Managing end-of-life symptoms

eGFR >30mL/min: 2.5mg morphine SC every hr (PRN) for pain and breathlessness

eGFR <30mL/min: 100mcg alfentanil SC every hr (PRN) for pain and breathlessness

If 3 consecutive doses are ineffective, seek specialist advice:

• in hours: specialist in house palliative care team
• out of hours: commonly palliative care dr contacted through local hospice

2.5mg midazolam SC every hr (PRN) for agitation

Same prescription regardless of renal function

Seek advice if 3 consecutive doses are ineffective

• antihistamine/anticholinergic (e.g. cyclizine): vestibular, raised ICP, organ damage (liver capsule pain, stretch pain), unknown/terminal phase
• dopamine antagonist + pro-kinetic (e.g. metoclopramide, domperidone): gastric stasis, do not use in Parkinson's disease
• dopamine antagonist (e.g. haloperidol): chemical causes (AKI, electrolyte, infection), unknown/terminal phase, do not use in Parkinson's disease
• serotonin antagonists (e.g. ondansetron): chemo-induced nausea, uncertain effectiveness
• benzodiazepines (e.g. midazolam, lorazepam): psychological e.g. anxiety

eGFR >30: 50mg cyclizine SC 8hrly (PRN), max 150mg/24hrs, consider infusion if regular doses required

eGFR <30: 1mg haloperidol 4hrly (PRN). If 2 consecutive doses ineffective, seek advice. Review after 24hrs and consider regular 2.5mg SC ON if effective

Hyoscine has antimuscarinic and anticholinergic effects- decreases excess secretions

eGFR >30: 400mcg hyoscine hydrobromide SC every hr (PRN), max 2.4mg in 24hrs

eGFR <30: 20mg hyoscine butylbromide SC every hr (PRN), max 120mg/24hrs