Symptom control in the last days of life

• All patients should have as required medication for symptom control available (refer to Anticipatory prescribing guideline).
• Opioid analgesic for pain or breathlessness SC, up to hourly if required. If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review. If more than 6 doses are required in 24 hours seek advice or review.
• Dose depends on the patient, clinical problem and previous opioid use
• 1/6th to 1/10th of 24 hour dose of any regular opioid and converted to SC dose
• If no previous opioid-starting dose is morphine SC 2mg.
• Anxiolytic sedative: midazolam SC 2mg to 5mg, hourly if required. If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review. If more than 6 doses are required in 24 hours seek advice or review
• Antisecretory medication: †hyoscine butylbromide SC 20mg, up to hourly if required. Maximum 6 doses in 24 hours.
• Anti-emetic: QT†levomepromazine SC 2.5mg to 5mg, 12 hourly if required. May need to be given more frequently initially, for example hourly, to control symptoms. If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review. If more than 6 doses are required in 24 hours seek advice or review
• Levomepromazine can be used in terminal agitation or agitated delirium under specialist advice at a different dose (refer to anxiety, distress, delirium section below)

• Paracetamol (PR dose) or diclofenac (SC dose). For pain or high temperature.
• The benefits of non-steroidal anti-inflammatory drugs (NSAIDs) may outweigh the risks in a dying patient and can help bone, joint, pressure sore and inflammatory pain.
• If prescribed regular oral opioids and the oral route is no longer reliable, convert the total 24-hour oral morphine or oxycodone dose to a 24-hour SC infusion, for example:

• For opioid dose conversions, refer to Choosing and changing opioids guideline or seek advice.
• Fentanyl patches should be continued in dying patients (refer to Fentanyl patches information sheet).
• For a patient with stage 4–5 chronic kidney disease, refer to Renal disease in last days of life  guideline.
• Breakthrough analgesia, should be prescribed up to hourly, as required:
• 1/6th to 1/10th of 24-hour dose of any regular opioid orally and SC
• If not on any regular opioid, use morphine SC 2mg.

Tables are best viewed in landscape mode on mobile devices

(Refer to Nausea and vomiting guideline)

• If already controlled with an oral anti-emetic, use the same drug as an SC infusion if suitable for SC administration.
• Treat new nausea and vomiting with a long acting anti-emetic given by SC injection or
• give a suitable anti-emetic as a 24 hour SC infusion in a syringe pump.

Long acting anti-emetics:

QThaloperidol SC 1mg 12 hourly, or 2mg once daily.

QT†levomepromazine SC 2.5mg to 5mg, 12 hourly.
May need to be given more frequently initially, for example hourly, to control symptoms. 

For doses of anti-emetics for use in an SC infusion, refer to Table 1 in the Syringe pumps guideline.

Persistent vomiting: a nasogastric tube, if tolerated, may be better than medication

(Refer to Breathlessness guideline)

• Oxygen can improve breathlessness, but only if the patient is hypoxic. If oxygen is needed for symptom control, nasal prongs may be better tolerated than a mask.
• A fan (either on a table or handheld) should be tried, and a more upright position can help.

Tables are best viewed in landscape mode on mobile devices

• Reduce risk by avoiding fluid overload; review any assisted hydration or nutrition (intravenous [IV] or SC fluids, feeding) if symptoms develop. Suction may also exacerbate secretions.
• Changing the patient’s position, for example head down or lateral position may help.
• Intermittent SC injections often work well or medication can be given as an SC infusion (be aware that conscious patients may be troubled by dry mouth on these medications, refer to Mouth care guideline):
• first line: hyoscine butylbromide SC 20mg, up to hourly as required (up to 120mg/24 hours).
• second line: glycopyrronium bromide SC 200 micrograms, 6 to 8 hourly as required.
• third line: hyoscine hydrobromide SC 400 micrograms, up to 2 hourly as required.

(Refer to Emergencies in palliative care guidelines)

• Dying patients occasionally develop acute distress. This can be due to:
• bleeding: haemorrhage from gastrointestinal or respiratory tract, or an external tumour
• acute pain: bleeding into a solid tumour, fracture, or ruptured organ
• acute respiratory distress: pulmonary embolism or retained secretions.
• Prescribe sedation in advance if the patient is at risk and warn the family. Agree an anticipatory care plan with the patient, if possible, and family, carers and key professionals.
• Give midazolam 5mg to 10mg intramuscular (IM), or IV, if available. 
• If the patient is in pain or has respiratory distress, give morphine SC at the usual breakthrough as required dose. Repeat if necessary.