End-of-life / anticipatory medication

Prescribing options to be considered:

MAAR Chart written up:

Morphine sulfate 2.5-5 mg SC for pain +/or breathlessness up to 2 hourly, max 30 mg/24 h

Haloperidol 0.5-1 mg SC for nausea/vomiting up to 6 hourly, max 3 mg/24 h

Cyclizine 50 mg SC for nausea/vomiting up to 8 hourly, max 150 mg/24 h

Midazolam 1.25-5 mg SC for agitation/distress up to 2 hourly, max 30 mg/24 h

Glycopyrronium 100-200 mcg SC for respiratory secretion up to 4 hourly, max 1.2 mg/24 h

Prescription provided:

Morphine sulfate 2.5-5 mg SC for pain +/or breathlessness up to 2 hourly, max 30 mg/24 h, supply 5 (five) 10 mg/ml (ten milligrams per one millilitre) ampoules

Haloperidol 0.5-1 mg SC for nausea/vomiting up to 6 hourly, max 3 mg/24 h, supply 5 5 mg/ml ampoules

Cyclizine 50 mg SC for nausea/vomiting up to 8 hourly, max 150 mg/24, supply 5 50 mg/ml ampoules

Midazolam 1.25-5 mg SC for agitation/distress up to 2 hourly, max 30 mg/24 h, supply 5 (five) 10 mg/2 ml (ten milligrams per two millilitres)

Glycopyrronium 100-200 mcg SC for respiratory secretion up to 4 hourly, max 1.2 mg/24 h, supply 5 (five) 200 mcg/ml ampoules

Pain?

Step 1: non opiods:

Paracetamol

(Paracetamol 500 mg qds if poor nutritional status, body weight <50 kg, hepatic impairment or chronic alcohol abuse)

Bone, liver, soft tissue infiltration or inflammatory pain?

NSAID +/- PPI

Neuropathic pain? First line:

Amitriptyline 10-25 mg in the evening, then increased if tolerated in steps of 10-25 mg every 3-7 days in 1-2 divided doses, usually 25-75 mg daily, max 150 mg per day

Gabapentin 300 mg od on day 1, then 300 mg bd on day 2, then 300 mg tds on day 3, alternatively initilly 300 mg tds on day 1, then increased in steps of 300 mg every 2-3 days in 3 divided doses adjusted to response, max 3.6 g per day

Second line: Pregabalin 150 mg in 2–3 divided doses, then increased if necessary to 300 mg daily in 2–3 divided doses after 3–7 days, then if necessary up to 600 mg daily in 2–3 divided doses after 7 days

Duloxetine 60 mg, max 120 mg per day (under specialist advice)

Dexamethasone +/- PPI (under specialist advice)

4-8 mg (for neuropathic and liver capsule pain)

8-16 mg (for raised intracranial pressure)

Specialist initiation:

Capsaicin cream or cutaneous patch

Lidocaine plaster (Versatis)

Bone pain?

Step 1 WHO

Step 3 opoids (as step 2 opoids only have marginal effect)

Radiotherapy

Bisphosphonates (pamidronate, zoledronate)

Step 2: weak opoids for mild to moderate pain:

Codeine or dihydrocodeine (DHC) 30-60 mg qds

Step 3: strong opoids for moderate to severe pain:

Stop any step 2 opioids (codeine/DHC 60 mg qds approximately equal to 24 mg oral morphine)

Opoid-naive/frail/elderly:

Morphine sulfate oral solution 10 mg/5 ml 2.5-5 mg 4 hourly for prn

Morphine sulfate MR 10-15 mg bd

Previously using regular weak opoid (eg codeine 240 mg/24 h):

Morphine sulfate oral solution 10 mg/5 ml 5 mg 4 hourly for prn

Morphine sulfate MR 20-30 mg bd

Frail/elderly:

Morphine sulfate oral solution 10 mg/5 ml 2.5-5 mg 4 hourly for prn

Morphine sulfate MR 10-15 mg bd

eGFR < 30 mL/min:

Oxycodone hydrochloride oral solution 5 mg/5 ml 5 mg 4-6 hourly prn

Oxycodone hydrochloride MR 10 mg

Morphine sulphate 2.5-5 mg SC up to (1-)2(-4) hourly, max 60 mg/24 h

(If not opioid naive: 4 hourly SC dose (if only oral regular opioid given before) = total oral dose of regular opioid given over the previous 24 hours divided by six)

Diamorphine hydrochloride 2.5-5 mg SC up to 4 hourly, max 10 mg/24 h (BNF)

If eGFR < 30 mL/min: Oxycodone hydrochloride (OxyNorm) 5 mg SC up to 4 hourly, max 7.5 mg/24 h (BNF)

Breathlessness?

First line:

Opoid naive?

Morphine sulfate oral solution 2 mg (2-)4-6 hourly

Morphine sulfate 1-2 mg SC up to (1-)2-4 hourly, max 60 mg/24 h

On opoids for pain control? Current breathrough dose (max 6 doses for all indications in 24 hours)

Dexamethasone 6-16 mg for tumour-associated airway obstruction

Third line:

Lorazepam 0.5 mg sublingually up to (2-)4-6 hourly, max 4 mg/24 h

Diazepam 2-5 mg nocte (if continuous distressing anxiety)

Midazolam 2-5 mg SC up to 4-6 hourly

If wheeze or COPD:

Salbutamol 2.5-5 mg nebules qds + Ipratropium bromide 250-500 mcg nebules qds (if sill wheeze)

Oxygen: Consider trial for symptom relief if SpO2 < 92% (may be poor relationship between hypoxaemia and breathlessness and response to oxygen)

Delirium/agitation:

First line:

Haloperidol 0.5-3 mg oral or SC once daily, repeat after 2 hours if necessary

Second line:

Lorazepam 0.5-1 mg sublingually up to (2-)-4-6 hourly, max 4 mg/24 h

Midazolam 2-5 mg SC prn, up to 1-2 hourly, max 60 mg/24 h

Diazepam orally or rectally 5 mg, 8-12 hourly

Increased sedation: Add or increase benzodiazepine: Midazolam SC infusion 10-30 mg every 24 h

Diazepam 5-10 mg rectally up to 6-8 hourly

Change haloperidol to levomepromazine 2.5-5 mg SC up to 2-hourly

Nausea/vomiting?

Clinical toxicity (including drug induced) or metabolic/biochemical upset (stimulation of chemoreceptor trigger zone [CTZ]) (eg drugs, metabolic (eg renal/liver failure, hypercalcaemia, hyponatraemia, hyperglycaemia, ketoacidosis):

Metocloproramide 10 mg orally up to 6-hourly

Haloperidol 0.5-1.5 mg orally or SC up to 8 hourly, max 5 mg/24 h

Levomepromazine 6.25-12.5mg SC up to 8 hourly, max 25mg/24 h

Motility disorders (gastric stasis, gastric outlet obstruction - pseudo-obstruction, mesenteric secondaries, severe impaction):

Domperidon 10 mg up to 8-hourly (if elderly)

Metocloproramide 10 mg orally up to 6-hourly

Intracranial disorders (eg raised ICP):

Cyclizine 50 mg orally or SC up to 8-hourly

Dexamethasone 8-16 mg orally or SC (if raised ICP) (daily reducing after 3 days) 2nd line: Levomepromazine 6.25-12.5mg SC up to 8 hourly, max 25mg/24 h

Prochlorperazine 3-6 mg buccal up to 12 hourly

Vestibular dysfunction or movement-related nausea:

Cyclizine 50 mg orally or SC up to 8-hourly2nd line: Levomepromazine 6.25-12.5mg SC up to 8 hourly, max 25mg/24 h

Hyoscine hydrobromide 150-300 mcg up to 6-hourly, max 900 mg/24 h

Cinnarizine 30 mg initially, then 15 mg up to 8-hourly

2nd line: Levomepromazine 6.25-12.5mg SC up to 8 hourly, max 25mg/24 h

Prochlorperazine 3-6 mg buccal up to 12 hourly

Oral/pharangeal/oesophageal irritation

Cyclizine 50 mg orally or SC up to 8-hourly

Hyoscine hydrobromide 150-300 mcg up to 6-hourly, max 900 mg/24 h

Levomepromazine 6.25-12.5mg SC up to 8 hourly, max 25mg/24 h

Multifactorial/unknown/refractory

Levomepromazine 6.25-12.5mg SC up to 8 hourly, max 25mg/24 h

Higher centres (pain/fear/anxiety)

Lorazepam 0.5-1 mg sublingually up to 6 hourly

Diazepam 2-5 mg orally

Respiratory secretions?

Glycopyrronium bromide injection, 200-400mcg SC prn for respiratory secretions, up to 6-8 hourly, max 1.2mg/24 h

Hyoscine butylbromide (Buscopan) solution for injection ampoules, 20mg SC prn for respiratory secretions, up to 4-6 hourly, max 120 mg/24 h

(Risk of) constipation?

Senna 15-30 mg OR bisacodyl 5-10 mg nocte (+ docusate 100 mg bd if stool becomes hard) (if colic stimulant should be discontinued and softener used instead)

Macrogol (eg Laxido) 1-3 sachets per day

Rectal options: Soft loading: bisacodyl suppository, sodium citrate or phosphate enema

Hard loading: glycerol suppository as lubricant or stimulant, then as above

Very hard loading: arachis oil enema (except in those with nut allergy) overnight, followed by phosphate enema

Mouth care problem?

Conscious?

- Mouth can be moistened every 30 minutes with water from a water spray or dropper or ice chips can be placed in the mouth Unconscious?

- Moisten the mouth frequently, when possible, with water from a water spray, dropper, or sponge stick or ice chips placed in the mouth

To prevent cracking of the lips: application of water-soluble lubricants

Pressure ulcers:

Reposition and turn the individual at periodic intervals, in accordance with the individual’s wishes, comfort and tolerance

High-specification foam mattress

Barrier preparation (eg 3M™ Cavilon™)

Prophylactic dressings with polyurethane foam dressing to bony prominences

Pressure ulcer assessment:

Location? Category/Stage?

- I: Nonblanchable Erythema?

- II: Partial Thickness Skin Loss?

- III: Full Thickness Skin Loss?

- IV: Full Thickness Tissue Loss?

- Unstageable: Depth Unknown?

- Suspected Deep Tissue Injury: Depth Unknown?

Size?

Tissue type(s)?

Color?

Periwound condition?

Wound edges?

Sinus tracts?

Undermining?

Tunneling?

Exudate?

Oodor?

Pain?

Cleanse most pressure ulcers with potable water (i.e., water suitable for drinking) or normal saline

Debride devitalized tissue within the wound bed or edge of pressure ulcers when appropriate to the individual’s condition and consistent with overall goals of care

Debride the wound bed when the presence of biofilm is suspected or confirmed

Dressings:

Hydrocolloid: clean stage II or shallow stage III pressure ulcers in body areas where they will not roll or melt

Transparent Film: as a secondary dressing for pressure ulcers treated with alginates or other wound filler that will likely remain in the ulcer bed for an extended period of time (eg 3-5 days)

Hydrogel: shallow,minimally exuding pressure ulcers

Alginate: moderately and heavily exuding pressure ulcers

Foam: exuding stage II and shallow stage III pressure ulcers

Silver-Impregnated: pressure ulcers that are clinically infected or heavily colonized

Honey Impregnated: stage II and III pressure ulcers

Cadexomer Iodine: moderately to highly exuding pressure ulcers

Gauze: when other forms of moisture-retentive dressing not available

Silicone: prevention of periwound tissue injury when periwound tissue is fragile or friable

Collagen Matrix: nonhealing stage III and IV pressure ulcers

For CSCI ('via syringe driver'):

Pain or breathlessness:

Morphine sulphate injection 10mg/1ml, 10 mg to 15mg over 24 hours SC Nausea/vomiting: Haloperidol injection 5mg/1ml, 1 mg to 5mg over 24 hours SC Levomepromazine injection 25mg/1ml, 12.5mg to 25mg over 24 hours SC

Agitation/restlessness/distress: Midazolam injection 10mg/2ml, 10mg to 30mg over 24 hours SC

Respiratory secretion: Glycopyrronium bromide injection 600mcg/3ml, 600mcg to 1.2mg over 24 h SC Water for Injection, 10 ml, use as directed as diluent/flush, supply 10 ampoules

Formulations:

Cyclizine tablets 50 mg, 100

Cyclizine injection 50 mg/ml, 5

Dexamethasone injection 3.3 mg/ml, 10

Dexamethasone tablets 2 mg, 50

Glycopyrronium bromide injection 200 micrograms/ml, 10

Haloperidol tablets 1.5 mg, 28

Haloperidol injection 5 mg/ml, 10

Hyoscine butylbromide injection 20 mg in 1ml, 10

Levomepromazine tablets 25 mg, 84

Levomepromazine injection 25 mg in 1ml, 10

Lorazepam tablets (Genus/ for use sublingually) 1 mg, 28