Palliative Care Guidelines: Last days of life
Palliative Care in the last days of life Introduction This guideline is an aid to clinical decision-making and good practice in person-centred
care for patients who are deteriorating and at risk of dying. The patient may have a new
life-limiting condition, and / or have one or more advanced illnesses. A decision will have
been made that transfer to HDU/ ITU or hospital admission is not appropriate. Initial assessment • Identify any potentially reversible causes for the patient’s deterioration. These may include:
Start treatment, if appropriate for the individual patient and care setting; plan review. • Discuss prognosis (patient is deteriorating and at risk of dying), agree goals of care and
preferred place of care with the patient or a welfare attorney, and the family.
• Take account of any advance/ anticipatory care planning or documented patient wishes.
• An individual care plan will be agreed with the patient if possible or any welfare attorney,
discussed with the family, and documented in the patient record.
• Clarify resuscitation status; consider a DNACPR form. (see: National policy)
o Explain to the patient/ family that all other appropriate treatment/ care will continue.
• Prompt and careful planning is needed for a safe discharge home or to a care home.
• If patient or family needs are complex, consider contacting the palliative care team for advice. Care planning and regular review ➢ Planned review and documentation of the care plan will make sure the best care is given as
the patient’s condition deteriorates, stabilises or improves.
• Food and drinks: support the patient to take these as long as they are able and want to.
• Comfort care: usually includes a pressure mattress, repositioning for comfort, eye care, mouth
• Medicines: review and stop any treatments not consistent with the agreed goals of care.
o Choose an appropriate route: If the patient is able to swallow, consider prescribing liquid
formulations, or change to the subcutaneous (SC) route.
o Consider the need for a SC infusion of medication via a syringe pump.
o Make sure anticipatory medication for common symptoms is available and prescribed
for as required use, by the oral and SC routes (see below).
• Investigations or clinical interventions: consider benefit/ burdens (eg blood tests, radiology,
vital signs and regular blood sugar monitoring).
Make a clear record of any interventions that are not appropriate. Review regularly.
• Assisted hydration/ nutrition: consider the benefits and risks; review care plan regularly .
o Over hydration can contribute to distressing respiratory secretions. However, where
indicated, a slow SC infusion may be considered on an individual basis.
• Consider emotional, spiritual/ religious, cultural, legal and family needs, including those of
children and people with cognitive impairment or learning disability.
• Bereavement: identify those at increased risk; seek additional support. Communication • Discuss the care plan with the patient, if possible, and the family. Explain what changes to
expect in the patient’s condition. (see leaflet: What happens when someone is dying.)
• Make sure key family members are aware of the care plan. Record a plan of how and when to
contact the family if the patient deteriorates or dies.
• Handover care plan to other team members; hospital at night team, GP, district nurses, out-of-
Palliative Care Guidelines: Last days of life
Symptom Control in the last days of life Anticipatory prescribing All patients should have as required medication for symptom control available.
• Opioid analgesic SC, hourly; dose depends on the patient, clinical problem and previous opioid
use.• 1/6th of 24 hour dose of any regular opioid.
• If not on a regular opioid, morphine SC 2mg or diamorphine SC 2mg.
• Anxiolytic sedative: midazolam SC 2mg to 5mg, hourly.
• Anti-secretory medication: hyoscine butylbromide (Buscopan) SC 20mg, hourly.
• Anti-emetic: levomepromazine SC 2.5mg to 5mg, 8 hourly. (see: Anticipatory prescribing guideline)
Pain • Paracetamol or diclofenac (as liquid/ dispersible or rectally).
NSAID benefits may outweigh risks in a dying patient; can help bone, joint, pressure sore,
Convert the total 24 hour oral morphine or oxycodone dose to a 24 hour, SC infusion
• For opioid dose conversions, see: Choosing and Changing Opioids and/ or seek advice.
• Fentanyl patches should be continued in dying patients. (see: Fentanyl patches)• For patient with stage 4-5 chronic kidney disease, see: Last days of life (renal) guideline. • Breakthrough analgesia, should be prescribed hourly as required:
• 1/6th of 24 hour dose of any regular opioid orally and subcutaneously.
• If not on any regular opioid, prescribe morphine SC 2mg or diamorphine SC 2mg. Breathlessness Oxygen can improve breathlessness, but only if the patient is hypoxic. If oxygen is needed for
symptom control, nasal prongs may be better tolerated than a mask.
A table or handheld fan should be tried, and a more upright position can help.
Midazolam SC 2mg to 5mg hourly, as required &/ or lorazepam sublingual
breathlessness/ 500micrograms, 4-6 hourly, as required.
• regular opioid → use the same 4 hourly breakthrough dose for pain or
• no opioid → morphine SC 2mg or diamorphine SC 2mg.
Midazolam SC 5mg to 20mg + morphine SC 5mg to 10mg or
diamorphine SC 5mg to 10mg (if no previous opioid use); given in a syringe
Respiratory tract secretions • Reduce the risk by avoiding fluid overload; review any assisted hydration / nutrition (IV/SC
fluids, feeding) if symptoms develop.
• Changing the patient’s position may help.
• Intermittent SC injections often work well or medication can be given as a SC infusion.
1st line: hyoscine butylbromide SC 20mg, hourly as required (up to 120mg/ 24hours).
2nd line: glycopyrronium bromide SC 200micrograms, 6-8 hourly as required.
3rd line: hyoscine hydrobromide SC 400micrograms, 2 hourly as required. 32 Re-issue date: November 2013
Palliative Care Guidelines: Last days of life
Agitation / delirium
midazolam SC 2mg to 5mg, hourly, as required
levomepromazine SC 12.5mg,
12 hourly and 12.5mg, 6 hourly as Nausea/ vomiting (see: Nausea / Vomiting) • If already controlled with an oral anti-emetic, use the same drug as a SC infusion. • Treat new nausea/ vomiting with a long acting anti-emetic given by SC injection or give a
suitable antiemetic as a SC infusion in a syringe pump.
Long acting anti-emetics: haloperidol SC 1mg 12 hourly, or 2mg once daily.
levomepromazine SC 2.5mg 12 hourly, or 5mg once daily.
• Persistent vomiting: an NG tube, if tolerated, may be better than medication. Acute terminal events (see: Emergencies in palliative care) Dying patients occasionally develop acute distress; this can be due to:
• Bleeding: haemorrhage from the GI or respiratory tract, or an external tumour.
• Acute pain: bleeding into a solid tumour, a fracture, or a ruptured organ.
• Acute respiratory distress: pulmonary embolism, retained secretions. Management
• Prescribe sedation in advance if the patient is at risk; warn the family. Agree an anticipatory care
plan with the patient, if possible, family carers and key professionals.
• Give midazolam IM 5mg to 10mg into the deltoid muscle or sedate using IV midazolam if IV
• If the patient is in pain or has continued respiratory distress despite midazolam, give morphine
SC at double the usual breakthrough, as required dose. Practice points • Opioid analgesics should not be used to sedate dying patients.
• Sudden increases in pain or agitation; exclude urinary retention or other reversible causes.
• Subcutaneous infusions of medication provide maintenance treatment only. Additional doses of
medication by SC injection will be needed if the patient’s symptoms are not controlled, or when
starting a SC infusion in an unsettled patient.
• Midazolam SC infusions are usually titrated in 5mg to 10mg steps. Up to 5mg can be given in a
single SC injection (1ml). Single SC doses can last 2-4 hours. Useful as an anticonvulsant.
• Terminal secretions can be controlled in about 60% of cases; fluid overload, recent aspiration
and respiratory infection increase the incidence.
• Consider a nicotine replacement patch in heavy smokers with withdrawal symptoms. Resources Patient leaflet: What happens when someone is dying.
Other relevant guidelines: Subcutaneous medication (prescribing advice and drug compatibilities);
Choosing and changing opioids; Subcutaneous fluids: Mouth care; Levomepromazine;
ARON FARREL STEIN, Ph.D. 858-523-9215 (Office) 858-523-0280 (Fax) SUMMARY: Over 20 years of pharmaceutical experience with demonstrated ability to lead, build, mentor, develop, and manage in both small and large organizations. Broad areas of management responsibilities include Toxicology, Regulatory and Medical Affairs, and Quality Assurance. Strategic FDA initiatives involved partneri
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