QuestionSBA
QuestionChoice
Nebulised salbutamol is used in the treatment of airway inflammation. As this patient does not currently have symptoms of airway inflammation, this is not currently indicated, and the use of the nebuliser may be more distressing for the patient
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Nebulised salbutamol
QuestionChoice
Glycopyrronium is a medication from the muscarinic anticholinergic group. It is often used for respiratory tract secretions in palliative care patients who can no longer manage their own secretions due to impaired cough reflex
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Glycopyrronium
QuestionChoice
High flow oxygen can be very uncomfortable and not well tolerated. This patient's issues are related to respiratory secretions, and oxygen will not assist with those secretions
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High flow nasal oxygen
QuestionChoice
Pain in the palliative setting is important to bear in mind and manage as patients may not be able to communicate fully. Morphine will cause respiratory depression, which again may be of benefit in this patient; however will not help with the distressing secretions
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Morphine
QuestionChoice
Haloperidol is often used in the palliative care setting for agitation and delirium. It may well be beneficial in this case; however, as this patient is likely agitated from his secretions, glycopyrronium will be of more help
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b
Haloperidol
QuestionComment
Just give us hyoscine hydrobromide please!
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subscriber
Botox Ben
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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Glycopyrronium is an effective anticholinergic medication used to reduce respiratory secretions in palliative care patients.
An 87-year-old male is admitted to hospital from a nursing home with aspiration pneumonia. He clinically deteriorates, and after discussion with his family, the decision is made to palliate and control his symptoms.
His family are concerned he is becoming increasingly agitated due to his respiratory secretions.

What medication might be of benefit here?
a