晚期肿瘤病人临终用药指南.pdf

Palliative Care Guidelines:Last days of life|Version 231 NHS Lothian Re-issue date:August 2010 Review date:August 2013Last days of lifeIntroduction When all reversible causes for the patients deterioration have been considered,the multi-disciplinary team agrees the patient is dying and changes the goals of care.Reversible causes to consider include:dehydration infection opioid toxicity renal impairment hypercalcaemia deliriumClinical signs may include:Patient is bedboundIncreasingly drowsy or semicomatoseOnly able to take sips of fluidDifficulty swallowing tabletsManagement of a dying patient and their family Plan and document care;consider using a care pathway or checklist.Team Discuss prognosis(patient is dying),goals of care(maintaining comfort)and preferred place of death with the patient and/or family.If discharge home is possible,prompt and careful planning are needed.Contact GP,district nurse and occupational therapist urgently.Medical staff Clarify resuscitation status;check DNA CPR form has been completed.(See:national policy)o Reassure the patient and family that full supportive care will continue.Discontinue inappropriate interventions(blood tests,IV fluids and medication,vital signs monitoring,frequent blood sugar tests).Medication review at least once daily.o Stop any treatment not needed for symptom control.o Choose an appropriate route.If able to swallow,consider liquid formulations otherwise change to the subcutaneous or rectal route.o Consider need for a SC infusion of medication via a syringe pump.o Anticipatory prescribing of as required medication in advance for common symptoms.Hydration:o Discontinue tube feeding/fluids if respiratory secretions are present,if there is risk of aspiration due to reduced conscious level,or at the patients request.o Over-hydration contributes to distressing respiratory secretions.Artificial fluids are usually not appropriate,but if indicated can be given subcutaneously overnight.(See:Subcutaneous fluids)Nursing staff Comfort nursing care(pressure relieving mattress,reposition for comfort only),eye care,mouth care(sips of fluid,oral gel),bladder and bowel care.Explain to the family why the nursing and medical care has been altered and what changes to expect in the patients condition.(See leaflet:What happens when someone is dying)Ward team;record arrangements for contacting the family when the patient deteriorates or dies.Community team;ensure the family/carers know who to contact when the patient dies.Consider emotional,spiritual/religious,legal and family needs including those of children.Identify those at increased risk in bereavement and seek additional support.o Previous multiple losses or recent bereavemento Ambivalent or dependent relationshipo Living alone and lacking a support networko Mental illness,drug or alcohol dependencyo Dependent children (See:Bereavement on website)Palliative Care Guidelines:Last days of life|Version 232Re-issue date:August 2010 Review date:August 2013 NHS LothianSymptom Control in the last days of lifeAnticipatory prescribingAll patients should have as required medication for symptom control available.Opioid analgesic SC,hourly;dose depends on patient,clinical problem and previous opioid use.1/6th of 24 hour dose of any regular opioid.If not on a regular opioid,morphine SC 2mg or diamorphine SC 2mg.Anxiolytic sedative:midazolam SC 2-5mg,hourly.Anti-secretory medication:hyoscine butylbromide(Buscopan)SC 20mg,hourly.Anti-emetic:haloperidol SC 0.5mg,12 hourly or levomepromazine SC 2.5-5mg,12 hourly.Pain Paracetamol or diclofenac(as liquid/dispersible or rectally).NSAID benefits may outweigh risks in a dying patient;can help bone,joint,pressure sore,inflammatory pain.Convert any regular oral morphine or oxycodone to a 24 hour,SC infusioneg.oral morphine 30mg=SC morphine 15mg=SC diamorphine 10mgeg.oral oxycodone 15mg=SC morphine 15mg=SC oxycodone 7-8 mg For opioid dose conversions,see:Choosing&Changing Opioids and/or seek advice.Fentanyl patches should be continued in dying patients.(See:Fentanyl patches)For patient with stage 4-5 chronic kidney disease,see:Last days of life(renal)guideline.Breakthrough analgesia,should be prescribed hourly as required:1/6th of 24 hour dose of any regular opioid orally and subcutaneously.If not on any regular opioid,prescribe morphine SC 2mg or diamorphine SC 2mg.Agitation/deliriumAnxiety/distressmidazolam SC 2-5mg,hourly,as required Confusion/deliriumhaloperidol SC 2mg,once or twice dailyEstablished terminal delirium/distress1st linemidazolam SC 20-30mg over 24 hours in a syringe pump+midazolam SC 5mg hourly,as required OR regular rectal diazepam 5-10mg,6-8 hourly.2nd linemidazolam SC 40-80mg over 24 hours in a syringe pump+levomepromazine SC 12.5-25mg,6-12 hourly,as required.Stop haloperidol.Nausea/vomiting(see:Nausea/Vomiting)If already controlled with an oral anti-emetic,use the same drug as a SC infusion.Treat new nausea/vomiting with a long acting anti-emetic given by SC injection or give a suitable antiemetic as a SC infusion in a syringe pump.Long acting anti-emetics:haloperidol SC 1mg 12 hourly or 2mg once daily.levomepromazine SC 2.5mg 12 hourly or 5mg once daily.Doses of antiemetics for use in a SC infusion-See:Subcutaneous medication.Persistent vomiting:an NG tube,if tolerated,may be better than medication.Other relevant guidelines Subcutaneous medication(prescribing advice and drug compatibility tables)Choosing&changing opioids Subcutaneous fluids Mouth Care Levomepromazine End-of-life care in non-cancer illnesses:Renal disease,Liver disease,Heart disease-see websitePalliative Care Guidelines:Last days of life|Version 233 NHS Lothian Re-issue date:August 2010 Review date:August 2013Breathlessness Oxygen is only useful if hypoxic;nasal prongs are better tolerated than a mask.A fan or position change can help.Intermittent breathlessness/distressmidazolam SC 2-5mg hourly,as required&/or lorazepam sublingual 0.5mg,4-6 hourly,as required.Opioid(2 hourly as required)regular opioid 25%of the 4 hourly breakthrough analgesia dose of opioid;titrate dose.no opioid morphine SC 2mg or diamorphine SC 2mg.Persistent breathlessnessmidazolam SC 5-20mg+morphine SC 5-10mg or diamorphine SC 5-10mg(if no previous opioid use)via a syringe pump over 24 hours.Respiratory tract secretions Avoid fluid overload;assess fluid balance,stop IV/SC fluids and tube feeding.Changing the patients position may help.Intermittent SC injections often work well or medication can be given as a SC infusion.1st line:hyoscine butylbromide SC 20mg,hourly as required(up to 120mg/24hours).2nd line:glycopyrronium bromide SC 200micrograms,6-8 hourly as required.3rd line:hyoscine hydrobromide SC 400micrograms,2 hourly as required.Acute terminal events(see:Emergencies in palliative care)Dying patients occasionally develop acute distress;can be due to:Bleeding:haemorrhage from GI or respiratory tract,or external tumour.Acute pain:bleeding into a solid tumour,fracture,ruptured organ.Acute respiratory distress:pulmonary embolism,retained secretions.Management Prescribe sedation in advance if patient at risk;document and discuss anticipatory care plan with family and key professionals.Give midazolam IM 5-10mg into deltoid muscle or diazepam rectal solution 10mg PR(can be given via stoma)or sedate using IV midazolam if IV access available.If patient is in pain or has continued respiratory distress despite midazolam,give additional morphine SC or diamorphine SC as required.Practice points Opioid analgesics should not be used to sedate dying patients.Sudden increase in pain or agitation;exclude urinary retention,constipation;other reversible causes.Subcutaneous infusions provide maintenance treatment only.Additional doses of medication by SC injection will be needed if the patients symptoms are not controlled.Midazolam is titrated in 5-10 mg steps.Up to 5mg can be given in a single SC injection(1ml).Single SC doses can last 2-4 hours.Useful as an anticonvulsant.Rectal diazepam solution;longer acting alternative to midazolam given PR or via a stoma.Terminal secretions can be controlled in about 60%of cases;fluid overload,aspiration and respiratory infection increase incidence.Consider a nicotine replacement patch for heavy smokers.Resources ProfessionalNHS End of life care Programme http:/www.endoflifecare.nhs.uk/eolcLiverpool Integrated Care Pathway http:/www.mcpcil.org.uk/liverpool_care_pathwayPatientPatient leaflet on website:What happens when someone is dying.Further reading:http:/www.palliativecareguidelines.scot.nhs.uk