Almost everyone who takes morphine gets constipated. You should have been prescribed a laxative along with your morphine — this should be taken regularly and may need to be increased as the dose of morphine increases. About a third of people feel a bit sick or actually are sick when starting morphine.
It just means that your body is adjusting to having the drug in your system. Specific medication can be added to reduce this, and stopped once your body has adjusted. It may need to be re-introduced if the morphine dose is increased.
In the past, morphine was often associated with drug addiction. But taking morphine for pain will not make you an addict. Commonly, people worry when their dose of morphine increases. But the increase is usually because the disease is changing and you need more to manage the pain. Because it is used for persistent pain you should not stop taking morphine suddenly without discussing this with your doctor or nurse. Some people find they get a bit sleepy with morphine. Once again, this is a sign of your body adjusting to the drug and should ease after a few days.
There are other possible side effects — very rarely some people will see things hallucinations. This may mean the dose is a little high. Occasionally some people will develop an itch. Morphine is unusual in that there is no maximum dose. If it is taken for pain as prescribed, the dose can be increased gradually to match your pain. The Investigating the Process of Dying study systematically examined physical signs in consecutive cancer patients.
The early signs had high frequency, occurred more than 1 week before death, and had moderate predictive value that a patient would die in 3 days. Early signs included the following:. The late signs occurred mostly in the last 3 days of life, had lower frequency, and were highly specific for impending death in 3 days. Late signs included the following:[ 9 ]. In particular, the high positive likelihood ratios LRs of pulselessness on the radial artery positive LR, A prospective observational study that examined vital signs in the last 7 days of life reported that blood pressure and oxygen saturation decreased as death approached.
However, a large proportion of patients had normal vital signs, even in the last 12 hours of life. Moderate changes in vital signs from baseline could not definitively rule in or rule out impending death in 3 days.
Therefore, predicting death is difficult, even with careful and repeated observations. Several other late signs that have been found to be useful for the diagnosis of impending death include the following:[ 14 ].
In conclusion, bedside physical signs may be useful in helping clinicians diagnose impending death with greater confidence, which can, in turn, assist in clinical decision making and communication with families. Preparations include the following:. In the final days to hours of life, patients often have limited, transitory moments of lucidity. Family members should be prepared for this and educated that this is a natural aspect of the dying process and not necessarily a result of medications being administered for symptoms or a sign that the patient is doing better than predicted.
Despite their limited ability to interact, patients may be aware of the presence of others; thus, loved ones can be encouraged to speak to the patient as if he or she can hear them. Educating family members about certain signs is critical.
In the final hours of life, patients often experience a decreased desire to eat or drink, as evidenced by clenched teeth or turning from offered food and fluids. Finally, the death rattle is particularly distressing to family members. It is important to assure family members that death rattle is a natural phenomenon and to pay careful attention to repositioning the patient and explain why tracheal suctioning is not warranted.
Such rituals might include placement of the body e. When death occurs, expressions of grief by those at the bedside vary greatly, dictated in part by culture and in part by their preparation for the death. Chaplains are to be consulted as early as possible if the family accepts this assistance. Health care providers can offer to assist families in contacting loved ones and making other arrangements, including contacting a funeral home. The available evidence provides some general description of frequency of symptoms in the final months to weeks of the end of life EOL.
However, when the results of published studies of symptoms experienced by patients with advanced cancer are being interpreted or compared, the following methodological issues need to be considered:[ 1 ]. Results of one of the larger and more comprehensive studies of symptoms in ambulatory patients with advanced cancer have been reported. The ESAS is a patient-completed measure of the severity of the following nine symptoms:. Analysis of the changes in the mean symptom intensity of 10, patients and involving 56, assessments over time revealed two patterns:[ 2 ].
In terms of symptoms closer to the EOL, a prospective study documented the symptom profile in the last week of life among cancer patients who died in acute palliative care units.
ESAS anorexia, drowsiness, fatigue, poor well-being, and dyspnea increased in intensity closer to death. In contrast, ESAS depression decreased over time. Dysphagia of solids and liquids and urinary incontinence were also present in an increasing proportion of patients in the last few days of life. Less common but equally troubling symptoms that may occur in the final hours include death rattle and hemorrhage. The following sections summarize some of the common symptoms and potential approaches to ameliorating those symptoms, based on available evidence.
A final note of caution is warranted. Symptoms often cluster, and the presence of a symptom should prompt consideration of other symptoms to avoid inadvertently worsening other symptoms in the cluster.
For example, a systematic review of observational studies concluded that there were four common clusters of symptoms anxiety-depression, nausea-vomiting, nausea-appetite loss, and fatigue-dyspnea-drowsiness-pain.
Delirium is associated with shorter survival and complicates symptom assessment, communication, and decision making. Furthermore, it can be extremely distressing to caregivers and health professionals. Safety measures include protecting patients from accidents or self-injury while they are restless or agitated. The use of restraints should be minimized. Reorientation strategies are of little use during the final hours of life. There are few randomized controlled trials on the management of delirium in patients with terminal or irreversible delirium.
Care of the patient with delirium can include stopping unnecessary medications, reversing metabolic abnormalities if consistent with the goals of care , treating the symptoms of delirium, and providing a safe environment.
Agents known to cause delirium include:. In a small, open-label, prospective trial of 20 cancer patients who developed delirium while being treated with morphine, rotation to fentanyl reduced delirium and improved pain control in 18 patients. The onset of effect and non-oral modes of delivery are considered when an agent is being selected to treat delirium at the EOL.
Agents that can be used to manage delirium include haloperidol, 1 mg to 4 mg orally, intravenously IV , or subcutaneously. Chlorpromazine can be used, but IV administration can lead to severe hypotension; therefore, it should be used cautiously.
In addition, a small, double-blind, randomized trial at the University of Texas MD Anderson Cancer Center compared the relative sedating effects of scheduled haloperidol, chlorpromazine, and a combination of the two for advanced-cancer patients with agitated delirium.
Rescue doses equivalent to the standing dose were allowed every 1 hour as needed and once at protocol initiation, with the goal of producing sedation with a Richmond Agitation-Sedation Scale RASS score of 0 to —2. Dose escalations and rescue doses were allowed for persistent symptoms.
Of the 68 randomized patients, 45 patients were treated and monitored until death or discharge. Patients in all three groups demonstrated clinically significant decreases in RASS scores within 30 minutes and remained sedated at 24 hours. No statistically significant difference in sedation levels was observed between the three protocols. However, the chlorpromazine group was less likely to develop breakthrough restlessness requiring rescue doses or baseline dosing increases.
The study was limited by a small sample size and the lack of a placebo group. Although benzodiazepines such as lorazepam or antidopaminergic medications could exacerbate delirium, they may be useful for the treatment of hyperactive delirium that is not controlled by other supportive measures.
In intractable cases of delirium, palliative sedation may be warranted. A randomized controlled trial compared the effect of lorazepam versus placebo as an adjunctive to haloperidol on the intensity of agitation in 58 patients with delirium in a palliative care unit. Once enrolled, patients began a regimen of haloperidol 2 mg IV every 4 hours, with 2 mg IV hourly as needed for agitation.
The RASS score was monitored every 2 hours until the score was 2 or higher. At this threshold, the patient received lorazepam 3 mg or matching placebo with one additional dose of haloperidol 2 mg. The primary outcome of RASS score reduction was measured 8 hours after administration of the study drug. Patients in the lorazepam group experienced a statistically significant reduction in RASS score increased sedation at 8 hours —4. Lorazepam-treated patients also required significantly lower doses of rescue neuroleptics and, after receiving the study medication, were perceived to be in greater comfort by caregivers and nurses.
No differences in mortality were noted between the treatment arms. Caution should be exercised in the use of this protocol because of the increased risk of significant sedation. Intensive evaluation of RASS scores may be challenging for the bedside nurse. Although patients may sometimes find these hallucinations comforting, fear of being labeled confused may prevent patients from sharing their experiences with health care professionals. Fatigue is one of the most common symptoms at the EOL and often increases in prevalence and intensity as patients approach the final days of life.
Scores on the Palliative Performance Scale also decrease rapidly during the last 7 days of life. Methylphenidate may be useful in selected patients with weeks of life expectancy. Treatment options for dyspnea, defined as difficult, painful breathing or shortness of breath, include opioids, nasal cannula oxygen, fans, raising the head of the bed, noninvasive ventilation, and adjunctive agents. Opioids are often considered the preferred first-line treatment option for dyspnea.
The routine use of nasal cannula oxygen for patients without documented hypoxemia is not supported by the available data. One group of investigators reported a double-blind randomized controlled trial comparing the severity of morning and evening breathlessness as reported by patients who received either supplemental oxygen or room air via nasal cannula. There were no significant differences in secondary outcomes such as extreme drowsiness or nasal irritation.
Potential criticisms of the study include the trial period being only 7 days and a single numerical scale perhaps inadequately reflecting the palliative benefit of oxygen. A small pilot trial randomly assigned 30 Chinese patients with advanced cancer with unresolved breathlessness to either usual care or fan therapy. The measurements were performed before and after fan therapy for the intervention group. There was a significant improvement in the self-reported scores of the patients in the fan group but not in the scores of controls.
There were no changes in respiratory rates or oxygen saturations in either group. A randomized trial compared noninvasive ventilation with tight-fitting masks and positive pressure with supplemental oxygen in a group of advanced-cancer patients in respiratory failure who had chosen to forgo all life support and were receiving palliative care.
Two hundred patients were randomly assigned to treatment. Patients in the noninvasive-ventilation group reported more-rapid improvement in dyspnea and used less palliative morphine in the 48 hours after enrollment.
Eleven patients in the noninvasive-ventilation group withdrew because of mask discomfort. It should be noted that all patients were given subcutaneous morphine titrated to relief of dyspnea. Whether patients with less severe respiratory status would benefit is unknown. The generalizability of the intervention is limited by the availability of equipment for noninvasive ventilation. In addition, while noninvasive ventilation is less intrusive than endotracheal intubation, a clear understanding of the goals of the intervention and whether it will be electively discontinued should be established.
Bronchodilators may help patients with evidence of bronchoconstriction on clinical examination. Corticosteroids may also be of benefit but carry a risk of anxiety, insomnia, and hyperglycemia. The treatment of potential respiratory infections with antibiotics likewise calls for a consideration of side effects and risks.
Many patients fear uncontrolled pain during the final days of life, but experience suggests that most patients can obtain pain relief and that very high doses of opioids are rarely indicated. Some patients, family members, and health care professionals express concern that opioid use may hasten death. Several studies refute the fear of hastened death associated with opioid use.
In several surveys of high-dose opioid use in hospice and palliative care settings, no relationship between opioid dose and survival was found. The principles of pain management remain similar to those for patients earlier in the disease trajectory, with opioids being the standard option. Refer to the PDQ summary on Cancer Pain for a more complete review of parenteral administration of opioids and opioid rotation. Because consciousness may diminish during this time and swallowing becomes difficult, practitioners need to anticipate alternatives to the oral route.
In one study, as patients approached death, the use of intermittent subcutaneous injections and IV or subcutaneous infusions increased. For patients who do not have a preexisting access port or catheter, intermittent or continuous subcutaneous administration provides a painless and effective route of delivery. Cough is a relatively common symptom in patients with advanced cancer near the EOL. The treatment of troublesome coughing in patients in the final weeks to days of life is largely empiric, although diagnostic imaging or evaluation may occasionally be of value.
However, simple investigations such as reviewing medications or eliciting a history of symptoms compatible with gastroesophageal reflux disease are warranted because some drugs e. In addition, patients may have comorbid conditions that contribute to coughing. The cough reflex protects the lungs from noxious materials and clears excess secretions. The reflex is initiated by stimulation of peripheral cough receptors, which are transmitted to the brainstem by the vagus nerve.
As discussed in the Dyspnea section of this summary, the use of bronchodilators, corticosteroids, or inhaled steroids is limited to specific indications, given the potential risks and the lack of evidence of benefit outside of specific indications. Such patients often have dysphagia and very poor oral intake. Treatment of constipation in patients with only days of expected survival is guided by symptoms.
If indicated, laxatives may be given rectally e. Functional dysphagia and structural dysphagia occur in a large proportion of cancer patients in the last days of life. Specifically, patients often experience difficulty swallowing both liquids and solids, which is often associated with anorexia and cachexia. Nonessential medications are discontinued. Instead of tube-feeding or ordering nothing by mouth, providing a small amount of food for enjoyment may be reasonable if a patient expresses a desire to eat.
Refer to the Artificial Hydration and Artificial Nutrition sections of this summary for more information. Death rattle, also referred to as excessive secretions, occurs when saliva and other fluids accumulate in the oropharynx and upper airways in a patient who is too weak to clear the throat. Rattle does not appear to be distressing for the patient; however, family members may perceive death rattle as indicating the presence of untreated dyspnea.
Thus, the family will benefit from learning about the nature of this symptom and that death rattle is not associated with dyspnea. The results of clinical trials examining various pharmacologic agents for the treatment of death rattle have so far been negative. Despite the lack of clear evidence, pharmacologic therapies are used frequently in clinical practice.
Glycopyrrolate is available parenterally and in oral tablet form. Doses typically range from 1 mg to 2 mg orally or 0. Repositioning may be helpful. Suctioning of excessive secretions may be considered for some patients. Health care professionals need to monitor patients for opioid-induced neurotoxicity, which can cause symptoms such as myoclonus, hallucinations, hyperalgesia, seizures, and confusion, and which may mimic terminal delirium.
Myoclonus is defined as sudden and involuntary movements caused by focal or generalized muscle contractions. The duration of contractions is brief and may be described as shocklike. There are many potential causes of myoclonus, most of which probably stem from the metabolic derangements anticipated as life ends.
Medications, particularly opioids, are another potential etiology. The reported prevalence of opioid-induced myoclonus ranges greatly, from 2. When opioids are implicated in the development of myoclonus, rotation to a different opioid is the primary treatment. In patients with rapidly impending death, the health care provider may choose to treat the myoclonus rather than make changes in opioids during the final hours.
Benzodiazepines, including clonazepam, diazepam, and midazolam, have been recommended. There are no reliable data on the frequency of fever. A prospective study of adults with terminal cancer admitted to a hospice and palliative care unit in Taiwan indicated that fever was uncommon and of moderate severity mean score, 0.
In addition to considering diagnostic evaluation and therapeutic intervention, the clinician needs to carefully assess whether the patient is distressed or negatively affected by the fever. There are no data showing that fever materially affects the quality of the experience of the dying person. While infection may cause a fever, other etiologies such as medications or the underlying cancer are to be strongly considered.
While the main objective in the decision to use antimicrobials is to treat clinically suspected infections in patients who are receiving palliative or hospice care,[ 61 - 63 ][ Level of evidence: II ] subsequent information suggests that the risks of using empiric antibiotics do not appear justified by the possible benefits for people near death. Patients may also experience gastrointestinal bleeding from ulcers, progressive tumor growth, or chemotherapy-induced mucositis.
The management of catastrophic bleeding may include identification of patients who are at risk of catastrophic bleeding and careful communication about risk and potential management strategies. However, two qualitative interview studies of clinicians whose patients experienced catastrophic bleeding at the EOL suggest that it is often impossible to anticipate bleeding and that a proactive approach may cause patients and families undue distress.
Another strategy is to prepare to administer anxiolytics or sedatives to patients who experience catastrophic bleeding, between the start of the bleeding and death. However, there is little evidence supporting the effectiveness of this approach;[ 65 , 67 ] the experience of clinicians is often that patients become unconscious before the drugs can be administered, and the focus on medications may distract from providing patients and families with reassurance that suffering is unlikely.
Nevertheless, the availability of benzodiazepines for rapid sedation of patients who experience catastrophic bleeding may provide some reassurance for family caregivers.
After the death of a patient from a catastrophic hemorrhage, team members are encouraged to verbalize their emotions regarding the experience, and their questions need to be answered. In rare situations, EOL symptoms may be refractory to all of the treatments described above. In such cases, palliative sedation may be indicated, using benzodiazepines, barbiturates, or neuroleptics. Refractory dyspnea is the second most common indication for palliative sedation, after agitated delirium.
Ultimately, the decision to initiate, continue, or forgo chemotherapy should be made collaboratively and is ideally consistent with the expected risks and benefits of treatment within the context of the patient's goals of care.
However, the following reasons independent of the risks and benefits may lead a patient to prefer chemotherapy and are potentially worth exploring:. In the era of personalized medicine, genomic tumor testing is indicated for multiple tumor types, and finding actionable mutations for targeted therapy holds promise for many patients with metastatic cancers. Similarly, immune checkpoint inhibitors have revolutionized the standard of care for multiple cancers.
These drugs are increasingly used in older patients and those with poorer performance status for whom traditional chemotherapy may no longer be appropriate, though they may still be associated with unwanted side effects. Predictive factors for whether any given patient will have a significant response to these newer agents are often unclear, making prognostication challenging.
Data on immune checkpoint inhibitor use at the EOL are limited, but a single-institution retrospective study showed that immunotherapy use in the last 30 days of life is associated with lower rates of hospice enrollment and a higher risk of dying in the hospital. Patients with advanced cancer who receive hospice care appear to experience better psychological adjustment, fewer burdensome symptoms, increased satisfaction, improved communication, and better deaths without hastening death.
Multiple patient demographic factors e. In one study, however, physician characteristics were more important than patient characteristics in determining hospice enrollment. There are many potential barriers to timely hospice enrollment.
Forgoing disease-directed therapy is one of the barriers cited by patients, caregivers, physicians, and hospice services. This 5-year project enrolled its first cohort of patients in January and the second cohort in January CMS will evaluate whether providing these supportive services can improve patient quality of life and care, improve patient and family satisfaction, and inform a new payment system for the Medicare and Medicaid programs.
The purpose of this section is to provide the oncology clinician with insights into the decision to enroll in hospice, and to encourage a full discussion of hospice as an important EOL option for patients with advanced cancer.
The related study [ 20 ] provides potential strategies to address some of the patient-level barriers.
Barriers are summarized in the following subsections on the basis of whether they arise predominantly from the perspective of the patient , caregiver , physician , or hospice , including eligibility criteria for enrollment.
Patients often express a sense that it would be premature to enroll in hospice, that enrolling in hospice means giving up, or that enrolling in hospice would disrupt their relationship with their oncologist. Patients may agree to enroll in hospice in the final days of life only after aggressive medical treatments have clearly failed.
Given the likely benefit of longer times in hospice care, patient-level predictors of short hospice stays may be particularly relevant. One group of investigators conducted a retrospective cohort study of 64, adults with cancer admitted to hospice.
The following factors and odds ratios [ORs] were independently associated with short hospice stays in multivariable analysis:. A diagnosis of depression may also affect how likely patients are to enroll in hospice. The authors found that NSCLC patients with precancer depression depression recorded during the 3—24 months before cancer diagnosis and patients with diagnosis-time depression depression recorded between 3 months before and 30 days after cancer diagnosis were more likely to enroll in hospice than were NSCLC patients with no recorded depression diagnosis subhazard ratio [SHR], 1.
The authors hypothesized that patients with precancer depression may be more likely to receive early hospice referrals, especially given previously established links between depression and high symptom burden in patients with advanced cancer. They also suggested that enhanced screening for depression in patients with cancer may impact hospice enrollment and quality of care provided at the EOL.
The highest rates of agreement with potential reasons for deferring hospice enrollment were for the following three survey items:[ 25 ]. Almost one-half of physicians believed incorrectly that patients must have do-not-resuscitate and do-not-intubate orders in place to qualify for hospice. Patients who are enrolled in hospice receive all care related to their terminal illnesses through hospice, although most hospice reimbursement comes through a fixed per diem.
Thus, hospices may have additional enrollment criteria. A further challenge related to hospice enrollment is that the willingness to forgo chemotherapy does not identify patients who have a high perceived need for hospice care.
Investigators conducted conjoint interviews of patients with cancer and family caregivers to determine the perceived need for five core hospice services visiting nurse, chaplain, counselor, home health aide, and respite care. In a multivariable model, the following patient factors predicted a greater perceived need for hospice services:. The following family factors predicted a greater perceived need for hospice services:.
Many patients with advanced-stage cancer express a desire to die at home,[ 31 ] but many will die in a hospital or other facility. Patients who die at home, however, appear to have a better quality of life than do patients who die in a hospital or ICU, and their bereaved caregivers experience less difficulty adjusting.
Enrollment in hospice increases the likelihood of dying at home, but careful attention needs to be paid to caregiver support and symptom control. In multivariable analysis, the following factors with percentages and ORs were correlated with a greater likelihood of dying at home:.
However, not all patients prefer to die at home, e. Approximately one-third to one-half of pediatric patients who die of cancer die in a hospital. A retrospective analysis of pediatric cancer patients who died while enrolled on the palliative care service at St.
Pediatric care providers may want to consider the factors listed above to identify patients at higher risk of dying in an intensive inpatient setting, and to initiate early conversations about goals of care and preferred place of death.
A necessary goal of high-quality end-of-life EOL care is the alleviation of distressing symptoms that can lead to suffering. An important strategy to achieve that goal is to avoid or reduce medical interventions of limited effectiveness and high burden to the patients. There is, however, a great deal of confusion, anxiety, and miscommunication around the question of whether to utilize potentially life-sustaining treatments LSTs such as mechanical ventilation, total parenteral nutrition, and dialysis in the final weeks or days of life.
To ensure that the best interests of the patient—as communicated by the patient, family, or surrogate decision maker—determine the decisions about LSTs, discussions can be organized around the following questions:. Medicine is a moral enterprise. The decisions clinicians make are often highly subjective and value laden but seem less so because, equally often, there is a shared sense of benefit, harm, and what is most highly valued.
Occasionally, disagreements arise or a provider is uncertain about what is ethically permissible. For example, an oncologist may favor the discontinuation or avoidance of LST, given the lack of evidence of benefit or the possibility of harm—including increasing the suffering of the dying person by prolonging the dying process—or based on concerns that LST interferes with the patient accepting that life is ending and finding peace in the final days.
Individual values inform the moral landscape of the practice of medicine. In the event of conflict, an ethics consult may be necessary to identify the sources of disagreement and potential solutions, although frameworks have been proposed to guide the clinician. Some community pharmacies provide a service for compounding medicine solutions in daily subcutaneous syringes.
Administration instructions do not need to include the rate of infusion, just the infusion duration usually 24 hours. This is because the Niki T34 syringe driver simplifies administration by detecting the syringe size and volume of medicine, and sets the rate to deliver the infusion over the required time period, e. Controlled drugs that are no longer required for a patient can be returned to the pharmacy or general practice for safe disposal.
In most cases, a healthcare professional trained in the use of syringe drivers, e. Instructions are also available online from many hospices. Plastic cannulae are recommended, although metal butterfly needles can be used. The preferred sites for insertion of the cannula for a continuous subcutaneous infusion are:. These sites are preferred because they are accessible, both for initial insertion and for monitoring, and they are rarely oedematous.
A number of factors influence the longevity of the insertion site. These include the site selected, the type of cannulae used and the medicine being given. If problems arise with an infusion site the patient may have localised discomfort, or there may be reduced absorption of the medicine and a loss of symptom control. As a general guide, plastic cannulae can stay in place for up to a week or more, whereas metal cannulae remain viable for approximately 72 hours.
Patients being cared for at home should ideally have a daily visit from a health professional for review of symptom control and monitoring of the infusion. This should occur at least every four hours when patients are in a hospice or residential aged care facility.
Breakthrough pain can be treated with additional subcutaneous doses of the opioid being used usually morphine. If possible, doses should be given through a side port in the syringe driver cannula line to minimise patient distress.
This can be given as often as required to relieve breakthrough pain. Doses can be prescribed in a flexible manner to achieve good symptom control, e.
Extra doses of antiemetics and other medicines in the syringe can also be given subcutaneously at the usual dose. If supplementary doses are required regularly for breakthrough symptoms, include these doses when calculating the amount of medicine needed for the subsequent 24 hour period. If the patient's symptoms remain uncontrolled despite an increase in dose, consider an alternative medicine e.
Also consider other methods to relieve a patient's distress - sometimes taking the time to sit and listen can be as effective as administering a medicine. General Practitioners and other carers can access hour telephone help from their nearest hospice: www. The Palliative Care Handbook, Guidelines for clinical management and symptom control.
Follow us on facebook. Decision support for health professionals ». South Island general practice support ». Practice acquisition and careers in health ». Click here to register ». Forgot your login? Login to my bpac. Remember me. Medicine indications Medicines management Palliative care Professional practice and development. When and how to use a syringe driver in palliative care Syringe drivers are often required to provide medicines for symptom management in patients who are terminally ill.
In this article What is a syringe driver? What is a syringe driver? The Niki T34 is used in a community setting The lockable, battery operated, Niki T34 syringe driver is the current device available in New Zealand for the continuous subcutaneous administration of medicines in a community setting.
Indications for use of a syringe driver Continuous subcutaneous administration of medicines using a syringe driver often becomes necessary for the control of symptoms during palliative care.
Consider using a syringe driver when: 3 The patient is unable to take medicines by mouth due to nausea and vomiting, severe oral lesions, e.
Some of the practical issues that may need to be addressed include: Care of the syringe driver once in use The safety aspects of the syringe driver What to do and where to get advice if the syringe driver is not working properly, or symptoms are not controlled, e. Most symptoms can be controlled with a continuous subcutaneous infusion In a palliative care setting, subcutaneous administration of medicines given via a syringe driver is useful for managing symptoms such as pain, nausea, anxiety and restlessness.
Choice of medicine and prescribing In palliative care, medicines may be prescribed for unapproved indications, be administered by an unapproved route or given in doses not seen in routine day-to-day practice. When prescribing consider: The patient's medicine requirements for 24 hours The doses that may be required for breakthrough symptoms - these need to be available for immediate use The choice of diluent The compatibility of the medicines required to manage symptoms Table 2.
In general, avoid combining more than three medicines in one syringe occasionally more than one syringe driver is required. Choice of diluent The choice of diluent for the infusion solution varies according to local guidelines as there is evidence for and against the two most commonly used diluents - sterile water water for injection and normal saline NaCl 0.
Compatibility of medicines When more than one medicine is used in an infusion solution there is a risk that they may not be compatible, either chemically or physically. Prescribing the medicines for the syringe driver Convert the patient's previous hour oral medicine requirements including regular and "as needed" doses to the equivalent subcutaneous dose.
Usual starting doses for subcutaneous infusion for commonly used medicines are: Morphine - use half the total 24 hour oral dose Oxycodone - use half the total 24 hour oral dose Metoclopramide, cyclizine and hyoscine hydrobromide the injectable hyoscine salt Buscopan - same as the oral dose Haloperidol - antiemetic dose is 1 - 2 mg for 24 hours Midazolam - 5 - 40 mg over 24 hours For patients who have not been on opioid medicine for analgesia, an example of an initial starting dose would be 10 mg morphine subcutaneously over 24 hours.
Starting the infusion In most cases, a healthcare professional trained in the use of syringe drivers, e. Selection of the infusion site Plastic cannulae are recommended, although metal butterfly needles can be used.
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