Treat cause ie renal failure reduce opioids
Consider CSCI – can be used for anti-emetic alone
Seek advice

33. Terminal Agitation Change in behaviour Reduced awareness
Mental distress/ anguish
Fluctuating confusion
Hallucinations/ paranoid ideas

34. Terminal Agitation Associated with progressive multi-organ failure
Generally not reversible
Medication usually necessary
85% patients prior to death

35. Causes of Terminal Agitation
Psychological
Fear
Unfinished business
Biochemical
Liver/ renal failure
Raised calcium
Hypoxia
Physical
Pain
Full bladder
Full rectum
Hypoxia/ breathlessness
Cerebral metastases

36. Management of Terminal Agitation
Treat cause
General measures
Nursing the patient-reassure, environment, safety
Carers-explanation
Review drugs/ reduce medication
Treat symptom
Midazolam (high doses can sometimes worsen if used alone)
Levemepromazine

37. Drugs Commonly Used
Midazolam
Levomepromazine
Haloperidol

38. Drug Treatment Antipsychotics are the drug of choice
BZD if given alone can make agitation worse

39. Levomepromazine Phenothiazine antipsychotic, anti-emetic
Half life 16-30hrs
Analgesic properties
Sedating

40. Levomepromazine Highly anxious pts who are overwhelmed
Pain exacerbated with onset of delirium

41. Levomepromazine Typical breakthrough sc doses 6.25-12.5mg to 12.5-25mg
Syringe driver start mg/24hrs
Maximum dose 300mg/24hrs

42. Midazolam BZD Half life 2-5hrs Reduces neuronal activity
Single stat dose 2-3x more potent than diazepam

43. Midazolam CSCI 10-30mg to 30-60mg/24hrs
Start 20-30mg/24hrs if fitting/ on antiepileptics
Breakthrough doses 2.5-5mg to 5-10mg can be give hrly and with antipsychotic

44. Midazolam Can make agitation worse if used alone
If needing higher doses use an antipsychotic

45. Breathlessness
Subjective difficulty in breathing associated with high levels of anxiety and fear (different from tachypnoea and hyperventilation)
OHPC 2005

46. Breathlessness Explanation/ relaxation Repositioning Fan
If O2 sat< 90% use oxygen 2-4l/min

47. Breathlessness Common in palliative care 40-80%
Complicated pathopysiology
Do not assume it is caused by cancer
If due to cancer ? treat cancer
Look for reversible causes

48. Reversible causes ? Bronchopneumonia Anaemia Pleural effusion COPD PE
SVCO
Heart failure

51. Patients Experience Common trigger for panic
Intermittent – exertion, bending, talking
Restriction of ADL/ social life
Feelings anxiety, pain, impending death

52. Terminal Breathlessness
Explanation to family/ carers
Use opioid with sedative- anxiolytic CSCI
Diamorphine/ morphine + midazolam
If agitated add levomepromazine/ haloperidol

53. Drug Treatment -Opioids
Reduce ventilatory response so reducing respiratory effort and SOB
Also reduce tidal volume and RR
Generally more beneficial for pts SOB at rest

54. Opioid Naive Start low 2.5-5mg sc/po morphine
Titrate to response and effect
If 2+ doses in 24hrs prescribe regularly
Always provide prns

55. Patients on opioids Use PRN dose – may need less or more
Some patients may tolerate CSCI with morphine/ diamorphine better

56. Anxiolytics To reduce panic/ anxiety – use prn also Diazepam 1-2mg po
Lorazepam 0.5-1mg sl/po
Midazolam 2.5-5mg stat
Midazolam 5-10mg/ 24hrs CSCI

57. Respiratory Symptoms Severe acute stridor
Bleed into bronchus or trachea
Noisy tachypnoea

58. Oxygen Use if hypoxic Decreases work of breathing
Consider fan/ open window

59. Death Rattle Secretions in hypopharynx-oscillation
If patient not distressed treatment for carers/staff
Explanation important

60. Death Rattle
Support-explanation
Postural drainage
Suction

61. Death Rattle Main treatment Buscopan/ Hyoscine butylbromide
Give promptly-no effect on existing secretions
Maximum dose 300mg/24hrs

62. Death Rattle Stat dose buscopan 20mg sc up to hrly
If 2+doses in 24hrs start CSCI 40-80mg buscopan/ 24hrs
Continue to give prns if needed

63. Catastrophic Bleed Stay with patient Prepare-green/ red towels
Occasionally medication

64. Psychological Support
How long?
Loss control-explanation
Fear-feeling safe/ valued
Spirituality

65. Psychological Support
Prepare-drugs, catheter, driver etc
Recognising own emotions/ support each other

66. Bereavement
Follow up support
Risk factors
Discussion/ learning/ audit

67. Case Study
87yr woman lung ca dying at home, supportive family, symptoms well controlled
Current meds: oramorph 5mg tds, paracetamol, cyclizine 50mg tds

68. Swallowing becomes difficult – what do you suggest?

69. Prepare family
CSCI diamorphine 5mg, cyclizine 150mg/24hrs

70. The next day she becomes unsettled and c/o abdominal pain – what could be happening?

71. Urinary retention – the pain and agitation settle on catheterisation

72. Later she becomes agitated and verbally aggressive
Later she becomes agitated and verbally aggressive. The family admit this has been happening for short periods over the last few days.

73. Case Study Explanation
Unable to get medication she is admitted to QMC and dies the next day
CSCI diamorphine 5mg, levomepromazine 12.5mg, midazolam 10mg/24hrs

74. Contacts
Hayward House and ask switchboard to ring palliative care doctor on call
Direct line