Anticipatory prescribing for symptoms at the End of Life

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1 Anticipatory prescribing for symptoms at the End of Life What is anticipatory prescribing? Patients who are dying often experience new or worsening symptoms or become unable to swallow essential medication such as analgesics or anti-emetics. Patients who wish to remain at home may require District Nurses to administer injections or a syringe driver to control their symptoms. For patients in the community who are in the last few weeks/ days of life it is good practice for the GP (or in the case of patients being discharged from hospital to die at home, the doctor on the ward looking after the patient) to prescribe a range of medications which will be kept in the home, to minimise delay, in case they are needed for symptom control (anticipatory prescribing). This tool aims to guide healthcare professionals on what medications should be prescribed after assessment of the individual patient. The principles are applicable to the care of patients who are dying whether of malignant or non-malignant disease. NOTE: it is important to discuss the need for anticipatory prescribing within the context of end of life care with both the patient and their carer as well as health care professionals involved. If the discussions are not initiated by the patient s GP or end of life care facilitator then it is important to engage them as necessary. Prescribing advice for the Doctor 1. Stop unnecessary medications -hypertensive drugs or statins that are no longer needed. 2. Prescribe medications in case a syringe driver is needed For patients who are unable to swallow, convert essential medications, such as analgesics, antiemetics, and anxiolytics to a syringe driver for continuous subcutaneous infusion. See conversion charts for dosages of opioids to prescribe and / or specialist advice (contact numbers below) For all patients, prescribe subcutaneous medication for each of the 4 common symptoms at the end of life. These include: Pain Agitation and restlessness Nausea and vomiting Respiratory secretions You may also wish to prescribe for Breathlessness if appropriate, in case they are needed in a syringe driver. Note: appropriate procedures for mixing of drugs in syringe drivers are to be followed Ensure each drug has an appropriate dose range written on the syringe driver authorisation sheet in case increases are required. 1

2 Prescribe normal saline for injection for use in case a syringe driver is needed. recommendation is 5 days supply. N.B For patients who have a fentanyl patch for pain: h stock for weekends and bank holidays. The usual The patch should be kept in place and changed as usual as stated in their prescription. However, if they are unable to swallow, they will need PRN subcutaneous analgesia prescribed at a dose appropriate to their patch dose. For example: 25mcg per hour fentanyl patch is equivalent to 60-90mg of oral morphine in 24 hours (See Opioid Conversion Chart). A PRN dose of oral morphine for interval pain would therefore be 10-15mg (one sixth of the 24 hour dose) and sc diamorphine injection 2.5-5mg (one third of oral morphine dose), every hour if needed. If 3 or more PRN doses are needed, a syringe driver can be set up containing diamorphine, for example 10-15mg over 24 hours via continuous subcutaneous infusion, in addition to the fentanyl patch. In this way the patient s extra analgesic requirements are supplemented via the syringe driver. To calculate the PRN dose for interval pain for patients on a patch and syringe driver, calculate and add the PRN dose for the fentanyl patch and the PRN dose for the syringe driver. For example, PRN 2.5mg sc diamorphine for fentanyl 25mcg/hr patch + PRN 2.5mg sc diamorphine for syringe driver of diamorphine 15mg/ 24 hours. This equates to PRN 5mg sc diamorphine. 3. Prescribe medications for Interval Doses (PRN) symptoms stated overleaf. PRN subcutaneous medications for each of the 4-1mg 8 hourly). Practical tips for District Nurse/ GP or key community health care professional Liaise with the local pharmacy to ensure that they have enough stock for the doctor s prescription. All the 100 hour pharmacies in North East Essex and a selection of other pharmacies have additional stock of palliative care drugs (see attached list). Explain to the patient and carers about anticipatory prescribing and ensure they can get medicines dispensed. Leave syringes and needles in the house for PRN injections. Update out of hours GP and District Nurse service about present clinical situation, medications prescribed and possible problems that may occur. Where can I get advice? For complex patients e.g. those with renal failure seek advice from either the Hospital Specialist Palliative Care Team on Tel for patients being discharged home or the Hospice Nurse Specialist (HNS) or St Helena Hospice on Tel for patients already at home. The Liverpool Care Pathway also includes Symptom Control Flowcharts for each of the 5 common symptoms at the end of life which are helpful to refer to. Reference. (1). 2

3 GUIDANCE FOR PAIN MEDICATION FOR SYRINGE DRIVER OVER 24 HOURS AND PRN DOSES SYMPTOM INDICATION DRUG Normal Strength of preparation used PAIN Opioid naïve Seek specialist advice for patients with renal failure Diamorphine 1 st line STARTING DOSE FOR SYRINGE DRIVER OVER 24 HRS SUBCUTANEOUS INTERVAL (PRN) DOSE & SUGGESTED FREQUENCY 5mg, 10mg or 30mg 5-10mg 2.5mg 1hrly Calculated as 1/6 th 24hr dose DOSE RANGE FOR SYRINGE DRIVER OVER 24 HRS (daily dose increase with upper limit) 30-50% dose increments only No maximum limit but note above. Confirm dose with prescriber at each dose increment. On oral opioid regularly See Opioid Conversion Chart for equivalent subcutaneous dose via syringe driver over 24 hours Review drug/ dose/ frequency for patients who are elderly, frail, have dementia or renal failure Calculated as 1/6 th of 24hr dose 30-50% dose increments only No maximum limit but note above. Confirm dose with prescriber at each dose increment. For patients who have a Fentanyl or Buprenorphine patch - the patch should be kept in place and changed regularly as usual and any extra analgesic requirements supplemented via a syringe driver. See Opioid Conversion Chart for the morphine equivalent interval dose (PRN) for the patch For example, the interval PRN dose of sc Diamorphine for a patient on a Fentanyl 25mcg/hr patch is 2.5-5mg If 3 or more PRN doses are needed, a syringe driver can be set up containing Diamorphine 10-15mg/ 24 hours The total PRN dose for patients on a patch and a syringe driver = PRN dose for patch + PRN dose for syringe driver If symptoms persist, during normal working hours Mon-Fri 9-5pm please contact: CHUFT Hospital Specialist Palliative Care Team on if the patient is in hospital St Helena Hospice on if the patient is in the community During Out of Hours and Bank Holidays, please contact St Helena Hospice on PLEASE NOTE THAT NO MORE THAN 3 PRN DOSES OF ANY DRUG SHOULD BE GIVEN WITHOUT CONSULTING WITH THE PRESCRIBER. SEEK SPECIALIST ADVICE IF UNSURE.

4 GUIDANCE FOR OTHER MEDICATIONS FOR SYRINGE DRIVER OVER 24 HOURS AND PRN DOSES SYMPTOM INDICATION DRUG NAUSEA & VOMITING 1 ST LINE 2 nd LINE AGITATION 1 st LINE 2 nd LINE RESPIRATORY TRACT SECRETIONS BREATHLESSNESS Metabolic or drug induced Central e.g. raised ICP GI cause e.g. gastric stasis Multi-factorial Anxiety Hallucinations or confusion Hallucinations or confusion 1 st line 2 nd line 1 st line Associated anxiety Note* for CD prescription requirements Haloperidol Cyclizine Metoclopromide Levomepromazine Midazolam * Haloperidol Levomepromazine Glycopyrronium Hyoscine Hydrobromide Diamorphine* Midazolam* Normal Strength of preparation used 5mg/ml 50mg/ml 10mg/2ml 25mg/ml 10mg/2ml 5mg/ml 25mg/ml 200micrograms/ml (600microgram/3ml) 400microgram/ml 5,10 and 30mg 10mg/2ml STARTING DOSE FOR SYRINGE DRIVER OVER 24 HRS 2.5-5mg 150mg 30-60mg mg 5-30mg 3-5mg mg 0.6mg 1.2mg 5-10mg 5-10mg SUBCUT INTERVAL (PRN) DOSE & SUGGESTED FREQUENCY 1.5-3mg bd 50mg tds (if not regular) 10mg qds 6.25mg tds 2.5-5mg 1hrly 1.5-3mg bd mg tds microgram 4hrly 400micrgram 4 hrly 2.5mg 1hrly 2.5mg 1hrly DOSE RANGE FOR SYRINGE DRIVER OVER 24HRS (daily dose increase with upper limit) 2.5mg increments to maximum dose of 10mg maximum dose 150mg 10mg increments to maximum dose of 90mg 6.25mg increments to maximum dose of 25mg 5-10mg increments to maximum dose of 60mg 2.5mg increments to maximum dose of 10mg 25mg increments to maximum dose of 100mg 0.6mg increments to maximum dose of 2.4mg maximum dose of 2.4mg 2.5-5mg increments to maximum of 20mg 2.5-5mg increments to maximum of 20mg PLEASE NOTE THAT NO MORE THAN 3 PRN DOSES OF ANY DRUG SHOULD BE GIVEN WITHOUT CONSULTING WITH THE PRESCRIBER. SEEK SPECIALIST ADVICE IF UNSURE.

5 LOCAL PHARMACY INFORMATION Pharmacies that stock medicines listed below giving hours of opening at 1 st Sept 2010: (Note-these are also available within the out of hours service) Diamorphine 5, 10 and 30mg ampoules (only 10mg in OOH for safety reasons) Haloperidol 5mg/ml Cyclizine 50mg/ml Metoclopramide 10mg/2ml Levomepromazine 25mg/ml Midazolam 10mg/2ml Glycopyrronium bromide 200microgram/ml Hyoscine hydrobromide 400microgram/ml Prescription 2 You 87 Pier Avenue Clacton Tel: Opening hours: Monday to Saturday 7am-11pm, Sunday 8am-8pm. Oakley Pharmacy 10 Oakley Road, Dovercourt Tel: Opening hours: Monday to Friday 9am-6pm, Saturday 9am-5pm Tollgate, Colchester Tel: Opening hours: Monday to Saturday 8am-Midnight, Sunday 10am-4pm Queens Street Pharmacy 12 Queen Street, Colchester Tel: Opening hours: Monday to Friday 7am-11pm, Saturday 7am-9pm, Sunday 10.30am-4.30pm North Road Pharmacy 4-5, Mansion House Precinct, St Johns Road, Clacton CO15 4BP Tel: Opening hours: Monday-Saturday 7am-10pm, Sunday 8am-6pm Asda Turner Rise, Colchester Tel: Opening hours: Monday -Friday 7am-11pm, Saturday 7am-10pm, Sunday 10am-4pm Lloyds Pharmacy 2 Jackson Road, Clacton Tel: Opening hours: Monday to Friday 9am-6pm, Saturday 9am-5pm

6 Crouch End Pharmacy 77 Crouch Street, Colchester Tel: Opening hours: Monday to Friday 8.30am-7pm, Saturday pm 52, Victoria Place, Brightlingsea CO7 0AB Tel: Opening hours: Monday-Friday 9am-6pm, Saturday 9am-5pm 37, Barfield Rd, West Mersea, CO5 8QX Tel: Opening hours: Monday-Friday 8.30am- 5.30pm Saturday 8.30am-5pm 10, Connaught Ave, Frinton CO13 9PW Tel: Opening hours: Monday- Saturday 9am-5.30pm Day Lewis Pharmacy 1-3 The Parade, Halstead Rd, Kirby Cross CO13 0LN Tel: Opening hours: Monday-Friday 9am-5.30pm, Saturday 9am-1pm The Green Pharmacy The Green, Great Bentley, CO7 8PJ Tel: Opening hours: Monday-Friday 9am-6.30pm, Saturday 9am-1pm

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