Transcript Midhurst Macmillan Consultant-Led Community Specialist

Post Liverpool Care Pathway
End of Life Conference
Wednesday 14 May 2014
Dr Catherine J Dent
Associate Specialist
Macmillan Specialist Palliative Care
Service, Midhurst
• The LCP acknowledged that death was
probably imminent; principles remain valid
• The focus of management should be on
comfort measures
• Medication should be simplified
• Anticipatory drugs should be prescribed
• Ensure family and health care colleagues
are aware of rationale
Symptom relief in the last days of life is generally a
continuation of what is already being done – but
mode of administration may need to change
However, new symptoms may develop and/or
pre-existing ones exacerbate
Time is of the essence – so anticipatory
prescribing of medication (with community +/or
‘in-house’ prescription sheets!!) optimises
management and comfort
DNACPR – emphasise benefits
Simplify
Simplify medication
Stop long term prophylaxis such as statins,
antihypertensives, oral hypoglycaemics,
Warfarin and laxatives
Review ‘artificial’ hydration and nutrition
Explain to patient and carers why this is
appropriate
Anticipate
Problems
Anticipate Problems
Pain
Dyspnoea
Vomiting
Nausea
Agitation
Delirium
Secretions in respiratory tract (‘death rattle’)
Seizures
‘Just-in-case’
medication’
Maintaining comfort
Pain
- Morphine, Diamorphine, Alfentanil
Dyspnoea (may be exacerbated by fear)
- Opioid plus Benzodiazepine
- Levomepromazine or Haloperidol
Secretions
- Hyoscine Butylbromide or Glycopyrronium
- Positioning and explanation to carers
Nausea (and vomiting)
- Levomepromazine or Haloperidol
Agitation/’terminal restlessness
- Midazolam, Levomepromazine, Haloperidol, Phenobarbitone
‘As needed
medication’
Commonly prescribed ‘prn’ medication
- Usually ‘subcut’ but may be ‘iv’
Pain: Morphine ‘Xmg’ 3-4hrly (2.5-5mg if opioid naïve)
Nausea: Levomepromazine 6.25mg 6-8hrly
Agitation: Midazolam 2.5-5mg 2-4hrly
Seizure: Midazolam10mg (can be given buccally); repeat
after 10minutes if needed
Delirium: Levomepromazine 12.5mg 6-8hrly
Haloperidol 1-5mg 6-8hrly
Secretions: Hyoscine Butylbromide 20mg 1-2hrly
Glycopyrronium 200microgram 1-2 hrly
Drugs commonly used in Syringe Drivers
(continuous subcutaneous infusion/csci)
Diamorphine/Morphine 5 -30+mg/24rs
Midazolam 5 -30+mg/24hrs
Levomepromazine 12.5 – 50+mg/24hrs
Glycopyrronium 600-1,200microgram/24hrs
If want to limit to THREE drugs, Levomepromazine may be
given once or twice daily (long ½ life)
NB Leave transdermal Fentanyl/Buprenorphine in place
Remember to adjust ‘rescue’ doses accordingly
Medications may be prescribed for specific
situations
- pre-existing disease +/or co-morbidities
- potential catastrophic events
Sometimes indicated
Midazolam 10mg+ sc/iv for Haemorrhage (+ dark towels/sheets)
Midazolam 10mg+ sc/iv for Stridor
Furosemide 20-40mg sc/iv for Pulmonary oedema
Metoclopramide 20mg sc/iv for gastric reflux
Ceftriaxone 1mg(in Lidocaine) for infection
Nicotine replacement patches
Insulin – low dose (eg Glargine) for Type 1 Diabetes Mellitus
Phenobarbital 100mg+ (iv then well diluted csci)
Alfentanil in renal failure (1/10th Diamorphine dose)
Clonazepam 500microgram for neuropathic pain
Diclofenac 50mg suppository for bone pain
Dexamethasone 4-16mg sc/csci for intracranial pressure
Transdermal Rotigotine 2-4mg/24hr for Parkinsonian rigidity
- nb this may cause delerium +/or agitation
Cost of ‘just-in-case’ drugs (2011)
Diamorphine 10mg ampoule (powder) £3
Morphine sulphate amps10-30mg £1-1.50
Midazolam 2mg and 5mg/ml
£1
Hyoscine Butylbromide 20mg/ml
£0.22
Glycopyrronium 200microgram/ml £1