End of life care in the ED



Background

  • Achieving a dignified death for all patients who die in the ED should be a principle aim for ED clinicians, and can be a rewarding experience for all involved in caring for the patient and family.
  • Symptom management should be individualised for each patient and encompasses both pharmacological and non-pharmacological support.
  • Symptom management is commonly used for the treatment of refractory pain, breathlessness, agitated delirium, and convulsions.
  • Some emergency end of life situations for which care is needed include massive hemorrhage, asphyxiation, an overwhelming pain crisis, and severe terminal breathlessness.
  • The objective of end-of-life care is to relieve suffering; the objective is not to lengthen or cut short the patient’s life.
  • Patients and their families should be involved, wherever possible, in end of life care decisions.
  • If a patient is at the end of life, it may be appropriate to set a ceiling of treatment in the ED.
  • Stop IV fluids if this will not help alleviate any symptoms or distress and the patient is approaching the final hours of life.
  • Opportunities for organ and tissue donation should be considered as a usual part of end of life care in the ED.
  • End-of-Life care is considered after all other measures to relieve reversible distress have been exhausted. The diagnosis of dying may not be straight forward – discuss with the consultant in Emergency Medicine.

Pharmacological Mx

General principles:

  • The doctor should base the decision on doses of sedative medication on effect, with the doses recommended below being adjusted upward or downward, depending on risk factors, such as body weight, or the presence of renal impairment. Doses cited below are a guide only.
  • Consider IV boluses initially for the first couple of hours as SC infusions will take time to reach steady state (4 hours).
  • Do not forget to prescribe PRN medications. There should be a review of the treatment plan within one hour to assess if the administered medication has had the desired effect/a partial, but inadequate, effect on the symptoms.
  • 1st line management of symptomatic breathlessness is an opioid.
  • Syringe driver doses are based on severity of symptoms and PRN usage.
  • Subcutaneous administration is preferable to intravenous administration and is acceptable on hospital wards. There is a greater risk of apnoea when bolus injections are administered intravenously.
  • All diluents for drugs are 0.9% saline except for Cyclizine (diluted in dextrose 5%).
  • The ratio of drugs when switching routes is:  IV : SC : Oral – 1 : 5 : 10
  • Golden Rule – when converting one opiate to another, always convert to morphine first before calculating ratios.
  • Reassess frequently – always check to see if any bolus dose administered has been effective after 30mins. Consider additional bolus doses if a suboptimal effect is noted.
  • If patients are requiring doses greater than what is indicated below seek advice seek senior advice.

Anxiolytic Sedatives for Anxiety or Agitation

Midazolam

  • SC sedation - Initial bolus of 2.5-5 mg. Assess after 20 minutes and if necessary, this can be repeated, with a double stat dose and frequency of administration adjusted based on response, and instruction of a doctor.
  • Rapid IV sedation – Initial boluses of 1-2 mg, with dose and frequency of administration adjusted based on response, and instruction of a doctor.
  • SC Infusion – Initially 10-20 mg/24 hours, titrate according to response. Dose and rate of increase are dependent on symptoms and response to PRNs. For convulsions increase to 20-40 mg/24 hours.
  • Additional 'breakthrough' bolus doses can be administered on top of the SC infusion 1-2 hourly, as required, to achieve the desired effect.
  • If the desired effect is not achieved with the continuous infusion then, after a min. of 4 hours, increase the dose by 50%.
  • NOTE: for patients on Clarithromycin consider reducing dose by 50% (reduced clearance on midazolam).

Levomepromazine

  • Levomepromazine may need to be used in addition to midazolam if anxiety/distress or delirium is severe.
  • Initial bolus of 3.125-6.25 mg SC/IV; reassess after 30 min and repeat if indicated.
  • Review if 3+ doses are required in 4hr with little/no benefit or if 6 doses are required in 24hrs.
  • Continuous SC/IV Infusion with 12.5-25 mg/24 hours.

Haloperidol

  • Haloperidol can be used if levomepromazine is unavailable.
  • Initial bolus of 0.5-1 mg SC/IV.
  • Review if 3+ doses are required in 4hr with little/no benefit or if 6 doses are required in 24hrs.
  • Continuous SC/IV Infusion with 2.5-5 mg/24 hours.

Opioid for Pain and/or Breathlessness

3 Types of Pain

Nociceptive Pain: This is from stretching or compression of organs. Management

Neuropathic Pain: This is the hardest pain to treat and comes from nerve injury. Management

Bone Pain: This is from bony mets or pathological fractures. Use NSAIDs ± dexamethasone.

  • May need to be combined with an anxiolytic sedative like midazolam for added benefit according to patient symptoms.

Morphine

For patients who are not previously on opioids:

  • Bolus of 2.5-5mg SC/IV; assess after every 30 minutes and repeat if needed.
  • SC Infusion of 5-10mg/24 hours adjusted according to response.

For patients who are already on regular opioids:

  • The PRN dose of opioid is usually 1/6th of the total daily dose of opioid, given 4 hourly, e.g. patient on PO MST 30mg bd = 60mg / 24hrs, then oral dose is morphine 10mg, and SC dose is half the PO dose i.e. 5mg.

When changing from one opioid to another aleays convert to morphine first

Change to morphine first
PO Morphine
to PO Opioids
PO Opioids
to Parenteral opioids
Parenteral Morphine
to other Opioids
Transdermal Opioid
to PO
PO → PO Ratio PO → IV/SC Ratio IV/SC → IV/SC Ratio TD → PO Ratio
Morphine→Oxycodone 1.5:1 Morphine→Morphine 2:1 Morphine→Oxycodone 1.5:1 Buprenorphine→Morphine 1:75
Morphine→Hydromorph 5:1 Oxycodone→Oxycodone 2:1 Morphine→Hydromorph 5:1 Fentanyl→Morphine 1:100
  Hydromorph→Hydromorph 2:1 Morphine→Alfentanyl 15:1  
This table does not incorporated recommended dose reduction of 30-50%
Morphine Oxycodone Hydromorphone Fentanyl Alfentanyl Buprenorphine
24 hour dose 24 hour dose
A 2:1 ratio with morphine may also be used.
24 hour dose   24 hour dose  
PO IV/SC PO IV/SC PO IV/SC Transdermal IV/SC Transdermal
5mg 2.5mg 3.33mg 1.66mg 1mg 0.5mg - - -
10mg 5mg 6.66mg 3.33mg 2mg 1mg - 0.3mg 5 mcg/hour
14.4mg 7.2mg 9.6mg 4.8mg 2.88mg 1.44mg 6 mcg/hour 0.5mg -
20mg 10mg 13.33mg 6.66mg 4mg 2mg - 0.7mg 10 mcg/hour
28.8mg 14.4mg 19.2mg 9.6mg 5.76mg 2.88mg 12 mcg/hour 1mg -
30mg 15mg 20mg 10mg 6mg 3mg - 1mg 15 mcg/hour
50mg 25mg 33.3mg 16.6mg 10mg 5mg - 1.5mg 25 mcg/hour
60mg 30mg 40mg 20mg 12mg 6mg 25 mcg/hour 2mg 35 mcg/hour
100mg 50mg 66.6mg 33.3mg 20mg 10mg - 3.3mg 52.5 mcg/hour
120mg 60mg 80mg 40mg 24mg 12mg 50 mcg/hour 4mg 70 mcg/hour
150mg 75mg 100mg 50mg 30mg 15mg - 5mg -
180mg 90mg 120mg 60mg 36mg 18mg 75 mcg/hour 6mg -
240mg 120mg 160mg 80mg 48mg 24mg 100 mcg/hour 8mg -
Print (pdf) version this table

Anti-Secretory for Respiratory Secretion

Hyoscine Butylbromide (Buscopan)

  • Initial Bolus of 20 mg SC/IV q4-hourly.
  • SC Infusion of 80-120mg SC via syringe pump over 24 hours.
  • Also useful as an anti-spasmodic in abdominal pain.
  • Use is advised in the deteriorating patient before secretions accumulate.
  • Non-sedating as it does not cross the blood brain barrier, therefore useful for the patient who still has meaningful/wakeful periods with their family.

Hyoscine Hydrobromide (Scopolamine)

  • Initial bolus of 600 mcg SC STAT.
  • SC Infusion of 2.4 mg over 24 hours (Max Dose of 3.6 mg in 24 hours which includes PRN doses).
  • Added sedative effect – useful in patients where sedation is required to help aid their comfort.
  • Useful as an anti-emetic and Anti-secretory agent.
  • Also available as Scopoderm 1.5mg/72hr transdermal patch. Steady state absorption achieved in 6hrs post application.

Persistent Nausea and Vomiting

Treating Nausea and vomiting
Cause Medication Action Comments
CTZ sensing meds or electrolyle imbalance Prochlorperazine, chlorpromazine, haloperidol Dopamine antagonist Address cause for nausea
GI distention Metoclopramide ±antihistamines Promotility
Vestibular Promethazine, antihistamines, benzodiazepines, anticholinergics
↑ ICP Dexamethasone
Chemotherapy induced nausea Ondansetron Also try in nonchemotherapy patients
CTZ = chemoreceptor trigger zone

Levomepromazine

  • Initial bolus of 3.125-6.25 mg SC/IV BD.
  • Continuous SC/IV Infusion with 6.25-12.5 mg/24 hours.

Haloperidol

  • Initial bolus of 0.5-1 mg SC/IV BD.
  • SC Infusion 1-2.5 mg/24 hours.

Cyclizine

  • Bolus of 50 mg SC/IV BD.
  • SC infusion 150mg/24hrs.

Ondansetron

  • Bolus of 4-8 mg SC/IV BD.

Supplemental O2 in Agitated/Distressed Patients

  • Patients who are agitated by oxygen masks or tubing can have oxygen discontinued and breathlessness managed with an opioid/anxiolytic combination instead.
  • Monitoring oxygen saturations are not required at end of life.
  • High flow oxygen systems, NIV are not appropriate for these patients.

Diuretics

  • Patients who have a history of congestive cardiac failure or who have received large volume fluid resuscitation may benefit from Furosemide 20-40mg SC/IV PRN.

Example of initial bolusing and combined drug SC infusions

Bolus

Midazolam Morphine Hyoscine Butylbromide Hyoscine Hydrobromide
2.5mg 2.5mg 10-20mg 0.6mg

Subcut. infusion/24 Hours (will require 4 hours to reach steady state)

Midazolam Morphine Hyoscine Butylbromide Hyoscine Hydrobromide
10 mg 10 mg 60-120 mg 2.4 mg
  • Each syringe driver can be loaded with up to three separate drugs. Start with an opioid and anxiolytic sedative. An anticholinergic can then be added on if needed.
  • BD-SAF-T Intima Subcut. insertion advice.
  • Ensue PRN dosing is also prescribed for breakthrough symptoms.


Non-pharmacological management

Talking with patients

Set the scene (quiet room with privacy).

Make sure you sit down so you are at eye level.

Questions to help initiate conversation:

  • Ask the patient what do you know about your illness/condition?
  • Then ask, do you want me to tell you what I know? This lets you know where the patient is at.
  • What does it look like for you to have peace at the end of your life?

Comfort directed care is not giving up. Use positive terms like aggressively treat your pain.

General Considerations

  • Ensure an Advanced Directive is valid or a DNACPR order is signed and should be discussed with all patients deemed to have capacity, or with the next of kin otherwise.
  • Document all discussions with the patient and family.
  • A decision of DNACPR should be made by a senior clinician and the final decision of whether a patient should receive CPR in the event of an arrest lies with the clinician if treatment is futile.
  • In the event of potentially reversible events such as a blocked tracheostomy tube, anaphylaxis, or choking, resuscitate to reverse cause.
  • Discontinue unnecessary prescriptions, monitoring, investigations, and procedures.
  • Discuss the need for hydration and nutrition with the patient and their family. IV hydration is typically not required but may occasionally make the patient more comfortable.

Environment

  • A single room providing a quiet, peaceful environment should be prioritized.

Psychological/Spiritual Care

  • Where appropriate, patient/family insight should be assessed, and fears/wishes explored.
  • Consider if formal spiritual or religious care support needed/rituals which are important to patient and family.

Respiratory Secretions

  • Suctioning is rarely useful and has the associated infection risks of an aerosol generating procedure. Re-positioning patient on side may help.

Urinary, Bowel, Eye, Oral and Skin Care

  • Catheterize if in urinary retention or incontinence aids comfort level of patient.
  • Regular oral, skin, and eye care.
  • Offer food and fluid if patient wishes to and is able.
  • Repositioning every 2-4 hourly to prevent pressure sores.

Family/Staff Support

  • The patient’s family may wish to participate in caring for their dying relative, if so, they should be helped by the staff to do so. A nurse should be assigned to support the family.
  • After every death or incident staff should be encouraged to talk together about the event, in many cases a formal debrief can be valuable.


Content By Dr Saema Saeed, Dr Íomhar O' Sullivan 09/06/2020. Last review Dr ÍOS 6/06/21.