Why: | Anticipating and planning management of possible symptoms and/or emergencies is essential in maintaining patients at home at the end of life. |
| Frequency of symptoms in the last 48 hours:1
Noisy and/or moist breathing, 56% Urinary dysfunction, 53% Restlessness and/or agitation, 42% Pain, 51% Dyspnoea, 22% Nausea and/or vomiting, 14%
|
| Consider also those related to a specific diagnosis, for example, fits, risk of haemorrhage. |
|
How: | Use of syringe driver for crises, not just in the last 48 hours |
| The Liverpool Care Pathway for the Dying Patient2 gives a framework for planning care at this stage and advocates anticipatory prescribing, ‘Just in Case Bag/Box’. |
| Although reversible causes for specific symptoms should be considered, most emergencies in the last 48 hours are irreversible and the focus is relief of distress. |
|
What next and when: | Treatments to consider for specific symptoms: |
| Excess bronchial secretions:
|
| Breathlessness:
|
| Pain:
If unable to take regular oral analgesia convert to equivalent dose of sc opioid; for example, diamorphine via csci; Have sc diamorphine or alternative available for breakthrough pain. Consider midazolam for anxiety or muscle spasm.
|
| Terminal agitation:
Identify and treat any reversible causes, for example, drugs, pain, hypoxia, urinary retention; Medication: midazolam 2.5–5 mg up to 2 hourly sc can be given to assess response. Large doses of midazolam may be needed via csci (30–160 mg/24hour). Levomepromazine 25 mg stat sc, up to 4 hourly or 50 mg to 150 mg/24 hour via csci may be needed. Titrate individually, seek advice if needed.
|
| Fits:
Increased risk if no longer able to take oral anticonvulsants. Midazolam (10–60 mg/24 hour) via csci should prevent; Sc or buccal midazolam (5–10 mg) or per rectum diazepam (10 mg) used if fits occur. Can repeat.
|
| Haemorrhage:
Consider discussing in advance: issues of resuscitation and/or use of sedation; Have dark towels available; Catastrophic bleed causes almost immediate death with no time for treatment — stay with patient; Severe bleeding lasting minutes to hours is frightening, have sedation available — midazolam iv/buccal 5 mg repeated as necessary. At home rectal diazepam 10 mg is alternative.
|
|
Patient information: | End of life: The Facts. |
| http://www.mariecurie.org.uk/aboutus/helpandinformation/publications_and_resources/end_of_life |
|
References/Web links: | 1Lichter I, Hunt E. The last 48 hours of life. J Palliat Care 1990; 6(4): 7–15. |
| 2Liverpool Care Pathway (includes patient information) http://www.mcpcil.org.uk/liverpool_care_pathway |
| See also: Gold Standards Framework http://www.goldstandardsframework.nhs.uk |
| NLH End of Life Care http://www.library.nhs.uk/healthmanagement/ViewResource.aspx?resID=235932 |
| More top tips can be found at http://www.addenbrookes-pgmc.org.uk/handouts.asp?title=Primary%20Care%3E |
|
Who are you: | Janet McCabe, associate specialist, Arthur Rank House, Cambridge |
| Angela Steele, GPwSI and Macmillan GP facilitator, Cambridge |
|
Date: | November 2007 |