Anticipatory prescribing Dr Jason Ward Consultant in Palliative Medicine, Mid Yorkshire NSH Trust , & Honorary Senior Lecturer, University of Leeds

Factors important for a good death Control of symptoms Preparation for death Opportunity for closure or "sense of completion" of the life Good relationship with healthcare professionals Steinhauser KE 2000

Symptoms on the last 48 hours Sweating Confusion Pain Urinary dysfunction Breathlessness Death rattle Nausea and vomiting Restlessness/agitation Jerking/plucking/twitching

Death rattle Prevalence 41-92% patients Most common with lung or cerebral primaries Median duration of onset 23 hours

Death rattle How do relatives interpret it? Awful/horrible/terrible Nothing/expected Relief/sign of dying Wee B et al 2006

Management of death rattle Non drug management Discuss with family/carers Re-position Drug - hyoscine butylbromide (buscopan) 20mg sc stat 60-120mg/24hrs Bennett M 2002

Pain Cancer Cancer treatment Debility e.g. immobility Concurrent problems e.g. osteoarthritis

Analgesics (1) Paracetamol NSAIDs Liquid, suppository No subcut preparation NSAIDs Diclofenac PR 100mg od

Analgesics (2) Diamorphine Morphine sulphate Divide total daily dose of oral morphine by 3 = total daily dose of subcut diamorphine Opioid naïve 2.5mg sc PRN 5-10mg/24hrs Morphine sulphate Divide total daily dose of oral morphine by 2 Opioid naïve 2.5mg sc PRN

Transdermal analgesia Name Drug Apply Lowest dose Oral morphine Equivalent 24 hours Durogesic D-Trans Fentanyl 3 days 25mcg -90mg Transtec Buprenorphine 35mcg 30-60mg BuTrans 7 days 5mcg 5-10mg

The dying patient with a patch Continue current patch strength and replace every 72 hours Supplement with diamorphine prn and/ or syringe driver ‘Rule of 5’ Fentanyl 25mcg/5= 5mg diamorphine prn

Restlessness Agitation/restlessness Confusion/delirium Vs Disorientated Hallucinations Sleep-wake reversal Plucking

General Management Reverse the ‘easily’ reversible Explanation Full bladder, position, pain Explanation Environment Family

Agitation Benzodiazapine Midazolam Useful alone if fear/anxiety is the only feature Midazolam 2.5-5mg stat Repeat every 60mins if needed 10mg-60mg/24 hrs

Confusion/delirium Haloperidol Levomepromazine 3-5mg stat sc repeated as necessary Generally 5 - 10mg/24hrs Levomepromazine Sedating anti-psychotic 25mg-50mg stat Infusion 50-300mg/24 hrs

Breathlessness Fan, open window Breathlessness/cough/tachypnoea Diamorphine Opioid naïve 2.5mg stat, 5-10mg/24hrs Or increase dose by 1/3rd Breathlessness/anxiety Midazolam 2.5 mg stat, 10-30mg /24hrs

‘Terminal’ nausea Persistent or intermittent Small vomits, ‘possets’, retching Chemical cause Hypercalcaemia Uraemia Jaundice Infection

Anti-emetics Cyclizine May precipitate with hyoscine butylbromide 50mg stat 150mg/24hrs, May precipitate with hyoscine butylbromide Avoid saline May cause irritation

INJ HYOSCINE BUTYLBROMIDE 20mg / ml 5 x 1ml amps as dir EXAMPLE INJ CYCLIZINE 50mg / ml 5 X 1ML amps as dir INJ HYOSCINE BUTYLBROMIDE 20mg / ml 5 x 1ml amps as dir INJ MIDAZOLAM 5mg / ml 5 x 2ml INJ DIAMORPHINE 5mg 5 ( five ) x 5mg (five milligram) WATER FOR INJECTION 10 X 10mls amps

To foresee and take care of in advance Costs