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

2. 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

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

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

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

6. 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

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

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

9. 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

10. 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

12. 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

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

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

15. 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

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

17. 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

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

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

20. 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

21. To foresee and take care of in advance
Costs