On this page

  1. Patients with COVID-19
  2. Non-COVID-19 patients
  3. Last days of life anticipatory prescribing guidance for adults with COVID-19 disease
  4. Document information

This guide provides a summary of information relevant to prescribing and medication administration in the last days of life. The purpose is to provide resources to support consistent care across clinical services and groups.

Patients with COVID-19

Last days of life anticipatory prescribing

  • Anticipatory prescribing guidance has been prepared for generalist clinicians on how to prescribe medications for patients with COVID-19 for the symptoms that may be experienced in the last days of life. See Last days of life anticipatory prescribing guidance for adults with COVID-19 disease.
  • All suggested medications have been listed with Strategic Procurement Services (HealthShare) and quarantined to ensure supply in NSW.

Supporting consistent prescribing

  • Where the eMeds system is in use, services should consider building a Power Plan for the agreed palliative care medication list if this has not already been attended to.
  • Access to medications should be based on patient need. Medications used for end of life care are included on the quarantine list which is being managed as part of the NSW Health pandemic response.
  • In line with normal business practices, contact your Director of Pharmacy if you have any questions about the availability or supply of medicines.

Non-COVID-19 patients

Last days of life anticipatory prescribing

Medication administration devices

  • The Anticipatory Prescribing Guidance includes information about recommended medication administration methods and doses.
  • Re-usable syringe drivers should be re-processed after use by a COVID-19 positive patient according to their intended use and manufacturer’s advice *
  • Alternative devices and administration methods should be considered if:
    • there is limited availability of syringe drivers
    • there is limited capacity to decontaminate syringe drivers after patient use
    • clinical staff are not accredited to use syringe drivers.
  • For advice on alternate devices and local practices Palliative Care Units can be contacted.
  • COVID-19 Palliative Care Community of Practice members can direct questions on local practices to other COP members. Information has also been added to the Palliative care COP.

* Clinical Excellence Commission Infection Prevention and Control Practice Handbook January 2020.

Core medications list for community pharmacies

The NSW Clinical Excellence Commission recommends community pharmacies in NSW stock the five injectable medicines on the Core Palliative Care Medicines List for NSW Community Pharmacy for use in the last days of life.

Last days of life anticipatory prescribing guidance for adults with COVID-19 disease

Important principles

  • Goals of care must be discussed early including the decision NOT to escalate to ICU/intubation/resuscitation.
  • Maintain frequent communication with families and carers as this is crucial to the provision of good care.
  • Be prepared to escalate symptom management to prioritise comfort (unmanaged symptoms add distress to patients, families and staff)
  • Remember not only physical needs but psychosocial and spiritual care needs as well.

Anticipatory prescribing for all patients at risk of dying

  • Pre-emptive: prescribe anticipatory medications when goals of care agreed on (chart one medication for each of the below symptoms).
  • Start with PRN dosing, if more than 4 PRN doses of a medication in 24 hours is required, regular dosing should be commenced and PRN prescribed for rescue as required.
  • The recommendations are starting doses only and may need titration depending on symptom severity.
  • PRN usage and syringe driver doses should be reviewed every 24 hours.
  • Observational studies highlight the most common symptoms experienced by people dying of COVID-19 are shortness of breath, agitation, fever, cough and pain.

If required, seek advice from local Specialist Palliative Care for any concerns or questions with the guidance provided below.

SymptomNon-PharmacologicalPharmacologicalGuidance notes
Distressing shortness of breath at rest
  • Positioning
  • Reassurance

If hypoxic, seek local guidance regarding the safe and appropriate use of oxygen.

Stat dose Morphine 2.5mg subcut injection plus Midazolam 2.5mg subcut injection. If eGFR <30mL/min or >65 years of age or frail: reduce both to 1.25mg subcut injection.

In addition, prescribe Morphine 2.5mg subcut injection plus Midazolam 2.5mg subcut injection PRN 1-2 hourly for breakthrough as necessary. If eGFR <30mL/min or >65 years of age or frail: 1.25mg subcut injection PRN 1-2 hourly for both medications.

If continuous subcut infusion is available:
Morphine 10mg plus Midazolam
10mg subcut infusion over 24 hours
or if eGFR <30mL/min or older than 65years of age or frail: Morphine 5mg plus Midazolam 5mg subcut infusion over 24 hours.

If continuous infusion unavailable: Morphine 2.5mg subcut injection
4 hourly plus Clonazepam 0.5mg sublingual drops (5 drops) 12 hourly.

Always ensure PRN medications are available. Based on the doses above, prescribe Morphine 2.5mg subcut injection plus Midazolam 2.5mg subcut injection PRN 1-2 hourly.

If eGFR <30mL/min or >65 years of age or frail: 1.25mg subcut injection PRN 1-2 hourly for both medications.

  • This is the most common problem expected to affect patients dying of COVID-19 with up to 80% of people dying with COVID likely to be affected.
  • Avoid hand-held fans.
  • Low flow conventional oxygen therapy is sufficient for most adult patients with SpO2<92%.
  • There is insufficient evidence to support the use of humidifiers when administering low flow oxygen.
  • Lower thresholds should be used in patients at risk of hypercapnic respiratory failure (SpO2 88–92%).
  • Avoid nebulised medications in patients with COVID19 disease.
  • Monitor patients receiving opioids for undesirable effects, particularly nausea and vomiting, and constipation.
  • Depending on individual circumstances including patient’ ability to swallow, consider a regular or PRN anti-emetic and a regular laxative. Refer to the CEC Last Days of Life Anticipatory Prescribing Recommendations for in-patient setting – adult.
  • For those people who may have already been receiving regular opioids, usual recommendations suggest that the opioid should be converted to a parenteral preparation with the 24 dose increased by 25%.
Agitation

If mild, encourage relaxation, breathing techniques

If severe: Midazolam 2.5mg subcut injection PRN 1-2 hourly.
If eGFR <30mL/min or >65 years of age or frail Midazolam 1.25mg subcut injection PRN 1-2 hourly.

If more than 4 PRN doses required, consider a continuous subcut infusion (starting dose Midazolam 10mg over 24 hours. If eGFR <30mL/min or >65years of age or frail: reduce to 5mg over 24 hours)
or Clonazepam 0.5mg sublingual drops (5 drops) 12-hourly.

Always ensure PRN medications are available. Based on the above, prescribe Midazolam 2.5mg subcut injection PRN
1-2 hourly.

  • This is one of the most distressing problems expected to be experienced by people dying of COVID, with reports suggesting up to 60% of people are likely to be agitated
  • Parenteral Subcutaneous Clonazepam
    12-hourly may be substituted for sublingual Clonazepam
    12-hourly if the patient has a very dry mouth.
  • Australian and international data suggests that the majority of people dying of COVID-19 who require benzodiazepines may need up-titration to the equivalent of 15-20mg Midazolam.
PainPositioning

If mild and able to swallow: Paracetamol 1gm QID

If severe: commence opiod analgesia as summarised for severe breathlessness.

  • Australian data suggests that up to 60% of people dying with CoVID-19 are likely to experience pain at the end of life.
  • Conditions reported as uncomfortable for COVID-19 patients include painful myalgia, arthralgia and headaches.
  • Monitor people for adverse effects of opioids as per the recommendations above.
Cough

If mild and able to swallow: Pholcodine 10mg orally QID.

If severe and continuous infusion is available: Morphine 10mg subcut infusion over 24 hours.

If eGFR <30mL/min or >65 years of age or frail: Morphine 5mg subcut infusion over 24 hours.

If continuous infusion is not available: Morphine 2.5mg subcut injection 4 hourly.
If eGFR <30mL/min or >65 years of age or frail: Morphine 1.25mg subcut injection 4 hourly.

Always ensure PRN medications are available. Based on the doses above, prescribe Morphine 2.5 mg subcut injection PRN 1-2 hourly.

If eGFR <30mL/min or >65 years of age or frail: Morphine 1.25mg subcut injection PRN 1-2 hourly.

  • Dry cough has been reported as likely to affect up to 65% of people though this number varies across patients.
  • Monitor patients receiving opioids for undesirable effects, especially nausea, vomiting and constipation.
Fever
  • Cool face washers
  • Ice to suck if tolerated
  • If able to swallow: Paracetamol 1g oral 6 hourly PRN orally or
  • PRN Diclofenac 75mg oral 8 hourly PRN (max dose 200mg daily)
  • If unable to swallow:
    Paracetamol 1gm intravenous injection 6 hourly PRN or
    Ketorolac 10mg sub cut injection stat followed by 10-30 mg subcut injection 8 hourly (max 90mg daily).

Reports suggest up to 70% of people may experience fevers.

Delirium
  • Mild and not distressed
  • Re-orientate to time and place
  • Reassurance
  • Ensure not in urinary retention
 If the patient is not settling or becoming more distressed: add Haloperidol 0.5-1mg subcut injection 4 hourly PRN.
  • Haloperidol is contraindicated in some patient groups e.g. Parkinson Disease.
  • Avoid Melatonin. There is insufficient evidence to support the use of melatonin in patients with delirium. Use is not recommended.
  • This may be very distressing for families.
Respiratory tract secretions
  • Repositioning the patient from side to side in a semi-upright position is recommended
  • Suctioning of the oropharynx is very rarely recommended
  • The most important non-pharmacological intervention is to preemptively counsel carers, families and other health professionals that noisy breathing is part of dying process.
Trial Glycopyrronium (or Hyoscine Butlybromide if Glycopyrronium

is not available) for 24 hours and cease if no change in noisy breathing observed.

Start with Glycopyrronium 0.2 mg subcut injection 4 hourly PRN.

If severe and continuous subcut infusion available: Glycopyrronium 1.2 mg subcut infusion over 24 hours.

If Glycopyrronium not available:

Start with Hyoscine Butlybromide 20mg subcut injection 4 hourly PRN.

If severe and continuous subcut infusion available: consider Hyoscine Butlybromide 120 mg subcut infusion over 24 hours.

  • Based on Australian and international data, there is very few data that suggest respiratory secretions impact people dying of COVID-19.
  • There is currently no evidence to show that medications for treating respiratory secretions at the end-of-life are more effective than placebo, although the evidence base is limited.
  • In the absence of evidence to guide recommendations, there is ongoing uncertainty as to the need to treat secretions as this is a normal part of the dying process.
  • Note: Hyoscine Butylbromide and Glycopyrronium Bromide inhibits salivary secretions and to a lesser extent bronchial secretions which means all patients will develop a very dry mouth so regular mouth care is essential.

Document information

Developed by

Health and Social Policy Branch.

Consultation

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.

Reviewed by

  • Professor Katherine Clark, Palliative care community of practice Clinical Lead
  • Dr Anthoulla Mohamudally, RPAH Head of Department Palliative Medicine
  • Professor Richard Chye, Palliative Care COP Clinical Lead
  • Drug and Therapeutics community of practice

For use by

Clinicians prescribing medications for patients with COVID-19 disease in last days of life in absence of palliative care specialist availability.


Current as at: Monday 6 September 2021
Contact page owner: Health Protection NSW