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