Noisy and/or moist breathing, 56%

Urinary dysfunction, 53%

Restlessness and/or agitation, 42%

Pain, 51%

Dyspnoea, 22%

Nausea and/or vomiting, 14%

Explanation;

Repositioning;

Medication: Glycopyrronium 200 to 400 mcg subcutaneous (sc) as required 6 hourly or 1.2–2.4 mg/24 hour via continuous sc infusion (csci) or hyoscine butylbromide 20 mg sc as required 6 hourly or 60 to 120 mg/24 hour csci.

General supportive measures including fan;

Diamorphine sc bolus or via csci over 24 hours (dose depending on previous opioid use) and/or midazolam sc bolus or via csci over 24 hours.

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.

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.

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.

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.