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.
|Morphine 2.5mg to 5mg sub-cut OR buccal, hourly as required for pain, breathlessness or distressing, persistent, cough|
|Midazolam 2.5mg to 5mg sub-cut OR buccal every 30 minutes as required for anxiety, agitation and /or breathlessness (buccal preparation more palatable but solution for injection [10mg/2mL] equally well absorbed)|
|Hyoscine butylbromide 20mg sub-cut every 4 hours as required OR Atropine 1% eye drops, 1 to 2 drops buccally every 4 hours as required for THIN respiratory secretions. Thick secretions may be more difficult to clear by anticholinergics.|
|Levomepromazine 5mg sub-cut OR buccal as required for nausea.|
|Levomepromazine 12.5mg to 25mg sub-cut OR buccal as required for severe agitation.|
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.
- 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:
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