Palliative: EOL

Question 1

Mx of intractable hiccups?

Answer 1

Chlorpromazine

Haloperidol, gabapentin

Question 2

What should you consider at EOL?

Answer 2

Family discussion - home, hospice?
Continue to treat reverisble problems
Stop observations and blood tests - comfort obs
Stop non-essential medications - medication review
Rationalise medications
Anticipatory medications - PRN SC meds before needed
DNAR
Allow natural death order
Document clearly - verbal and written communication

Question 3

What are anticipatory end of life medications?

Answer 3

Pain - morphine (max 60mg SC)
Agitation + N/V - Haloperidol
Agitation + Anxiety - Midazolam
N/V - Levomepromazine
Respiratory secretions - Glycopyrrronium, Hyoscine butylbromide, hyoscine hydrobromide
Bowel colic - hyoscine butybromide

Question 4

What are syringe drivers?

Answer 4

Allows continuous SC infusion of drugs avoiding repeated cannulation and injection when oral route is no longer feasible due to nausea, dysphagia, intestinal obstruction, weakness or coma.

Most drugs are compatible with water for injection.
Ondansetron requires 0.9% sodium chloride

Question 5

What is used for pain?

Answer 5

Morphine
10-15mg/24h if opioid naive
If on opioids calculate daily dose and convert to SC morphine (divide by 2)

Question 6

What is used for anxiety agitiaton and delirium?

Answer 6

Midazolam
Levomapromezine
Haloperidol

Question 7

What is used for N/V

Answer 7

Cyclizine
Haloperidol
Levomepromazine

Question 8

What is used for respiratory secretions?

Answer 8

Hyoscine butylbromide

Glycopyrrhonium

Question 9

What is used for seizures?

Answer 9

Midazolam prophylaxis

Question 10

How is agitation managmed?

Answer 10

Look for reversible causes (pain, dehydration, urinary retention)

Antipsychotic agent: haloperidol

IF anxiety, restlessness in terminal phase - midazolam

Question 11

How are excessive secretions managed?

Answer 11

Repositioning
Intermittent suctioning
Glycopyrrhonium
Hyoscine butylbromide
Hyoscine hydrobromide

Question 12

What is used for bowel colic?

Answer 12

Hyoscine butylbromide - less sedating than hysocine hydrobromide

Question 13

What should you do after death?

Answer 13

Verifying death:
Carotid pulse, HS, respiratory effort
Fixed dilated pupils
No motor response to voice/pain
Check for pacemaker, hip screw

Death certification

Cremation form

Coroners referral:
<24 hours admission
Unnatural causes
Linked to occupation