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

2. 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'

3. 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

4. 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

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

6. Case Scenarios

7. 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

8. 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?

9. 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

10. 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

11. 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?

13. 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?

14. 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.”

15. 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?

16. 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

17. 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?

18. 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

19. Y&H Symptom Control Guidelines

20. Ref: Y&H Symptom Control Guidelines

21. 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

22. 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

23. Useful Resources