1. health and fitness
2. drugs

Recognising dying and pro-active
prescribing – keeping patients at
home
Dr Andrew Tysoe-Calnon
Lead Consultant
Principles of a good death
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To know when death is coming, and to understand what can be expected.
To be able to retain control of what happens.
To be afforded dignity and privacy.
To have control over pain relief and other symptom control.
To have choice and control over where death occurs (at home or
elsewhere).
To have access to information and expertise of whatever kind is
necessary.
To have access to any spiritual or emotional support required.
To have control over who is present and who shares the end.
To be able to issue advance directives which ensure wishes are respected.
To have time to say goodbye
To be able to leave when it is time to go, and not to have life prolonged
pointlessly.
“The Future of Health and Care of Older People”
Debate of the Age Health and Care Study Group
What prevents a good death at
home?
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Poorly controlled symptoms
Oral medications burden
Lack of equipment
Lack of injectable drugs when you need them
Lack of authorisations to use injectable drugs
at home
Fear/anxiety of patient and/or carers
Inappropriate resuscitation
Unfinished business/unable to say goodbye
Involvement of coroners/police
Wills/finances not sorted out
How to achieve a good death at home
• Assess if patient has any complex symptoms that
requires input from the local palliative care team
• Ensure DN’s are involved
• Continue drugs for symptom control so think about
route
• Put DNACPR orders in place
• Prescribe injectables
• Syringe driver and prn pink charts written and in the
house
• Spiritual care
• Advice from solicitors
• Visit every 14 days
When to do anticipatory prescribing?
• If you think a patient is approaching the end of life
then it is good practice to do a pink chart covering
the most likely potential symptoms
• This may be within the last few weeks of life but a
stable patient can also rapidly deteriorate
• Try to anticipate emergencies that may arise and
plan for them e.g. haemorrhage, seizures, stridor
• However, it is prudent for patients who develop a
new diagnosis of for eg: brain metastases who may
have or be at risk of seizures to have an
anticipatory chart for seizure control.
• Think about bank holidays, Christmas etc
Recognising dying
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Becoming much weaker
Bed bound
Drinking sips only
Struggling to take oral medications
Semi-conscious/unconscious
May see plucking/restlessness
Apnoeas
Often if a patient is deteriorating over days
then they will have a prognosis of days
Anticipatory Prescribing at the End of Life
• Anticipatory prescribing forms a key part of good proactive End of Life Care and should be initiated as the
patient enters the last few weeks of life.
• Ensure that in the last days or hours of life there is no
delay in responding to symptoms
• Administer medication if and when needed, but no
more than is required to relieve symptoms
• Review all medication including doses and frequency
• Commence a syringe pump if several prns required in
24 hours. Not all dying patients require a continuous
subcutaneous infusion
• Contact the Specialist Palliative Care Team if symptoms
persist
Pain at the end of life
• Think about cause or if new pain consider
urinary retention, fracture, constipation, acute
bleed, anxiety
• If you think it is a fracture consider if
appropriate to send to hospital or advise for
bed rest and analgesia
• Follow the anticipatory guidance
• Morphine remains the gold standard
• Oxycodone is double the strength of morphine
Guidance - Pain
• If opioid naive, Morphine Sulphate 5-30mg sc over
24 hours in syringe pump with 2.5 – 5mg sc prn
• If already on analgesic patch, continue patch add in
sc morphine sulphate as required
• If already on oral morphine, divide 24 hr oral dose
by 2 to calculate 24 hr syringe pump dose. If on
other oral opioids, use conversion chart to calculate
dose
• In renal failure, seek Specialist Palliative Care advice
on Alfentanil use
Nausea and vomiting
• Think about cause
• Unless specific cause then I would usually
go for haloperidol as this covers most
situations
• Don’t use tiny doses such as 1.5mg in a
SD as this will be too small for most
patients
• Guidance has starting doses, patients
may need more, so titrate up
Guidance - Nausea and vomiting
• Haloperidol 3-5mg sc over 24 hr with
1.5mg sc prn
• Brain tumour/mets Cyclizine 150mg sc
over 24hr with 50mg sc prn
• Poor gut motility, Metoclopramide 3060mg sc over 24hr
Agitation/restlessness
• Can occur in late stages
• ? Cause – physical - pain, retention,
metabolic etc or psychological - are there
unmet spiritual needs or not come to
terms with events in their lives
• Distresses family
• Distresses staff
• Distresses patient
Agitation/restlessness
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Treat with sedation
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Give continuously in syringe driver as irreversible event
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Use Midazolam first line up to 60-100mg
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If midazolam fails then see specialist advice
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Levomepromazine second line (high dose) 50-300mg
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Use phenobarbital as third line drug
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Midazolam and Levomepromazine can cause paradoxical agitation (rare)
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If starting levomepromazine or phenobarbital do not stop the midazolam as patient
may have a benzodiazepine withdrawal
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Encourage family to remain calm, to stroke and talk to the patient
Guidance- Agitation/restlessness
• Midazolam 10-40mg sc over 24 hours with 2.5-5mg sc
prn
Respiratory secretions
From secretions in the pharynx
‘Death rattle’
Patient can’t expectorate
Usually in last couple of days or hours
Patients are usually unaware and not
distressed
• Carers often are distressed
• Reassure carers
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Respiratory secretions
• Treat early as once secretions are formed very difficult
to treat
• Use re-positioning to help and drain
• Can use glycopyrronium if conscious or unconscious
• Other drugs are hyoscine hydrobromide 0.4-0.6mg prn
if unconscious, or hyoscine butylbromide (buscopan)
20mg prn if conscious
• Can suction but can be unpleasant if patient not fully
unconscious, so do as last resort – hard to do at home
• Maximum doses for glycopyrronium and hyoscine
hydrobromide in a SD is 2.4mg
Guidance- Respiratory secretions
• Glycopyrronium 0.6-1.2mg sc over 24
hours with 0.2-0.4mg sc prn
• Maximum 2.4mg in 24 hours
Dyspnoea at the end of life
Can be very distressing
Can induce panic attacks
Consider oxygen
Someone to stay with the patient
Positioning
Use nebulisers, benzodiazepines, opioids
to control symptoms
• May need SD with opioid and midazolam
to control symptom
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Guidance- Dyspnoea
• If opioid naive, Morphine sulphate 5-30mg sc
over 24 hours with 2.5 - 5mg sc prn.
Concurrent Midazolam recommended.
Seizures
• Can occur with primary cerebral tumours or
metastases or in epileptics
• Likely to occur if steroids or anti-epileptics
stopped because can’t swallow
• Can give steroids s/c once daily to replace oral
at half the dose
• Use midazolam in syringe driver starting at
30mg if patient can’t manage to swallow oral
anti-epileptics
• Remember, levomepromazine can decrease the
threshold for fits
Guidance- Seizures
• Midazolam 30-90mg over 24 hours with
10-20mg sc prn
• Start if patient fitting or unable to take
oral anti epileptic drugs
Intestinal Obstruction
• Will likely need to use several drugs in
the syringe driver
• Anti-emetic
• Opioid
• Anti-spasmodic – titrate quickly 60-120180-240mg
• Can go up as far as 480mg buscopan
Guidance- Intestinal Obstruction
• Hyoscine butylbromide (Buscopan)
• 60-240mg over 24 hours with 20mg sc prn
Prescribing advice
• Suggestions for the initial prescription for
injectables:
• Morphine sulphate 10mg/2ml x 10 amps
(30mg/ml if on larger doses)
• Haloperidol 5mg/ml x 10 amps
• Midazolam 10mg/2ml x 10 amps
• Glycopyrronium 600mcg/3ml x 10 amps
• Remember to prescribe water for injection
10mls x 10amps
Other injectables
• Oxycodone 10mg/ml or 10mg/2ml. For large
doses, 50mg/ml available if greater
concentration required to fit in syringe pump
but much more expensive
• Hyoscine butylbromide (Buscopan) 20mg/ml
for bowel obstruction
• Hyoscine hydrobromide 600mcg/ml –
alternative to Glycopyrronium
Indications for using a syringe driver
Unable to swallow
Not absorbing oral medications eg: bowel obstruction
Vomiting
To avoid lots of separate prn subcut injections when
symptoms uncontrolled
• If titration is proving difficult
• Agitation
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• However, not everyone dying will need a driver
What goes in the driver?
Convert oral opioid to injectable for SD
Continue anti-emetics
For terminal agitation or distress use sedation
Treat secretions
Can use up to 4 drugs in driver
Not all drugs are compatible with each other
Some mix with saline instead of water
Sometimes small doses of dexamethasone are needed
in the driver to prevent site reactions
• Consider how much sub cut fat they have
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Frequency of prns
• Unless drug has to be given at specific
intervals I write all drugs as hourly
• My justification - if patient has severe
symptom then writing 4-6hourly for a prn
means they will have to wait that length
of time in pain, SOB, agitated before they
can be given another injection
• This is not acceptable
Titration of SD’s
• Patient has range 40-80mg morphine over 24 hours in
SD
• If patient currently has 60mg of morphine in the SD
and has used another 60mg in prn stats in the past 24
hours there is little point in only increasing the SD to
70 or 80mg within the current allowed range.
• Chart needs to be re-written with larger range eg: 100200mg
• You may start at 100, 120 or 160mg depending on
circumstances
Midazolam
• When midazolam is prescribed on the pink
chart you can write underneath give 10mg in
emergency
• This allows a DN/paramedic to administer
midazolam in different emergency situations
eg: seizures, large bleeds, severe agitation
Steroids
• Some patients may be on high dose oral steroids or may
have been on steroids for a long time
• In this case you may worsen symptom control by
stopping them by potentially increasing pain, causing
seizures, increasing agitation
• Consider giving half the oral dose as a once daily
injection
• Injectable steroids come in different strengths:
• dexamethasone 4mg/ml stopping
• dexamethasone 3.3mg/ml equivalent to 4mg – USE
THIS
• dexamethasone 3.8mg/ml equivalent to 5mg
Concerns over abuse of drugs
• Drugs once collected from a chemist are the property
of the patient
• It is the families responsibility to return them to a
chemist after death
• All CD’s in the house should be logged by the DN’s who
keep count of the number and batch numbers
• If a patient is a known drug user then the primary care
team can manage the amount of drugs going into the
house
• In some circumstances another arrangement may be
made
• Don’t allow concerns over abuse to prevent appropriate
prescribing, they may well need larger doses – seek
specialist advice
How can the hospice help to
ensure a good death?
• Home care team – CNS specialist advice
• Crisis support team – care in last 2 weeks of
life, don’t have to be under our other services,
can provide 24 hour care
• Respite care – daytime few hours or occasional
night at home to give carers a rest
• In-patient unit
• OOH service for advice – always CNS on call
and consultant on call
• Consultant advice – open door
Consultant mobile numbers
Andrew Tysoe-Calnon
07968 481081
Siva Subramaniam
07918 561058
Any questions?
for families facing terminal illness