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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.

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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

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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 and agitation.​​​​​​​​​​​

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

 ​​​​
​Symptom ​Non-Pharmacological ​Pharmacological ​Guidance 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.

In addition, prescribe MORPHINE 2.5mg 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 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 0.30mg
(3 drops) 12 hourly.

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

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

  • ​Avoid hand-held fans.
  • Low flow conventional oxygen therapy is sufficient for most adult patients with SpO2<92%.
  • 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.
  • Contact the Specialist Palliative Care team if any concerns or extra advice required.
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

​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 0.2mg subcut injection 4 hourly PRN.

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

If GLYCOPYRRONIUM not available: Start with HYOSCINE BUTLYBROMIDE 20mg subcut 4 hourly PRN.

If severe and continuous subcut infusion available: consider HYOSCINE BUTLYBROMIDE 120mg subcut infusion over 24 hours.

  • ​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 some uncertainty as to the need to treat secretions.
  • Counselling of relatives and caregivers is important. Noisy breathing can be distressing to carers and family but with education many patients do not require interventions such as medications.
  • Note: HYOSCINE BUTYLBROMIDE and GLYCOPYRRONIUM BROMIDE inhibit salivary secretions more than bronchial secretions which means all patients will develop a very dry mouth so regular mouth care is essential.
Anxiety​
  • ​If mild, encourage relaxation, breathing techniques

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

  • ​PARENTERAL CLONAZEPAM
    12-hourly may be substituted for SUBLINGUAL CLONAZEPAM
    12-hourly if the patient has a very dry mouth.
  • Contact Specialist Palliative Care if there are any questions or extra advice needed.
Cough

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

If severe and continuous infusion is available: MORPHINE 10mg continuous subcut infusion over 24 hours.
If eGFR <30mL/min or >65 years of age or frail: 5mg subcut infusion over 24 hours.

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

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

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

  • ​Monitor patients receiving opioids for undesirable effects, especially nausea
Fever​
  • ​Cool face washers
  • Ice to suck if tolerated
If able to swallow: PARACETAMOL 1g QID orally
  • ​​Avoid NSAIDs except in the very final stages of life.
Delirium​
  • ​Mild and not distressed
  • Reorientate 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 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.
  • For ongoing prescribing recommendations or if very distressed and agitated, contact Specialist Palliative Care for further advice.

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

Dr Katherine Clark, Palliative care community of practice Clinical Lead.

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: Tuesday 6 October 2020
Contact page owner: Health Protection NSW