End of Life Symptoms - The Dying Patient - General Practitioner

Providing care at the end of life

Terminal care usually refers to the last few days to weeks of life when a person is irreversibly dying. Management of the last days of life can be supported by discussions that have occurred previously.

Key points

All medications prescribed at the end of life should be based on careful assessment of the dying person’s condition and symptoms, and doses should be proportionate to the the severity of those symptoms
Prescribing in end of life care involves a combination of
- Anticipatory prescribing of as needed medications for common symptoms that may occur at some stage when a person is dying and
- Ongoing management of pre-existing symptoms by prescribing regular medications, with additional PRN doses for emergent symptoms
Medicines that do not contribute to comfort should be ceased. Most patients will no longer be able to take oral medications.
The subcutaneous route is generally preferred as least invasive and most reliable in dying patients.
Regularly review symptoms and the effects of treatment. If frequent PRN doses are required or the treatment is for a pre-existing symptom, order a regular subcutaneous dose, and consider using a syringe driver to give the 24 hour requirements and reduce the burden of medication administration. Opioid conversions can be calculated using the EviQ opioid calculator.
If the patient requires complex medications or has difficult symptom issues, contact the palliative care team for prescribing advice.

Sometimes people can deteriorate suddenly. In this case anticipatory medicines may not have been arranged. The caring@home National Core Community Palliative Care Medicines List can guide GPs, nurse practitioners, and other prescribers with their care of their home-based palliative care patients in the terminal phase.

Download the caring@home core medicines list (534kb pdf)

Prescribing information: for managing common end of life symptoms

The following information is based on palliAGED - Prescribing and care in the terminal phase

Anticipatory prescribing:

Midazolam - 2.5mg - 5mg SC every 2 hours PRN (non-PBS) (can be used in a syringe driver)

CLONazepam 0.25mg - 0.5mg oral or SC every 4 hours PRN (PBS) (cannot be used in a syringe driver)

Continuing management of anxiety and emotional distress:

Calculate previous benzodiazepine doses, including PRN doses, and convert to a SC alternative given regularly over 24 hours, using either BD CLONazepam or a continuous SC infusion of midazolam
Continue to administer additional PRN doses as required

For anxiety and emotional distress which is not controlled by these measures seek palliative care advice.

Anticipatory prescribing:

Haloperidol - 0.5mg - 1mg SC twice a day PRN (PBS)

Continuing management of delirium which is causing distress:

Give haloperidol regularly over 24 hours, either as a BD dose or in a continuous SC infusion
Consider adding midazolam or CLONazepam if agitation persists
Continue to administer additional PRN doses of haloperidol and / or benzodiazepine as required

For delirium which is not controlled by these measures seek palliative care advice.

Anticipatory prescribing:

Hyoscine BUTYLbromide (Buscopan®) - 20mg SC every 2 - 4 hours PRN (PBS - palliative care listing)

Continuing management of excessive secretions:

Give hyoscine BUTYLbromide (Buscopan®) regularly every 2 - 4 hours or as a continuous SC infusion of the previous 24 hour dose
Continue to administer additional PRN doses as required

For excessive secretions which are not controlled by these measures seek palliative care advice.

Anticipatory prescribing:

Metoclopramide - 10mg SC three times a day PRN (PBS)

Haloperidol 0.5mg SC twice a day PRN (PBS)

Continuing management of nausea and vomiting:

Give metoclopramide regularly SC three times a day or as a continuous SC infusion of 30 - 40mg

Give haloperidol regularly twice a day or as a continuous SC infusion of 1 - 2 mg
Continue to administer additional PRN doses as required

For nausea and vomiting which is not controlled by these measures seek palliative care advice.

Anticipatory prescribing:

Morphine - 2.5mg to 5mg SC every 2 hours PRN (PBS)

Hydromorphone 0.5 - 1mg SC every 2 hours PRN (PBS)

Fentanyl 25 micrograms - 50 micrograms SC every 2 hours PRN (non-PBS)

Continuing management of pain:

If an opioid patch is in situ consider continuing patch at same dose and ordering an opioid PRN dose SC for breakthrough pain

Convert the patient’s previous oral and / or transdermal opioids (including all opioids that are being used) to an equivalent subcutaneous dose. Give either as a continuous subcutaneous infusion via a syringe driver over 24 hours, or divided as regular boluses every four hours. See EviQ Opioid calculator for opioid conversions.
Administer additional PRN doses of opioid as required
For patients who are on regular opioids the PRN dose (or breakthrough dose) is proportional to their regular dose. Calculate it as:
PRN dose ~ 10% of total daily SC opioid dose every 2 hours.

For pain which is not controlled by these measures seek palliative care advice.

Anticipatory prescribing:

Morphine 1.25 - 2.5 mg SC every 2 hours PRN (PBS)

Continuing management of shortness of breath:

Calculate the PRN opioid dose used in the previous 24 hours and give as either a continuous subcutaneous infusion over 24 hours in a syringe driver, or divided as regular subcutaneous doses every 4 hours
If already receiving opioids for pain, and the patient is distressed by shortness of breath, titrate up current regular opioid dose by 30%
Administer additional PRN doses of the person’s regular opioid as required - for either pain or shortness of breath
For shortness of breath which is not controlled by these measures seek palliative care advice.