Download Whose death is it anyway?

Anticipatory prescribing
Dr Jason Ward
Consultant in Palliative Medicine,
Mid Yorkshire NSH Trust , &
Honorary Senior Lecturer,
University of Leeds
Factors important for a good death
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Control of symptoms
Preparation for death
Opportunity for closure or "sense of
completion" of the life
Good relationship with healthcare
professionals
Steinhauser KE 2000
Symptoms on the last 48 hours
Sweating
Confusion
Pain
Urinary dysfunction
Breathlessness
Death rattle
Nausea and vomiting
Restlessness/agitation
Jerking/plucking/twitching
Death rattle
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Prevalence 41-92% patients
Most common with lung or cerebral
primaries
Median duration of onset 23 hours
Death rattle
How do relatives interpret it?
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Awful/horrible/terrible
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Nothing/expected
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Relief/sign of dying
Wee B et al 2006
Management of death rattle
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Non drug management
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Discuss with family/carers
Re-position
Drug - hyoscine butylbromide (buscopan)
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20mg sc stat
60-120mg/24hrs
Bennett M 2002
Pain
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Cancer
Cancer treatment
Debility e.g. immobility
Concurrent problems e.g. osteoarthritis
Analgesics (1)
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Paracetamol
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Liquid, suppository
No subcut preparation
NSAIDs
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Diclofenac PR 100mg od
Analgesics (2)
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Diamorphine
Divide total daily dose of oral morphine by 3
= total daily dose of subcut diamorphine
 Opioid naïve
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2.5mg sc PRN
5-10mg/24hrs
Morphine sulphate
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Divide total daily dose of oral morphine by 2
Opioid naïve 2.5mg sc PRN
Transdermal analgesia
Name
Drug
Apply Lowest Oral
morphine
dose
Equivalent
24 hours
Durogesic
D-Trans
Fentanyl
3 days 25mcg
-90mg
Transtec
Buprenorphine
3 days 35mcg
30-60mg
BuTrans
Buprenorphine
7 days 5mcg
5-10mg
The dying patient with a patch
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Continue current patch strength and
replace every 72 hours
Supplement with diamorphine prn and/
or syringe driver
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‘Rule of 5’
Fentanyl 25mcg/5= 5mg diamorphine prn
Restlessness
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Agitation/restlessness
Vs
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Confusion/delirium
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Disorientated
Hallucinations
Sleep-wake reversal
Plucking
General Management
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Reverse the ‘easily’ reversible
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Full bladder, position, pain
Explanation
Environment
Family
Agitation
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Benzodiazapine
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Useful alone if fear/anxiety is the only feature
Midazolam
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2.5-5mg stat
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Repeat every 60mins if needed
10mg-60mg/24 hrs
Confusion/delirium
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Haloperidol
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3-5mg stat sc repeated as necessary
Generally 5 - 10mg/24hrs
Levomepromazine
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Sedating anti-psychotic
25mg-50mg stat
Infusion 50-300mg/24 hrs
Breathlessness
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Fan, open window
Breathlessness/cough/tachypnoea
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Diamorphine
Opioid naïve 2.5mg stat, 5-10mg/24hrs
 Or increase dose by 1/3rd
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Breathlessness/anxiety
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Midazolam
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2.5 mg stat, 10-30mg /24hrs
‘Terminal’ nausea
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Persistent or intermittent
Small vomits, ‘possets’, retching
Chemical cause
Hypercalcaemia
Uraemia
Jaundice
Infection
Anti-emetics
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Cyclizine
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50mg stat
150mg/24hrs,
May precipitate with hyoscine
butylbromide
Avoid saline
May cause irritation
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
To foresee and take care of in
advance
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Costs