Anticipatory Prescribing in Last Hours/ Days of Life
Plaese discuss with Palliative Care Team for additional advice.
Step 1
| 1st line | Alternative | |
|---|---|---|
| Pain Breathlessness |
Morphine 2.5mg SC every hour PRN* Patient already on regular opioids - Convert 24-hour dose of regular opioid to SC (SC=half po dose) and give 1/6th dose PRN** |
Oxycodone 1.25mg SC every hour PRN* |
| Anxiety SoB |
Midazolam 2.5mg SC every hour PRN* | |
| Resp. secretions |
Hyoscine BUTYLbromide 20mg SC every hour PRN* (Max 120mg/24 hours). Non-sedating. Does not cross blood-brain barrier (BBB) | Hyoscine HYDRObromide 400 - 600 microgram SC every four hours PRN (Max dose - see Step 2 below). Sedating-crosses BBB |
| Agitation delirium |
Levomepromazine 3.125mg to 6.25mg SC every hour PRN | Haloperidol 0.5mg to 1mg SC every hour PRN |
| N&V | Levomepromazine 3.125mg to 6.25mg SC every 12 hours PRN | Haloperidol 0.5mg to 1mg SC every 12 hours PRN |
| Review PRN medication within 1 hour of administration. If symptoms persist OR ≥3 PRN doses are needed seek advice and progress to STEP 2 | ||
Step 2
| 1st line | Alternative | |
|---|---|---|
| Pain Breathlessness |
Morphine 5 - 10mg CSCI over 24 hours OR Oxycodone 2.5mg - 5mg CSCI over 24h Patient already on regular opioids: Convert 24-hour dose of regular opioid to a 24hours CSCI (SC=half po dose)** |
If CrCl <30mls/min consider Fentanyl 1st line. Consult Palliative Care for further advice. Fentanyl 100microgram to 200microgram CSCI over 24h |
| Anxiety SoB |
For breathlessness: Midazolam 5mg- 10mg CSCI over 24 hours For anxiety/distress: Midazolam 10mg - 20mg CSCI over 24h ± Levomepromazine 6.25mg to 12.5mg CSCI over 24 hours if severe anxiety/distress |
|
| Resp. secretions |
Hysocine BUTYLbromide 60 - 120mg CSCI over 24h. Non-sedating. Does not cross blood- brain barrier (BBB) | Hyoscine HYDRObromide 1.2 - 2.4mg CSCI over 24hours. Sedating-crosses BBB. Max total dose = 3.6mg in 24h (Including PRN doses) |
| Agitation delirium |
Levomepromazine 6.25mg to 12.5mg CSCI over 24h. Higher starting doses can be used under specialist advice | Haloperidol 2.5 - 5mg CSCI over 24h |
| N&V | Cyclizine 150mg CSCI over 24h or Haloperidol 1mg to 2.5mg CSCI over 24h or Metoclopramide 30mg CSCI over 24h or Levomepromazine 6.25mg to 12.5mg CSCI over 24h |
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