Download symptom management guidelines for supporting care in the last

Version No
Version Date
Review Date
1.0
01/09/09
01/09/10
SYMPTOM MANAGEMENT GUIDANCE TO BE USED WITH CARE PATHWAY FOR THE LAST DAYS OF LIFE
PAIN
YES
Is the patient already taking Morphine or other strong opioids?
Continuous S/C Diamorphine
Calculate the 24 hour dose of oral Morphine, divide the total dose by 3, which is
the equivalent dose of Diamorphine over 24 hours s/c via syringe driver – e.g.
patient on 90mg Zomorph BD = 180mg oral Morphine over 24 hours, which
equals 60mg Diamorphine s/c over 24 hour infusion.
Transdermal Fentanyl
If the patient is using Transdermal Fentanyl but now has uncontrolled pain,
continue the Fentanyl and use appropriate dose s/c Diamorphine as required in
addition. See Guidelines.
Breakthrough Analgesia
To calculate the breakthrough dose of Diamorphine divide the 24 hour dose of
Diamorphine in the syringe driver by 6, e.g. if the patient is receiving 60mg
Diamorphine s/c over 24 hours the breakthrough dose of Diamorphine is 10mg
s/c prn.
Alternatively
Morphine oral liquid may be used if the patient is taking sips of fluid. To calculate
the equivalent oral Morphine breakthrough dose, multiply the s/c breakthrough
dose by 3, e.g. s/c Diamorphine 10mg for breakthrough up to hourly = 30mg oral
Morphine for breakthrough.
NO
Has the patient got pain?
YES
1. Diamorphine 2.5mg stat
2. Diamorphine 10mg/24 hours
via s/c infusion
3. Diamorphine 2.5mg s/c prn
NO
As Required Medication
1. Diamorphine 2.5mg s/c prn
2. Morphine Sulphate 5mg
orally prn
To calculate the subsequent doses of Diamorphine over 24 hours:
Review the doses of prn analgesia given in the previous 24 hour period. If more than one dose has been required, other than to pre-empt during care, (e.g. before a
dressing etc.) then consider a 30% to 50% increase in the daily subcutaneous dose. If this is not controlling the pain or doses need escalating on a daily basis, seek
specialist advice.
If Diamorphine is unavailable or the patient has previously been on oral Oxycodone, use the same format as above using Oxycodone.
Oral Oxycodone 1.5mg in 24 hours = Sub Cut : Diamorphine 1mg in 24 hours = Oxycodone 1mg in 24 hours
For further information see the additional conversion sheet attached.
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE.
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RETAINED SECRETIONS
Present
Absent
1. Explain to relatives that for the patient retained
secretions are not bothersome due to decreased
sensitivity of pharynx.
As required medication
Hyoscine Butylbromide 20mg s/c
IF the relatives are concerned or the patient
appears distressed:
2. Hyoscine Butylbromide 20mg s/c stat.
3. Hyoscine Butylbromide 60mg / 24 hours via s/c
Infusion.
4. Hyoscine Butylbromide 20mg s/c hourly prn
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
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TERMINAL RESTLESSNESS AND AGITATION
Present
Absent
1. Exclude Treatable Causes
Pain
Retention of urine or faeces
Hypercalcaemia if it would be appropriate to treat
2a. Delirium
i. Haloperidol 2.5mg stat.
ii. Haloperidol 5mg/24 hours
via s/c infusion.
iii. Haloperidol 2.5mg s/c prn
2b. Anxiety / Dyspnoea
i. Midazolam 2.5mg s/c stat.
ii. Midazolam 10mg / 24 hrs
via s/c infusion.
iii. Midazolam 2.5mg s/c prn
Review Every 24 Hours
Increase the dose of
Haloperidol to 10mg / 24
hours via s/c infusion if
necessary.
NB: A total dose of 15mg / 24
hours – including stat dose,
continuous dose and prn
doses should not be
exceeded.
Review every 24 hours
Increase the 24 hour dosage
according to the total dose of
Midazolam given on a prn
basis. The dose should not be
increased by more than
10mg/day without specialist
advice
As Required Medication
Haloperidol 2.5mg s/c p.r.n.
Review in 24 hours
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
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NAUSEA
Previously on Anti-Emetic
YES
NO
Convert to s/c as appropriate
YES
Nausea
present
1. Haloperidol 1.5 – 2.5mg s/c stat.
2. Haloperidol 5mg via s/c infusion.
3. Haloperidol 1.5 – 2.5mg s/c prn.
NB: A total of 15mg / 24 hours –
including stat doses, continuous s/c
doses and prn doses – should not be
exceeded.
NO
Prescribe, so available
if needed, Haloperidol
1.5 – 2.5mg s/c prn (up
to a total of 15mg / 24
hours)
Review in 24 hours
Increase to 10mg / 24 hours s/c if nausea persists
For persistent nausea switch to:
1. Levomepromazine 6.25mg / via s/c infusion.
2. Levomepromazine 6.25mg prn s/c.
NB: A total of 50mg / 24 hours – including continuous and prn doses – should not be exceeded.
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
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TERMINAL BREATHLESSNESS
GFR > 30
NO
Refer to National Guidelines for Patients with
Renal Failure
(Consider discussion with Specialist
Palliative care team)
YES
Absent
Present
Prescribe so available if needed:
 Diamorphine 2.5mg (or if on regular
Opiods dose as per equivalence chart)
s/c hourly for Tachypnoea.
 Midazolam 2.5-5mg s/c hourly for
distress
Previously on oral Opioid or
Fentanyl patch
YES
Convert to s/c pump (or in case of Fentanyl patch add CSCI, do not remove
patch) following Guidelines for Pain Management, BUT consider increasing
Opioid dose, e.g. give 30-50% more than the recommended equivalent
dose (or for Transdermal Fentanyl add 30-50% of the equivalent dose).
Prescribe appropriate prn as for breakthrough pain, e.g.1/6th of total daily
dose Diamorphine for Tachypnoea.
Give as soon as possible appropriate prn of:
 Diamorphine s/c see equivalence chart for
Tachypnoea.
 Midazolam 2.5-5mg s/c if patient distressed
NO
Give as soon as possible:
 Diamorphine 2.5mg s/c hourly for Tachypnoea.
 Midazolam 2.5-5mg s/c hourly for distress.
If no relief 30 minutes after first drug, try alternative,
repeating if necessary.
Prescribe Midazolam 2.5-5mg s/c hourly prn for distress caused by
breathlessness.
Consider adding Midazolam 10mg to s/c pump, particularly if prn dose has
helped.
AIM for patient’s breathing to be calm and effortless
If repeated doses are needed, consider
starting syringe driver with combination
of Diamorphine and Midazolam.
Suggested starting doses are 5mg of
each over 24 hours. Remember to use
prns as needed.
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ANTICIPATORY PRESCRIBING
Patients who are dying may develop new symptoms over the course of the terminal phase.
To avoid delays in responding to these symptoms all patients should be prescribed the following PRN medication in anticipation:
Drug
Dose / Route / Frequency
Use
Diamorphine
See guidance for appropriate dose s/c four
hourly
Pain
Breathlessness
Haloperidol
1 – 2.5mg s/c four hourly
Nausea and vomiting
Confusion / hallucinations
Midazolam
2.5 – 5mg s/c two hourly
Breathlessness
Anxiety / distress
Hyoscine Butylbromide
20mg s/c one hourly. Maximum 80mg in
24 hours
Respiratory secretions
For further information, see
individual symptom guidance
Suggested doses are for the “average” patient. Doses may need reducing for patients with:
 End stage heart failure;
 Renal or Liver failure; and
 In the frail elderly,
e.g. to Diamorphine 1mg, Midazolam 1mg)
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
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PALLIATIVE CARE DOSE CONVERSION CHART
Morphine
4 hourly
Zomorph or
MST b.d.
MXL o.d.
Oxynorm
4 hourly
Oxycontin
b.d.
Oxycodone
s/c in 24
hours
Diamorphine
or Oxynorm
s/c 4 hourly
Diamorphine
s/c in 24
hours
Fentanyl
patch 72
hourly
10 mg
30 mg
60 mg
5 mg
15 mg
20 mg
5 mg
20 mg
25 mcg
20 mg
60 mg
120 mg
10 mg
30 mg
40 mg
5 mg
40 mg
30 mg
90 mg
180 mg
10 mg
40 mg
60 mg
10 mg
40 mg
120 mg
240 mg
20 mg
60 mg
80 mg
50 mg
150 mg
300 mg
20 mg
70 mg
60 mg
180 mg
360 mg
30 mg
70 mg
200 mg
400 mg
80 mg
240 mg
90 mg
Buprenorphine patch
72 hourly
Hydromorphine
4 hourly
Hydromorphone
SR b.d.
35-52.5 mcg
1.3 mg
4 mg
25-50 mcg
52.5-70 mcg
2.6 mg
8 mg
60 mg
50 mcg
87.5-105 mcg
3.9 mg
12 mg
15 mg
80 mg
50 -75 mcg
105-122.5 mcg
5.2 mg
16 mg
100 mg
20 mg
100 mg
75 -100 mcg
122.5-140 mcg
6.5 mg
20 mg
90 mg
120 mg
20 mg
120 mg
100 mcg
7.8 mg
24 mg
30 mg
100 mg
140 mg
20 mg
140 mg
125 mcg
9.1 mg
28 mg
480mg
40 mg
120 mg
160 mg
30 mg
160 mg
125-150 mcg
10.4 mg
32 mg
260 mg
540 mg
40 mg
130 mg
180 mg
30 mg
180 mg
150 mcg
11.7 mg
36 mg
100 mg
300 mg
600 mg
50 mg
150 mg
200 mg
30 mg
200 mg
150-175 mcg
13 mg
40 mg
110 mg
330 mg
660 mg
50 mg
160 mg
220 mg
40 mg
220 mg
175 mcg
14.3 mg
44 mg
120 mg
360 mg
720 mg
60 mg
180 mg
240 mg
40 mg
240 mg
200 mcg
15.6 mg
48 mg
140 mg
420 mg
840 mg
70 mg
200 mg
300 mg
50 mg
300 mg
225-275 mcg
18.2 mg
56 mg
160 mg
480 mg
960 mg
80 mg
240 mg
320 mg
60 mg
330 mg
250-275 mcg
20.8 mg
64 mg
180 mg
540 mg
1080 mg
90 mg
250 mg
360 mg
60 mg
360 mg
300 mcg
23.4 mg
72 mg
Immediate Release Preparations
Sevredol tablets 10, 20, 50mg
Oramorph 10 mg/5ml, 20mg/ml
Hydromorphone 1.3, 2.6mg
Oxynorm 5, 10, 20mg
Oramorph UDVz, 10, 30, 100mg/5ml
Slow Release Preparations
MXL 30, 60, 90, 120, 150, 200mg
Zomorph 10, 30, 60, 100, 200mg
MST tablets 5, 10, 20, 30, 60, 100mg
Hydromorphone SR 2, 4, 8, 16, 24mg
Oxycontin 10, 20, 40, 80mg
 Breakthrough analgesia, dose of Opioid should be ONE SIXTH of the total daily
dose (dose over 24 hours). This is the same as the four hourly dose.
Diamorphine Injections
5, 10, 30, 100, 500mg
Fentanyl Patches
12, 25, 50, 75, 100mcg/hr
Oxynorm Injection
10mg/ml. 20mg/2ml
Buprenorphine Patches
35, 52.5, 70mcg/hr
 These doses are only approximate and the dose may need to be adjusted
accordingly to responses.
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