ANTICIPATORY DRUGS AT THE END OF LIFE

Question 1

What is anticipatory prescribing?

Answer 1

Drugs that may but not necessarily will be needed for someone dying
E.g. just in case meds - symptoms may not yet be present

Question 2

For cachechetic pt what route of drugs should you use?

Answer 2

Subcutaneous or oral
NOT IM

Question 3

Examples of unnecessary medications in pt last few days of life?

Answer 3

Steroids
Antibiotics
Hormones
Antidepressants
Diabetic drugs
Statins and other CVD drugs
Vitamins/irons
Prophylactic LMWH

(Clinically assess first!!)

Question 4

Anticipatory pain management for a pt not currently taking any pain medication?

Answer 4

Prescribe diamorphine s/c injections

If 2-3 prn doses are required then commence a syringe driver

Review and assess pain every 24 hours

Question 5

Anticipatory pain management for a pt taking oral morphine who now cannot swallow?

Answer 5

Convert oral morphine dose to diamorphine (divide 24 hr dose by 3)
Also prescribe prn diamorphine s/c for breakthrough pain
Review and assess pain every 24 hours

Question 6

Common indications for syringe drivers?

Answer 6

Severe dysphagia
Persistent n&v
Poor alimentary absorption

Question 7

Anticipatory pain management for a pt on fentanyl?

Answer 7

Maintain fentanyl patch at existing dose and prescribe diaphoresis s/c prn in anticipation of breakthrough pain

If 2-3 prn doses are required in 24 hours then commence diamorphine s/c via a syringe driver over 24 hours

Review and asssess pain every 24 hours

Question 8

How much more potent is fentanyl than morphine?

Answer 8

X150

Question 9

Most important initial management in respiratory tract secretions?

Answer 9

Explanation to family - often more distressing to family than pt

Question 10

Anticipatory management for respiratory tract secretions?

Answer 10

Prescribe in anticipation at first sight glycopyrronium or hyoscine butylbromide

If present:
Try turning pt
Explain to family
Glycopyrronium or hydrocine butylbromide s/c injections 200 micrograms and syringe driver 800 micrograms (need the injections first as syringe driver takes 6 hours to work so this is bridging )
And continue to administer s/c PRN doses as needed up to a maximum daily dose of 1200 micrograms

Question 11

Anticipatory prescribing for restlessness and agitation?

Answer 11

Midazolam s/c

Optimise non-pharm measures: fix full bladder, pain, constipation, anxiety, sepsis etc.

If they are agitated then give midazolam and repeat dose when needed.

(Second line - levomepromazine if midazolam only had a partial effect)

Question 12

What pharmacological therapy is 1st line for delirium?

Answer 12

Haloperidol

Question 13

Management delirium in anticipatory prescribing?

Answer 13

Haloperidol - prescribe in anticipation and start when present

Also assess for any underlying cause and reverse if possible. Nurse in a quiet well lit room with family present. Relieve physical factors and avoid precipitating situations e.g. change in environment

(Second line - add in midazolam or change to levomepromazine)

Question 14

Anticipatory prescribing for dyspnoea?

Answer 14

Prescribe diamorphine in anticipation

If present then prescribe 1/20th of the 24 hour analgesic dose of a prn dose - give 1-2 hourly

(Second line: if pt has a lot of fear and anxiety then benzodiazepines can be used)

Question 15

Anticipatory prescribing for nausea and vomiting?

Answer 15

Prescribe haloperidol in anticipation

If present then use most appropriate anti-emetic based on the aetiology