Palliative Care Guidelines - NHS Lanarkshire

Palliative Care Guidelines: Renal Palliative Care - Last Days of LifeBreathlessness• May be due to pulmonary oedema, acidosis, anxiety or lung disease.• Oral diuretic if able to swallow. Avoid fluid overload; consider ultrafiltration.Intermittentbreathlessness/ distressPersistentbreathlessness/ distressmidazolam SC 2.5mg hourly, as required &/ or lorazepamsublingual 0.5mg 8 hourly, as required.alfentanil SC hourly, as required.- fentanyl patch or alfentanil infusion: see chart for dose.- no regular opioid: alfentanil SC 100-250micrograms.midazolam SC 5-20mg + alfentanil SC 500 micrograms (if noopioid for pain) via a syringe driver or pump.Respiratory tract secretions1 st line: hyoscine butylbromide SC 20mg, hourly as required (up to 120mg/ 24hours).2 nd line: glycopyrronium bromide SC 100micrograms, 6-8 hourly as required.Nausea / vomiting (see: Nausea / Vomiting, Subcutaneous medication)• Nausea is common due to uraemia and co-morbidity.• If already controlled with an oral anti-emetic, continue it as a subcutaneous infusion or use along acting anti-emetic: haloperidol SC 0.5-1mg twice daily or 1-2.5mg once daily.levomepromazine SC 2.5mg twice daily or 5mg once daily.• Treat persistent nausea with levomepromazine SC 5-12.5mg once or twice daily or use 5-25mgover 24 hours in a syringe driver/ pump.Delirium• Common and may worsen as uraemia increases; needs active managementMild delirium/ hallucinations Haloperidol SC 2.5mg, once dailyEstablished terminaldelirium/ distressPractice points1 st linemidazolam SC 20-30mg over24 hours in a driver/pump+ midazolam SC 5mg hourly,as required OR regular rectaldiazepam 5-10mg, 6-8 hourly.2 nd linemidazolam SC 40-80mg over24 hours in a syringe driver/ pump+ levomepromazine SC12.5-25mg, 6-12 hourly, asrequired, stop any haloperidol.• Opioid analgesics should not be used to sedate dying patients.• Avoid renally excreted opioids (codeine, dihydrocodeine, morphine, diamorphine, oxycodone).• Subcutaneous infusions provide maintenance treatment only; additional SC doses of medicationwill be needed if the patient’s symptoms are not controlled.• Midazolam is titrated in 5-10 mg steps. Up to 5mg can be given in a single SC injection (1ml).Single SC doses can last 2-4 hours. Useful as an anticonvulsant.• A marked increase in pain in the dying patient is unusual; reassess and seek advice.• As uraemia worsens, the patient may become more agitated and need an increased dose ofmidazolam, and in some cases additional levomepromazine.ResourcesProfessionalNHS End of life care Programme http://www.endoflifecare.nhs.uk/eolcLiverpool Integrated Care Pathway http://www.mcpcil.org.uk/liverpool_care_pathwayPatientPatient leaflet on website: What happens when someone is dying.Key references1. Bunn R, Ashley C. The renal drug handbook Oxford, Radcliffe Medical Press 20042. Chambers J. Supportive care for the renal patient Oxford, OUP 20043. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Management 2004; 28(5): 497-504Further reading: http://www.palliativecareguidelines.scot.nhs.uk2 Issue date: January 2009 Review date: March 2012 © NHS Lothian