Symptom control Guidance - Last days of life

What is essential in symptom management at end of life?

Regular assessment of symptoms

Name common symptoms in the last days of life

• Pain

• Breathlessness

• Nausea/vomiting

• Anxiety

• Delirium/agitation

• Noisy respiratory secretions

What must always be considered when assessing symptoms?

Reversible causes i.e. urinary retention and constipation

How should management be tailored?

Individualised to the patient

What non-drug measures should be considered?

• Positioning

• Environment

• Reassurance

What type of medications should be prescribed in advance?

Anticipatory medications (including injectables)

Why prescribe anticipatory medications?

To manage symptoms before they occur

What route is commonly used for anticipatory meds?

Subcutaneous (SC)

When is a syringe driver indicated?

• Cannot take oral meds

• Needs continuous symptom control

• Concerns about oral absorption

What does CSCI stand for?

Continuous Subcutaneous Infusion

What diluent is used in syringe drivers?

Water for injection

What should always be specified for medications?

Maximum dose in 24 hours

Why specify a max 24-hour dose?

• Enables safe use of PRN doses

• Prompts clinical review if frequent use

What must the max 24-hour dose include?

• Regular meds

• PRN meds

• Syringe driver doses

What’s a key prescribing omission in end-of-life care?

Not prescribing anticipatory PRN injectable meds

End-of-life pain management: If the patient is NOT in pain and not on morphine, what do you prescribe?

• Morphine 2.5 mg SC PRN

• Up to every 2 hours

• Prescribed anticipatorily

If NOT in pain but already on oral morphine and can’t swallow?

• Convert to CSCI (syringe driver)

• Divide total 24h oral dose by 2

What PRN dose is given after starting CSCI?

• 1/6th of total 24-hour CSCI dose

• SC PRN up to every 2 hours

If patient is in pain and NOT on regular morphine but can take oral?

• Continue oral morphine PRN

• Add morphine 2.5 mg SC PRN (2-hourly)

When should you consider starting a syringe driver?

If ≥2 PRN doses needed in 24 hours

How do you convert oral morphine → CSCI?

In the last days of life, oral morphine → SC

• Divide oral dose by 2 and this is dose for SC

• Then increase by 20-30% - this is in last days of life (it is the equivalent of 2 PRN doses)

• Then prescribe PRN SC morphine at 1/6th of 24 hour CSCL dose up to 2 hourly

When CSCL is initiated what must we do?

STOP oral morphine

When should pain be reassessed after starting CSCI?

After 24 hours

If still in pain after 24 hours, what do you do?

Increase CSCI dose by ~30%

What caution is needed with morphine?

Renal and/or hepatic impairment

When is diamorphine preferred?

• When large opioid doses are needed

• Smaller volume required (more concentrate

How do you convert oral morphine → SC diamorphine?

👉 Divide by 3
(e.g. 30 mg oral morphine = 10 mg SC diamorphine)

When is oxycodone used instead of morphine?

• Morphine not tolerated

• Mild–moderate renal impairment

When is oxycodone contraindicated?

👉 Moderate to severe hepatic failure

How do you convert oral → SC oxycodone?

• Reduce by 1/3 OR

• Reduce by 1/2
  (→ check local guidance / SPCT)

What do you do with fentanyl/buprenorphine patches when starting a syringe driver?

👉 Leave patch in situ and continue as prescribed

How is PRN dose calculated with patches + CSCI?

1/6th of total 24h opioid dose (patch + CSCI combined)

Key opioid issue in renal failure?

Drug elimination is slower → toxicity risk

What is a safer opioid option in renal impairment?

👉 Oxycodone (with caution)
👉 Alfentanil (specialist use

Key points about alfentanil in palliative care?

• Used in moderate–severe renal impairment

• Specialist input required

• Convert oral morphine → SC alfentanil: divide by 30

• PRN usually morphine or oxycodone (not alfentanil as too short acting)

What should be prescribed anticipatorily if patient not yet breathless?

• Morphine 2.5 mg SC PRN (2-hourly) AND

• Midazolam 2.5 mg SC PRN (2-hourly)

First-line non-pharmacological measures for breathlessness in last days of life?

• Reposition (sit upright)

• Fan / open window

• Oxygen only if hypoxic

First-line drug for breathlessness in last days of life?

Morphine 2.5 mg SC PRN (2-hourly)

What if the patient is already on opioids?

Give breakthrough dose = 1/6th of total 24h opioid dose

If morphine not sufficient for breathlessness, what next?

Midazolam 2.5 mg SC PRN (2-hourly)

When should you consider a syringe driver (CSCI)?

More than 2 PRN doses required in 24 hours

What can be included in a syringe driver for breathlessness?

Morphine and/or midazolam

Roles of morphine vs midazolam in breathlessness?

• Morphine → relieves sensation of breathlessness

• Midazolam → treats anxiety/distress

First step when managing agitation/restlessness?

Assess and treat reversible causes:

• Pain

• Full bladder

• Constipation (full rectum)

• Breathlessness

• Anxiety/fear

What should be prescribed in anticipation?

• Midazolam 2.5–5 mg SC PRN (2-hourly) → anxiety/agitation

• Haloperidol 2.5 mg SC PRN (4-hourly) → delirium

First-line for agitation due to delirium?

👉 Haloperidol 2.5 mg SC PRN (4-hourly)

• Alternative: Levomepromazine

• Consider CSCI if ≥2 PRNs in 24h

First-line for agitation due to anxiety?

👉 Midazolam 2.5–5 mg SC PRN (2-hourly)

• If ≥2 PRNs → consider CSCI midazolam (e.g. 10 mg/24h)

• Can titrate up to 30 mg/24h

Key principle in terminal agitation?

👉 Usually hyperactive delirium

• Use antipsychotic first-line (haloperidol)

• ± benzodiazepine (midazolam)

What symptom is referred to as the “death rattle?

Noisy respiratory secretions in the last days of life

What should be explained to families about noisy secretions?

They are a normal part of dying as fluid pools in the oropharynx

First‑line anticipatory medication

• Hyoscine butylbromide

• OR

• Glycopyrronium

Used for maintenance and PRN up to 4 hourly

When should PRN anticholinergics be converted to a CSCI?

After two or more PRN doses, convert to CSCL

if symptoms continue to not be managed, increase dose to maximum dose in 24 hours.

Key reassurance message for families

Noisy secretions are usually more distressing to observers than to the patient

How are anti-emetics prescribed in the last faw days of life?

• One regular anti‑emetic is used as the main treatment (often via CSCI at end of life).

• One PRN anti‑emetic is added for breakthrough symptoms.

• If symptoms persist despite this, clinicians switch to a different anti‑emetic (often levomepromazine), rather than adding multiple regular ones.

How often would PRN anti-emetic be given?

• Give up to every 4 hours

What are examples of common anti-emetic regimens for nausea/vomiting in the last few days of life?

• Haloperidol via CSCL over 24 hours, cyclizine or levomepromazine PRN

• Cyclizine (± haloperidol) via CSCl over 24 hours, levopromazine PRN

• Metoclopramide via CSCl over 24 hours, levomepromazine PRN

• Levopromazine via CSCl over 24 hours, levopromazine and/or ondansteron PRN

Cyclizine and metoclopramide - would this be a suitable anti-emetic regimen?

NO - Not to be used together as they counteract each other

Cyclizine - anticholinergic - slows gut - calming

Metoclopramide - prokinetic - speeds gut - moving

Reduced efficacy when used together

DONT mix calm + move

Anti-motility - anticholinergic -cyclizine

Pro-motility - metoclopramide

Anti vs pro = no go

Considering the cause of nausea and vomiting: What anti-emetic would we use in a patient with renal failure/ opioid induced N&V or hypercalcaemia?

• haloperidol

Nausea and vomiting due to raised intracranial pressure? First-line antiemetic?

• Cyclizine

First line anti-emetic in N&V induced by gastric stasis/ functional bowel obstruction?

-Metoclopramide

If a patient has N&V and parkinsons, what would we consider first line anti-emetic?

ondansteron

When would we use levopromazine?

Used as a second/ thrid line anti-emetic as it is broad spectrum

Why do we avoid certain anti-emetics in parkinsons disease?

Avoid anti-dopaminergic medications such as haloperidol (a first-generation anti-psychotic that blocks dopamine), metoclopramide (dopamine antagonist), and levopromazine (a first-generation anti-psychotic that inhibits dopamine).

If unable to take oral Parkinson’s medications, consider using a rotigotine transdermal patch starting at 2mg/24 hours.

What medications would we avoid abruptly stopping in last days of life?

Heart failure medication may offer significant symptomatic relief so do not discontinue just because its last few days of life

What anti-emetic should be avoided in heart failure?

Cyclizine - anticholinergic so can cause tachycardia so avoid in HF patients where medication is aimed at reducing workload and increasing cardiac efficacy

If a patient is epileptic, what should be prescribed if risk of seizures in last days of life?

• Prescribe buccal midazolam 10mg PRN

For patients with renal failure, what medication is preferred for hypersecretions?

• glycopyrronium is preferred to hyoscine hydrobromide in end-stage renal failure

• consider lower doses and longer dosing intervals for all meds in renal failure

• not that most symptomatic medications can be used in renal impairment with caution