End of Life (COVID-19)

This guidance is intended to be used alongside the Scottish Palliative Care Guidelines for COVID-19 and is a simple addendum employing the standard NHS Highland ‘Just-in-Case’ medicines.

• The main symptoms approaching end-of-life will be anxiety, agitated delirium, cough, breathlessness / air hunger, failure to clear secretions and pain.
• The following recommendations assume the patient has been ‘diagnosed as dying’ and is in the last days / hours of life when swallowing is inconsistent.

Anticipatory (‘Just-in-Case’) prescribing for end-of-life care

The following parenteral preparations will all be well absorbed via the buccal or intranasal route if the subcutaneous route cannot be used for staffing or for confidence issues. Doses may need to be drawn up by trained staff and left in the house for carer / family administration.

If repeated dosing of any of the above is required (and effective) then consider a continuous subcutaneous infusion if syringe pumps are available. If there is no pump availability then instruct carers in regular buccal dosing (every 4 hours for all above medications, unless evidence of renal failure, in which case administration every 8 hours) or train in subcutaneous administration via butterfly or similar device. This should maintain comfort almost as well as a continuous infusion.

If regular dosing is difficult to maintain, alternative long-acting background preparations include MST per rectum, opioid transdermal patches (but 18 to 24 hours to peak effect so continue regular dosing for 12 hours after placing patch), lorazepam (500 micrograms) buccally, clonazepam (500 micrograms) by sub cut injection, hyoscine hydrobromide transdermal patch (‘Scopaderm’) for thin secretions and nausea.

Notes

• The morphine ‘as required’ dose may need to be higher if the patient is already on an opioid (an appropriate dose would be 1/6 of the 24 hour background dose).
  If the patient is already on oxycodone it is preferable, but not imperative, to use oxycodone in place of morphine. For all other background opioids (eg fentanyl) use morphine as above.
• Buprenorphine patch 5micrograms/hr = approx 12mg oral morphine/24hrs
  Fentanyl patch 12micrograms/hr = approx 40mg oral morphine/24hrs.
• Morphine is a very poor sedative; midazolam is an excellent sedative.
• Watch for morphine toxicity, particularly as patients dying of COVID-19 often develop renal failure (vivid dreams, hallucinations, myoclonus, hypersensitivity / total body pain).
• Morphine can be given in severe renal impairment. Effects are likely to last longer so regular dosing interval is extended and a background infusion may never be needed.
• Give morphine and midazolam together for severe breathlessness.
• Give midazolam and levomepromazine together for severe agitation that is not settling with midazolam alone – assuming no reversible cause is identified and sedation is the only means to manage the patient.
• Anticipatory medicines are typically given up to hourly. More frequent administration may be required to rapidly control severe symptoms – seek advice.
• Reassess if breakthrough doses are ineffective or frequent dosing is required.

More comprehensive guidelines for the control of symptoms specifically in patients with COVID-19 infection and for general palliative care can be found at:

https://www.palliativecareguidelines.scot.nhs.uk/

Local advice can be obtained 24/7 by calling Highland Hospice (01463 243132)

COVID-19 End-of-Life Symptom Control Using NHS Highland ‘Just-in-Case’ Medicines

COVID-19 End-of-Life Symptom Control - Non-Pharmacological Interventions

Symptom control

• main symptoms approaching end-of-life will be agitation, respiratory symptoms and pain
• following recommendations assume the patient has been ‘diagnosed as dying’ and is in the last days/ hours of life
• Abbreviations
  • Sub cut = subcutaneous
  • csci = continuous subcutaneous infusion

Anticipatory prescription (uncomplicated end-of-life care)

Morphine sulfate 5mg sub cut as required for pain, cough and breathlessness

Midazolam 5mg sub cut as required for agitation and breathlessness

Hyoscine butylbromide 20mg sub cut as required for respiratory secretions

Levomepromazine 5mg sub cut as required for nausea

Levomepromazine 25mg sub cut as required for severe agitation

Notes

• Consider whether the patient is benefiting from any oxygen prescribed. If not, consider discontinuing non-beneficial oxygen and using medication and non-pharmacological measures for symptom control.
• Morphine dose may need to be higher if the patient is already on an opioid.
• Morphine is a very poor sedative.
• Watch for morphine toxicity (vivid dreams, hallucinations, myoclonus, hypersensitivity)
• Morphine can be given in severe renal impairment. Effects are likely to last longer so may never need background infusion. Dose reduction or increased dose intervals may be required.  Co-administration of midazolam can reduce emergence of morphine toxicity.
• Give morphine and midazolam together for severe breathlessness.
• Give midazolam and levomepromazine together for severe agitation not settling with midazolam alone – assuming no reversible cause is identified and sedation is the only means to manage the patient.
• Anticipatory medicines are typically given up to hourly. More frequent administration may be required to rapidly control severe symptoms.
• Reassess if breakthrough doses ineffective or frequent dosing required.

This guidance supplements the Scottish Palliative Care Guidelines: End of Life Care medication guidance to support professionals in all settings to reduce suffering when a person is rapidly dying from Covid-19 available at: https://www.palliativecareguidelines.scot.nhs.uk/

24h Specialist palliative care telephone advice available 01463 243132

Management of acute distress/ agitation

If the patient is acutely distressed and a risk to themselves or others.

Seek senior review/ advice.

Management of severe breathlessness (air hunger)

It is appropriate to use morphine as a respiratory depressant to reduce the perception of breathlessness.  Breathlessness is by definition frightening so the co-administration of an anxiolytic will usually be necessary.

Management of severe agitation

Rapid patient assessment required.  Specific attention to potentially reversible causes and environmental factors.      

Two new COVID-19 Guidelines have been added to the Scottish Palliative Care Guidelines. The new guidelines are:

• for symptom management for when a person is imminently dying from COVID-19 and when no reversible causes for symptoms can be found
• for supporting end of life care when alternatives to medication normally given through syringe pumps are required.

The standard end of life care guidelines should be used for all other situations.

Further guidance related to COVID-19 is also now available on the Guidelines website and includes: 

• Anticipatory Care Planning guidance
• Communications guide
• Practical resources to help professionals giving medicines
• Signposts to support members of the public through serious illness death and loss
• Support for professionals themselves

This information is subject to review and update in the light of on-going experience.

Highland Palliative Care COVID-19 Guidance 

Local Highland Guidance for community sector is also available to accompany the Scottish Guidelines.  See: http://intranet.nhsh.scot.nhs.uk/Org/DHS/Pharmacy/PALLIATIVECAREPHARMACY/Pages/Default.aspx.

Anticipatory Care Planning (ACP) during COVID-19

Guidance around ACP information re COVID-19 is available in this link for information and signposting https://ihub.scot/acp-covid-19

Scottish Government Clinical & Ethical Advice - COVID-19 

Scottish Government clinical advice re COVID-19 is available along with primary care triage advice https://www.gov.scot/publications/coronavirus-covid-19-clinical-advice/ 

The ethical advice and support framework is available at: https://www.gov.scot/publications/coronavirus-covid-19-ethical-advice-and-support-framework/

Please also see general guidance on TAM for palliative care.

Click here.

Click here

Key Information Toward the End of life - Inverness area - Patient Information

Key Information Toward the End of life during COVID-19 - NHS Highland and Argyll and Bute - Patient information