1. PRESCRIBING IN THE LAST DAYS OF LIFE
Peter Nightingale
Macmillan GP

2. The Seven C’s Communication Palliative Care Register/MDT meetings
Co-ordination Key person
Control of Symptoms Assessment, Treatment and Patient Centred care
Continuity Handover to out-of-hours/protocol. Information to patients/carers
Continued Learning Practice-based learning/reflection on experiences.
Carer Support Practical, Emotional, Bereavement
Care of the Dying Liverpool Integrated care pathway (Dying Phase)

3. Diagnosing the Terminal Phase
BEDBOUND
ONLY ABLE TO TAKE SIPS OF FLUID
SEMI COMATOSE
NO LONGER ABLE TO TAKE ORAL MEDICATION
2 out of four required for Liverpool Care Pathway

4. Last Days Of Life- Anticipating and planning for common problems at home 
Loss of mobility and ability to transfer safely
Loss of ability to drink
Loss of ability to eat
Pain
Vomiting
Dyspnoea
Excess secretions
Delerium and agitation

5. Loss of mobility Unable to transfer safely
Generally safer and more manageable to nurse in bed
Consider loan of hospital bed/monkey pole/cot sides/commode/urine bottles
Assess for pressure area care and implement appropriate strategy
Indwelling urinary catheter/sheath for men if more acceptable if incontinent/unable to transfer to commode
Bowel care

6. Methylnaltrexone (relistor)
SC methylnaltrexone is approved for use in patients with 'advanced illness' suffering from opioid-induced constipation despite usual laxative therapy. Constipation is common in advanced disease, even in patients not taking opioids. Thus, so-called 'opioid-induced constipation' is often multifactorial in origin; and methylnaltrexone will normally augment laxatives rather than replace them. It is important that laxative therapy is optimized before using methylnaltrexone.
About 1/2 patients defaecate within 4h of a dose without impairment of analgesia or the development of withdrawal symptoms. Common undesirable effects include abdominal pain, diarrhoea, flatulence, and nausea.
Initially give a single dose on alternate days. If there is no response, a second dose can be given after 24h, but not more often.

7. Loss of ability to drink
Prepare family and patient for this happening
Explain it is a natural process and may aid comfort by reducing secretions/gastric secretions and chance of vomiting/urine output
Encourage sips/mouth care
In the occasional situation, if still distressed by thirst consider S/C fluids (N.saline 1l over 12h via a butterfly into anterior abdominal wall or thigh)

9. What can we conclude? Parenteral hydration in palliative care context:
probably improves
mucous membrane hydration status
sedation and ?myoclonus
probably worsens
peripheral oedema, ascites and pleural effusions
is unlikely to affect
delirium and hallucinations
agitation
bronchial secretions
fatigue
can produce a significant placebo effect

10. Loss of ability to eat Prepare family and patient for this happening
Explain it is a natural process
Forcing food may create discomfort if too weak to swallow/digest

11. Pain
Morphine or Diamorphine SC prn in proportion to overall opioid requirement
Consider leaving pre drawn-up syringes :possibly leave an indwelling butterfly needle SC
OTFC Fentanyl increasingly considered

12. Vomiting
Levomepromazine is a useful broadspectrum antiemetic for the end of life. 6.25mg SC
Cyclizine 50mg tds SC or other antiemetic targeted at likely cause

13. Dyspnoea Common and frightening
Morphine/Diamorphine preferably SC (or sublingual) titrated up as for pain.
Midazolam 2-10mg S.C. or sublingual prn or 5-30mg SC/24h for breathlessness/fear or
Diazepam

14. Excess respiratory secretions (note Cochrane rev 2008)
Positioning important
Antimuscarinics
Glycopyrronium
Hyoscine hydrobromide 0.4mg sublingual or SC 4h prn or
Hyoscine butylbromide 20mg SC

15. Delirium and agitation
Common at the end of life· Distressing and frightening for everyone involved
Haloperidol 5-30mg/24h/sc and/or midazolam5-60mg/24h(if agitation only)

16. Changing breathing pattern
Explanation to family "He may appear to stop breathing for a time, then draw another breath"

17. The Pathway in Today’s Health Care System
There must be continuous improvement in the delivery of health care and the care of the dying patients must improve to the level of the best
(DOH 1998, NHS Cancer Plan 2000)
Patients want to die in the place of their choice and be assured that their carers will be supported throughout their illness and in bereavement
(Commission for health improvement/Audit Commission 2002)
There is a need to describe and transfer best practice in Hospice care into hospital and other care settings
(Bonick 2004)
How has it arisen? Well, it was recognised in 2000 in the NHS cancer plan that care of the dying pt needed to improve nationally and the audit commission identified that patients want to die at home and they want to feel assured that their carers will be supported throughout their illness and in bereavement hence the preferred place of care document evolved and there has been a general acceptance that the standards of care for the dying in hospices should be adopted in other care settings.

18. What Is The LCP and How Does It Work?
ICP is a multidisciplinary document which provides a template for managing patient centred care, it acts as a flow chart for the care being given
It Describes Care
It Tracks Care
It Monitors Care
It Evaluates Care
The idea of an integrated care pathway originally came from American engineering industry and was later adopted as a health care initiative. An ICP is a template of managing care, it acts as a flow chart for the care being given. It describes care, it tracks care, it monitors and evaluates care

19. 3 Sections To The LCP Initial assessment and care
Ongoing assessment and care
Care after death

20. Goals Of Patient Care Encompassed By The LCP
Physical
Psychological
Religious/Spiritual
Social

21. GP’s Involvement Diagnose that the patient is dying
Discontinue oral medication/syringe driver if required
Prescribe 4 core drugs
Liaise with nursing staff, relatives and out of hours/put the pt on pathway
Sign documentation
So what are the potential pitfalls? Well, I think to try and roll this out in the mass would be a recipe for disaster I do not think many would take this on board however, if it is addressed in small groups and well supported and evaluated and found to work it won’t be long before word gets around that this is a good way of working.
In hospital I think resistance may come as a result of nursing rituals. With the notion that we’ve always done it this way, it’s ok why should we change now which I think that is why it is important to identify key links with staff who are enthusiastic about it.
In the community I think the resitance will come from the Gp’s in terms of why should they adopt this when they have no financial incentives and they also have not taken on the GSF. We need to promote the quality of service they will be providing and highlight the benefits of the LCP in terms of it’s evaluation and how it can improve practice and pt care. (review medication)

22. What Are The Benefits of Using The Pathway?
It organises the process of caring
It is multisectoral (community/hospital)
Multi-professional/aids communication
It can influence ethical decision making
Incorporates guidelines, evidence based practice and clinical effectiveness
What are the benefits? Well it organises the process of caring. It can be adapted to any setting including, residential and nursing homes. It can be used by many professionals. It guides practice and is evidence based. It integrates education and practice.
It is outcome focused in that we know that it is often difficult to prove what we do is right the pathway gives us the capacity to do that. It replaces and reduces documentation and is a legal record which can be written or used electronically. And the great advantage of variances allows us to record why care has not been carried out.

23. Benefits Outcome focused (clinical supervision)
Replaces and reduces documentation
Legal record (written or electronic)
Variances (allow staff to justify non-actions)
Flexibility (pts can come off the pathway)
Quality of care
In hospital we need to identify key areas, where people die in hospital ie, unlikely to use in opthalmic ward or outpatients We need to emphasis that it can be used on all dying pts not just those dying with cancer.
And then I think we need to ask the staff what they feel about how pts die in their area and listen to their Scenarios and respect their perspectives. We need to identify nurses who are keen and enthusiastic about it, then provide them with the education programme and introduce the document.
Set up a pilot study on two or three of the most appropriate wards. Evaluate how it’s gone and listen to staff and how they’ve found it and then repeat the process on other wards.

24. PLANNING NO LONGER ABLE TO TAKE ORAL MEDICATIONS:-
Discontinue unnecessary drugs
Review medication required
Plan for what medication may be required

25. Discontinuing Drugs Stop Non Essentials e.g. statins
Probably continue diuretics –furosemide can be given subcutaneously
Review steroids

26. Steroids in Palliative Care
Used to improve quality of life after risk/benefit assessment for:-
16mg Dexamethasone in emergencies
12mg for inflammation in brain, liver or after chemotherapy
4mg to temporarily help appetite
But taper down quickly because of:-

27. Side effects of steroids
Hyperglycaemia
Thrush
GI bleeding
Agitation and restlessness
Muscle loss
Bed sores
Bacterial infection

28. P A I N Is patient already taking oral morphine? Yes No
Convert to 24hr s/c infusion of DIAMORPHINE
For conversion divide the total daily dose of MORPHINE by 3
( eg MST 90mg bd orally = DIAMORPHINE 60mg
via syringe driver)
Make available subcutaneous DIAMORPHINE dose PRN for
breakthrough pain
PRN dose equals total daily dose divided by 6
(eg if DIAMORPHINE 60mg subcutaneous in syringe driver
PRN dose equals 10mg subcutaneously)
Make available DIAMORPHINE
2.5mg – 5mg prn s/c
After 24 hours review medication. If
2 or more doses required PRN then
consider a syringe driver.
Starting dose would be the total
requirements over the previous
24 hours. The PRN dose may then
need to be recalculated
If the patient is still in pain after
12 hours consider increasing the
infusion by 30 – 50%

29. TERMINAL RESTLESSNESS & AGITATION
Present
Absent
Make available
MIDAZOLAM 2.5mg-5mg s/c 4hrly PRN
Make available
MIDAZOLAM 2.5 – 5mg s/c 4hrly PRN
Review the medication after 24hrs
If two or more PRN doses have been
required then consider a syringe driver.
Starting dose would be the dose required
over the previous 24 hours
Review the medication after 24hrs
If two or more PRN doses have been
required then consider a syringe driver
Starting dose would be the dose required
over the previous 24 hours
Continue to give PRN dosage accordingly

30. RESPIRATORY TRACT SECRETIONS
Present
Absent
Glucopyrronium 200 microgram SC stat then 1200mcg over 24 hours
Glycopyrronium 200mcg
s/c 8 hrly PRN should be
made available
Continue to give 200microgram PRN dosage
8 hourly
If two or more doses of
PRN Glycopyrronium
required then commence syringe driver
s/c over 24 hrs
Increase total 24hr dose to
1.2 mg after 24 hours if
symptoms persist

31. NAUSEA & VOMITING NB. If patient is already on an effective
Absent
Present
Levomepromazine 6.25 s/c 8 hrly PRN
Levomepromazine 6.25mg s/c 8rly PRN
Review dosage after 24hrs. If 2 or more PRN
doses required, then consider use of syringe
driver. Starting dose mg s/c over
24 hours
NB. If patient is already on an effective
Antiemetic then switch to parental route
and continue

32. Fentanyl at the end of Life
Almost always better to leave the patch on in the last days of life and add in other drugs via a syringe driver if necessary, because:-
Fentanyl reservoir active for up to 17hrs
Opioid requirements vary greatly at this time of life, they can decrease due to renal failure or increase due to disease progression

33. THE SYRINGE DRIVER IN PALLIATIVE MEDICINE
GRASEBY MS26
GREEN FRONTED
RATE = mm/24 hours

34. INDICATIONS Dysphagia Swallowing difficulties mouth/throat lesions
Intestinal obstruction
Severe weakness
Nausea & vomiting
Poor alimentary absorption
Semi comatose/comatose

35. ADVANTAGES Steady drug levels Avoids repeat injections
Loaded once a day
Does not limit mobility
Can be used to control >1 symptom

36. DISADVANTAGES Seen as a panacea
Irritation or swelling can limit absorption-Normal Saline is the preferred diluent unless cyclizine is being used

37. THE BOOST BUTTON There is no “lock out” period
The dose of analgesia is less than the prn dose
All drugs will be boosted
The driver will run out more quickly

38. COMMONLY USED DRUGS Drug Action Analgesic Antiemetic Agitation
Anticonvulsant
Excessive Secretions
Smooth muscle spasm
Steroids
Drug
Morphine/Diamorphine
Cyclizine
Haloperidol
Levomopromazine
Metoclopramide
Midazolam
Hyoscine hydrobromide
Glycopyrronium
Hyoscine butylbromide
Dexamethasone
24 Hour Dose
Starting dose 5 – 10mgs
50 – 150mgs
1.5 – 5mgs
2.5 – 12.5mgs
30-60mgs
2.5 – 5mgs
6.25 – 25mgs(up to 150mgs)
5 – 30mgs
10 – 40mgs
40 – 1200mcgms
600 – 1200mcgms
20 – 120mgs
4 – 16mgs

39. CAUTION
Cyclizine precipitation occurs when mixed with Diamorphine if either one exceeds 20mgs/ml-needs water as diluent
Metoclopramide extrapyramidal reactions can occur with higher doses or if used with Haloperidol or Levomopromazine
Levomopromazine exessive sedation and skin irritation can occur with higher doses or when used with other D2 receptor antagonists, eg Haloperidol or Metoclopramide
Dexamethasone should not be mixed with any other drug-very small doses occasionally used for site reactions

41. The verification of death
Dr Hong Tseung
Macmillan GP Adviser

42. Definitions verifying death certifying death registering a death
confirming death has actually occurred – 'fact of death'
certifying death
written confirmation of cause of death
registering a death
formal notification to authorities (Registrar of births and deaths) of fact of death and its cause

43. Who does what? verification of death certification of death
doctor (GMC registered)
registered nurse
certification of death
doctor (GMC registered) only
must have seen the patient alive in preceding two weeks before death
registration of death
by 'the informant' – carer, relative, family member who takes death certificate to the Registrar

44. The coroner’s involvement
when the cause of death is not known
eg sudden death
when there is a suspicious cause of death
eg bullet wounds, knife wounds, strangulation, asphyxiation, overdose, suicide
when no medical practitioner has seen patient alive within the last two weeks before death

45. The signs of human life breathing pulse/heart beat pupil reaction
responsiveness
auditory, sensation (pain), reflexes

46. The signs of dying (impending death)
not always easy to 'diagnose dying'
bed-bound
comatose/semi-comatose
taking sips of fluids only
no oral intake
irregular breathing (Cheyne Stokes, shallow)

47. What happens when death has occurred?
no organs work
no brain activity, heart stops, lungs stop, liver and kidneys stop, muscles stop
tissues start to breakdown
rigor mortis (several hours later), blood pools, decomposition

48. The signs of death looks pale (blood pooling) no breathing no pulse
no heart sounds
pupils fixed and unreactive to light
no response to sensory stimuli (eg pain)
no reflexes (no brainstem activity)

49. What to do None of the above present? = death confirmed look feel
for skin colour (pink)
for chest movement (breathing)
feel
for a MAJOR pulse: carotid
listen
for breath sounds
for heart sounds
test
for BOTH pupil reflexes to light
None of the above present?
= death confirmed

50. Don’t get it wrong
very embarrassing
distressing for relatives