For many patients the fear of dying in a state of marked breathlessness with acute anxiety / panic is their biggest, if unspoken, fear.
Advance care planning is essential in order to ensure that patients and their family are as well prepared as possible.
For many patients advancing disease is often associated with reduced awareness. However it is usually prudent to discuss the option of sedation should increasing distress become an issue. Most patients are comforted by the knowledge that medication is helpful and available if required.
In the last days of life:
- Review the ongoing plan of care and ensure that it remains appropriate for the patient’s changing needs. Think specifically about ceiling of treatment including DNACPR.
- Prescribe PRN drugs as described below in anticipation of anxiety or distress caused by breathlessness. Many patients will become unable to take drugs by the oral route so prescribe medication to be given parenterally e.g. subcutaneously.
- Consider stopping or reducing clinical (artificial) hydration if this is causing fluid overload leading to pulmonary oedema or excessive upper airway secretions.
Drugs for breathlessness
There will be geographical variation in recommended drugs for the dying phase (eg morphine vs diamorphine). Cross reference with local guidelines/prescribing policies.
- Midazolam 2.5mg–5mg SC hourly PRN
- Morphine 2.5mg–5mg SC 1–2 hourly PRN (higher doses may be appropriate in patients who are already receiving regular strong opioids A lower dose of morphine (1.25mg-2.5mg SC ) may be appropriate for those who are elderly / impaired renal function. In patients who need repeated (hourly) doses seek specialist palliative care advice.
See chapter: Palliation of Breathlessness and chapters: Symptom control in patients with renal disease and Cardiac failure.
Patients who are persistently breathless and distressed may benefit from a continuous infusion of opioid and/or midazolam – in practice try to ascertain the required dose(s) by observing and titrating according to usage of opioid or midazolam over the previous 24–48 hours.
For some patients in the dying phase it may be more practical to commence an infusion of morphine/diamorphine or midazolam at an earlier stage alongside the provision of additional PRN medication.
The following ranges are usually appropriate:
- Morphine 5mg–10mg sub cut infusion over 24 hours. See conversion chart in pain chapter for other opioids. (higher doses of morphine may be appropriate if the patient is already receiving regular strong opioids for pain).
- Combining opioids and midazolam to manage breathlessness and anxiety in the last days of life is common practice in palliative care.
See also the chapter Palliation of Breathlessness.
Disclaimer
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.