Symptom Management Guidance Palliative care DCHS
3
Version No
Version Date
9/09/13
Review Date
9/09/15
SYMPTOM MANAGEMENT GUIDANCE PALLIATIVE CARE
YES
PAIN
Is the patient already taking Morphine or other strong opioids?
Continuous S/C Diamorphine
Calculate the 24 hour dose of oral Morphine, divide the total dose by 3, which is
the equivalent dose of Diamorphine over 24 hours s/c via syringe driver – e.g.
patient on 90mg Zomorph BD = 180mg oral Morphine over 24 hours, which
equals 60mg Diamorphine s/c over 24 hour infusion.
Transdermal Fentanyl
If the patient is using Transdermal Fentanyl but now has uncontrolled pain,
continue the Fentanyl on current dose, do not increase, and use appropriate
dose s/c Diamorphine as required in addition. See Guidelines.
Breakthrough Analgesia
To calculate the breakthrough dose of Diamorphine divide the 24 hour dose of
Diamorphine in the syringe driver by 6, e.g. if the patient is receiving 60mg
Diamorphine s/c over 24 hours the breakthrough dose of Diamorphine is 10mg
s/c prn.
Alternatively
Morphine oral liquid may be used if the patient is taking sips of fluid. To calculate
the equivalent oral Morphine breakthrough dose, multiply the s/c breakthrough
dose by 3, e.g. s/c Diamorphine 10mg for breakthrough up to hourly = 30mg oral
Morphine for breakthrough.
NO
Has the patient got pain?
YES
1. Diamorphine 2.5mg stat
2. Diamorphine 10mg/24 hours
via s/c infusion
3. Diamorphine 2.5mg s/c prn
NO
As Required Medication
1. Diamorphine 2.5mg s/c prn
2. Morphine Sulphate 5mg
orally prn
To calculate the subsequent doses of Diamorphine over 24 hours:
Review the doses of prn analgesia given in the previous 24 hour period. If more than one dose has been required, other than to pre-empt during care, (e.g. before a
dressing etc.) then consider a 30% to 50% increase in the daily subcutaneous dose. If this is not controlling the pain or doses need escalating on a daily basis, seek
specialist advice.
If Diamorphine is unavailable or the patient has previously been on oral Oxycodone, use the same format as above using Oxycodone.
Oral
Oxycodone
2mg inincluding
24 hoursif=CKD
Sub Cut
Diamorphine
1.5mg
in 24 hours
= Oxycodone
1mg in 24
For
further
information,
4 or: 5,
see the Dose
Equivalence
Guidance
Chartpages
7 &hours
8.
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE.
Page 1 of 8
RETAINED SECRETIONS
Absent
Present
1. Explain to relatives that for the patient retained
secretions are not bothersome due to decreased
sensitivity of pharynx.
IF the relatives are concerned or the patient
appears distressed:
As required medication
Hyoscine Butylbromide 20mg s/c
- Maximum dose up to 80mg in
24hrs
2. Hyoscine Butylbromide 20mg s/c stat.
3. Hyoscine Butylbromide 60mg / 24 hours via s/c
Infusion.
4. Hyoscine Butylbromide 20mg s/c hourly prn
- Maximum dose up to 80mg in 24hrs
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
Page 2 of 8
TERMINAL RESTLESSNESS AND AGITATION
Present
Absent
1. Exclude Treatable Causes
Pain
Retention of urine or faeces
Hypercalcaemia if it would be appropriate to treat
As Required Medication
Haloperidol 2.5mg s/c prn– up to
hourly (maximum including
syringe driver dose 15mg in
2a. Delirium
i. Haloperidol 2.5mg stat.
ii. Haloperidol 5mg/24 hours
via s/c infusion.
iii. Haloperidol 2.5mg s/c prn
Review Every 24 Hours
Increase the dose of
Haloperidol to 10mg / 24
hours via s/c infusion if
necessary.
NB: A total dose of 15mg / 24
hours – including stat dose,
continuous dose and prn
doses should not be
exceeded.
2b. Anxiety / Dyspnoea
i. Midazolam 2.5mg s/c stat.
ii. Midazolam 10mg / 24 hrs
via s/c infusion.
iii. Midazolam 2.5mg s/c prn–
one hourly for maximum of 3
doses, then seek medical
advice.
24hrs)
Review in 24 hours
Review every 24 hours
Increase the 24 hour dosage
according to the total dose of
Midazolam given on a prn
basis. The dose should not be
increased by more than
10mg/day without specialist
advice
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
Page 3 of 8
NAUSEA
Previously on Anti-Emetic
YES
NO
Convert to s/c as appropriate
YES
Nausea
present
1. Haloperidol 1.5 – 2.5mg s/c stat.
2. Haloperidol 5mg via s/c infusion.
3. Haloperidol 1.5 – 2.5mg s/c prn.
NB: A total of 15mg / 24 hours –
including stat doses, continuous s/c
doses and prn doses – should not be
exceeded.
NO
Prescribe, so available
if needed, Haloperidol
1.5 – 2.5mg s/c prn (up
to a total of 15mg / 24
hours)
Review in 24 hours
Increase to 10mg / 24 hours s/c if nausea persists
For persistent nausea switch to:
1. Levomepromazine 6.25mg / via s/c infusion.
2. Levomepromazine 6.25mg prn s/c.
NB: A total of 50mg / 24 hours – including continuous and prn doses – should not be exceeded.
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE
Page 4 of 8
TERMINAL BREATHLESSNESS
YES
Absent
Prescribe so available if needed:
 Diamorphine 2.5mg (or if on regular
Opioids dose as per equivalence chart)
s/c hourly for Tachypnoea.
 Midazolam 2.5-5mg s/c hourly for
distress

YES
Convert to s/c pump (or in case of Fentanyl patch add CSCI, DO NOT REMOVE
PATCH) following Guidelines for Pain Management, BUT consider increasing
Opioid dose, e.g. give 30-50% more than the recommended equivalent dose (or
for Transdermal Fentanyl add 30-50% of the equivalent dose).
Prescribe appropriate prn as for breakthrough pain, e.g.1/6th of total daily dose
Diamorphine for Tachypnoea.
Prescribe Midazolam 2.5-5mg s/c hourly prn for distress caused by
breathlessness – hourly for a maximum of 3 doses then seek medical advice
Consider adding Midazolam 10mg to s/c pump, particularly if prn dose has helped.
AIM for patient’s breathing to be calm and effortless
Present
Previously on oral Opioid or
Fentanyl patch
Give as soon as possible appropriate prn of:
 Diamorphine s/c (see equivalence chart) for
Tachypnoea.
 Midazolam 2.5-5mg s/c if patient distressed
NO
Give as soon as possible:
 Diamorphine 2.5mg s/c hourly for Tachypnoea.
 Midazolam 2.5-5mg s/c hourly for distress.
If no relief 30 minutes after first drug, try alternative,
repeating if necessary.
If repeated doses are needed, consider
starting syringe driver with combination
of Diamorphine and Midazolam.
Suggested starting doses are 5mg of
each over 24 hours. Remember to use
prns as needed.
IF SYMPTOMS PERSIST – SEEK SPECIALIST ADVICE. If CKD 4 or 5, see the Dose Equivalence Guidance Chart, page 8
Page 5 of 8
GUIDELINES FOR CARE OF DIABETES IN PATIENTS IN THE LAST FEW DAYS OF LIFE
Aim of treatment is to avoid symptoms of hyperglycaemia and hypoglycaemia
Practical points:1. In Type 2 diabetes insulin and oral agents can usually be stopped in the terminal phase; steroid treated patients may be
an exception.
2. Blood glucose monitoring should be kept to the minimum necessary.
3. It is important to ensure clinical deterioration not due to hyperglycaemia or hypoglycaemia before making decisions re
management.
4. Regular review of the patient and management plan is necessary, due to difficulties with prognostication of death and
varying terminal phase.
5. If death imminent i.e. expected in less than 24 hours it may be appropriate to discontinue all monitoring and insulin,
usually after discussion with the family.
6. SEEK SPECIALIST ADVICE EARLY
 Community Diabetes Specialist Nurse
Monday to Friday, in office hours, usually 9am to 5pm
Tel 01629 817878 Mobile 07884415168 or 07900584162
 Out of Hours Ashgate Hospice Tel: 01246 568801 01246 568801
Further information also available at http://www.trend-uk.org/documents
Page 6 of 8
PALLIATIVE CARE DOSE EQUIVALENCE GUIDANCE CHART, Page 7 & 8
Morphine
4 hourly
po
Zomorph or
MST 12
hourly
po
MXL o.d.
5mg
7.5
15mg
20mg
10mg
15mg
Buprenorphine patch
per hour
Oxycodone
MR
12 hourly
po
Oxycodone
s/c in 24
hours
Diamorphine
s/c 4 hourly
Diamorphine
s/c in 24
hours
Fentanyl
patch 72
hourly
30mg
40mg
Oxycodone
immediate
release
4 hourly
po
2.5mg
2.5mg
5-10mg
10mg
5-10mg
10mg
2.5mg
2.5mg-
10mg
15mg
6mcg
12mcg
5mcg
10-20mcg
30 mg
40mg
60 mg
90mg
5 mg
7.5
15 mg
20mg
15 mg
20mg
5 mg
5mg
20 mg
30mg
12-25 mcg
25mcg
35mcg
35mcg
20 mg
60 mg
120 mg
10 mg
30 mg
30mg
7.5mg
40 mg
37mcg
52.5mcg
30 mg
90 mg
180 mg
15 mg
45 mg
45 mg
10 mg
60 mg
50 mcg
40 mg
120 mg
240 mg
20 mg
60 mg
60 mg
15 mg
80 mg
62mcg
70mcg
Suggest use
Fentanyl Patch
50 mg
150 mg
300 mg
25mg
75 mg
75 mg
20 mg
100 mg
75- mcg
60 mg
180 mg
360 mg
30 mg
90 mg
90mg
20 mg
120 mg
100 mcg
“
70 mg
200 mg
400 mg
35 mg
100 mg
100mg
20 mg
140 mg
125 mcg
“
80 mg
240 mg
480mg
40 mg
120 mg
120 mg
30 mg
160 mg
125-150 mcg
“
90 mg
260 mg
540 mg
45 mg
130 mg
130mg
30 mg
180 mg
150 mcg
“
100 mg
300 mg
600 mg
50 mg
150 mg
150mg
30 mg
200 mg
175 mcg
“
110 mg
330 mg
660 mg
55 mg
160 mg
160mg
40 mg
220 mg
175 mcg
“
120 mg
360 mg
720 mg
60 mg
180 mg
180mg
40 mg
240 mg
200 mcg
“
140 mg
420 mg
840 mg
70 mg
200mg
200mg
50 mg
300 mg
250 mcg
“
160 mg
480 mg
960 mg
80 mg
240 mg
240mg
50mg
330 mg
275 mcg
“
180 mg
540 mg
1080 mg
90 mg
250 mg
250 mg
60 mg
360 mg
300 mcg
“
po
“
Tramadol po100mg = 10mg po Morphine. Tramadol po 100mg qds ie 400mg/24 hours = Morphine po 40mg/24 hours
Suggested breakthrough dose of po Morphine =7.5mg 4 hourly
Page 7 of 8
 These doses are only approximate and the dose may need to be adjusted
accordingly to responses.
 Breakthrough analgesia, dose of Opioid should be ONE SIXTH of the total daily
dose (dose over 24 hours). This is the same as the four hourly dose.
 A patient may be routinely missing dose(s) e.g. night dose of 4 hourly regime so
check recent totals over 24 hours for this and prn regimes.
 For patients with known CKD 4 or 5 adjust doses accordingly and seek specialist
help if needed. Repeat routine testing of U&E’s in last days of life need not be done.
Immediate Release Preparations
Sevredol tablets 10, 20, 50mg
Morphine Sulphate liquid
10 mg/5ml e.g. Oramorph 100mg/5ml,
e.g. Oramorph concentrate
Oxycodone capsules 5, 10, 20mg, e.g.
Oxynorm
Oxycodone liquid 5mg/5ml, 50mg/5ml,
e.g. Oxynorm
Diamorphine Injections
5, 10, 30, 100, 500mg
Fentanyl Patches
12, 25, 50, 75, 100mcg/hr
Oxycodone Injection
10mg/ml. 20mg/2ml
Buprenorphine Patches
5, 10, 20mcg/hr (seven day patches)
35, 52.5, 70mcg/hr (four day patches)
Slow Release Preparations
MXL 30, 60, 90, 120, 150, 200mg
Zomorph 10, 30, 60, 100, 200mg
MST 5, 10, 15, 30, 60,100, 200mg
Oxycodone MR 5, 10, 15, 20, 40, 60, 80,
120mg e.g. Oxycontin
References:- Palliative Care Formulary (PCF4). Fourth Edition. ISBN: 978-0-9552547-5-8. Editors: Robert Twycross Andrew Wilcock
Summary of Product Characteristics:- Oxynorm Injection. Napp Pharmaceuticals, EMC updated 22/06/2013; Oxycodone injection, Wockhardt UK Ltd EMC
Updated 14/01/2011.
British National Formulary (BNF) 65 March-September 13
Page 8 of 8