End of Life Care Prescribing
🔑 Principles of End-of-Life Prescribing
- 👩⚕️ Assess symptoms regularly and titrate doses to effect.
- 💉 Prefer subcutaneous (SC) route if oral not possible.
- 🚽 Anticipate side effects (e.g. constipation with opioids → always prescribe laxatives).
- 🩺 In renal impairment (eGFR <30), avoid morphine; consider oxycodone, fentanyl, or alfentanil.
- 🤝 Holistic care: communication with patient, family, and the wider MDT is essential.
📊 Symptom Management (without table)
- 💢 Pain / Dyspnoea:
- Morphine 2.5–5 mg SC PRN
- Oxycodone 1.25–2.5 mg SC PRN (preferred in renal impairment)
- Consider continuous infusion if frequent PRN needed.
- 😵 Agitation / Delirium:
- Midazolam 2.5–5 mg SC PRN (good for anxiety/restlessness)
- Haloperidol 0.5–1 mg SC PRN (less sedating).
- 💧 Respiratory Secretions:
- Glycopyrronium 0.2 mg SC PRN (does not cross BBB → less confusion)
- Hyoscine butylbromide 20 mg SC PRN.
- 🤢 Nausea / Vomiting:
- Haloperidol 0.5–1 mg SC PRN (esp. opioid-induced nausea)
- Metoclopramide 10 mg SC PRN
- Cyclizine 50 mg SC every 8 hours.
- Choice guided by cause: metabolic vs gastric vs vestibular.
- ⚡ Seizures:
- Midazolam 5–10 mg SC stat
- Infusion: 20–60 mg/24h
- Continue regular antiepileptics if possible.
💡 Clinical Pearls
- 🌙 Midazolam: short half-life, versatile (agitation, anxiety, seizures).
- 🤢 Haloperidol: gold standard antiemetic in palliative care (esp. opioid-induced nausea).
- 😴 Levomepromazine: broad-spectrum antiemetic; sedating at higher doses, useful in refractory cases.
- 💧 Glycopyrronium vs Hyoscine: Glycopyrronium preferred if confusion/delirium risk.
🩺 Syringe Driver Tips
- 📌 Indicated when oral route not possible (vomiting, dysphagia, reduced consciousness).
- ⚗️ Always check compatibility of mixes — cyclizine often precipitates with opioids.
- 👀 Inspect syringe daily for cloudiness or crystallisation.
📌 Renal Impairment Summary
- 🚫 Morphine: Avoid — active metabolites accumulate and cause toxicity.
- ⚠️ Oxycodone: Use with caution; start low and titrate carefully.
- ✅ Fentanyl / Alfentanil: Safe in severe renal impairment.
🧠 Teaching Pearl
💡 In end-of-life care, the focus is on comfort, not cure.
💡 Prescribe anticipatory medications early (pain, agitation, secretions, nausea, seizures) so symptoms can be managed promptly.
