Dr Sarah Callin Consultant in palliative Medicine Key Drugs Dr Sarah Callin Consultant in palliative Medicine

Learning Objectives Understand barriers to achieving good symptom control in the dying phase 4 key drugs Know what to prescribe and when Calculate the correct doses Signpost to useful resources 2015 NICE guidelines 'Care of dying adults in the last days of life'

Barriers to effective symptom management Patients may: Not want to cause a ‘fuss’ Perceive staff as too busy Believe that nothing will help Want to avoid upsetting family/carers Fear being sent into hospital Believe that if they start medications now, they will be ineffective later when symptoms are worse Fear side effects of medication anxious about medications hastening death

Barriers to effective symptom management Healthcare professionals may: Not diagnose that a patient is dying Pursue interventions to treat the cause of deterioration at the expense of treating symptoms Not prescribe effectively Lack knowledge in relation to symptom management Not anticipate symptoms Not know what to prescribe and when Limited time/inadequate assessment Fail to give medication in a timely fashion "I'll prescribe the medications tomorrow – he doesn't need them yet.“ Not communicate sufficiently with the patient and family Fear of hastening death

What are the commonest symptoms at the end of life? Pain Restlessness/agitation Excess respiratory secretions Nausea Breathlessness

Case Scenarios

Case 1 88 year old woman with severe COPD and osteoarthritis PPC/PPD is home Patient does not want further admission to hospital Clear plan not for escalation beyond oral antibiotics at home Deteriorating condition

Case 1 Current medications: Cocodamol 30/500 x 2 tablets qds Oramorph 5mg prn for breathlessness (taking qds) Lorazepam 1mg bd What anticipatory medications would you prescribe?

Case 2 90 year old man with sepsis, acute on chronic renal failure, ischaemic heart disease Not responding to iv antibiotics and rehydration Discharged back to care home for end of life care Has not been on regular analgesia but now appears to be in pain What would you prescribe? For people starting treatment who have not previously been given medicines for symptom management, start with the lowest effective dose and titrate as clinically indicated

Case 3 76 year old woman with pancreatic cancer Increasing upper abdominal pain On assessment drowsy but clearly uncomfortable Now bed bound Not able to reliably swallow medication

Case 3 Current medication: Fentanyl 75mcg Oramorph 40mg prn – used 2-3 doses in the last 24 hours What changes would you make to her regular analgesia? What anticipatory medications would you prescribe?

Case 4 67 year old man with end stage pulmonary fibrosis Breathless with significant anxiety Home oxygen (15 litres/minute) Commenced on a Midazolam syringe driver 4 weeks ago which has steadily been increased to 40mg/24 hours Increasingly agitated in last 24 hours Trying to climb out of bed, plucking at the bed sheets, agitated, confused and calling out How would you manage his agitation?

Agitation/Restlessness Palliative Sedation ‘‘The intentional administration of sedative drugs in dosages and combinations required to reduce the consciousness of a terminal patient as much as necessary to adequately relieve one or more refractory symptoms.”

Case 5 92 year old man with end stage dementia Care home Barely conscious Breathing very noisy Daughter distressed, thinks he is ‘drowning’ How would you advise the staff in relation to managing his secretions?

Excess respiratory secretions Explanation is key Non pharmacological management at least as good in management as drugs If using drugs USE EARLY Hyoscine butylbromide (Buscopan) 20mg sc Glycopyrronium 200mcg sc

Case 6 76 year old woman with colorectal cancer, liver and brain metastases Increasingly fatigued and bedbound Now feeling very nauseous Recently started on Morphine 10mg bd for abdominal pain BNO 4/7 Which antiemetic would you prescribe?

Nausea Less common at the end of life Drug management will focus on the cause for the nausea eg ICP, obstruction, renal failure If has been on PO or SC treatment for nausea continue or convert from PO to SC 1:1 conversion Avoid Metoclopramide and Cyclizine together If no specific cause 1st line Haloperidol 1.5-3mg SC

Y&H Symptom Control Guidelines

Ref: Y&H Symptom Control Guidelines

4 key drugs Analgesic Agitation Excess respiratory secretions Opioid (Which opioid and dose will be determined by current regular analgesia) Agitation Consider reversible causes including urinary retention and constipation Non pharmacological approaches Midazolam Levomepromazine Excess respiratory secretions Hyoscine Butylbromide Glycopyronium Anti-emetic Consider cause and current oral antiemetics Haloperidol if no specific cause Additional considerations: Parkinson’s Disease and Heart Failure When deciding which anticipatory medicines to offer take into account: the likelihood of specific symptoms occurring the benefits and harms of prescribing or administering medicines the benefits and harms of not prescribing or administering medicines the possible risk of the person suddenly deteriorating (for example, catastrophic haemorrhage or seizures) for which urgent symptom control may be needed the place of care and the time it would take to obtain medicines

Key things to remember Ensure the medication is prescribed on the community syringe driver chart subcutaneous range frequency PRN dose for most strong opioids is 1/6th total daily regular opioid dose e.g. PO Morphine 30mg BD = 60mg total 24hr dose PO PRN = 10mg Morphine (1/6th of 60mg) SC PRN = 5mg Morphine

Useful Resources https://www.yorkhospitals.nhs.uk/our-services/gp-hub/palliative-care/