Covid-19 HSE Clinical Guidance and Evidence

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Anticipatory Prescribing in the Last Hours or Days of Life (CD19-008 001 / 06.04.20)

• Introduction

• Opioid for pain and/ or breathlessness

• Anxiolytic sedative for anxiety or agitation or breathlessness

• Anti-secretory for respiratory secretions

• Anti-emetic for nausea or vomiting

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Introduction

• If a patient is in the last hours or days of life it is helpful if ‘anticipatory medication’ for symptom control is considered at the end of life (EOL). 
• It is essential to review the effect of any PRN medicine after it has been administered.
• There should be a review of the treatment plan within one hour to assess if the administered medication has had the desired effect/ no effect/ a partial, but inadequate, effect on the symptom.
• There should be a review of the treatment plan within 24 hours when the administered medication:
  • Is effective for an appropriate and expected time,
  • Has had a limited duration of effectiveness that has necessitated three or more repeated doses.
• As part of the review, the doses of regular medication, such as modified release tablets, transdermal patches or those given by syringe pump, should be considered. If there are signs of toxicity, a dose reduction, or drug switch, may be required. Advice from specialist palliative care should be sought if needed.
• Consider starting a syringe pump if symptoms persist (see syringe pump information).
• Adherence to guideline recommendations will not ensure a successful outcome in every case. It is the responsibility of all professionals to exercise clinical judgement in the management of individual patients. Palliative care specialists occasionally prescribe or recommend other drugs, doses or drug combinations. For more detailed guidance, visit https://www.palliativecareguidelines.scot.nhs.uk  AND/ OR contact specialist palliative care team for advice.

What medications?

4 symptoms commonly require medications for relief at the EOL:

• pain and/ or breathlessness
• anxiety or agitation
• respiratory secretions
• nausea or vomiting

Updated 25/03/2020
 

Opioid for pain and/ or breathlessness

For opioid naive patient

Morphine sulphate injection (10mg/ml ampoules)

• Dose: 2.5mg SC repeated at hourly intervals as needed for pain or breathlessness
• If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review
• If more than 6 doses are required in 24 hours seek advice or review

Note: Patients who are severely distressed may require rapid dose titration and urgent palliative care advice should be sought to guide management in these cases.

For patient already on regular opioids

If the patient is on a regular opioid, the prn dose is 1/6th of the 24-hour dose of the regular opioid and converted to SC dose, which is half of the oral dose, e.g. MST 30mg BD = 60mg of morphine sulphate in 24 hours. PRN dose is 10mg oramorph PO or morphine sulphate 5mg SC.

Updated 25/03/2020
 

Anxiolytic sedative for anxiety or agitation or breathlessness

Midazolam injection (10mg in 2ml ampoules)

Dose: 2.5mg SC, repeated at hourly intervals as needed for anxiety/distress

• If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review
• If more than 6 doses are required in 24 hours seek advice or review
• Note: if on large background doses of BZDs, a larger dose may be needed (if they are frail, a smaller dose may be enough)

Levomepromazine or haloperidol can be used in agitated delirium.

• Levomepromazine 3.125 to 6.25mg SC, hourly as needed OR haloperidol 0.5 to 1mg hourly as needed if levomepromazine not available
• If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review
• If more than 6 doses are required in 24 hours seek urgent advice or review

Updated 25/03/2020
 

Anti-secretory for respiratory secretions

Hyoscine butylbromide injection (Buscopan®) (20mg/ml ampoules)

• Dose: 20mg SC, hourly as needed. (Maximum dose 120mg in 24 hours)

OR

Glycopyrronium injection (200mcg/ml ampoules)

• Dose: 200mcg SC, hourly as needed (Maximum dose 2.4mg in 24 hours)

Updated 25/03/2020
 

Anti-emetic for nausea or vomiting

Levomepromazine injection (25mg/ml ampoules)

• Dose: 3.125 to 6.25mg SC, 12 hourly as needed.

OR

Haloperidol

• 0.5 to 1mg SC, 12 hourly as needed if levomepromazine not available.

Updated 25/03/2020