Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient (LCP)

Transcription

1 Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient (LCP) This prescribing guidance is intended to work in conjunction with the Liverpool Care Pathway for the Dying Patient (LCP) CPME146. Key Words: Care of the Dying; ICP; Pathway; Palliative Care; Prescribing Document No: CPDI076 Version: 4.3 Developed in Consultation with: NE Sector End of Life Subgroup & NE Sector Education subgroup Ratified by: Pennine Acute Drugs & Therapeutic Committee Date Ratified: 17 th March 2011 Date Amended: 8 TH June 2011 Next Review Due to start: 17 th September 2013 Expiry Date: 17 th March 2014 Document Author: A joint project produced by the North East Sector of the Greater Manchester & Cheshire Cancer Network End of Life Care Subgroup

2 Pennine Acute Hospitals NHS Trust Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient: CPDI076 V4.3 Pennine Acute Hospital NHS Trust Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient (LCP) Main Revisions from previous issue Name of Previous Document: Previous Document Number: Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient CPDI076 Previous Version Number: Version 4.2 Chapters, sections and pages which have been changed Sub appendices in Appendix 3 re numbered for ease of reference Expiry date: 17/03/14 Page 2 of 30

3 Pennine Acute Hospitals NHS Trust Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient: CPDI076 V4.3 Contents Page 1. Introductory Statement/Purpose 4 2. Scope Roles, Responsibilities & Accountabilities The Prescribing Guidance (see also Appendix 3) 6 5. Implementation Dissemination Training Arrangements Financial Impact 7 6. Monitoring Arrangements 7 7. Review Arrangements 7 8. References List of Abbreviations & Terms used Appendices Appendix 1 - Summary of Monitoring Arrangements 9-10 Appendix 2 - Equality Impact Assessment Appendix 3 - The Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient (LCP) Expiry date: 17/03/14 Page 3 of 30

4 Pennine Acute Hospitals NHS Trust Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient: CPDI076 V Introduction/Purpose 1.1 The Liverpool Care Pathway for the Dying Patient (LCP) has been recommended for use as a template of best practice in the last hours and days of life in : End of Life Care Strategy: Quality Markers and Measures for End of Life Care (2009) & Route to success in end of life care achieving quality in acute hospitals (2010). The care pathway is intended as a guide to treatment and an aid to documenting patient progress in the dying stage. Practitioners are free to exercise their own judgement, however any alteration to the practice identified within this care pathway (LCP) must be recorded as a variance. The Marie Curie Palliative Care Institute Liverpool (2010) recommends that the LCP be supported by local medication guidance for the management of the 5 key symptoms that may develop in the last hours or days of life. This guidance will be used by Healthcare Professionals with the aim to providing effective symptom control to their patients preventing crisis situations. 1.2 Many drugs are used in palliative care outside their licensed indication at the prescriber s discretion. Details of these, together with "typical" doses and maximum doses are included. However, the inclusion of a drug or treatment in these guidelines does not absolve the prescriber of their professional responsibility in providing treatment that they are confident with and can justify, and that is tailored to the individual patient's circumstances. For further information please call your local Specialist Palliative Care Team. Contact Numbers: Fairfield General Hospital Specialist Palliative Care Team North Manchester General Hospital Specialist Palliative Care Team Oldham Macmillan Integrated Specialist Palliative Care Team Community Services Bury Specialist Palliative Care Team Heywood Middleton and Rochdale Community Healthcare Integrated Macmillan and Specialist Palliative Care Team. 2. Scope 2.1 This document is intended to be used by Health Care Professionals across the North East Sector including Pennine Acute Hospitals NHS Trust (PAHNT), for patients that have been identified as being in the dying phase. 2.2 It should be read in conjunction with the following trust documents: Expiry date: 17/03/14 Page 4 of 30

5 Pennine Acute Hospitals NHS Trust Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient: CPDI076 V4.3 Liverpool Care Pathway (LCP) for Care of the Dying Patient Version 12 Adapted for use in Pennine Acute Hospitals NHS Trust (CPME146) Medicines Policy (EDC018) Accident & Incident Reporting Policy (EDQ008) other related documents listed at Section Roles, Responsibilities & Accountabilities 3.1 Specialist Palliative Care Clinical Governance group The Specialist Palliative Care Clinical Governance Group is responsible for monitoring overall compliance to these guidelines, and ensuring that any action plans are implemented. 3.2 Divisional Managers Are responsible for ensuring that any clinical incidents relating to the practice contained within these guidelines are investigated and acted upon as appropriate and that concerns regarding their implementation are addressed. 3.3 End of Life Care Facilitator team/specialist Palliative Care team Are responsible for raising awareness about these guidelines, providing teaching sessions and support to relevant staff, and monitoring compliance. 3.4 Clinicians and Nurse Prescribers Clinicians and nurse prescribers working in areas where they may be required to prescribe medication to terminally ill patients should ensure that they are familiar with these guidelines and know how to access them to ensure that the copy that they are referring to is the most recent approved copy They should use these guidelines as a point of reference, in conjunction with clinical judgment and experience, to ensure that they are prescribing the most appropriate medication for each patient s individual needs. Prescriptions should be written accurately and legibly in accordance with the Trust s Medicine Policy (EDC018) Clinicians and Nurse Prescribers are also responsible for raising any difficulties or concerns they have with implementing these guidelines to their managers and for reporting any clinical incidents or near misses relating to the practice stated within these guidelines as per the Trust s Accident & Incident Reporting Policy (EDQ008). 3.5 Ward Managers Ward Managers are responsible for supporting the implementation of these guidelines and ensuring that their staff are aware of and know how to access the documents They are also responsible for reporting back to their Divisional Nurse Managers any difficulties/concerns they or their staff have raised regarding the implementation of these guidelines. Expiry date: 17/03/14 Page 5 of 30

6 Pennine Acute Hospitals NHS Trust Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient: CPDI076 V All Relevant Staff All relevant staff that have responsibility to care for dying patients will:- Ensure that they are familiar with the contents of the document Know how to access these guidelines They also have a duty to report adverse untoward events and near misses in accordance with the Trusts Accident & Incident Reporting Policy (EDQ008) and where appropriate as per the Medicines Policy (EDC018). In particular, any adverse reactions or suspected reactions to medications should be reported to the Medicines & Healthcare Products Regulatory Agency (MHRA) using the yellow cards which are available in the back of each copy of the BNF or via the website 4. The Prescribing Guidance for the Liverpool Care Pathway for the Dying (LCP) 4.1 The full Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient (LCP) can be found in Appendix It should be used in conjunction with the Trusts Liverpool Care Pathway (LCP) for Care of the Dying Patient Version 12 (CPME146). This can be found via the Documents page of the Trust Intranet. NB: Any adverse incidents, such as equipment failure, adverse drug reactions should be recorded and reported as per the Trusts Accident & Incident Reporting Policy EDQ Implementation 5.1 Dissemination This document will be uploaded onto the Trusts intranet and will be listed under the Clinical Integrated Care Pathways section of the Documents page. Dissemination will also be via; An article will be placed in the Pennine News to notify clinical teams that the document has been revised via the End of Life Care Facilitator team It will be announced in the Medical Director/ Nursing Director Bulletin and Core Brief via the End of Life Care Facilitator team IT screen saver will be used for the week of release via the End of Life Care Facilitator team Paper documents will be provided to all members of Specialist Palliative Care Teams via the End of Life Care Facilitator team Paper copies will be handed out to all relevant ward managers with policy confirmation slips via the End of Life Care Facilitator team/specialist Palliative Care team Expiry date: 17/03/14 Page 6 of 30

7 Pennine Acute Hospitals NHS Trust Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient: CPDI076 V Training Arrangements Training will continue to be delivered to medical and nursing staff by the Pennine End of Life Care Facilitator & Specialist Palliative Care Teams. Training will be conducted formally and informally. Attendance sheets will be completed for formal training sessions & forwarded to the Pennine Acute End of Life Care Facilitators for monitoring purposes. Training will be advertised the Trust Training Bulletin. Should ad hoc sessions be required please contact the End of Life Care Facilitator team on: or Financial Impact There are resource implications associated with the LCP. However resources are already in place within the Trust to support this clinical practice. 6. Monitoring Arrangements The Palliative Care Governance meeting is held bi-monthly, any clinical incidents are reviewed and action plan agreed. The Trust complies with the LCP National Audit Programme. The arrangements for monitoring compliance of this policy are summarised in Appendix Review Arrangements 7.1 This document will be reviewed in 3 years by members of the North East Sector Specialist Palliative Care Team. Ad hoc reviews may be necessary if new national guidelines are issued or if the outcomes of clinical incidents dictate the need for change. 8. References and Bibliography 8.1 Associated Documents CPME146 Liverpool Care Pathway (LCP) for Care of the Dying Patient Version 12 EDN004 Record Keeping Policy EDC018 Medicines Policy EDC017 Guidelines for the Ordering, Storage and Administration of Controlled Drugs EDQ008 Accident & Incident Reporting Policy EDG004 Complaints Handling Policy CPME075 Guidelines for staff using & managing the Graseby MS 26 Expiry date: 17/03/14 Page 7 of 30

8 Pennine Acute Hospitals NHS Trust Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient: CPDI076 V4.3 Syringe Driver & Saf-t-intima cannula in palliative care EDN031 Policy for training in safe administration of medicines CPDI081 Policy for the aseptic preparation of pharmaceutical products in Clinical areas; EDE019 Medical Devices Policy EDT004 Procedure for the Administration of Prescribed Medicines to Inpatients EDC037 Procedure for checking RECORDED Drugs by nursing staff on wards and departments. EDC017 Guidelines for the Ordering, Storage and Administration of Controlled Drugs CPDI067 Guidelines for Using Fentanyl Patches in the Last Few Days of Life 8.2 Supporting References Department of Health (2009). End of Life Care Strategy: Quality Markers and Measures for End of Life Care. Crown Copyright. London National End of Life Care Programme (2010). Route to success in end of life care achieving quality in acute hospitals. Crown Copyright, London. Marie Curie Palliative Care Institute Liverpool (MCPIL) (2010). LCP Supporting Information: Medication Guidance Examples. Liverpool 8.3 Bibliography Ellershaw JE, Wilkinson S. Care of the Dying: A pathway to excellence. Oxford University Press. Oxford Abbreviations & Definitions of terms used s/c mg micrograms ml amp prn stat bd tds qds subcutaneous milligram micrograms (do not abbreviate) millilitres ampoule administer when required for immediate administration twice daily to be taken three times a day to be taken four times a day Expiry date: 17/03/14 Page 8 of 30

9 Appendix 1 - Arrangements for Monitoring Compliance with this document The arrangements for monitoring compliance of this document are summarised in the following table: Standard/ Criterion Minimum requirement to be monitored Process for Monitoring Responsible Individual/ Group/ Committee for Monitoring Frequency of Monitoring Responsible Individual/ Group/ Committee for Review of Results Responsible Individual/ Group/ Committee for Development of Action Plan Responsible Individual/ Group/ Committee for Monitoring of Action Plan Staff responsible for prescribing, administering &/or caring for patients requiring management in the last days of life will be aware of current trust guidelines. Ward managers for all wards where the LCP is in use will be made aware of the existence of these guidelines. Each ward will receive a paper copy of the guidelines from the palliative care team. Ward managers will be asked to confirm that they have read, understood and cascaded the information in these guidelines to their staff using the sign off sheet. Review of returned sign off sheets. Pennine Acute End of Life Care Facilitators Pennine Acute Specialist Palliative Care team Once after reviewed version is disseminated Pennine Acute End of Life Care Facilitators Pennine Acute Specialist Palliative Care team Pennine Acute End of Life Care Facilitators Pennine Acute Specialist Palliative Care team Specialist Palliative Care Clinical Governance group The guidelines are used in practice to ensure patients in the dying phase receive care based on best evidence based practice. There is evidence across the Trust of the use of the prescribing guidelines within clinical practice for palliative care patients being managed on the LCP Trust audit of a sample of notes of patients managed on the LCP. National LCP Care of the Dying in Hospitals Pennine Acute End of Life Care Facilitators Pennine Acute Specialist Palliative Care Annual 2 yearly Pennine Acute End of Life Care Facilitators Pennine Acute Specialist Palliative Pennine Acute End of Life Care Facilitators Pennine Acute Specialist Palliative Care team. Expiry date: 17/03/14 Page 9 of 30 Specialist Palliative Care Clinical Governance group

10 National Audit. team Care team There will be a variety of opportunities where education regarding the use of the prescribing guidance can be accessed Education will be provided through a variety of different sessions and programmes across the trust. Comprehensive record of education will be provided and attendance sheets forwarded to Pennine Acute End of Life Care Facilitators Pennine Acute End of Life Care Facilitators 6 monthly Pennine Acute End of Life Care Facilitators Pennine Acute Specialist Palliative Care team Pennine Acute End of Life Care Facilitators Pennine Acute Specialist Palliative Care team NE Sector Education subgroup Specialist Palliative Care Clinical Governance group There is an agreed process for reporting all incidents/near misses relating to end of life symptom control issues for patients being managed on the LCP. All clinical incidents are reviewed and discussed as per Accident & Incident Reporting Policy (EDQ008). Any feedback from the Clinical Governance Group for Medicine is discussed at the bi-monthly Specialist Palliative Care Clinical Governance group Expiry date: 17/03/14 Page 10 of 30

11 Appendix 2 Completed Equality Impact Assessment Pro-forma Part One Name of Policy Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient (LCP) Date of assessment 07/03/2011 Is the policy new or for review? For review Area Pennine Acute NHS Trust Name of Author(s) NE Sector End Of Life Care Subgroup 1.1 Briefly describe the aims and objectives and the purpose of the policy 1.2 Are there any associated objectives or directives of the policy? i.e. Care Quality Commission (CQC), NHS Litigation Authority (NHSLA) 1.3 Who is the policy intended to benefit, and what are the expected outcomes? 1.4 What factors could influence the intended outcomes either positively or negatively? Aim: To provide an evidenced based framework that will empower ward staff in the acute hospital setting to deliver high quality appropriate symptom management for the care for the dying patient Objective: To ensure that symptoms are effectively controlled in the last hours/days of life of the patient Advocated as best practice within national palliative & end of life care documents. It will primarily benefit patients by having their symptoms effectively controlled using an evidence based framework. The framework will also assist all health care professionals and will improve staff knowledge in relation to the process of dying & therefore improve the quality of care in the last hours/days of life of the patient/carer. Lack of resources within the End of Life Facilitator & Specialist Palliative Care Team to sustain the prescribing guidance Lack of organisational recognition that all staff that Care for the Dying require education and training. The prescribing guidance needs to accompany the Liverpool Care Pathway and be firmly embedded in the organisation and be supported by a continuous learning programme. Needs to be established within the organisational governance framework & post analysis competencies maintained & improved where necessary. 1.5 Who are the main stakeholders in relation to the policy Staff Service Users Public Other 1.6 Who implements and is responsible for the policy? Pennine Acute NHS Trust End of Life Care Facilitators & Specialist Palliative Care Team Expiry date: 17/03/14 Page 11 of 30

12 Part One (cont) For each of the nine Equality Categories ask the question below: Human Rights Age Disability Ethnicity (Race) Religion Gender Sexual orientation Carers Social Deprivation 1.7 From the evidence, does the policy affect or have the potential to affect individuals or communities differently or disproportionately, either positively or negatively (including discrimination)? 1.8 Is there potential for, or evidence that, the proposed policy will promote equality of opportunity for all and promote good relations with different groups? 1.9 Is there public concern (including media, academic, voluntary or sector specific interest) in the policy area about actual, perceived or potential discrimination about a particular community? 1.10 Is there any doubt about answers to any of the questions? No Yes In 2009, there was adverse media coverage regarding the Liverpool Care Pathway & symptom management. In response to the media coverage the Liverpool Care Pathway Central Team at the Marie Curie Palliative Care Institute Liverpool (MCPCIL) issued a statement on regarding the care of the dying and the Liverpool Care Pathway (LCP). The Statement can be viewed in full at The prescribing guidance has been developed by adult palliative care services for adult patients This pathway has been developed by adult palliative care services for adult patients No No No No No No No Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No Expiry date: 17/03/14 Page 12 of 30

13 Part Two 2.1 In what way does the policy impact on any particular group listed above? Include here what evidence you have collated, whether there are any gaps and what further information is required. The equality impact assessment guidelines promote equity and fairness for all of the groups listed above. The document does not impact on any particular group disproportionately. 2.2 Adverse Impact - if you have identified potential or real direct or indirect discrimination? If so, can it be justified (e.g., legislation, clinical or social evidence)? None 2.3 Positive Impact - does the policy actively promote equality of opportunity and/or good relations between different groups of people? The prescribing guidance is intended to be used in conjunction with the Liverpool Care Pathway. The Liverpool Care Pathway positively promotes equality of opportunity for all communities and individuals who are nearing the end of life. The Liverpool Care Pathway is continuous quality improvement model for care of the dying that informs and responds to the national agenda. It provides a benchmarking of care provision within a National Audit Process and assists the organisation to identify real or potential adverse impact or discrimination and enable appropriate action to be taken to eliminate any inequality or disadvantage arising. The End of Life Care End of Life Care Strategy (2008) fully promotes the use of the Liverpool Care Pathway & Professor Mike Richards, Chair of the National End of Life Care Strategy Advisory Board states "How we care for the dying must surely be an indicator of how we care for all our sick and vulnerable patients. Care of the dying is urgent care; with only one opportunity to get it right to create a potential lasting memory for relatives and carers." Further evidence can be viewed on; Expiry date: 17/03/14 Page 13 of 30

14 Part Three Policy Title (as it appears on the Document Management System) Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient (LCP) Ratifying Committee: Drugs & Therapeutics Committee for Medicine Division Policy Number CPDI076 Date sent to Committee 17/03/2011 This policy has been assessed as having no or low equality impact. Part 1 is completed. This policy has been assessed as having low to medium impact. Parts 1 and 2 have been completed. Full impact assessment is unnecessary. This policy has been assessed as having medium to high impact. Parts 1 and 2 have been completed. Full impact assessment is necessary. Assessors Name Yvonne Loughlin Equality Champion Mike Griffiths Designation Macmillan Specialist Palliative Care Clinical Nurse Specialist Directorate Division of medicine Signed* Yvonne Loughlin Date 10 th March 2011 Signed* Mike Griffiths Please scan or insert electronic signature Expiry date: 17/03/14 Page 14 of 30

15 Appendix 3 The Prescribing Guidance for the Liverpool Care Pathway for the Dying Patient 3.1 Pain All patients should be prescribed prn s/c Diamorphine (for dose guidance see below) whether or not they are currently in pain. If Diamorphine is not available use another strong opioid; Morphine Sulphate is the first line alternative choice. Please refer to Appendix E for appropriate conversions and Appendix C for equi-analgesic doses. Pain present and: Is not taking opioids: Prescribe Diamorphine 2.5-5mg s/c prn. (2) Continue to use prn doses for the first 24 hours. If pain remains an ongoing problem consider starting a syringe driver with 10-20mg Diamorphine over 24hrs (according to clinical need). (3) However it recommended to use prn doses for first 24hrs to allow accurate titration prior to starting syringe driver. Is taking oral opioids: Prescribe Diamorphine via syringe driver. The equivalent dose of Diamorphine is the 24hr dose of oral morphine divided by 3 (include extra doses of breakthrough analgesia taken). (2) Stop oral analgesic medication on commencing syringe driver. Also prescribe 4 hourly prn s/c Diamorphine. To calculate this divide the total 24 hour dose of Diamorphine by 6. (2) Example: Patient on MST/Zomorph 60mg bd plus 3 x 20mg of oramorph/day. Total morphine dose = (2 x 60mg) + (3 x 20mg) = 180mg Divide this dose by 3 to calculate the Diamorphine dose (180mg 3 = 60mg diamorphine over 24 hours s/c via a syringe driver) Calculate the 4 hourly prn dose of s/c Diamorphine (60mg 6 = 10mg, 4 hourly s/c prn). Is using a Fentanyl patch: Continue the patch and refer to guidelines for using fentanyl patches in the last few days of life version 3. (Appendix B) If the patient is taking an alternative opioid to oral morphine refer to Appendix C and D for conversion tables and guidance on how to convert to Diamorphine. TO CALCULATE SUBSEQUENT 24 HR DOSES OF DIAMORPHINE Add the total of all Diamorphine administered in the last 24 hrs, and increase/commence syringe driver doses accordingly. (4) Example: Patient on 60mg Diamorphine/24hr and has had 3 doses of 10mg Diamorphine in that time. The dose of Diamorphine for the next 24hrs is 90mg (and the prn dose is 15mg i.e. 1/6 of 90mg). Pain absent: If symptoms persist contact the Specialist Palliative Care Team. If the patient is not currently in pain, still prescribe an appropriate 4 hourly prn s/c dose of Diamorphine. (2) Please see above guidance regarding how the dose can be calculated. Please note: If exact dose calculations are not possible a dose may need to be rounded down to the nearest most practical dose. (4) Patients with uncontrolled pain may need more frequent administration of the 4 hourly prn s/c dose of diamorphine. This can be given up to 1 to 2 hourly if necessary. (4) For specific advice relating to patients in renal failure please consult the Specialist Palliative Care Team / Pharmacy. (1) Expiry date: 17/03/14 Page 15 of 30

16 3.2 Nausea and Vomiting Present Absent Prescribe: Levomepromazine 5mg s/c for stat and 8 hourly prn use. And Consider whether a continuous infusion of 5mgs via syringe driver is necessary, based upon patient s previous requirements and clinical situation. (This can be increased to 10mgs s/c via syringe driver over 24hours as per clinical need). Prescribe in anticipation: Levomepromazine 5mg s/c for 8 hourly prn use. And if symptom develops refer to Symptoms Present box. If symptoms persist contact the Specialist Palliative Care Team. Note: Cyclizine should be used with caution in patients with severe heart failure. In such patients, cyclizine may cause a fall in cardiac output associated with an (2, 5) increase in heart rate, mean arterial pressure and pulmonary wedge pressure. For specific advice relating to patients in renal failure please consult the Specialist Palliative Care Team / Pharmacy. (1) Expiry date: 17/03/14 Page 16 of 30

17 3.3 Terminal Restlessness and Agitation This includes myoclonus, which is mild twitching/sudden jerking type of movement Present Absent Prescribe: Midazolam 2.5mg 5mg s/c for stat and 4 hourly prn use. Consider whether a continuous infusion of 10mgs via syringe driver is necessary, based upon patient s previous requirements and clinical situation), Prescribe in anticipation: Midazolam 2.5mg 5mg s/c for 4 hourly prn use. And if symptom develops refer to Symptoms Present box. And (Should clinical assessment determine there is a need to increase the dose then increase by 10mg increments up to a maximum of 60mgs s/c via syringe driver over 24 hours.) If symptoms persist contact the Specialist Palliative Care Team / Pharmacy. Please note: Patients with uncontrolled terminal restlessness may need more frequent administration of the 4 hourly prn s/c dose of midazolam. Midazolam can be given up to 1 to 2 hourly if necessary. (4) For specific advice relating to patients in renal failure please consult the Specialist Palliative Care Team / Pharmacy. (1) Expiry date: 17/03/14 Page 17 of 30

18 3.4 Excessive Respiratory Tract Secretions This may be very distressing to relatives, and should be treated promptly as it is easier to prevent secretions forming than removing secretions that have gathered in the upper airways or oropharynx (6). Present Absent Prescribe: Glycopyrronium (6, 13) 0.2mg 0.4mg s/c as a stat dose Review response after 1 hour. (6) Consider whether a continuous infusion of 0.6mgs via syringe driver is necessary, based upon patient s previous requirements and clinical situation (This can be increased to 1.2mgs via syringe driver over 24hours as per clinical need) Prescribe in anticipation: Glycopyrronium 0.2mg 0.4mg for s/c 8 hourly prn use (7) And if symptom develops refer to Symptoms Present box. Also prescribe Glycopyrronium 0.2mg (7, 13) 0.4mg for s/c 8 hourly prn use. If symptoms persist contact the Specialist Palliative Care Team / Pharmacy (on-call if necessary). For specific advice relating to patients in renal failure please consult the specialist palliative care team / pharmacy. (1) If Glycopyrronium is commenced please consult mouth care policy for guidance to managing dry mouth. (4) Expiry date: 17/03/14 Page 18 of 30

19 3.5 Breathlessness If diamorphine is not available use another strong opioid. Morphine Sulphate is the first line alternative choice. Please refer to appendix D for appropriate conversions, and appendix C for equianalgesic doses. Present General measures: Explanation Fan/open window Consider oxygen Repositioning (3) Is there a reversible cause that can be treated without invasive/aggressive intervention? Absent Prescribe in anticipation: If not already on an opioid prescribe: Diamorphine 2.5mg 5mg s/c for 4 hourly prn use. (4) If already taking opioids use the 4 hourly prn dose of s/c Diamorphine that is prescribed for pain, for the management of breathlessness. (4) Yes No Treat the cause e.g., nebulised bronchodilators for bronchospasm and diuretics for heart failure. (3) Symptomatic treatment to relieve distress. FIRST LINE TREATMENT: opioids. (4) If not already on opioids commence Diamorphine 2.5mg- 5mg s/c for stat and 4 hourly prn s/c use. (4) If already taking opioids use the 4 hourly prn dose of s/c Diamorphine that is prescribed for pain, for the management of breathlessness. (4) After 24hrs, review medication, if 2 more prn doses of Diamorphine have been required then consider commencing a syringe driver over 24hrs based on clinical need. To calculate this total all the prn s/c Diamorphine doses received by the patient in the previous 24 hours. Administer this dose of Diamorphine via a syringe driver s/c over 24 hours. (4) For specific advice relating to patients in renal failure please consult the Specialist Palliative Care Team / Pharmacy. (1) Expiry date: 17/03/14 Page 19 of 30

20 3.6 Minimum Community LCP drugs The following is recommended as the minimum prescription when the patient is NOT experiencing any symptoms. Please prescribe in anticipation: Midazolam (controlled drug) (5mg/ml, 2ml amps) 10 amps Levomepromazine (25mg/ml, 1ml amps) 10 amps Glycopyrronium (200micrograms/ml, 3ml amps) 10 amps Water for injection (10ml amps) 10 amps Diamorphine (controlled drug) (5mg amps) or alternative analgesia 10 amps If a patient is already taking opioids or any medications via s/c route then the recommended minimum prescription should be sufficient for a minimum of 4 days (for syringe driver and additional prn doses please refer to page 5 for opioid dose guidance and pages 6 9 for other symptoms). If Diamorphine is not available, Morphine Sulphate is the first line alternative opioid. Use conversion charts in appendices or the North East Sector Dose Conversion Chart to calculate equi-analgesic doses. For specific advice relating to patients in renal failure please consult the specialist palliative care team / pharmacy (1). Expiry date: 17/03/14 Page 20 of 30

21 Appendix A - Anticonvulsant Therapy Patients who are taking anticonvulsant therapy will obviously need this to be considered when prescribing for the last days of life, as the patient, if not already unable to take oral medication, will likely to be unable to do so soon. If patient is not known to take anticonvulsant therapy and seizure occurs then follow algorithm Symptom Present. Present Absent For those unable to take oral anticonvulsants now, prescribe: For those likely to be unable to take oral anticonvulsants soon or who are thought to be at risk of seizure, prescribe: Midazolam 10mg s/c for 4 hourly prn use. (7) And Consider whether a continuous infusion of 20mgs via syringe driver is necessary, based upon patient s previous requirements and clinical situation), And (Should clinical assessment determine there is a need to increase the dose then increase by 10mg increments up to a maximum of 60mgs s/c via syringe driver over 24 hours) Midazolam 10mg s/c for 4 hourly prn use. (7) And if symptom develops refer to Symptoms Present box. Please note: If a patient develops a grand mal seizure or status epilepticus the dose of Midazolam can be repeated after minutes if not settled. If despite this the fitting continues, immediately contact Medical team / Specialist Palliative Care Team for advice. (6) Midazolam (s/c) is not licensed as an anticonvulsant. (9) For specific advice relating to patients in renal failure please consult the Specialist Palliative Care Team / Pharmacy. (1) Expiry date: 17/03/14 Page 21 of 30

22 Appendix B Guidelines for using Fentanyl Patches in the Last Few Days of Life (including matrix and reservoir formulations) Version 3 (2009) The purpose of this document is to clarify the situation regarding the care of terminally ill patients who are being treated with trans-dermal Fentanyl patches for pain control, who are no longer able to take oral breakthrough medication because they are semi-comatosed, or comatosed and dying. If you are in any doubt please contact the Specialist Palliative Care Team for advice. This guidance could also be applied when patients receiving Fentanyl patches but are not able to take oral breakthrough medication due to an acute problem e.g. vomiting. (4) 1. The patch should be continued at the same dose, being changed every 72 hours. (10, 11) If there are any concerns or problems about the dose or continuation of the patch discuss with the Specialist Palliative Care Team. 2. If the patient experiences breakthrough pain, administer prn s/c diamorphine. (10,11) To calculate the prn dose divide the total fentanyl patch dose strength by 5 to give the prn dose of diamorphine in mg. (10) e.g. Fentanyl patch 25 micrograms 5 = 5mg diamorphine s/c prn 3. If the patient requires 2 or more doses of prn s/c diamorphine within 24 hours extra analgesia should be given using continuous subcutaneous diamorphine in a syringe driver over 24 hours. (4) 4. To calculate the dose of diamorphine to be administered in the syringe driver: Total all the prn diamorphine doses received by the patient in the previous 24 hours and prescribe that dose for administration in a syringe driver over 24 hours (4) If the patient has received any other additional oral breakthrough medication during this period this will need to be taken into account and the appropriate conversion factor used to convert to diamorphine. (4) If unsure discuss with the Specialist Palliative Care Team Continue the patch and change every 72 hours as normal. (10) E.g. Patient is on 25 micrograms Fentanyl patch and has received 2 x 5 mg of diamorphine over 24 hours. Therefore, prescribe and administer 10 mg of diamorphine via a syringe driver over 24 hours. 5. Then re-calculate the prn dose of s/c diamorphine: (4) Divide the total fentanyl patch dose by 5 (=a) Divide the total amount of diamorphine in the syringe driver by 6 (=b) a+b = prn dose of diamorphine s/c in mg. E.g. Patient on fentanyl 25 microgram patch and diamorphine 10mg. a = 5 b = 1.66mg a+b = 6.6mg (therefore use 5 mg diamorphine s/c prn) 6. Syringe driver requirements need to be assessed every 24 hours If the patient appears still to be in pain. REASSESS. Ask yourself are there any reversible causes e.g. full bladder? Is the pain likely to be responsive to opiates? Is the problem restlessness rather than pain? (4) Expiry date: 17/03/14 Page 22 of 30

23 7. To further increase the dose of subcutaneous diamorphine within the syringe driver Add any prn doses of s/c diamorphine given in the previous 24 hours to the dose of diamorphine within the syringe driver (4) Remember to recalculate the prn dose of diamorphine as in point 5. e.g. Patient on fentanyl 25 microgram patch and diamorphine 10mg over 24 hours via a syringe driver, additionally the patient has had 2 x s/c prn doses of diamorphine 5mg. Therefore increase diamorphine to 20 mg over 24 hours via the syringe driver and continue the patch. The prn diamorphine dose is re-calculated as (25 5 =) 5mg + ( 20 6=) 3.33mg = 8.33mg. Therefore prescribe 7.5mg or 10mg of diamorphine s/c prn depending on clinical judgement. In very exceptional circumstances the fentanyl patch may be discontinued but should only ever be done in conjunction with specialist palliative care advice. 9. IN THE EVENT OF AN INABILITY TO OBTAIN DIAMORPHINE, please refer to the NE sector drug conversion chart and use an alternative strong opioid. Morphine sulphate injection is first line choice. To convert from a dose of s/c diamorphine to the equivalent dose of s/c morphine sulphate injection multiply the diamorphine dose by 1 5 (one point five). (4) For example: E.g. diamorphine 20mg prn s/c = morphine sulphate 30mg prn s/c E.g. diamorphine 30mg over 24 hours = morphine sulphate 45mg/ 24 hours E.g. diamorphine 100mg over 24 hours = morphine sulphate 150mg/ 24 hours For specific advice relating to patients in renal failure please consult the specialist Palliative Care Team / Pharmacy. (1) Extracted from the Trust s Guidelines for Using Fentanyl Patches in the Last Few Days of Life (CPDI067) Version 3 available from the Documents pages of the Trusts Intranet Expiry date: 17/03/14 Page 23 of 30

24 Appendix C Pain Management: Equi-analgesic doses (oral opioids) Guidance on changing to morphine from another analgesic Analgesic doses can vary between individuals and within an individual over time. This is an approximate guide only. If exact conversions are not possible a dose may need to be rounded to the nearest most practical dose. Adjusted doses for diamorphine are shown in the table. IF IN DOUBT ABOUT CONVERTING TO DIAMORPHINE CONTACT THE SPECIALIST PALLIATIVE CARE TEAM OR A PHARMACIST. Drug To obtain equivalent of oral morphine multiply by: For example if the patient is having: The patient is taking this much in 24 hours: Amount of oral morphine in 24 hours is: Amount of s/c Diamorphine in 24 hours is: Dihydrocodeine (3) mg qds 120mg 12mg 5mg Codeine (3) mg qds 120mg 12mg 5mg Tramadol (4) 0.1* 100mg qds 400mg 40mg 15mg Buprenorphine (sublingual) (3) micrograms tds Oxycodone (3) Oxynorm 2.0 5mg 4 hourly 600 micrograms 48mg 15mg 30mg 60mg 20mg Oxycontin mg 12 hourly 20mg 40mg 15mg * The literature suggests tramadol is 1/5 as potent as morphine. (3) However, in clinical practice some patients have become over-opiated using this potency ratio. Therefore the potency ratio of 1/10 or the conversion factor (4, 12) of 0.1 is recommended. Please note: If a patient is on Methadone as an analgesic always seek Specialist Palliative Care advice. For specific advice relating to patients in renal failure please consult the Specialist Palliative Care Team / Pharmacy. (1) Expiry date: 17/03/14 Page 24 of 30

25 Appendix D - Comparative doses of buprenorphine and morphine. These recommendations are based on a PO morphine:td buprenorphine dose ratio of 100:1 derived from published data, which is in keeping with the manufacturer's dose ratio range of :1 (see PCF Guidelines (12) ); it is an approximation, and inevitably there will be individual variation. Buprenorphine patch strength (microgram/h) Equivalent codeine dose Equivalent oral morphine dose (mg/24 h) prn dose of oral morphine (mg) * Bu Trans 5** 30mg qds ** 60mg qds Transtec * using traditional 1/6 of total daily dose as prn dose and rounded to a convenient dose. ** At these doses prn codeine may suffice. Expiry date: 17/03/14 Page 25 of 30

26 Appendix E - North East Sector Opioid Dose Conversion Chart (version 5) Total 24hr dose of Oral Morphine Oral Morphine Sulphate (Oramorph/ Sevredol) Immediate release Oral Morphine Sulphate MST / Zomorph 12 hourly dose Modified release Oral Oxycodone (Oxynorm) Immediate release Oral Oxycodone (Oxycontin) 12 hourly dose Modified release Total 24hr dose of Oral Oxycodone 20mg 2.5mg 10mg 1.25mg 5mg 10mg Oral Hydromorphone Immediate release Oral Hydromorphone 12 hourly dose Modified release Total 24hr dose of Oral Hydromorphone Fentanyl Patch 72 hrly (Transdermal) micrograms per hour (5) 30mg 5mg 15mg 2.5mg 5mg 10mg 12micrograms 60mg 10mg 30mg 5mg 15mg 30mg 1.3mg 4mg 8mg 25 micrograms 120mg 20mg 60mg 10mg 30mg 60mg 2.6mg 8mg 16mg 37 micrograms 180mg 30mg 90mg 15mg 45mg 90mg 3.9mg 12mg 24mg 50 micrograms 240mg 40mg 120mg 20mg 60mg 120mg 5.2mg 16mg 32mg 75 micrograms 300mg 50mg 150mg 25mg 75mg 150mg 6.5mg 20mg 40mg 75 micrograms 360mg 60mg 180mg 30mg 90mg 180mg 7.8mg 24mg 48mg 100 micrograms 420mg 70mg 210mg 35mg 105mg 210mg 9.1mg 28mg 56mg 125 micrograms 480mg 80mg 240mg 40mg 120mg 240mg 10.4mg 32mg 64mg 125 micrograms 540mg 90mg 270mg 45mg 135mg 270mg 11.7mg 36mg 72mg 150 micrograms 600mg 100mg 300mg 50mg 150mg 300mg 13mg 40mg 80mg 175 micrograms 660mg 110mg 330mg 55mg 165mg 330mg 14.3mg 44mg 88mg 175 micrograms 720mg 120mg 360mg 60mg 180mg 360mg 15.6mg 48mg 96mg 200 micrograms 840mg 140mg 420mg 70mg 210mg 420mg 18.2mg 56mg 112mg 225 micrograms 960mg 160mg 480mg 80mg 240mg 480mg 20.8mg 64mg 128mg 275 micrograms 1080mg 180mg 540mg 90mg 270mg 540mg 23.4mg 72mg 144mg 300 micrograms Conversion Factors Oral morphine to oral oxycodone divide by 2 Oral codeine to oral morphine divide by 10 Oral tramadol to oral morphine divide by 10 This chart is intended as a guide only. The immediate release doses may need to be adjusted according to the patient s tolerance and response. Expiry date: 17/03/14 Page 26 of 30

27 North East Sector Opiate Conversion Chart for Syringe Drivers Total 24hr dose of Oral Morphine s/c Diamorphine via syringe driver over 24 hours Diamorphine s/c prn s/c Morphine sulphate via syringe driver over 24 hours Morphine sulphate s/c prn Total 24hr dose of Oral oxycodone s/c Oxycodone via syringe driver over 24 hours Oxycodone s/c prn Conversion Factors Oral morphine to s/c morphine divide by 2 Oral morphine to s/c diamorphine divide by 3 Oral oxycodone to s/c oxycodone divide by 2 s/c diamorphine to s/c alfentanil divide by 10 Alfentanil must only be used following advice from the Specialist Palliative Care Team or Pain Team. For any queries regarding fentanyl patches please contact Specialist Palliative Care Team or Pharmacy. Expiry date: 17/03/14 Page 27 of 30 s/c Alfentanil via syringe driver over 24 hours (see note below) Alfentanil s/c prn (see note below) 20mg 5mg 2.5mg 10mg 2.5mg 10mg 5mg 1mg 0.5-1mg 0.1mg 30mg 10mg 2.5mg 15mg 2.5mg 10mg 5mg 1mg 1mg 0.1mg 60mg 20mg 5mg 30mg 5mg 30mg 15mg 2.5mg 2mg 0.3mg 120mg 40mg 5mg 60mg 10mg 60mg 30mg 5mg 4mg 0.5mg 180mg 60mg 10mg 90mg 15mg 90mg 45mg 7.5mg 6mg 1mg 240mg 80mg 10mg 120mg 20mg 120mg 60mg 10mg 8mg 1.3mg 300mg 100mg 15mg 150mg 25mg 150mg 75mg 10mg 10mg 1.6mg 360mg 120mg 20mg 180mg 30mg 180mg 90mg 15mg 12mg 2mg 420mg 140mg 20mg 210mg 35mg 210mg 105mg 15mg 14mg 2.3mg 480mg 160mg 25mg 240mg 40mg 240mg 120mg 20mg 16mg 2.6mg 540mg 180mg 30mg 270mg 45mg 270mg 135mg 20mg 18mg 3mg 600mg 200mg 30mg 300mg 50mg 300mg 150mg 25mg 20mg 3.3mg 660mg 220mg 35mg 330mg 55mg 330mg 165mg 25mg 22mg 3.6mg 720mg 240mg 40mg 360mg 60mg 360mg 180mg 30mg 24mg 4mg 840mg 280mg 45mg 420mg 70mg 420mg 210mg 35mg 28mg 4.6mg 960mg 320mg 50mg 480mg 80mg 480mg 240mg 40mg 32mg 5.3mg 1080mg 360mg 60mg 540mg 90mg 540mg 270mg 45mg 36mg 6mg

28 Appendix F - Commonly used drugs and their compatibility for syringe driver use (3, 4, 7, 8) Drug Action Indications Comments Compatible with Incompatible with Alfentanil Analgesic Pain. Only to be used in significant /severe renal failure Alfentanil must only be used follow advice from the Specialist Palliative Care Team or Pain Team Use water for injection to dilute Glycopyrronium, Haloperidol, Hyoscine butylbromide, Levomepromazine, Metoclopramide, Midazolam Precipitation may occur with cyclizine. Seek specialist advice Cyclizine Anti-emetic Broad spectrum anti-emetic. Intestinal obstruction and raised intracranial pressure Use water for injection to dilute Diamorphine, Morphine Sulphate, Hyoscine hydrobromide, **Metoclopramide Diamorphine and cyclizine may be mixed in syringe driver. However, as concentration of diamorphine is increased precipitation may occur. Higher concentrations of cyclizine also increase the risk (>10mg/ml) of compatibility problems. When diamorphine concentration >20mg/ml concentration of cyclizine should be no more than 10mg/ml. Some clinical experience of precipitation when combined with midazalom or Hyoscine butylbromide has been observed. Diamorphine Analgesic Pain and breathlessness Use water for injection to dilute Cyclizine, Metoclopramide, Haloperidol, Midazolam, Glycopyrronium, Hyoscine hydrobromide, Hyoscine butylbromide, Levomepromazine Diamorphine and cyclizine may be mixed in syringe driver. However, as concentration of diamorphine is increased precipitation may occur. Higher concentrations of cyclizine also increase the risk (>10mg/ml) of compatibility problems. When diamorphine concentration >20mg/ml concentration of cyclizine should be no more than 10mg/ml Glycopyrronium Anticholinergic Reduction of excessive respiratory tract secretions Use water for injection to dilute Diamorphine, Morphine Sulphate, Cyclizine, Haloperidol, Midazolam, Levomepromazine Problems with higher concentrations of Glycopyrronium with Diamorphine and Cyclizine. Haloperidol Anti-emetic Antipsychotic Drug induced, chemical/toxic causes of vomiting Use water for injection to dilute. However when using morphine sulphate and haloperidol in combination, use 0.9% sodium chloride as diluent Diamorphine, Morphine Sulphate, Midazolam, Cyclizine, Oxycodone Precipitates at concentrations above 2mg/ml Expiry date: 17/03/14 Page 28 of 30

29 Drug Action Indications Comments Compatible with Incompatible with Hyoscine hydrobromide (HBr) Hyoscine butylbromide (BBr) Levomepromazine Metoclopramide Midazolam Anticholinergic Anticholinergic Anti-emetic Sedative / Antipsychotic Anti-emetic Anxiolytic Antiepileptic Useful for drying up secretions. Additional sedation To reduce colic Little sedation Good broad spectrum anti-emetic, can also be used second line for terminal restlessness Nausea & vomiting due to delayed gastrointestinal emptying Terminal agitation, restlessness and myoclonus. Used as an anti-convulsants when patients are no longer able to take oral anticonvulsants (unlicensed use) Use water for injection to dilute Use water for injection to dilute Use 0.9% saline as diluent when administered alone. If when combined with another drug, water for injection as the diluent is usually used Avoid use in gastrointestinal obstruction and Parkinsonian patients. Use water for injection to dilute Use water for injection to dilute Diamorphine, Morphine Sulphate, Haloperidol, Midazolam,, Oxycodone Metoclopramide, Cyclizine Diamorphine, Morphine Sulphate, Midazolam, Oxycodone Diamorphine, Morphine Sulphate, Haloperidol, Midazolam, *Hyoscine hydrobromide, *Hyoscine butylbromide, Glycopyrronium, Oxycodone Diamorphine, Morphine Sulphate, **Cyclizine, Midazolam, Oxycodone Levomepromazine Diamorphine, Morphine Sulphate, Haloperidol, *Hyoscine butylbromide, Glycopyrronium, Metoclopramide, Levomepromazine, Hyoscine hydrobromide, Oxycodone Haloperidol compatible at lower doses. Some clinical experience of precipitation with cyclizine has been observed. Some clinical experience of precipitation with cyclizine has been observed when diluted in small volumes. Morphine Sulphate Analgesic Pain and breathlessness Use water for injection to dilute. However when using morphine sulphate and haloperidol in combination, use 0.9% sodium chloride as diluent Cyclizine, Metoclopramide, Haloperidol, Midazolam, Glycopyrronium, Hyoscine hydrobromide, Hyoscine butylbromide, Levomepromazine Oxycodone Analgesic Alternative opioid to Morphine indicated in renal failure or other Morphine intolerance Use water for injection to dilute Haloperidol, Midazolam, Hyoscine hydrobromide, Hyoscine butylbromide, Levomepromazine, Metoclopramide Incompatible with cyclizine at high concentrations (maximum combination oxycodone 200mg with cyclizine 100mg) Please note: This chart has been prepared using the best available evidence concerning compatibilities of different drugs. However despite this, factors such as, concentration, heat and exposure to sunlight may also affect the stability of drug combinations within a syringe driver. It is therefore advised that simple visual inspection of the mixture before and during administration will detect most problems or crystallisation / precipitation. If any evidence of this occurs please discard immediately (including giving set if during administration). * Clinical experience indicates compatibility. ** Cyclizine may antagonise the prokinetic effects of metoclopramide and they should not be administered simultaneously. Expiry date: 17/03/14 Page 29 of 30

30 Appendix G - References 1. Marie Curie Palliative Care Institute Liverpool et al (2008) Guidelines for LCP Drug Prescribing in Advanced Chronic Kidney Disease. Liverpool. 2. Ellershaw, J. and Wilkinson, S. (2004) Care of The Dying A Pathway to Excellence. Oxford University Press. New York. 3. Back, I.N. (2001) Palliative Medicine Handbook (3 rd Ed). BPM Books. Cardiff. 4. Evidence is based on expert opinions of the Specialist Palliative Care Teams across the North East Sector of Greater Manchester. (With the exception of NHS Manchester.) 5. Data from manufacturer s summary (March 2011) 6. Watson, M, Lucas, C, Hoy, A and Back I. (2005) Oxford Handbook of Palliative Care. Oxford University Press. Oxford. 7. Twycross, R, Wilcock, A, Charlesworth, S and Dickman, A. (2002) Palliative Care Formulary (2 nd Ed).Radcliffe Medical Press. Oxon. 8. Dickman, A. Schneider J. and Varga, J. (2005) The Syringe Driver Continuous S/C Infusions in Palliative Care. (2 nd Ed). Oxford University Press. Oxford 9. British National Formulary 58 (2009) BMJ Group. London. 10. Twycross, R. and Wilcock, A. (2001) Symptom Management in Advanced Cancer (3 rd Ed). Radcliffe Medical Press. Oxon 11. Ellershaw, J.E. (2003) Guidelines for the use of transdermal fentanyl in dying patients. Merseyside and Cheshire Palliative Care Network Audit Group. Liverpool. 12. Twycross, R. and Wilcock, A. (2007) Palliative Care Formulary (3 rd Ed). palliativedrugs.com Ltd. Nottingham 13. Bennett, M. et al. (2002) Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliative Medicine Vol 16: pp Expiry date: 17/03/14 Page 30 of 30