Palliative Care - Last days of life

N.B. If your patient is (or is suspected of being) COVID-19 positive, see separate guideline on the End of Life Care Guidance when a Person is Imminently Dying from COVID-19 Lung Disease for guidance on symptom management. 

When all reversible causes for the patient's deterioration have been considered, the multidisciplinary team agrees the patient is dying and change the goals of care. Reversible causes to consider include: dehydration, infection, opioid toxicity, renal impairment, hypercalcaemia or delirium. 

If discharge home is being considered, assess the feasibility of rapid compassionate discharge with prompt and careful planning. Refer to Rapid Transfer Home in the Last Days of Life guidance.

Anticipatory prescribing

In all patients anticipatory medicines should be prescribed 'when required' on HEPMA or the inpatient prescription chart. HEPMA prescribing protocol ('last days of life anticipatory medicine') is available under the protocol tab. See table 1 for details.

Management of symptoms present in last days of life

Pain

  • Paracetamol (PR dose) or diclofenac (as SC) for pain or high temperature.
  • The benefits of non-steroidal anti-inflammatory drugs (NSAIDs) may outweigh the risks (i.e. cardiovascular risk and renal impairment) in a dying patient and can help bone, joint, pressure sore and inflammatory pain. 
  • If prescribed regular oral opioids and the oral route is no longer reliable, convert the total 24 hour oral morphine or oxycodone dose to a 24 hour SC infusion, for example:

oral morphine 30mg ≈ SC morphine 15mg ≈ SC diamorphine 10mg

oral oxycodone 15mg ≈ SC oxycodone 7mg–8mg

  • For opioid dose conversions, refer to Choosing and Changing Opioids or seek advice.
  • Fentanyl patches should be continued in dying patients, refer to Fentanyl Patches information sheet.
  • For a patient with stage 4-5 chronic kidney disease, refer to Renal Disease in Last Days of Life guideline.
  • Breakthrough analgesia should be prescribed hourly, as required:
    • 1/6th to 1/10th of the 24 hour dose of any regular oral or SC opioid.
    • If not on any regular opioid, prescribe morphine SC 2mg hourly as required.

    If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review.

  • Review breakthrough usage to assess dosing requirements for continuous subcutaneous infusion (CSCI).
  • Consider compatibilities when mixing medicines in CSCI. Refer to Syringe Pumps guidance. Re-assess CSCI compatibility if changes are made to medicines or doses being prescribed within the syringe pump. Seek specialist advice if compatibility unclear.

Anxiety / distress

Intermittent anxiety / distress:

  • Midazolam SC 2mg, repeated at hourly intervals as required.
  • If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review.

Persistent anxiety / distress:

Agitation / delirium

  • First-line: Haloperidol* SC 500micrograms 2 hourly as required (max 5mg in 24 hours).
  • Second-line: levomepromazine* may be required. Refer to the National Guidelines - Delirium for further information and seek advice from the Palliative Care team.

Nausea / Vomiting

If already controlled with an oral anti-emetic, use the same drug as a SC infusion, see National Guidelines - Nausea and Vomiting. Treat new nausea / vomiting with a long-acting anti-emetic given by SC injection or give a suitable anti-emetic as a SC infusion in a syringe pump. Long-acting anti-emetics include:

  • Levomepromazine* SC 2.5mg (TWO point FIVE milligrams) 12 hourly when required. 
  • Haloperidol* SC 1 mg 12 hourly or 2 mg once daily. 

For anti-emetic doses in SC infusion see National Guidelines - Syringe Pumps.

For intractable vomiting due to bowel obstruction, a nasogastric tube may be considered if the medication is ineffective. Contact the Palliative Care team for advice.

*N.B. Haloperidol and levomepromazine can prolong QT interval. Haloperidol contraindications include: patients with prolonged QTc interval and in combination with other drugs that prolong QT interval. Where possible modifiable risk factors for QT interval prolongation should be minimised e.g. discontinue other drugs known to prolong QT interval. There may be certain circumstances when haloperidol may be used despite contraindications (e.g. distressed individual with an incurable condition at the end of life). Seek senior advice before prescribing. A list of drugs that can prolong QT interval can be found at http://crediblemeds.org. Further information can also be found in the Drug-induced QT Prolongation guideline. 

Respiratory tract secretions

Reduce risk by avoiding fluid overload; review any assisted hydration or nutrition (IV or SC fluids, feeding) if symptoms develop. Suction may also exacerbate secretions.

First-line agent is hyoscine butylbromide SC 20mg hourly as required (up to 120mg/24 hours). See table 1c here for more guidance on the use of anticholinergics in a syringe pump. 

For information on management of other symptoms in the patient's last days of life, see National Guidelines - Care in the Last Days of Life. 

 

Guideline reviewed May 2023
Page updated June 2023



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