End of Life Symptoms

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.

Prescribing information:  for managing common end of life symptoms

Based on PalliAGED - 'Prescribing and care in the terminal phase' 
 
For: Anxiety and emotional distress
Anticipatory prescribing:
  • Midazolam - 2.5mg - 5mg SC every 2 hours PRN (non-PBS) (can be used in a syringe driver)
    or
  • 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 additonal PRN doses as required
For anxiety and emotional distress which is not controlled by these measures seek palliative care advice.

For: Delirium which is causing distress
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.

For: Excessive secretions
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.

For:  Nausea and vomiting
Anticipatory prescribing:
  • Metoclopramide - 10mg SC three times a day PRN (PBS)
    or
  • 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 
    or
  • 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.

For: Pain
Anticipatory prescribing:
  • Morphine - 2.5mg to 5mg SC every 2 hours PRN (PBS)
    or
  • Hydromorphone 0.5 - 1mg SC every 2 hours PRN (PBS)
    or
  • 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 
    or
  • 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.

For: Shortness of breath
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.

From: Decision Assist Smartphone apps

Last updated 21 February 2017