Makindo Medical Notes

🔑 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.