Palliative care emergencies

D R L E S L E Y H E N S O N
P A L L I A T I V E C A R E R E G I S T R A R
M A R C H 2 0 1 1
 Gain confidence in managing a dying patient in the community Be able to write a syringe driver prescription for medications  Understand the role of the district nurse and palliative care community team in managing patients at the end of life  Fentanyl Patch 75mcg/hr 3/7 Paracetamol 1g qds  Diclofenac SR 75mg bd Oramorph 10mg PRN Gliclazide 80mg bd  Metformin 1g tds Amlodipine 10mg od Simvastatin 20mg od  Bendroflumethiazide 2.5mg od Metoclopramide 20mg tds  Fentanyl Patch 75mcg/hr 3/7 Paracetamol 1g qds Diclofenac SR 75mg bd Oramorph 10mg PRN Gliclazide 80mg bd Metformin 1g tds Amlodipine 10mg od Simvastatin 20mg od Bendroflumethiazide 2.5mg od Metoclopramide 20mg tds  Start a syringe driver with an appropriate dose of analgesia First line diamorphine unless indications otherwise  To calculate starting dose add up breakthroughs in last 24 hours  Oramorph: 5mls = 10mg (there is a concentrated version available)  In last 24 hours = 70mg oramorph
 Still in pain and stopping paracetamol and diclofenac  CSCI 30mg diamorphine over 24 hours (range 30-60mg)
 Need to calculate total 24 hour opioid dose
 Diamorphine 30mg & Fentanyl 75mcg/hr patch  Total diamorphine equivalent 90mg in 24 hours  90/6 = 15mg sc PRN/4hrly (range 15-25mg)  DON’T FORGET TO PRESCRIBE THE WATER FOR  Fentanyl Patch 75mcg/hr 3/7 Paracetamol 1g qds Diclofenac SR 75mg bd Oramorph 10mg PRN Gliclazide 80mg bd Metformin 1g tds Amlodipine 10mg od Simvastatin 20mg od Bendroflumethiazide 2.5mg od Metoclopramide 20mg tds  Metoclopramide 60mg sc over 24 hours (range 60-90mg)  Levomepromazine: 1ml amp = £2.01 (25mg/ml)  Fentanyl Patch 75mcg/hr 3/7 Paracetamol 1g qds Diclofenac SR 75mg bd Oramorph 10mg PRN Gliclazide 80mg bd Metformin 1g tds Amlodipine 10mg od Simvastatin 20mg od Bendroflumethiazide 2.5mg od Metoclopramide 20mg tds  Stop oral medications  At end of life don’t worry about longterm complications but want to control any symptoms secondary to diabetes – hypoglycaemic attacks more difficult to manage and should be avoided as much  Hyperglycaemia can cause distressing symptoms but BMs <17 are generally felt to be acceptable  In type 2 diabetes when the patient is unable to take oral medications start by monitoring BMs once daily or more often if symptomatic  Who will be checking BMs?  Fentanyl Patch 75mcg/hr 3/7 Paracetamol 1g qds Diclofenac SR 75mg bd Oramorph 10mg PRN Gliclazide 80mg bd Metformin 1g tds Amlodipine 10mg od Simvastatin 20mg od Bendroflumethiazide 2.5mg od Metoclopramide 20mg tds Other Factors to Consider: who needs to know  Available for advice, case discussion, joint visits to help with difficult symptoms and bereavement care if required  Set up CSCI once medications and prescription in the house Arrange any equipment required Catheterise Organise care package Review patient and give stats of medication if prescribed and  Check BMs Verification of death if expected  Fax with information about the patient and what medications are in the You go back the next day and find that Mr Jones has deteriorated further but are pleased to hear that his pain is better controlled. He is however feeling increasingly sick and has vomited this morning. He says he has had some abdominal cramping since the CSCI started. His wife says he is now incontinent of urine. He has been asking for water every 15minutes but then retching afterwards. She is exhausted and worried that she won’t be able to manage his care at home. His obs are the same as yesterday but today his BM is 26.0.  Will a type 2 diabetic need more or less insulin that a type 1  Actrapid available for DNs to administer  Change CSCI to haloperidol 1.5mg sc over 24 hours You go back to visit Mr Jones the next day. He is still complaining of pain and keeps moving around in the bed. Mrs Jones says he hasn’t settled all night. The district nurse has been out three times since yesterday and given the following: Diamorphine 15mg sc at 21.30Diamorphine 15mg sc at 23.00Diamorphine 15mg sc at 04.00 Mr Jones says the injections help with the pain for a few hours.  45mg of diamorphine in last 24 hours in addition to  Still getting some pain, but history does suggest it is  Increase CSCI to 90mg diamorphine (and change  Or consider lesser increase and alternative analgesic The next day Mr Jones is in more pain than ever before. He is crying and groaning and the family are all in tears. He has had 6 further sc injections of diamorphine by the DNs and this time there seems to be no improvement in his pain when they are given. He is not able to hold a conversation but keeps pulling at the bed covers and his catheter. You are worried that he might pull out the catheter and/or CSCI.  Add midazolam (first line for agitation)  10mg sc over 24 hours in CSCI (range 10-30mg)  Breakthrough doses of 2.5mg available sc You go back the next day and Mr Jones is jerking and hallucinating. He says he sees monkeys sitting on top of the TV talking to his wife and little French children eating croissants. He is clearly distressed by this and keeps saying he doesn’t want to lose his mind. His wife says he is increasingly drowsy.  Likely secondary to renal impairment  Might be better to under dose as diamorphine will take a while to get out of system – 2mg alfentanil, but explain to DNs and family that may need extra doses Mr Jones becomes unconscious over the next day. Objectively he appears much more settled but has developed some chest secretions. You discuss adding some medication to the CSCI to help with this which his wife agrees to. As you are writing the prescription she asks what to do when he dies.  Add Hyoscine Hydrobromide to CSCI 1.2mg sc over 24 hours  Or Glycopyrronium 1.2mg sc over 24 hours  Range 1.2 – 2.6mg (can go up to 3.4mg)  Hyoscine Hydrobromide versus Glycopyrronium  Hyoscine: 1ml amp = £2.67 (600mcg/ml)  Glycopyrronium: 3ml amp = £1.50 (200mcg/ml) – but  Family should phone GP surgery if in hours and oncall care if out of hours The patient’s GP, on-call GP or DN can then go out to verify the  Once death has been verified the family should contact a funeral director to arrange collection of the body Most funeral directors will collect out of hours including overnight. It may be worth discussing this with the family before the patient dies and often families choose a funeral director before death.  Leaflets are available from the hospice with funeral directors phone numbers and general information for relatives.
 Who is your late night pharmacy? Do they have the  Don’t forget the water for injection  Inform oncall care, DNs and palliative care team if  Consider leaflets or discussions with family about A N Y Q U E S T I O N S

Source: http://www.hospiceintheweald.org.uk/docs/Health%20Care%20Professionals/Presentations/Palliative-Care-Emergencies---GPVTS.pdf