QuestionSBA
QuestionChoice
Always make sure in these questions, and in practice, to calculate the full 24 hour dose of oral morphine e.g. 2x90mg given the twice daily dosing
33246
d
30-40mg oral morphine sulfate immediate release as required, 4-hourly
QuestionChoice
This would be an appropriate starting dose for a patient who is opioid-naïve, although this patient is already on high-strength long-acting morphine for her cancer pain and so breakthrough doses must be calculated appropriately
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5-10mg oral morphine sulfate immediate release as required, 4-hourly
QuestionChoice
Breakthrough dose of morphine in adults with cancer is calculated by dividing the 24-hour dose of oral morphine by 6. Usually a range is required and so the range should be approximately 1/10th-1/6th of the 24-hour total morphine dose.
 

 The principal is the same for all opioids, although it is best practice to convert the full 24 hour dose of opioids to the corresponding _oral_ morphine dose, and then convert back to the desired drug and route. This is of use when the long-acting drug is different to the breakthrough drug e.g. oral oxycodone breakthrough with a buprenorphine patch.
 

 The total dose of oral morphine in this case is 180mg/24hrs. 1/6th of this is 30mg and 1/10th of this is 18mg. For practicality in administration, this has been rounded to 20-30mg
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a
20-30mg oral morphine sulfate immediate release as required, 4-hourly
QuestionChoice
This would be too large of an increment of as required oral morphine to increase to for the current long-acting morphine dose. This increases the risk of needless opioid toxicity/overdose and of systemic side-effects
33247
e
40-50mg oral morphine sulfate immediate release as required, 4-hourly
QuestionChoice
Always make sure in these questions, and in practice, to calculate the full 24 hour dose of oral morphine e.g. 2x90mg given the twice daily dosing
33244
b
10-15mg oral morphine sulfate immediate release as required, 4-hourly
QuestionComment
i was always taught 1/6th of background makes up a breakthrough dose - so seeing 2 answers with 30 mg really isn't that helpful
22378
QuestionComment
Max breakthrough dose is 1/6th of maintenance, so you really shouldn't be giving anything higher than 30mg
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;-;
QuestionComment
1/6 - 1/10 is the range
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Relapse CT
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Axillary Gas
QuestionComment
what the hell is this question
26421
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Serotonin Gland
QuestionComment
Why not just say 30mg ffs
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Imran
Concept
Chapter
# Summary

Medications in end-of-life care focus on alleviating distressing symptoms in patients nearing death. A holistic approach is vital, considering physical, emotional, and social aspects of symptoms, often involving a multidisciplinary team. For pain management, the WHO pain ladder guides pharmacological strategies, with morphine as the primary strong opioid. Specific treatments for other symptoms depend on the underlying cause and it is important to consider reversible causes and non-pharmacological measures.



# Definition

Medications used in end of life care aim to relieve distressing symptoms which may appear in the last days, weeks, or months of life. They are commonly prescribed as 'anticipatory' or 'just in case' medications for a patient known to be nearing the end of life.


They can be administered:


- Orally - if the patient is safely able to swallow
- Subcutaneously - via single dose or continuous syringe pump
- Transdermally - especially for stable symptoms and if available
- Intramuscularly - less common
- Intravenously - less common, but may be helpful if a patient already has access

## A note on holistic care

In palliative care, and in medicine, it is important to consider all symptoms in context. There are many different aspects to symptoms. These include the physical cause, the patient's beliefs about their illness and symptoms, social contributors and impacts, their emotional and behavioural responses. Holistic assessment and management are crucial, which is why the multidisciplinary team is so important. 

For example, a patient may have been prescribed very effective analgesia but is unable to administer medicines themselves. They may also have a very strong emotional response to pain or believe that they deserve their symptoms. They may benefit from a package of care or financial support for terminal illness which a social worker could help with, or an occupational therapist to help with activities of daily living. Counselling may give the patient a space to explore their feelings around their symptoms and their illness, while spiritual support could alleviate some existential distress. These additional interventions work alongside pharmacological therapy to optimise a person's quality of life through their illness.

This chapter focuses on medications for symptoms towards the end of life, but it is crucial to remember that each patient has a different combination of needs which requires an individual assessment and management plan, often with input from a range of health and social care professionals.

# Pain


Initial pharmacological management of pain should follow the WHO pain ladder. Once patients have reached the top of this ladder (requiring regular strong opioids), careful optimisation is necessary to ensure the right level of pain relief while minimising side effects.

- Morphine is the first-line strong opioid analgesic. This can be given as a modified release or immediate release form. 
- Generally, patients would have a regular 'background' dose based on their 24-hour requirements, plus a PRN dose available for **breakthrough pain.** PRN doses are usually 1/6-1/10 of the 24 hour dose. Analgesia requirements should be reviewed regularly, for example every 24 hours.
- Alternatives to morphine may be necessary for patients with poor renal function. These include oxycodone, alfentanyl or buprenorphine.
- When prescribing opioid analgesia consider co-prescribing a regular laxative and an as-required anti-emetic. Monitor for signs of opioid toxicity (respiratory depression, sedation, myoclonus) and switch to alternatives or dose reduce as necessary.

When switching analgesia, it is helpful to convert the dose first to oral morphine before converting to the desired medication. Please note that different routes also have different equivalent doses, so it is always safest to check guidelines.


The following table shows dose equivalents of 10mg oral morphine


| Analgesic/Route | Dose | Conversion Factor |
| ----------------------------- | ------- | ----------------- |
| Codeine/tramadol/dihydrocodeine oral | 100mg | x10 |
| Diamorphine IM/IV/Subcut | 3mg | x3.3 |
| Morphine IM/IV/Subcut | 5mg | x2 |
| Oxycodone oral\* | 5mg\* | x2\* |
| Oxycodone Subcut\* | 2.5mg\* | x4\* |
| Alfentanil Subcut | 0.3mg | x30 |


*NB - oral oxycodone potency is between 1.3-2x that of oral morphine. Different trusts will adopt different guidance on which you should use. If in doubt, always opt for the lower dose and titrate up.


# Breathlessness

Consider non-pharmacological measures for breathlessness first. For example, sitting the patient up, opening a window or setting up a fan can all help.

Pharmacological management may involve low-dose opioids, benzodiazepines or therapeutic oxygen, and should be tailored to the patient.


# Nausea and vomiting

It is important to consider the likely cause of nausea and vomiting, as medications target different parts of the vomiting pathway. Perform a full assessment to determine the likely cause of the nausea and vomiting. Consider parenteral routes of administration - patients may have severe gastrointestinal disturbance or at least may not be able to keep down oral antiemetics long enough to be effective.

The following table shows the primary site of activity and side effects of commonly used antiemetics:

| Antiemetic | Receptor activity | Side effects & cautions | Useful for |
|---|---|---|---|
| Metoclopramide | Dopamine antagonist | Extrapyramidal symptoms, drowsiness, restlessness, diarrhoea. Do not give with antimuscarinics or in mechanical bowel obstruction | Gastric stasis, functional bowel obstruction |
| Cyclizine | Histamine, acetylcholine antagonist | Drowsiness, antimuscarinic | Raised intracranial pressure, vestibular dysfunction |
| Hyoscine | Acetylcholine antagonist | Antimuscarinic | Motion sickness |
| Haloperidol | Dopamine antagonist | Less common in palliative care doses | Chemical |
| Levomepromazine | Dopamine, histamine, acetylcholine, 5HT2 antagonist | Sedation, postural hypotension, antimuscarinic |Broad range |
| Ondansetron | 5HT3 antagonist | Constipation, arrhythmias, movement disorder | Cytotoxic-related |

- For chemically-mediated symptoms (for example medications, metabolic derangemenet), aim to treat the underlying cause. Antiemetics that may be helpful include haloperidol, metoclopramide or levomepromazine.
- For nausea and vomiting due to raised intracranial pressure, cyclizine is usually used first-line. Dexamethasone or radiotherapy may be helpful to reduce the pressure-associated symptoms.
- For patients with vestibular disturbance (for example symptoms associated with movement), cyclizine usually used first-line. Alternatives include hyoscine hydrobromide.
- For patients with bowel obstruction, seek specialist advice. If due to peristaltic failure, review medications and consider starting metoclopramide (providing there is no colic). Likewise for gastric stasis, consider metoclopramide. For patients with mechanical obstruction and/or colic, do not give metoclopramide. Exclude constipation, give cyclizine for nausea and treat colic with hyoscine butylbromide.
- If nausea and vomiting is due to compression from an abdominal or pelvic tumour, cyclizine should be used first-line.
- For anxiety-related nausea and vomiting, begin with non-pharmacological measures for anxiety, such as CBT. A benzodiazepine or levomepromazine would be first-line pharmacological options.

# Agitation

As with other symptoms, aim to manage reversible causes of agitation and possible delirium first. Consider non-pharmacological measures such as environmental modification. For patients in their last days of life, haloperidol or low-dose midazolam may be prescribed. Often, this is done as part of anticipatory prescribing.


# Respiratory tract secretions

Respiratory tract secretions often occur in the last days of life as a person becomes less able to clear their airways. They are rarely a cause of distress to the patient, but may be upsetting for family members or those close to the patient. An antimuscarinic such as hyoscine butylbromide or glycopyrronium bromide may be prescribed for noisy respiratory secretions.


# NICE guidelines


[NICE Guidance: Care of dying adults in the last days of life](https://www.nice.org.uk/guidance/ng31)

[NICE CKS: Palliative care - general issues](https://cks.nice.org.uk/topics/palliative-care-general-issues/)

[NICE CKS: Palliative care - dyspnoea](https://cks.nice.org.uk/topics/palliative-care-dyspnoea/)

[NICE CKS: Palliative care - nausea and vomiting](https://cks.nice.org.uk/topics/)

[NICE CKS: Palliative care - secretions](https://cks.nice.org.uk/topics/)

[NICE CKS: Palliative cancer care - pain](https://cks.nice.org.uk/topics/)

# References

[Pallcare.info](https://www.pallcare.info/book.php)

[BNF: Ondansetron](https://bnf.nice.org.uk/drugs/ondansetron/#drug-action)

[BNF: Nausea and labyrinth disorders](https://bnf.nice.org.uk/treatment-summaries/nausea-and-labyrinth-disorders/)

[BNF: Prescribing in palliative care](https://bnf.nice.org.uk/medicines-guidance/prescribing-in-palliative-care/)
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20-30mg oral morphine sulfate immediate release as required, 4-hourly
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In cancer pain management, the breakthrough dose of oral morphine is typically 1/6th to 1/10th of the total daily morphine dose.
A 75-year-old woman with metastatic mesothelioma presents with progressive shortness of breath and uncontrolled pleuritic chest pain. Her eGFR is 85mL/min/1.73m<sup>2</sup> and her liver function tests are all within normal range.


She currently takes 900mg gabapentin TDS, 1g paracetamol QDS, 80mg modified standard release morphine sulfate (long acting) BD, and 75mg amitriptyline ON. S She is currently using all her prescribed as-needed oral morphine doses and frequently requests her next dose due to ongoing pain.


You decide to increase her modified standard release morphine sulfate dose to 90mg twice daily. Calculate the most appropriate breakthrough oral morphine sulfate immediate release dose for this new regime.
a