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PRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT
This guidance has been developed as a tool to support safe and effective prescribing of medication that al eviates the common symptoms that occur in the dying patient. 2. Nausea and Vomiting 4. Respiratory Tract Secretions Most patients who are dying will experience one or more of these symptoms and will require medication that is administered subcutaneously either PRN or via a syringe driver. The IV or IM routes are not routinely recommended in the dying patient. It is good practice to prescribe PRN medication in advance of the last few days of life. This prevents delays in patients receiving medication. Suggested quantities of standard as required medication prescribed in anticipation and dose /
ampoule.
CYCLIZINE
50mg/1ml amps x 10
MIDAZOLAM
5mg/ml 2ml amps x 10
GLYCOPYRRONIUM
200 micrograms/ml amps x 20
WATER FOR INJECTIONS
10ml amps x 20
MORPHINE
10mg/1ml amps x 10
DIAMORPHINE
5mg amps x 10
For patients who have epilepsy or have experienced seizures and are no longer able to take oral medication commence a syringe driver with 20mg MIDAZOLAM over 24 hours to prevent seizures. Ensure MIDAZOLAM 5mg SC PRN is also prescribed in addition for seizures. Where patients have been prescribed DEXAMETHASONE for symptoms associated with raised intracranial pressure continue the same dose either once or twice daily as an SC injection or via a separate syringe driver 24/7 PALLIATIVE CARE ADVICE LINE FOR HEALTH PROFESSIONALS 0844 225 0677
HALTON, ST.HELENS & KNOWSLEY
Resources – Merseyside and Cheshire Palliative Care Network Audit Group Standards and Guidelines 4th Ed. 2010 Pal iative Care Formulary 4th Ed 2012 Palliativedrugs.com Ltd Version 2 – September 2013 – September 2016 PRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT
PAIN MANAGEMENT
Patient established on oral morphine or opioid naive. Important; It is the responsibility of the prescriber to ensure that guidelines are fol owed when prescribing
opioids. Every member of the team has a responsibility to check that the intended dose is safe for the individual
patient. Knowledge of previous opioid dose is essential for the safe use of these products. Advice should be
sought if prescribing outside of these guidelines or when the limits of own expertise are reached
CONTACT THE PALLIATIVE CARE TEAM (Details below) FOR ADVICE IF:  The patient has moderate to severe renal failure.  The patient has new severe pain or pain that has persisted after 24 hours on a syringe driver. PATIENTS IS TAKING ORAL
MORPHINE

 Stop al oral Morphine
 Convert total daily dose of oral Morphine to
subcutaneous route by dividing by 2 and prescribe this dose subcutaneously via a syringe driver over 24 hours (see example (a) below).  Prescribe and give Prescribe in anticipation Prescribe a breakthrough pain dose of Morphine
Morphine 2.5 mg-5 mg
that is 1/6th of the calculated total Morphine dose
Morphine
IN SYRINGE DRIVER, SC hourly PRN (see example (b)  Prescribe Morphine
2.5 mg-5 mg SC PRN 10 mg via syringe driver Reassess after 24 hours.  Prescribe Morphine
2.5-5 mg SC PRN hourly for breakthrough pain.  If patient has required additional Morphine for
 Reassess after 24 hours breakthrough pain calculate total dose given over 24 hours and increase dose in syringe driver by 50% of
 Ensure breakthrough dose remains at 1/6th of SC = Subcutaneous syringe driver dose. PRN = as required Example (a) syringe driver dose Converting from oral Morphine to syringe driver
e.g. Zomorph 60 mg 12 hourly = 120 mg
120mg/2 = 60 mg Dose of Morphine subcutaneously via syringe driver over 24 hours = 60 mg
Example (b) calculating breakthrough dose The breakthrough dose is 1/6 th of total daily morphine dose e.g. Patient requires 60 mg Morphine via syringe driver over 24 hours
60/6 = 10 mg Morphine SC PRN
24/7 PALLIATIVE CARE ADVICE LINE FOR HEALTH PROFESSIONALS 0844 225 0677
HALTON, ST.HELENS & KNOWSLEY
Resources – Merseyside and Cheshire Palliative Care Network Audit Group Standards and Guidelines 4th Ed. 2010 Pal iative Care Formulary 4th Ed 2012 Palliativedrugs.com Ltd Version 2 – September 2013 – September 2016 PRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT
PAIN MANAGEMENT
Patients established on Fentanyl Patches Important; It is the responsibility of the presriber to ensure that guidelines are fol owed when prescribing opioids. Every member of the team
has a responsibility to check that the intended dose is safe for the individual patient. Knowledge of previous opioid dose is essential for the
safe use of these products. Advice should be sought if prescribing outside of these guidelines or when the limits of own expertise are reached
DO NOT COMMENCE FENTANYL PATCHES FOR PAIN RELIEF IN THE DYING PHASE.
If the patient has severe renal dysfunction and requires additional pain relief seek advice on prescribing from the palliative care team.
FENTANYL ESTABLISHED
DO NOT remove Fentanyl Patch
Prescribe opioid for continue and re-apply every 72 breakthrough pain as Prescribe adequate dose of breakthrough opioid analgesia as table below.  Re-asses after 24 Hrs  If 2 or more doses of breakthrough opioid are required in 24 hrs commence syringe driver. Prescribe 50% of the total
amount of breakthrough given in previous 24hrs via syringe driver in addition to Fentanyl patch.
OBTAIN SPECIALIST PALLIATVE CARE ADVICE REGARDING CALCULATING SUBSEQUENT PRN DOSE OF OPIOID S/C ONCE OPIOID IS
REQUIRED IN SYRINGE DRIVER.
Fentanyl Patch strength Up to hourly Morphine sc PRN
Up to hourly Oxycodone sc PRN
12 micrograms per hour 1.25mg – 2.5mg 25 micrograms per hour 50 micrograms per hour 75 micrograms per hour SC = Subcutaneous PRN = as required 24/7 PALLIATIVE CARE ADVICE LINE FOR HEALTH PROFESSIONALS 0844 225 0677
HALTON, ST.HELENS & KNOWSLEY
Resources – Merseyside and Cheshire Palliative Care Network Audit Group Standards and Guidelines 4th Ed. 2010 Pal iative Care Formulary 4th Ed 2012 Palliativedrugs.com Ltd Version 2 – September 2013 – September 2016 PRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT
PAIN MANAGEMENT
For patients established on oral Oxycodone Important it is the responsibility of the presriber to ensure that guidelines are fol owed when prescribing opioids. Every member of the team
has a responsibility to check that the intended dose is safe for the individual patient. Knowledge of previous opioid dose is essential for the
safe use of these products. Advice should be sought if prescribing outside of these guidelines or when the limits of own expertise are reached
 BOTH 3:2 AND 2:1 CONVERSIONS FROM ORAL OXYCODONE TO THE SUBCUTANEOUS ROUTE ARE USED.
 IN THE DYING PHASE USE 3:2 AS BELOW
CONVERT ORAL OXYCODONE TO SUBCUTANEOUS ROUTE AS BELOW
 CALCULATE DOSE REQUIRED OVER 24 HOURS IN SYRINGE DRIVER:
SYRINGE DRIVER DOSE = 2/3 OF ORAL DAILY DOSE.
e.g. Oxycontin 45 mg 12 hrly = 90 mg
dose required in syringe driver = 60 mg CALCULATE DOSE OF OXYCODONE REQUIRED FOR RELIEF OF BREAKTHROUGH
BREAKTHROUGH DOSE = 1/6TH DOSE IN SYRINGE DRIVER.
e.g. Oxycodone 60 mg/24 hours in syringe driver = 10 mg Oxycodone SC PRN
 RE-ASSESS AFTER 24HRS – if patient has required breakthrough analgesia calculate
total amount given in previous 24 hrs and increase dose in syringe driver by 50% of
 ENSURE THAT BREAKTHROUGH DOSE REMAINS 1/6th of DOSE IN SYRINGE DRIVER
SC = Subcutaneous PRN = as required 24/7 PALLIATIVE CARE ADVICE LINE FOR HEALTH PROFESSIONALS 0844 225 0677
HALTON, ST.HELENS & KNOWSLEY
Resources – Merseyside and Cheshire Palliative Care Network Audit Group Standards and Guidelines 4th Ed. 2010 Pal iative Care Formulary 4th Ed 2012 Palliativedrugs.com Ltd Version 2 – September 2013 – September 2016 PRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT
NAUSEA & VOMITING – for patients without heart failure
Not on anti-emetics Prescribe in anticipation Prescribe Cyclizine 50mg SC stat dose and
Cyclizine 50 mg SC 8
commence 150 mg/24 hours via syringe Seek advice via advice line
If symptoms persist ADD Haloperidol 1.5
– number below
mg – 5 mg SC via syringe driver over 24 CYCLIZINE IS NOT RECOMMENDED IN PATIENTS WITH HEART FAILURE.
Alternative anti-emetics according to local policy & procedure may be prescribed, e.g. Haloperidol 1.5mg – 3mg SC PRN max 10mg/24 hours.
1.5mg-5mg via a syringe driver over 24 hours
Levomepromazine 6.25mg SC PRN 8 hourly or
6.25 mg – 25 mg via a syringe driver over 24 hrs
SC = Subcutaneous PRN = as required 24/7 PALLIATIVE CARE ADVICE LINE FOR HEALTH PROFESSIONALS 0844 225 0677
HALTON, ST.HELENS & KNOWSLEY
Resources – Merseyside and Cheshire Palliative Care Network Audit Group Standards and Guidelines 4th Ed. 2010 Pal iative Care Formulary 4th Ed 2012 Palliativedrugs.com Ltd Version 2 – September 2013 – September 2016 PRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT
TERMINAL RESTLESSNESS & AGITATION
The intention of sedation in pal iative care is to relieve distress – unconsciousness may occur
but is not a desired outcome (refer to NPSA/2008/RRR011)
Urinary retention and rectal distension from constipation are common reversible causes of agitation – ensure these are excluded. Midazolam 2.5 mg – 5
 Prescribe Midazolam 2.5 mg – 5 mg SC PRN until syringe driver
commenced. If 2.5 mg ineffective after 30 minutes, give a further 5 mg (total 7.5 mg in 1 hour) If patient remains agitated Maximum 30 mg in 24 seek medical review and contact Specialist Palliative Care Team for advice.  If agitation likely to persist commence Midazolam 10 mg-20 mg
SC via Syringe Driver over 24 hours.  In addition prescribe Midazolam 2.5 mg-5 mg SC PRN up to
To calculate the subsequent subcutaneous dose of Midazolam over 24 hours:
Calculate and add total dose of Midazolam given on a PRN basis over previous 24 hours to
current 24 hour dose via syringe driver.  Increase the dose of Midazolam accordingly up to 30 mg in syringe driver over 24 hours.
 Continue with PRN Midazolam – calculate dose as 1/6th of syringe driver dose.
If Midazolam 30 mg in syringe driver is reached and symptoms are not control ed, please seek
SC = Subcutaneous PRN = as required 24/7 PALLIATIVE CARE ADVICE LINE FOR HEALTH PROFESSIONALS 0844 225 0677
HALTON, ST.HELENS & KNOWSLEY
Resources – Merseyside and Cheshire Palliative Care Network Audit Group Standards and Guidelines 4th Ed. 2010 Pal iative Care Formulary 4th Ed 2012 Palliativedrugs.com Ltd Version 2 – September 2013 – September 2016 PRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT
RESPIRATORY TRACT SECRETIONS
It is important to start treatment
as soon as symptoms occur
 Prescribe Glycopyrronium 200 micrograms SC
Prescribe Glycopyrronium
200 micrograms sc 6 hourly  Commence syringe driver containing PRN (Max 2400 micrograms Glycopyrronium 1200 micrograms over 24 hours.
 Prescribe in addition Glycopyrronium 200
Prescribing in anticipation micrograms 6 hourly prn (max dose 2400 of this common symptom micrograms in 24 hours) may prevent delay in commencing treatment. If respiratory tract secretions persist over the next 24 hours, increase Glycopyrronium to 2400 micrograms
over 24 hours. This is a maximum dose. There is no benefit from additional PRN doses. NB- Hyoscine Hydrobromide can be used as an
alternative use 400 micrograms SC as PRN dose and
1200 micrograms via syringe driver
SC = Subcutaneous PRN = as required 24/7 PALLIATIVE CARE ADVICE LINE FOR HEALTH PROFESSIONALS 0844 225 0677
HALTON, ST.HELENS & KNOWSLEY
Resources – Merseyside and Cheshire Palliative Care Network Audit Group Standards and Guidelines 4th Ed. 2010 Pal iative Care Formulary 4th Ed 2012 Palliativedrugs.com Ltd Version 2 – September 2013 – September 2016 PRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT
DYSPNOEA
 Prescribe Morphine 2.5 mg -5 mg SC 4
Prescribe PRN opioids & anxiolytic hourly PRN & Midazolam 2.5 mg SC 4 hourly
in anticipation of symptom Morphine 2.5 mg SC 4 hourly PRN
 State on drug chart that indication is
Midazolam 2.5 mg SC 4 hourly PRN
Or if breathlessness is constant  Morphine 5 mg -10 mg via syringe driver
over 24 hours (if previously taking oral opioid for breathlessness convert previous oral opioids dose) (see pain algorithm) Midazolam 5 mg-10 mg via syringe driver
24/7 PALLIATIVE CARE ADVICE LINE FOR HEALTH PROFESSIONALS 0844 225 0677
HALTON, ST.HELENS & KNOWSLEY
Resources – Merseyside and Cheshire Palliative Care Network Audit Group Standards and Guidelines 4th Ed. 2010 Pal iative Care Formulary 4th Ed 2012 Palliativedrugs.com Ltd Version 2 – September 2013 – September 2016

Source: http://www.sthk.nhs.uk/library/documents/endoflifeprescribingalgorithms2013.pdf