Anticipatory prescribing

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Anticipatory prescribing. Dr Jason Ward Consultant in Palliative Medicine, Mid Yorkshire NSH Trust , & Honorary Senior Lecturer, University of Leeds. Factors important for a good death. Control of symptoms Preparation for death - PowerPoint PPT Presentation

Transcript of Anticipatory prescribing

  • Anticipatory prescribing Dr Jason WardConsultant in Palliative Medicine,Mid Yorkshire NSH Trust , & Honorary Senior Lecturer,University of Leeds

  • Factors important for a good deathControl of symptoms Preparation for death Opportunity for closure or "sense of completion" of the life Good relationship with healthcare professionals Steinhauser KE 2000

  • Symptoms on the last 48 hours

  • Death rattle Prevalence 41-92% patients Most common with lung or cerebral primariesMedian duration of onset 23 hours

  • Death rattle How do relatives interpret it? Awful/horrible/terrible

    Nothing/expected

    Relief/sign of dying Wee B et al 2006

  • Management of death rattle Non drug management Discuss with family/carers Re-positionDrug - hyoscine butylbromide (buscopan) 20mg sc stat60-120mg/24hrs

    Bennett M 2002

  • PainCancerCancer treatmentDebility e.g. immobility Concurrent problems e.g. osteoarthritis

  • Analgesics (1) Paracetamol Liquid, suppository No subcut preparation

    NSAIDsDiclofenac PR 100mg od

  • Analgesics (2) Diamorphine Divide total daily dose of oral morphine by 3 = total daily dose of subcut diamorphineOpioid nave 2.5mg sc PRN 5-10mg/24hrs Morphine sulphate Divide total daily dose of oral morphine by 2Opioid nave 2.5mg sc PRN

  • Transdermal analgesia

  • The dying patient with a patchContinue current patch strength and replace every 72 hours Supplement with diamorphine prn and/ or syringe driver Rule of 5Fentanyl 25mcg/5= 5mg diamorphine prn

  • RestlessnessAgitation/restlessnessVsConfusion/deliriumDisorientatedHallucinations Sleep-wake reversal Plucking

  • General Management Reverse the easily reversibleFull bladder, position, pain Explanation Environment Family

  • Agitation Benzodiazapine Useful alone if fear/anxiety is the only feature Midazolam 2.5-5mg stat Repeat every 60mins if needed10mg-60mg/24 hrs

  • Confusion/delirium Haloperidol 3-5mg stat sc repeated as necessary Generally 5 - 10mg/24hrs Levomepromazine Sedating anti-psychotic 25mg-50mg stat Infusion 50-300mg/24 hrs

  • Breathlessness Fan, open window Breathlessness/cough/tachypnoeaDiamorphineOpioid nave 2.5mg stat, 5-10mg/24hrs Or increase dose by 1/3rd Breathlessness/anxiety Midazolam 2.5 mg stat, 10-30mg /24hrs

  • Terminal nausea Persistent or intermittentSmall vomits, possets, retching

    Chemical causeHypercalcaemiaUraemiaJaundice Infection

  • Anti-emetics Cyclizine 50mg stat150mg/24hrs, May precipitate with hyoscine butylbromide Avoid saline May cause irritation

  • EXAMPLE

    INJ CYCLIZINE 50mg / ml5 X 1ML amps as dirINJ HYOSCINE BUTYLBROMIDE 20mg / ml 5 x 1ml amps as dir INJ MIDAZOLAM 5mg / ml5 x 2ml INJ DIAMORPHINE 5mg 5 ( five ) x 5mg (five milligram) WATER FOR INJECTION10 X 10mls amps

  • To foresee and take care of in advanceCosts