End of Life Symptoms

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 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)

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.

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.

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.