anticipatory prescribing dr jason ward consultant in palliative medicine, mid yorkshire nsh trust,...
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Anticipatory prescribing Anticipatory prescribing
Dr Jason WardDr Jason WardConsultant in Palliative Medicine,Consultant in Palliative Medicine,Mid Yorkshire NSH Trust , & Mid Yorkshire NSH Trust , & Honorary Senior Lecturer,Honorary Senior Lecturer,University of Leeds University of Leeds
Factors important for a good Factors important for a good deathdeath
Control of symptoms Control of symptoms Preparation for death Preparation for death Opportunity for closure or "sense of Opportunity for closure or "sense of
completion" of the life completion" of the life Good relationship with healthcare Good relationship with healthcare
professionals professionals Steinhauser KE
2000
Symptoms on the last 48 Symptoms on the last 48 hours hours
SweatingSweating
ConfusionConfusion
PainPain
Urinary dysfunction Urinary dysfunction
BreathlessnessBreathlessness
Death rattleDeath rattle
Nausea and vomiting Nausea and vomiting
Restlessness/agitation Restlessness/agitation
Jerking/plucking/twitching Jerking/plucking/twitching
Death rattle Death rattle
Prevalence 41-92% patients Prevalence 41-92% patients Most common with lung or cerebral Most common with lung or cerebral
primariesprimaries Median duration of onset 23 hours Median duration of onset 23 hours
Death rattle Death rattle How do relatives interpret it? How do relatives interpret it?
Awful/horrible/terribleAwful/horrible/terrible
Nothing/expected Nothing/expected
Relief/sign of dying Relief/sign of dying
Wee B et al 2006
Management of death rattle Management of death rattle
Non drug management Non drug management Discuss with family/carers Discuss with family/carers Re-positionRe-position
Drug - hyoscine butylbromide Drug - hyoscine butylbromide (buscopan) (buscopan) 20mg sc stat20mg sc stat 60-120mg/24hrs 60-120mg/24hrs
Bennett M 2002 Bennett M 2002
PainPain
CancerCancer Cancer treatmentCancer treatment Debility e.g. immobility Debility e.g. immobility Concurrent problems e.g. Concurrent problems e.g.
osteoarthritis osteoarthritis
Analgesics (1) Analgesics (1)
Paracetamol Paracetamol Liquid, suppository Liquid, suppository No subcut preparation No subcut preparation
NSAIDsNSAIDs Diclofenac PR 100mg od Diclofenac PR 100mg od
Analgesics (2) Analgesics (2)
Diamorphine Diamorphine Divide total daily dose of oral morphine by 3Divide total daily dose of oral morphine by 3
= total daily dose of subcut diamorphine= total daily dose of subcut diamorphine Opioid naïveOpioid naïve
2.5mg sc PRN 2.5mg sc PRN 5-10mg/24hrs 5-10mg/24hrs
Morphine sulphate Morphine sulphate Divide total daily dose of oral morphine by 2Divide total daily dose of oral morphine by 2 Opioid naïve 2.5mg sc PRNOpioid naïve 2.5mg sc PRN
Transdermal analgesiaTransdermal analgesia NameName DrugDrug ApplAppl
yyLowesLowest doset dose
Oral Oral morphine morphine
Equivalent Equivalent 24 hours24 hours
DurogesiDurogesic D-Trans c D-Trans
Fentanyl Fentanyl 3 3 days days
25mcg 25mcg -90mg -90mg
Transtec Transtec BuprenorphinBuprenorphine e
3 3 days days
35mcg35mcg 30-60mg 30-60mg
BuTrans BuTrans BuprenorphinBuprenorphine e
7 7 daysdays
5mcg5mcg 5-10mg 5-10mg
The dying patient with a The dying patient with a patchpatch
Continue current patch strength Continue current patch strength and replace every 72 hours and replace every 72 hours
Supplement with diamorphine prn Supplement with diamorphine prn
and/ or syringe driver and/ or syringe driver ‘ ‘Rule of 5’Rule of 5’ Fentanyl 25mcg/5= 5mg diamorphine Fentanyl 25mcg/5= 5mg diamorphine
prn prn
RestlessnessRestlessness
Agitation/restlessnessAgitation/restlessnessVsVs
Confusion/deliriumConfusion/delirium DisorientatedDisorientated Hallucinations Hallucinations Sleep-wake reversal Sleep-wake reversal PluckingPlucking
General Management General Management
Reverse the ‘easily’ reversibleReverse the ‘easily’ reversible Full bladder, position, pain Full bladder, position, pain
Explanation Explanation Environment Environment FamilyFamily
Agitation Agitation
Benzodiazapine Benzodiazapine Useful alone if fear/anxiety is the only Useful alone if fear/anxiety is the only
feature feature Midazolam Midazolam
2.5-5mg stat 2.5-5mg stat Repeat every 60mins if neededRepeat every 60mins if needed
10mg-60mg/24 hrs 10mg-60mg/24 hrs
Confusion/delirium Confusion/delirium
Haloperidol Haloperidol 3-5mg stat sc repeated as necessary 3-5mg stat sc repeated as necessary Generally 5 - 10mg/24hrs Generally 5 - 10mg/24hrs
Levomepromazine Levomepromazine Sedating anti-psychotic Sedating anti-psychotic 25mg-50mg stat 25mg-50mg stat Infusion 50-300mg/24 hrs Infusion 50-300mg/24 hrs
Breathlessness Breathlessness
Fan, open window Fan, open window Breathlessness/cough/tachypnoeaBreathlessness/cough/tachypnoea
DiamorphineDiamorphine Opioid naïve 2.5mg stat, 5-10mg/24hrs Opioid naïve 2.5mg stat, 5-10mg/24hrs Or increase dose by 1/3Or increase dose by 1/3rdrd
Breathlessness/anxiety Breathlessness/anxiety Midazolam Midazolam
2.5 mg stat, 10-30mg /24hrs 2.5 mg stat, 10-30mg /24hrs
‘‘Terminal’ nausea Terminal’ nausea
Persistent or intermittentPersistent or intermittent Small vomits, ‘possets’, retchingSmall vomits, ‘possets’, retching
Chemical causeChemical causeHypercalcaemiaHypercalcaemia
UraemiaUraemia
Jaundice Jaundice
Infection Infection
Anti-emetics Anti-emetics
Cyclizine Cyclizine 50mg stat50mg stat 150mg/24hrs, 150mg/24hrs,
May precipitate with hyoscine May precipitate with hyoscine butylbromide butylbromide
Avoid saline Avoid saline May cause irritation May cause irritation
EXAMPLE
INJ CYCLIZINE 50mg / ml5 X 1ML amps as dirINJ HYOSCINE BUTYLBROMIDE 20mg / ml 5 x 1ml amps as dir INJ MIDAZOLAM 5mg / ml5 x 2ml INJ DIAMORPHINE 5mg 5 ( five ) x 5mg (five milligram) WATER FOR INJECTION10 X 10mls amps
To foresee and take care of in To foresee and take care of in advanceadvance
CostsCosts