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

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 mg/24rs Midazolam 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 (1/10 th 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 £ Midazolam 2mg and 5mg/ml £1 Hyoscine Butylbromide 20mg/ml £0.22 Glycopyrronium 200microgram/ml £1