Symptom control guidance
Regular assessment of people’s symptoms in their last days of life is of paramount importance. Reversible causes such as urinary retention or constipation or infections causing delirium should be screened for and treated appropriately. In addition to prescribing medications for symptoms, consideration should be given to non-pharmacological strategies e.g. reassurance, positioning, use of a fan and a comfortable environment.
Most people will initially be prescribed oral medication but its useful to have the availability of subcutaneous injections in anticipation of common symptoms encountered in case the oral route is not tolerated. A continuous subcutaneous infusion via a syringe driver or pump can be used if people require regular symptom control but cannot tolerate oral preparations. When using a syringe driver, the diluent of choice would be water for injection.
Pain is usually managed with a variety of opioids. The usual medication of choice is morphine. The right dose will depend on many factors including the patient and whether they are opioid naïve, their age, the body build, any evidence of renal or hepatic impairment etc. Other options are diamorphine, oxycodone, fentanyl, buprenorphine and alfentanil. If people are already taking some form of an opioid, it is important to correctly calculate what dose of morphine or equivalent is required. If there is any doubt in how to calculate drug doses, there is a chapter at the beginning of the British National Formulary called ‘prescribing in palliative care’ that should be used, or specialist advice should be sought.
Nausea and vomiting are difficult symptoms to contend with due to the several possible causes. Considering the likely cause can help to decide which anti-emetic will be most appropriate. As a guide:
- Biochemical/toxic causes (e.g. opioids, hypercalcaemia, renal failure) – Haloperidol
- Vestibular causes/raised intra-cranial pressure – Cyclizine
- Functional bowel obstruction/gastric stasis – Metoclopramide
For people with Parkinson’s disease, ondansetron seems to be the drug of choice. Levomepromazine is a broad-spectrum anti-emetic and can be used second or third line. Some specialists will suggest that cyclizine and metoclopramide should not be co-prescribed because of an increased risk of extrapyramidal and anticholinergic side effects. This is not universally accepted.
Breathlessness can be helped by repositioning the patient and sitting them more upright or using fan therapy and opening windows. Oxygen should only be used in cases of hypoxia. Morphine can also be used for this indication (for the relief of the sensation of breathlessness) and midazolam can be given via subcutaneous injection (usually for anxiety surrounding breathlessness).
Agitation can often be caused by uncontrolled pain, urinary retention, constipation, breathlessness or anxiety or fear. If the agitation is thought to stem from delirium (with features of hallucinations, confusion and restlessness), haloperidol is recommended first-line. When anxiety is the predominant reason for the agitation, midazolam should be used.
Noisy respiratory secretions are part of the process of dying caused by pooling of fluids in the oropharynx. Most patients are unaware of these and sometimes an explanation and reassurance to those around the person is all that is needed. Mouth care should be continued. If symptoms persist, hyoscine hydrobromide or glycopyrronium may be prescribed.
In summary as a quick reference, here is a list of commonly used subcutaneous medications for expected symptoms towards the end of life:
§ Pain/breathlessness (if opioid naïve)
o Morphine 2.5mg 2 hourly
o Diamorphine 2.5mg 2 hourly
§ Nausea/vomiting
o Cyclizine 50mg 4 hourly (maximum 150mg/24 hours)
o Haloperidol 1.25mg 4 hourly
o Levomepromazine 6.25mg 4 hourly (maximum 25ng/24 hours)
§ Agitation
o Midazolam 2.5mg 2 hourly (if anxiety-related)
o Haloperidol 2.5mg 4 hourly (if delirium-related)
§ Noisy respiratory secretions
o Hyoscine hydrobromide 400 micrograms 4 hourly (maximum 2.4mg/24 hours)
o Glycopyrronium 200 micrograms 4 hourly (maximum 1.2mg/24 hours)