End of life care

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Please note that this guidance is intended for use only in situations where patients requiring symptom management and end of life care cannot be supported by the usual resources. It is not intended as a substitute for seeking specialist palliative care advice should this be deemed necessary.

Hospital Palliative Care Teams (9am-5pm):

  • RIE bleep 5175;
  • WGH bleep 8174;
  • SJH bleep 3833

On-Call Palliative Medicine (out of hours): phone 07515199019

Symptom management

Discontinue medical and nursing interventions such as blood tests and routine observations. This optimises patient comfort and minimises unnecessary episodes of staff exposure.

The main symptoms of COVID-19 are cough, high temperature and shortness of breath

Prescribe subcutaneous (SC) anticipatory medicines on the ‘as required’ chart of all patients:

  • Opioid for pain/breathlessness/cough: SC morphine 5mg up to every 30 minutes [if severe renal impairment of eGFR <30ml/min, use SC oxycodone 2mg 1 hourly]
  • Anxiolytic sedative for anxiety, distress or breathlessness: SC midazolam 5mg up to every 30 minutes - agitation/delirium: SC levomepromazine 5-10mg 2 hourly
  • Anti-secretory for respiratory secretions: SC hyoscine butylbromide 20mg 1 hourly [please also follow guidance on page 2 re: productive and/or moist-sounding cough] - anti-emetic for nausea and vomiting: SC levomepromazine 2.5mg 4 hourly
  • Anti-pyretic for high temperature and/or sweating: oral paracetamol 1g QDS or 500mg if patient weighs less than 50kg (can be given PR at same dose if deemed necessary in a patient unable to take oral medicine). Remember non-pharmacological measures such as reducing room temperature, removing excess bedding, and cooling forehead with tepid sponging.

Patients who are deteriorating rapidly – such as those with acute respiratory distress syndrome (ARDS) – may need several ‘as required’ doses of these medicines in their last hours of life to achieve good symptom control. 

  • If you are unable to access a syringe pump (or alternative) for the dying patient, manage symptoms proactively with ‘as required’ medicines.
  • Site a subcutaneous line to avoid repeated injections. 

If you have access to a syringe pump (or alternative), a continuous subcutaneous infusion may be indicated: 

  • If productive and/or moist-sounding cough, prescribe a continuous subcutaneous infusion of hyoscine butylbromide 60mg/24hrs immediately. This is to provide symptomatic anti-secretory relief for the patient and to minimise further droplet transmission.
  • If persistent and/or troublesome cough, consider prescribing a continuous subcutaneous infusion of morphine 15mg/24hrs [if severe renal impairment of eGFR <30ml/min, use alfentanil 500 micrograms/24hrs instead]. Note that both of these opioids would be compatible in a syringe pump with hyoscine butylbromide (diluent: water for injection).
  • If feeling short of breath or if respiratory rate is greater than 20 breaths per minute, consider prescribing a continuous subcutaneous infusion of morphine 15mg/24hrs and midazolam 15mg/24hrs [if severe renal impairment of eGFR <30ml/min, give alfentanil 500 micrograms/24hrs and midazolam 10mg/24hrs instead]. Note that both of these opioids + midazolam would be compatible in a syringe pump with hyoscine butylbromide (diluent: water for injection). 

Have a low threshold to increase the doses of medicines in the syringe pump in response to symptoms and use of ‘as required’ medicine.

  • Review the need for an increase in dose every 12 hours.
  • A proactive approach is more likely to achieve patient comfort and, in turn, reduce the need for ‘as required’ medication, limiting further episodes of staff exposure.