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PRESCRIBING IN THE LAST DAYS OF LIFE

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PRESCRIBING IN THE LAST DAYS OF LIFE Peter Nightingale Macmillan GP – PowerPoint PPT presentation

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Title: PRESCRIBING IN THE LAST DAYS OF LIFE


1
PRESCRIBING IN THE LAST DAYS OF LIFE
  • Peter Nightingale
  • Macmillan GP

2
The Seven Cs
  • Communication Palliative Care Register/MDT
    meetings
  • Co-ordination Key person
  • Control of Symptoms Assessment, Treatment and
    Patient Centred care
  • Continuity Handover to out-of-hours/protocol.
    Information to patients/carers
  • Continued Learning Practice-based
    learning/reflection on experiences.
  • Carer Support Practical, Emotional, Bereavement
  • Care of the Dying Liverpool Integrated care
    pathway (Dying Phase)

3
Diagnosing the Terminal Phase
  • BEDBOUND
  • ONLY ABLE TO TAKE SIPS OF FLUID
  • SEMI COMATOSE
  • NO LONGER ABLE TO TAKE ORAL MEDICATION
  • 2 out of four required for Liverpool Care Pathway

4
Last Days Of Life- Anticipating and planning for
common problems at home 
  • Loss of mobility and ability to transfer safely
  • Loss of ability to drink
  • Loss of ability to eat
  • Pain
  • Vomiting
  • Dyspnoea
  • Excess secretions
  • Delerium and agitation

5
Loss of mobility Unable to transfer safely
  • Generally safer and more manageable to nurse in
    bed
  • Consider loan of hospital bed/monkey pole/cot
    sides/commode/urine bottles
  • Assess for pressure area care and implement
    appropriate strategy
  • Indwelling urinary catheter/sheath for men if
    more acceptable if incontinent/unable to transfer
    to commode
  • Bowel care

6
Methylnaltrexone (relistor)
  • SC methylnaltrexone is approved for use in
    patients with 'advanced illness' suffering from
    opioid-induced constipation despite usual
    laxative therapy. Constipation is common in
    advanced disease, even in patients not taking
    opioids. Thus, so-called 'opioid-induced
    constipation' is often multifactorial in origin
    and methylnaltrexone will normally augment
    laxatives rather than replace them. It is
    important that laxative therapy is optimized
    before using methylnaltrexone.
  • About 1/2 patients defaecate within 4h of a dose
    without impairment of analgesia or the
    development of withdrawal symptoms. Common
    undesirable effects include abdominal pain,
    diarrhoea, flatulence, and nausea.
  • Initially give a single dose on alternate days.
    If there is no response, a second dose can be
    given after 24h, but not more often.

7
Loss of ability to drink
  • Prepare family and patient for this happening
  • Explain it is a natural process and may aid
    comfort by reducing secretions/gastric secretions
    and chance of vomiting/urine output
  • Encourage sips/mouth care
  • In the occasional situation, if still distressed
    by thirst consider S/C fluids (N.saline 1l over
    12h via a butterfly into anterior abdominal wall
    or thigh)

8
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9
Loss of ability to eat
  • Prepare family and patient for this happening
  • Explain it is a natural process
  • Forcing food may create discomfort if too weak to
    swallow/digest

10
Pain
  • Morphine or Diamorphine SC prn in proportion to
    overall opioid requirement
  • Consider leaving pre drawn-up syringes possibly
    leave an indwelling butterfly needle SC
  • OTFC Fentanyl increasingly considered

11
Vomiting
  • Levomepromazine is a useful broadspectrum
    antiemetic for the end of life. 6.25mg SC
  • Cyclizine 50mg tds SC or other antiemetic
    targeted at likely cause

12
Dyspnoea
  • Common and frightening
  • Morphine/Diamorphine preferably SC (or
    sublingual) titrated up as for pain.
  • Midazolam 2-10mg S.C. or sublingual prn or 5-30mg
    SC/24h for breathlessness/fear or
  • Diazepam

13
Excess respiratory secretions (note Cochrane rev
2008)
  • Positioning important
  • Antimuscarinics
  • Glycopyrronium
  • Hyoscine hydrobromide 0.4mg sublingual or SC 4h
    prn or
  • Hyoscine butylbromide 20mg SC

14
Delirium and agitation
  • Common at the end of life Distressing and
    frightening for everyone involved
  • Haloperidol 5-30mg/24h/sc and/or
    midazolam5-60mg/24h(if agitation only)

15
Changing breathing pattern
  • Explanation to family "He may appear to stop
    breathing for a time, then draw another breath"

16
The Pathway in Todays Health Care System
  • There must be continuous improvement in the
    delivery of health care and the care of the dying
    patients must improve to the level of the best
  • (DOH 1998, NHS Cancer Plan 2000)
  • Patients want to die in the place of their choice
    and be assured that their carers will be
    supported throughout their illness and in
    bereavement
  • (Commission for health improvement/Audit
    Commission 2002)
  • There is a need to describe and transfer best
    practice in Hospice care into hospital and other
    care settings

  • (Bonick 2004)

17
What Is The LCP and How Does It Work?
  • ICP is a multidisciplinary document which
    provides a template for managing patient centred
    care, it acts as a flow chart for the care being
    given
  • It Describes Care
  • It Tracks Care
  • It Monitors Care
  • It Evaluates Care

18
3 Sections To The LCP
  • Initial assessment and care
  • Ongoing assessment and care
  • Care after death

19
Goals Of Patient Care Encompassed By The LCP
  • Physical
  • Psychological
  • Religious/Spiritual
  • Social

20
GPs Involvement
  • Diagnose that the patient is dying
  • Discontinue oral medication/syringe driver if
    required
  • Prescribe 4 core drugs
  • Liaise with nursing staff, relatives and out of
    hours/put the pt on pathway
  • Sign documentation

21
What Are The Benefits of Using The Pathway?
  • It organises the process of caring
  • It is multisectoral (community/hospital)
  • Multi-professional/aids communication
  • It can influence ethical decision making
  • Incorporates guidelines, evidence based practice
    and clinical effectiveness

22
Benefits
  • Outcome focused (clinical supervision)
  • Replaces and reduces documentation
  • Legal record (written or electronic)
  • Variances (allow staff to justify non-actions)
  • Flexibility (pts can come off the pathway)
  • Quality of care

23
PLANNING
  • NO LONGER ABLE TO TAKE ORAL MEDICATIONS-
  • Discontinue unnecessary drugs
  • Review medication required
  • Plan for what medication may be required

24
Discontinuing Drugs
  • Stop Non Essentials e.g. statins
  • Probably continue diuretics furosemide can be
    given subcutaneously
  • Review steroids

25
Steroids in Palliative Care
  • Used to improve quality of life after
    risk/benefit assessment for-
  • 16mg Dexamethasone in emergencies
  • 12mg for inflammation in brain, liver or after
    chemotherapy
  • 4mg to temporarily help appetite
  • But taper down quickly because of-

26
Side effects of steroids
  • Hyperglycaemia
  • Thrush
  • GI bleeding
  • Agitation and restlessness
  • Muscle loss
  • Bed sores
  • Bacterial infection

27
P A I N
Is patient already taking oral morphine?
Yes
No
Convert to 24hr s/c infusion of
DIAMORPHINE For conversion divide the total daily
dose of MORPHINE by 3 ( eg MST 90mg bd
orally DIAMORPHINE 60mg
via syringe driver) Make available
subcutaneous DIAMORPHINE dose PRN for
breakthrough pain
PRN dose equals total daily dose divided by
6 (eg if DIAMORPHINE 60mg subcutaneous in syringe
driver PRN dose equals 10mg
subcutaneously)
Make available DIAMORPHINE 2.5mg 5mg prn
s/c
After 24 hours review medication. If 2 or more
doses required PRN then consider a
syringe driver. Starting dose would be the
total requirements over the previous 24
hours. The PRN dose may then need to
be recalculated
If the patient is still in pain after 12 hours
consider increasing the infusion by 30 50
28
TERMINAL RESTLESSNESS AGITATION
Present
Absent
Make available MIDAZOLAM
2.5mg-5mg s/c 4hrly PRN
Make available
MIDAZOLAM 2.5 5mg s/c 4hrly PRN
Review the medication after 24hrs If two or more
PRN doses have been required then consider a
syringe driver. Starting dose would be the dose
required over the previous 24 hours
Review the medication after 24hrs If two or more
PRN doses have been required then consider a
syringe driver Starting dose would be the dose
required over the previous 24 hours
Continue to give PRN dosage accordingly
29
RESPIRATORY TRACT SECRETIONS
Present
Absent
Glucopyrronium 200 microgram SC stat then
1200mcg over 24 hours
Glycopyrronium 200mcg s/c 8 hrly PRN should be
made available
Continue to give 200microgram PRN dosage 8
hourly
If two or more doses of PRN
Glycopyrronium required then commence syringe
driver s/c over 24 hrs
Increase total 24hr dose to 1.2 mg after 24
hours if symptoms persist
30
NAUSEA VOMITING
Absent
Present
Levomepromazine 6.25mg s/c 8rly PRN
Levomepromazine 6.25 s/c 8 hrly PRN
Review dosage after 24hrs. If 2 or more PRN doses
required, then consider use of syringe driver.
Starting dose 12.5-25mg s/c over
24 hours
NB. If patient is already on an
effective Antiemetic then switch to parental
route and continue
31
Fentanyl at the end of Life
  • Almost always better to leave the patch on in the
    last days of life and add in other drugs via a
    syringe driver if necessary, because-
  • Fentanyl reservoir active for up to 17hrs
  • Opioid requirements vary greatly at this time of
    life, they can decrease due to renal failure or
    increase due to disease progression

32
THE SYRINGE DRIVER IN PALLIATIVE MEDICINE
  • GRASEBY MS26
  • GREEN FRONTED
  • RATE mm/24 hours

33
INDICATIONS
  • Dysphagia
  • Swallowing difficulties mouth/throat lesions
  • Intestinal obstruction
  • Severe weakness
  • Nausea vomiting
  • Poor alimentary absorption
  • Semi comatose/comatose

34
ADVANTAGES
  • Steady drug levels
  • Avoids repeat injections
  • Loaded once a day
  • Does not limit mobility
  • Can be used to control gt1 symptom

35
DISADVANTAGES
  • Seen as a panacea
  • Irritation or swelling can limit
    absorption-Normal Saline is the preferred diluent
    unless cyclizine is being used

36
THE BOOST BUTTON
  • There is no lock out period
  • The dose of analgesia is less than the prn dose
  • All drugs will be boosted
  • The driver will run out more quickly

37
COMMONLY USED DRUGS
Drug Action Analgesic Antiemetic Agitation Anticonvulsant Excessive Secretions Smooth muscle spasm Steroids Drug Morphine/Diamorphine Cyclizine Haloperidol Levomopromazine Metoclopramide Haloperidol Levomopromazine Midazolam Midazolam Hyoscine hydrobromide Glycopyrronium Hyoscine butylbromide Dexamethasone 24 Hour Dose Starting dose 5 10mgs 50 150mgs 1.5 5mgs 2.5 12.5mgs 30-60mgs 2.5 5mgs 6.25 25mgs(up to 150mgs) 5 30mgs 10 40mgs 40 1200mcgms 600 1200mcgms 20 120mgs 4 16mgs
38
CAUTION
  • Cyclizine precipitation occurs when mixed
    with Diamorphine if either one exceeds
    20mgs/ml-needs water as diluent
  • Metoclopramide extrapyramidal reactions can occur
    with higher doses or if used with Haloperidol
    or Levomopromazine
  • Levomopromazine exessive sedation and skin
    irritation can occur with higher doses or when
    used with other D2 receptor antagonists, eg
    Haloperidol or Metoclopramide
  • Dexamethasone should not be mixed with any other
    drug-very small doses occasionally
    used for site reactions

39
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40
The verification of death
Dr Hong Tseung Macmillan GP Adviser
41
Definitions
  • verifying death
  • confirming death has actually occurred 'fact of
    death'
  • certifying death
  • written confirmation of cause of death
  • registering a death
  • formal notification to authorities (Registrar of
    births and deaths) of fact of death and its cause

42
Who does what?
  • verification of death
  • doctor (GMC registered)
  • registered nurse
  • certification of death
  • doctor (GMC registered) only
  • must have seen the patient alive in preceding
    two weeks before death
  • registration of death
  • by 'the informant' carer, relative, family
    member who takes death certificate to the
    Registrar

43
The coroners involvement
  • when the cause of death is not known
  • eg sudden death
  • when there is a suspicious cause of death
  • eg bullet wounds, knife wounds, strangulation,
    asphyxiation, overdose, suicide
  • when no medical practitioner has seen patient
    alive within the last two weeks before death

44
The signs of human life
  • breathing
  • pulse/heart beat
  • pupil reaction
  • responsiveness
  • auditory, sensation (pain), reflexes

45
The signs of dying (impending death)
  • not always easy to 'diagnose dying'
  • bed-bound
  • comatose/semi-comatose
  • taking sips of fluids only
  • no oral intake
  • irregular breathing (Cheyne Stokes, shallow)

46
What happens when death has occurred?
  • no organs work
  • no brain activity, heart stops, lungs stop, liver
    and kidneys stop, muscles stop
  • tissues start to breakdown
  • rigor mortis (several hours later), blood pools,
    decomposition

47
The signs of death
  • looks pale (blood pooling)
  • no breathing
  • no pulse
  • no heart sounds
  • pupils fixed and unreactive to light
  • no response to sensory stimuli (eg pain)
  • no reflexes (no brainstem activity)

48
What to do
  • look
  • for skin colour (pink)
  • for chest movement (breathing)
  • feel
  • for a MAJOR pulse carotid
  • listen
  • for breath sounds
  • for heart sounds
  • test
  • for BOTH pupil reflexes to light
  • None of the above present?
  • death confirmed

49
Dont get it wrong
  • very embarrassing
  • distressing for relatives

50
(No Transcript)
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