Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
Palliative Care for Adults - Guidance for Primary Care
These principles are intended for guidance and do not cover all aspects of an individual patients care. They
reflect commonly accepted practice in palliative medicine. The use of some medicines may be off-label –
this may relate to dose, route or indication.
Contents
Pain Control
Management of Toxicity to Opioids
Nausea and Vomiting
Constipation
Use of A Syringe Driver
p 1-5
p6
p7
p8
p9
McKinley T34 Syringe Pump
Symptom Control in the last days of life
 Shortness of Breath
 Bronchial Secretions
 Agitation
Useful Contacts
p 10
p 11
p 12
Effective Communication Is Imperative For Effective Symptom Control
PRINCIPLES OF PAIN CONTROL
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Assess: Prior to treatment an accurate assessment should be made to determine the cause
(consider if reversible), type and severity of the pain and its affect on the patient.
Assess All Pains and treat accordingly. Patients with cancer still develop other pains, which could
be related to the treatment, debility or unrelated causes.
Consider Total Pain: The physical, emotional, social, and spiritual dimensions of distress all affect
a patient’s perception of pain.
Consider any Factors That Lower Or Raise Pain Tolerance (see page 2).
Discuss and Explain symptoms and treatments (pharmacological and non-pharmacological) to
patient and carer.
With Continuous Pain Prescribe Continous Analgesia, never just PRN.
Use the WHO Pain Ladder in choosing appropriate analgesia.
If Strong Opioids are required discuss and resolve any concerns about strong opioids, including
concerns about addiction and overdose. All patients/carers should be provided with a patient
information leaflet.
Start with immediate release oral morphine every 4 hours. If higher frequency use is anticipated in
an individual case, contact specialist palliative care for advice.
The patient does not need to be specifically woken to take a dose during the night.
In some cases, it may be appropriate to start with a 12 hour release oral morphine preparation.
This should be started at low dose and titrated accordingly.
Use low doses and titrate the dose slowly if the patient is frail, elderly or has renal impairment.
Breakthrough Pain: If only prescribed immediate release morphine, give additional PRN doses for
breakthrough pain at the same dose as the regular 4-hourly dose.
If on sustained release opioids prescribe additional immediate release opioid for episodes of
breakthrough pain. This is given 4-hourly PRN at a dose of one sixth of the total daily dose of opioid
(ask the patient to keep a record of usage). Use this record of all morphine administered to
calculate dose increases in the sustained release opioid.
Constipation occurs with all opioids. Laxatives are usually needed (see page 9)
Nausea should be treated with an appropriate anti-emetic (see page 10).
Review frequently to optimise analgesia as soon as possible. Pain can be managed in the majority
of patients. If pain is not controlled, review assessment.
Specialist Advice should be sought ASAP especially if pain has not responded to treatment, dose
of opioid has increased rapidly but patient is still in pain, there are episodes of severe acute pain or
pain is worse on movement.
Consider renal and hepatic function. Dose adjustment or alternative medicine choices may be
required. Seek specialist advice if required.
IF UNCERTAIN PLEASE CONTACT A SPECIALIST TEAM FOR ADVICE.
see useful contact numbers on page 12
Key References
NHS Lanarkshire Palliative Care Guidelines 3rd Edition
NICE CG140. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. May 2012
The British Pain Society. Opioids for persistent pain:Good practice January 2010
Page 1 of 12
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
MEASUREMENT AND ASSESSMENT AND OF PAIN
Factors affecting pain tolerance*
* SIGN Guideline 106: Control of pain in patients with Cancer 2008
Measuring pain
The patient should be the prime assessor of his or her pain.
Measuring using the scales below* creates some objectivity between one review and the next.
* Turk DC and Okifuji A. Lancet 1999;353:17848
In addition to, or as a minimum, grade pain as per the Gold Standards Framework PACA tool (Patient and
Carer assessment tool SCR3):
GSF PACA score
0
1
2
3
Pain level
Pain absent
Pain present, not affecting daily life.
Pain present, moderate effect on daily life
Pain present, daily life dominated by symptom
Key References
SIGN Guideline 106: Control of pain in patients with Cancer 2008
Turk DC and Okifuji A. Assessment of patients’ reporting of pain: an integrated perspective Lancet 1999;353:17848
Gold Standards Frameork for Palliative care. http://www.goldstandardsframework.org.uk/
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Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
WHO Step 1
Mild pain
Non-opioid
analgesics +/adjuvant
WHO Step 2
Moderate
pain
Weak opioids
+ non-opioid
+/- adjuvant
WHO Step 3
Moderate to
severe pain
Strong
opioids
+ nonopioid
+/- adjuvant
TREATMENT GUIDANCE FOR PAIN
NON-OPIOIDS
Paracetamol or NSAIDs (e.g.
ibuprofen or naproxen)
WEAK OPIOIDS
e.g.Codeine
Max dose in 24h – 60mg qds
Ensure dose is titrated and optimised
before considering strong opioid
Co-prescribing of weak and strong opioids is
NOT recommended – stop any weak opioid
before initiating a strong opioid
STRONG OPIOIDS
(Immediate release Morphine)
e.g. Morphine sulphate oral solution 10mg/5ml
5-10mg 4 hourly.
Increase dose by 30-50% each day if necessary to
achieve pain control.
Use a record of all immediate release morphine
used to inform increases.
If pain remains uncontrolled consult with specialist.
Lower doses should be used in elderly/renally
impaired.
Pain controlled on regular dose.
Convert to equivalent dose of slow release
opioid if not already prescribed.
1st LINE SLOW RELEASE MORPHINE
Use 12 hour release preparation ONLY
Calculate 12 hourly dose by adding up total amount of
immediate release morphine taken over the last 24
hours and divide by 2.
New breakthrough dose (4 hourly immediate release
dose) will be 1/6th of the dose of the total daily dose.
2nd LINE STRONG OPIOIDS
If there are unacceptable side effects from morphine
e.g. excessive drowsiness, constipation or itching or
significant renal impairment, then use of 2nd line opioid
may need to be considered.
Second line choices - Fentanyl patches or oral
oxycodone HCl – refer to guidance overleaf re choice.
SEEK SPECIALIST ADVICE FIRST
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ANTICIPATE
CONSTIPATION
a stimulant and
faecal softener
laxative is
recommended (see
table on page 8)
 Start with slow
release
morphine
preparation (12
hour release)
instead of
immediate
release if
appropriate
 Continue laxative
 Consider antiemetic PRN
(may only be
necessary for the
first 4-5 days)
 Ensure
patient/carer is
counselled on
regular and
breakthrough
medication to
avoid confusion
 If pain remains
uncontrolled
refer to specialist
 Refer to page 5
for approximate
conversion
doses between
opioids
ADJUVANT ANALGESICS
NSAIDs e.g. ibuprofen 400mg tds or other adjuvant drugs e.g. tricyclics, anticonvulsants e.g. gabapentin may be added at any stage.
Assess and continue if of benefit
Steps on the
WHO Pain
Ladder
For all patients on regular strong opioids, always prescribe an opioid for breakthrough pain – to be used
when required. A maximum total daily dose of 120mg morphine (or equivalent) should not be exceeded
without specialist advice.
The dose of opioid for breakthrough pain is equivalent to one sixth of the 24 hour dose (i.e 4 hourly dose).
Ask the patient to keep a record of how much breakthrough medication they have needed.
All patients on opioids should be prescribed a regular laxative and a prn anti-emetic.
Refer to page 5 for approximate equivalent doses when converting between opioids
For management of opioid toxicity see guidance on page 6.
Key References
NHS Lanarkshire Palliative Care Guidelines 3rd Edition
NICE CG140. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. May 2012
The British Pain Society. Opioids for persistent pain:Good practiceJanuary 2010
Page 3 of 12
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
COMMON TYPES OF PAIN
VISCERAL / SOFT
TISSUE
BONE PAIN
NEUROPATHIC PAIN
Constant dull pain
poorly localised.
Usually opioid responsive
Usually well localised
worse on movement
local tenderness.
Partly opioid responsive
Generally NSAID and paracetamol
responsive
Radiotherapy may help if metastases are
present at the site of pain
May be partially opioid responsive Likely to
require an adjunctive analgesic e.g. tricyclic
antidepressant or anticonvulsant e.g.
gabapentin
Often described as burning, stabbing,
shooting or ‘pins and needles’
USE OF SECOND LINE STRONG OPIOIDS
Oral morphine is the first line choice where a strong opioid is required. A second line choice should be
used for moderate to severe opioid responsive pain where oral morphine is not suitable.
Specialist advice should be sought before changing treatment and to discuss alternatives.
The table below outlines the place in treatment for oral oxycodone and fentanyl patches:
ORAL OXYCODONE
FENTANYL PATCHES
Consider if
 Analgesia is inadequate with morphine
despite dose optimisation (this may
include circumstances in which opioid
rotation is being considered); or
 Dose optimisation of morphine is limited
by persistent adverse effects.
Consider if:
 There is an established swallowing difficulty, persistent nausea
and vomiting, GI blockage or severe renal impairment where
dose adjustment with morphine is not feasible.
 There are unacceptable side effects from morphine
 The patient is not tolerating oral medication.
Not suitable for patients with unstable or rapidly changing
pain.
Can be prescribed generically.
Should be prescribed by brand name to ensure patients remain on
the same preparation.
Oxycodone is available as both modified
Patches are changed every 72 hours (3 days). If more than one
release formulation (12 hour) preparation and patch is needed apply them at the same time to avoid confusion.
immediate release preparation.
Patients should be counselled appropriately
Patients should be counselled to use a new area of (hairless) skin
on the differences between the preparations
and remove old patches.
to avoid confusion regarding which is for
Heat/pyrexia increases the rate of fentanyl absorption and can
regular dosing and which for breakthrough
cause toxicity – ensure pyrexic patients are monitored for adverse
pain.
events and counsel all patients to avoid exposing the application
site to external heat e.g radiators, hot water bottles.
There should be a clear reason for changing
If dose needs to be increased, increase patch dose by 12 – 25
to oxycodone and for ongoing prescribing. If, micrograms/hr (unless dose >100-150 micrograms/hr, in which case
after an adequate trial of oxycodone, no
increase by 50 micrograms/hr). Frail or elderly patients may need
benefit has been achieved, consider
lower doses and slower titration. Improved analgesic effect may
changing back to morphine or alternative
take up to 12 hours. Leave a minimum interval of 48 hours between
analgesia.
dose increases.
Reduced clearance in mild to moderate renal
No initial dose reduction is needed in renal impairment but monitor
impairment so titrate slowly and monitor.
for signs of accumulation. Dose reduction may be needed in severe
Consider dose reduction and increased
liver impairment.
dosage and time between doses if required.
Avoid in stage 4-5 chronic kidney disease
Avoid in moderate to severe liver impairment
as clearance is reduced.
Immediate release oxycodone can be used
Ensure immediate release morphine i.e. morphine sulphate oral
for breakthrough pain. Ensure the
solution 10mg/5ml is available for breakthrough pain at an
patient/carer is aware of when and at what
appropriate dose
dose to use the immediate release and
The 12mcg/hr strength patch is licensed for dose titration but may
modified release preparations.
be used for patients requiring a lower starting dose (unlicensed)
It can take 22 hours or longer for the plasma fentanyl concentration
to decrease by 50%. Therefore if replacing fentanyl with another
strong opioid seek specialist advice.
Key References
NHS Quality and Productivitybulletin. Appropriate prescribing of fentanyl patches December 2011 and Appropriate prescribing of
oxycodone December 2011
NHS Lanarkshire Palliative Care Guidelines 3rd Edition
British National Formulary Ed66 September 2013-March2014
Page 4 of 12
Page 5 of 12
Reproduced with permission of NHS Lanarkshire
If a dose that is greater than 1ml is needed as a stat SC dose this should be given in divided separate doses of no more than 1ml in volume
For higher doses consider specialist advice for any changes.
The doses listed in the table above are approximate equivalent doses only. Patients should be carefully monitored after any change in medication and dose titration
may be required. Seek specialist advice.
With acknowledgement to (and adpated from) NHS Lanarkshire palliative care guidelines 3rd edition
Converting to or from oral morphine to alternative opioids – dose conversions
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
MANAGEMENT OF TOXICITY TO OPIOIDS
There is a wide variation in the dose of opioid that causes symptoms of toxicity. Be aware this can also
occur if the level of pain has reduced significantly e.g. after radiotherapy used to manage bone metastases
as opioid requirements may decrease post treatment.
Common warning signs of opioid toxicity or overdose
 Increasing/persistent drowsiness (exclude other causes)
 New onset or worsening confusion
 Muscle twitching/myoclonus/jerking
 Vivid dreams/hallucinations
 Agitation
 Respiratory depression (overdose/severe toxicity)
 Coma (overdose/severe toxicity)
Management of toxicity
Mild toxicity:
 Consider decreasing the opioid dose by a third and closely monitor the patient.
 Ensure patient is well hydrated
 Contact specialist palliative care team for advice regarding ongoing management
 Consider advance care plan and admitting patient
 Change syringe driver medications/dose on specialist advice
Moderate to severe toxicitiy:
 Seek specialist advice immediately
 Call an ambulance if medical emergency
Be careful not to confuse a dying patient with someone who is experiencing opioid toxicity, be clear
on the diagnosis. If in doubt, seek specialist advice.
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Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
NAUSEA AND VOMITING
1.GENERAL MEASURES
Consider potentially reversible factors and treat these if possible and appropriate (correction may not be
indicated for some of these if the patient is imminently dying). Causes include:
Medicines
Uraemia
Hypercalcaemia
Constipation
Cough
Anxiety
Bowel obstruction
Ascites
Severe pain
Infection
Raised intracranial pressure
2. MANAGEMENT
Choice of medication is based on likely cause, side effect profile and route of administration as well as
patients condition/prognosis.
Cause
First Line
Second Line
For gastritis or gastric stasis
use a prokinetic anti-emetic
(provided the patient is not in
bowel obstruction).
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Metoclopramide 10mg orally
tds (caution in those at risk of
extrapyramidal side effects
e.g. Parkinson’s disease) or
Domperidone 10mg orally or
rectally tds
(note MHRA advice re
cardiac risk). Extrapyramidal
side-effects rare with
domperidone
Haloperidol 1.5-3mg orally
once daily or
2.5-5mg continuous
subcutaneous infusion (both
unlicensed) / 24hrs
For most chemical causes of
vomiting (e.g. opioids,
hypercalaemia, uraemia) use
a centrally acting anti-emetic
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Raised intra-cranial pressure,
motion sickness
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Cyclizine 50mg orally tds or
50-150mg continuous
subcutaneous infusion / 24hrs
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Syringe driver for
continuous subcutaneous
infusion or IM Injections
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Levomepromazine
6.25-12.5mg orally ON (avoid
when at risk of seizure e.g. brain
metastases, epilepsy).
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Levomepromazine 6.25-12.5mg
(i.e. ¼ - ½ 25mg tablet) orally
nocte
or 6.25-25mg continuous
subcutaneous infusion /24hrs
(avoid when at risk of seizure).
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OTHER CONSIDERATIONS
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Also consider use of an antacid or
proton pump inhibitor
Use metoclopramide with caution in those at risk of/from extrapyramidal side-effects e.g. Parkinson’s
disease. Extrapyramidal side-effects are rare with domperidone.
Review efficacy of anti-emetic medication every 24 hours until control achieved
If underlying cause is resolved, review and discontinue antiemetic medication
Avoid combining medications with similar mode of action or side-effect profile
Do not combine prokinetics with anticholinergics
If nausea and vomiting are not controlled with oral antiemetics, review the patient’s regular oral
medications and consider conversion to alternative route in order to maintain absorption e.g to fentanyl
patches or syringe driver
Advise patient/carer on good mouth care and on avoiding any nausea triggers e.g. strong smells
Refer to local specialist palliative care team if causes such as bowel obstruction or raised
intracranial pressure are suspected.
Key References
British National Formulary Ed 66 September2013-March 2014
NHS Lanarkshire Palliative Care Guidelines 3rd Edition
NHS Wales Adult Palliative Care General Guidelines. October 2011
Palliative Care Formulary 4, September 2012
Page 7 of 12
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
CONSTIPATION
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Regularly enquire about constipation.
Clarify the cause before starting treatment.
Beware, chronic constipation can mislead and be misdiagnosed . Signs include:
 abdominal pain
 anorexia
 malaise
 colic
 tenesmus
 spurious diarrhoea
 urinary retention
 intestinal obstruction
 mental confusion
Patients should be advised to maintain an adequate fluid intake
A stepwise approach to laxative therapy should be adopted – prescribe regular laxative treatment
and optimise before adding or changing treatment.
Daily laxatives are necessary for almost all patients on strong opioids (unless already liable to
diarrhoea).
Most patients will need a softener and a stimulant.
Increase doses as necessary every 1-2 days. Rectal measures may still be required e.g. glycerol
suppositiories or sodium citrate enema
Stimulant laxatives act within 6-12 hours
Osmotic laxatives may take 1-3 days to have an effect
Stool softeners take 24-36 hours to act
For patients experiencing abdominal pain, do not titrate opioid dose to treat this – investigate
and treat cause.
ROUTINE LAXATIVES
Softener
Docusate sodium
100mg capsules
Initially 100mg BD
Max 200mg TDS
Softener at lower doses and mild stimulant at higher
doses. Mostly a faecal softener.
Lactulose
10-20mls OD-BD
Can be unpalitable, and can cause wind and distension,
but some patients may prefer.
Macrogol oral
powder
Initially 1-3 sachets a
day.
Max 8 sachets daily for
1-3 days for faceal
impaction
1 sachet administered with 125ml water is isotonic. It is
important to ensure sachet is administered in the correct
volume of liquid. For use in faecal impaction refer to
current edition of the BNF
Large volume of liquid may be difficult to take for some
patients e.g. frail.
Osmotic laxative
Stimulant – avoid in intestinal obstruction
Senna tablets or
liquid
1-2 tabs OD-BD
or 7.5mg/5ml syrup
10–20mls ON
5-10mg ON (oral)
10mg ON (PR)
Can cause abdominal cramps.
Bisacodyl 5mg
Mostly acts on large bowel.
tablets or 10mg
suppositories
Docusate sodium
Initially 100mg BD
Softener at lower doses & mild stimulant at higher
100mg capsules
Max 200mg TDS
doses. Mostly a softener.
Co-danthramer and co-danthrusate are options for severe constipation in palliaitive care patients ONLY.
Seek advice from a specialist before initiating and refer to full prescribing information for dosage
information.
Key References
British National Formulary Ed 66 September2013-March 2014
NHS Lanarkshire Palliative Care Guidelines 3rd Edition
NHS Wales Adult Palliative Care General Guidelines. October 2011
Palliative Care Formulary 4, September 2012
Page 8 of 12
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
USE OF A SYRINGE DRIVER
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A syringe driver is an alternative administration route where other routes of administration are
not viable or continuous infusion is needed.
Medication is delivered by continuous subcutaneous infusion (CSCI).
Indications for its use include: persistant nausea and vomiting, dysphagia, intestinal obstruction, coma,
or too weak to take oral medications.
Take advice from the local specialist palliative care team regarding the need for a syringe driver,
medications, doses etc. If there is no specialist palliative care support available a GP could initiate and
write a prescription for treatment including completing a syringe driver prescription sheet.
Try to anticipate the need for a syringe driver and prescribe in advance so that drugs and
paperwork are all correct and present when the drugs are needed and can be sourced within working
hours. Most pharmacies can obtain palliative care drugs within 24 hours and should be able to inform
you if there is any likely delay.
Engage district nurse service to set up and monitor syringe driver
A syringe driver prescription/authorisation sheet will need to be completed and given to the DN or left
with the patient for the DN to action.
A maximum of three medications can be administered via a syringe driver. On rare occasions four
drugs can be given – ONLY on specialist palliative care team advice.
Water for injection is the usual diluent
The use of most opioids for continuous subcutaneous infusion is unlicensed.
Before setting up a syringe driver, it is important to explain its use to the patient and their family. It is
important that the syringe driver is not seen just as the last resort but as an effective method of relieving
certain symptoms by injection.
Ensure compatibilities of medications in the syringe driver have been checked prior to
prescribing – check with the specialist palliative care team if required.
Refer to table on page 5 for approximate dose conversions between opioids
Note: Morphine injection is available in different strengths (e.g. 10mg/ml, 30mg/ml). Care needs to be taken
when prescribing, preparing and administering, to ensure patient receives the correct dose. Seek specialist
advice
SYMPTOM
DRUGS
GUIDELINES TO DOSAGE
Pain
Morphine sulphate
If opioid naïve start at 1015mg/24hrs.
Diamorphine hydrochloride
If opioid naïve start at 510mg/24hrs.
Hyoscine butylbromide
Hyoscine
Hydrobromide
Glycopyrronium bromide
Metoclopramide
Cyclizine (do not dilute with
sodium chloride 0.9%)
20-160mg in 24 hours
1200-2400 micrograms in 24 hours.
Confusion limits use.
200-400 micrograms, 6-8 hourly as required
30-100mg in 24 hours
50-150mg in 24 hours
Nausea and vomiting/
restlessness
Levomepromazine
(avoid if risk of fitting.)
Nausea and vomiting
Haloperidol
Terminal agitation, anticonvulsant
Midazolam
6.25-25mg in 24 hours (for anti-emetic)
12.5-150mg in 24 hours (for restlessness/sedation)
Higher doses for sedation only
2.5-5mg in 24 hours
Doses >8mg/day risk extrapyramidal effects
Above 2mg/ml can precipitate in diamorphine
10-60mg in 24 hours
(ensure flumazenil available)
Colic
Bronchial secretions
Nausea and vomiting
For both medications:No
ceiling limit. Titrate
cautiously. Do not titrate
above 120mg morphine
daily (or equivalent)
without specialist advice
LESS COMMONLY USED DRUGS – SPECIALIST INITIATED

Dexamethasone (If possible, should be administered as sole drug in syringe driver. Seek specialist advice if site
irritation occurs)

Ketorolac (Bone pain)
Key References
British National Formulary Ed 66 September2013-March 2014
NHS Lanarkshire Palliative Care Guidelines 3rd Edition
Page 9 of 12
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
McKinley T34 Syringe Pump
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There is only one type of syringe driver in use across North Central London – this is the McKinley
T34
The volume in the syringe will infuse over 24 hours
Refer to local guidance (community nursing policy) or consult with specialist palliative care team or
district nurses for advice on equipment, setting up and administration of syringe pump.
The infusion line should be checked each visit/regularly for signs of redness, induration,
crystallisation of the infusing solution, leakage.
For advice on managing injection site reactions, seek advice from the palliative care team.
A Syringe driver prescription/authorisation chart should be completed for medicines to be
administered via the pump. This can be accessed via community nurses or palliative care team or
local GP website.
Compatibility of medications to be mixed in a syringe driver should be checked. Seek advice from
the palliative care team.
Syringe driver drug compatibility chart
Key
Compatible
Sometimes incompatible
Incompatible
No data available
Key References
British National Formulary Ed 66 September2013-March 2014
NHS Lanarkshire Palliative Care Guidelines 3rd Edition
NHS Cumbria and Lancashire North Palliative Care guidance 2008
Page 10 of 12
Midazolam
Metoclopramide
Levomepromazine
Hyoscine Hydrobromide
Haloperidol
Glycopyrrolate/
Glycopyrronium
Bromide
Diamorphine
Dexamethasone
Cyclizine
Hyoscine
Butylbromide
With acknowledgement to (and adpated from) NHS Cumbria and Lancashire North Palliative Care guidance
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
SYMPTOM CONTROL IN LAST DAYS OF LIFE
SHORTNESS OF BREATH
KEY POINTS
 Very frightening for patient– empathy important.
 Is it appropriate to treat underlying cause? e.g. CCF - Seek specialist advice if in doubt
 Are there reversible causes that can be treated? e.g. pulmonary embolism, infection, pleural effusion
etc.
 Check oxygen saturation
SYMPTOM CONTROL
 Visualised reminder charts can be used to remind patient in crisis
 Physical measures e.g. open windows, fan, keep face cool
 Refer to physio for relaxation techniques
 Where appropriate - bronchodilators (via spacer/nebuliser), antibiotics, steroids, diuretics, oxygen
(only if hypoxic). Oxygen must be specialist intiated.
Consider low dose oral morphine to help manage e.g. 1- 2.5mg oral morphine liquid regularly 4 hourly or
PRN. Patient will require an oral syringe to measure small volumes/doses of morphine liquid
BRONCHIAL SECRETIONS IN LAST 48 HOURS
KEY POINTS
 Consider if these are due to treatable underlying cause e.g. heart failure
 General management measures include repositioning to lateral position, avoiding over hydration,
addressing family distress
SYMPTOM CONTROL
Conscious Patient
 hyoscine butylbromide 20mg sc/orally stat or 60 – 120mg over 24 hrs in syringe driver OR
 glycopyrronium bromide 200-400mcg SC, 6-8 hourly as required
Unconscious Patient or where sedation may be of benefit
 hyoscine hydrobromide 400-600 micrograms sc stat PRN or 1200-2400 micrograms over 24 hrs in
syringe driver
For other measures available – consult local specialist palliative care team.
AGITATION
KEY POINTS
 Ensure calm and comfortable environment
 Treat reversible causes
- Pain
- Urinary retention
- Constipation
 May still be appropriate to use sedation even if reversible causes are present.
SYMPTOM CONTROL
 Subcutaneous stat administration or CSCI (continuous subcutaneous infusion) via a syringe driver
over 24hrs may be needed.
1st line
 LORAZEPAM (if patient conscious) 500microgram to 1mg orally or sublingually 4-6 hourly PRN
(max 4mg daily)
 MIDAZOLAM - useful in patients who are at risk of seizure
 Use 2.5-5mg SC hourly PRN or 10-60mg over 24 hours in syringe driver
2nd line LEVOMEPROMAZINE - avoid if risk of seizure.
 Is both sedative and anti-emetic.
 Use 6.25-25mg SC OD-BD (antiemetic) or 25-100mg (restlessness) over 24 hours in syringe driver
 Higher doses should only be used for restlessness
A combination of both sedatives may be needed, but ONLY on specialist advice.
Key References
British National Formulary Ed 66 September2013-March 2014
NHS Lanarkshire Palliative Care Guidelines 3rd Edition
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Palliative Care for Adults – Guidance for Primary Care v 2 (Updated March 2014 – next review date March 2016)
USEFUL CONTACTS - LOCAL SPECIALIST PALLIATIVE CARE TEAMS
If you wish to discuss how you manage the palliative care needs of a patient with a specialist palliative care service the
following are the options. This may enable the patient to be managed in their own home and avoid a hospital admission.
Local community specialist palliative care teams
Area
Team base
Office hours
Islington
ELiPse team, Well
House, Benwell Road
Mon-Fri: 09:00-17:00
Tel: 020 3317 5777
Fax: (for referrals) 020 7607 3995
South
Camden
UCLH
Mon-Fri: 08:30-17:00
Tel: 020 3447 7140
Fax: (for referrals) 020 3447 7677
North
Camden
Royal Free Hospital
Mon-Fri: 09:00-17:00
Tel: 020 7830 2905
Haringey
Whittington Health
Community Palliative
Care Team
St Joseph’s Hospice
Mon-Fri: 09:00-17:00
Tel: 020 3224 4340
Fax: 020 3224 4304
Mon-Fri: 09:00-17:00
Tel: 020 8525 6060
First Contact Team
Tel: 0300 303 0400
City and
Hackney
Out of hours
Tel: 0845 155 5000 (UCLH Trust
Switchboard) and ask to air-call
the palliative care team.
Provides telephone advice and
visiting where needed.
Sat-Sun: 9.00-5.00
Tel: 020 7794 0500 and ask to
air-call the palliative care team
No direct OOH service.
Contact St. Josephs Hospice or
Marie Curie Hampstead
Mon-Sun: 18:00-08:00
Tel: 020 8525 6000
DISTRICT NURSES
24hr District Nurse (DN) Message Service
Camden
(DN Available 24h - 7 days a week)
Islington (Whittington Health)
(DN Available 08:30-24:00 - 7 days a week)
City and Hackney
(DN available 08:30-23:30 - 7 days a week)
Haringey
(DN available 09:00–17:00 & 18:00–24:00
7 days a week)
Marie Curie Hospice Hampstead
St John’s Hospice
St Joseph’s Hospice
North London Hospice
Telephone No.
Tel: 020 3317 5916
Fax: 020 7813 8719
OOH referrals: Tel: 0207 391 6360 (from 17:00–08:30)
Tel: 020 3316 1111
Fax: 0844 774 6419
OOH referrals: Tel: 020 7527 4250
Tel: 020 7683 4144
Fax: 020 7014 7274
Tel: 020 8442 6296
Fax: 020 8442 6849
Local Hospices contact details
Tel: 020 7853 3400
Tel: 020 7806 4065
Tel: 020 8525 6000
Tel: 020 8343 8841
Pharmacy services
Islington Pharmacies (Palliative care medicines scheme) for Islington patients only:

Clan Pharmacy. 150 Upper Street. N1 1RA Tel:020 7359 7595

Dev’s Chemist (Atchem Ltd). 110 Seven Sisters Road. N7 6AE Tel:020 7607 3081
Camden 100 hour pharmacies

Boots the Chemists, Unit 19, St Pancras Station, N1C 4QL. Tel: 020 7833 0216

Boots the Chemists, Western Ticket Hall, Kings Cross Station. N1C 4AP Tel: 020 7278 5861

Baban Pharmacy, 42 Chalton St, NW1 1JB. Tel: 020 7388 9989

IPSA Pharmacy, 7 Harben Parade, Finchley Road. NW3 6JP. Tel: 020 7449 9490

Sainsburys Pharmacy, 17-21 Camden Road, London NW1 9LJ. Tel 020 7482 3828
Haringey Pharmacies providing on demand medicines for end of life care and other specialist medicines

Boots the Chemist Unit A2, Tottenham Hale Retail Park, N15 4QD. Tel: 0208 801 7243
Monday – Saturday 09:00 – 19:00, Sunday 11:00 – 17:00

Hornsey Central Pharmacy 151 Park Rd, Crouch End N8 8JD Tel: 020 3074 2700
Monday – Saturday 07:00 – 22:00, Sunday 09:00 – 19:00

Philips Chemist 193 Lordship Lane, Tottenham, London, N17 6XF Tel: 020 8808 4040
Monday – Friday 09:00 – 18:30, Saturday 09:00 – 17:30

Pharmacy Express 214 High Road, London, N22 8HH. Tel: 020 8888 1669

Monday – Friday 09:00 – 18:30, Saturday 09:00 – 13:00
This guideline is an update of the 2010 guideline and was reviewed with input from CCG representatives and local specialists from Camden,
Islington and Haringey teams – March 2014
Adapted from the original The Pocket Guide for Palliative Care 2004. For clinical queries relating to this guideline please contact the local CCG
borough medicines management team or local specialist team
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