Guidance for the Management of Symptoms in Adults in the Last Days of Life (March 2023)

Cover page Guidance for the Management of Symptoms in Adults in the Last Days of Life

The guidance recognises the dying person may be unable to tolerate oral medicines. Therefore, administration is via the subcutaneous (SC) route (SC injection and SC syringe pump over 24 hours).

When it is recognised that a person may be entering the last days of life:

Consider any potentially reversible causes for the patient’s symptoms e.g. hypoglycaemia, infection, medication side effects, hypercalcaemia.
Ensure the patient or their family are aware time is short.
Review current medicines and stop any not providing symptomatic benefit.
Discuss and agree any medication changes with the dying person (where appropriate) and those important to them.
Inform the dying person (where appropriate) and those important to them that some of the medications have the potential to increase drowsiness.

Users are advised to:

Review patients regularly for side effects and response to treatment.
When prescribing always start with the lowest dose in the range specified in this guide.
Seek specialist advice in moderate or severe renal and/ or hepatic impairment or those with complex needs.
Consider the non-pharmacological management of symptoms at the end of life g. repositioning to manage pain.
Higher doses of the agents included in this guideline may be advised by the Specialist Palliative Care Team.
The recommendations are a GUIDE and should be used as such. They may differ from other recommendations but have been chosen to reflect expert opinion, best evidence, safety and local practice in NI. Responsibility for the use of these recommendations lies with the health care professional(s) managing each patient.

Careful assessment for the underlying cause of symptoms is required and patient’s should always be managed in the context of their individualised end of life care plan.

Details of Palliative Care Network Pharmacies and Palliative Care Supply Service pharmacies (i.e. those with extended opening hours who are contracted to stock the regional palliative care medicines list) can be found at Palliative Care (hscni.net) https://hscbusiness.hscni.net/services/2481.htm

Further information is available from your Specialist Palliative Care Team, the Palliative Adult Network Guidelines (PANG) Book 2016 and at www.book.pallcare.info

Pain

Morphine Sulfate is the 1st line choice of strong opioid in non-specialist settings. Renal failure is an exception – see choice of 1st opioid with renal impairment section below.

Image of table showing options for Patient current experiencing pain (patient unable to take oral analgesia)

Opioid Conversions Tables

Refer also to HSC Guidance “Northern Ireland guidelines on converting doses of opioid analgesics for adult use”.
Morphine Sulfate is the first line choice of strong opioid in non-specialist settings. Renal failure is an exception- see choice of 1st opioid with renal impairment section below.

Image of table showing Recommended strengths and pack size to prescribe

* Breakthrough analgesia is usually worked out as 1/6th of the total 24 hour opioid dose, but can also be given as 1/10th of the total 24 hour opioid dose. Refer to BNF “Prescribing in Palliative Care” section.

Image of 2 tables. Table 1 shows Opioid Conversions PO (Oral) to SC (Subcutaneous) and SC (Subcutaneous) to SC and PO (Oral) to PO. Table 2 shows Transdermal Patch Conversions Fentanyl Patch eg. Mezolar®, Durogesic® Replace patch every 3 DAYS and Buprenorphine Patch eg. Butec®, BuTrans® Replace patch every 7 DAYS

Example Opioid Calculations

Changing from Oral Morphine to SC Morphine via syringe pump.
1. Work out total oral dose Morphine in 24 hours
e.g. MST 15mg BD = 30mg morphine total/ 24 hrs
2. Convert from oral to SC route
e.g. 30 ÷ 2 = 15mg Morphine SC syringe pump over 24hours

And

Calculating the oral breakthrough/ PRN dose (immediate release preparation)
1. Work out total oral dose Morphine in 24 hours
e.g MST 15mg BD = 30mg total/24hours
2. Divide by 6 to get 1/6th of the dose
e.g. 30 ÷ 6 = 5mg Morphine Sulfate Oral Solution (Oramorph®) PRN 2 to 4 hourly

And

Calculating the SC breakthrough/ PRN dose
Divide total SC morphine dose in 24h by 6
e.g. Morphine 15mg via syringe pump over 24h = 15 ÷6 = 2.5mg. Prescribe 2mg Morphine Sulfate injection SC PRN 2 to 4 hourly. For safety and clarity, prescribe in whole milligrams. Use of decimal places should be avoided.

Note: Breakthrough analgesia is usually worked out as 1/6th of the total 24 hour opioid dose, but can also be given as 1/10th of the total 24 hour opioid dose. Refer to BNF “Prescribing in Palliative Care” section.

Choice of first opioid with renal impairment

Opioids may accumulate in renal impairment and thus Morphine Sulphate should not be initiated with an eGFR< 60ml/min.
Prescribing in renal failure at the end of life has many nuances including the rate of renal function decline, degree of opioid tolerance, level of pain, imminence of dying and level of opioid toxicity.
Blood tests to determine renal function probably would not be appropriate for patients in the last hours/days of life.
If the patient is in last hours/ very short days of life and tolerating their current opioid, it may be appropriate for them to remain on this regardless of renal function. However, ensure close monitoring for signs of toxicity and have a low threshold for seeking specialist palliative care advice.
Alfentanil is drug of choice for syringe pumps when eGFR is 20ml/min or less although specialists may recommend earlier, especially where a rapid decline in renal function is anticipated.
If using Alfentanil the PRN opioid of choice is SC Oxycodone.
Oxycodone can be used in renal failure/ renal disease at end of life but there is greater potential for opioid toxicity than with Alfentanil and so caution is advised when using Oxycodone and increased dosing intervals may be appropriate. Different care settings may impact on ease of availability of medicines.
For patients with rapidly changing or complex problems please discuss with the specialist palliative care team.

Nausea and Vomiting

Consider potentially reversible causes such as constipation, hypercalcaemia, infection and raised intracranial pressure. Choice of antiemetic should be influenced by likely underlying causes.

Image showing flow chart options for No Symptoms Present and Symptomatic

Table 3. Choice of Antiemetic

Lower doses are indicated in severe renal or hepatic impairment

Image of Table showing Choice of Antiemetic

Breathlessness

Image showing flow chart options for Intermittent Symptoms and Persistent Symptoms

For patients on other opioids use Table 1 for opioid conversions and use guidance as above

For patients who are conscious and can tolerate oral medicines consider oral opioid in a dose equivalent to the SC doses recommended above.
Oxygen is only indicated for patients who are are hypoxic.

Image of table showing If patient is breathless AND anxious, consider: Midazolam 2mg SC PRN and/or Midazolam 5mg-10mg via SC syringe pump over 24 hours. If tolerating oral medicines consider Lorazepam tablets 500 micrograms sublingually 4-6 hourly PRN. Table shows Recommended strengths and pack size to prescribe.

Anxiety, Delirium and Agitation

Assess the patient first to exclude potentially reversible and treatable causes such as pain, drug withdrawal including nicotine, urinary retention or severe constipation.

Image of 2 flow charts, one for No Symptoms Present and one for Symptomatic

Noisy Respiratory Secretions

Repositioning can be Early use of anti-secretory agents should be considered and can prevent accumulation of new secretions, although has limited effect in clearing those already accumulated.
Reassure family and carers that although respiratory secretions sound uncomfortable, if the patient is deeply asleep or unconscious, they are most likely not distressed by them. They are present because the patient is not coughing or clearing their throat as they normally would.
Good mouth care is essential in reducing the sensation of thirst. Use of intravenous or subcutaneous fluids should be reviewed as part of the patient’s individualised care plan.