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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3090_Библиотеки_им_академика_М_И_Перельмана
.pdf
298 Chapter 20
resources?utm_campaign=1544209_IPC+newsletter+-
+COVID-19+update+October+2020+-+PDL-CCON-
121054-1809&utm_medium=email&utm_
source=dotdigital&dm_i=4JL6%2cX3IP%2c2XH24Z%2c43N
KX%2c1 (11 November 2021).
45.
Hospice UK and National Nurse Consultant Group (Palliative
Care). (2020 Available from). Special Edition of Care after Death:
Registered Nurse Verification of Expected Adult Death (Rnvoead)
Guidance. Hospice UK. https://www.hospiceuk.org/what-we-
offer/clinical-and-care-support/clinical-resources?utm_
campaign=1544209_IPC+newsletter+-+COVID-19+
update+October+2020+-+PDL-CCON-121054-1809&utm_
medium=email&utm_source=dotdigital&dm_i=4JL6%2cX3I
P%2c2XH24Z%2c43NKX%2c1 (11 November 2021).
46.
Academy of Medical Royal Colleges. (2008). A Code of
Practice for the Diagnosis and Confirmation of Death. PPG
Design and Print Ltd. Available from: https://www.aomrc.
org.uk/wp-content/uploads/2016/04/Code_Practice_
Confirmation_Diagnosis_Death_1008-4.pdf (11 November
2021).
47.
Cheshire and Merseyside Palliative Care Network. Opening
the spiritual gate. Available from: www.openingthespriritualgate.
net/all-faiths (28 June 2021).
48. NHS Scotland. Scottish Palliative Care Guidelines. Available
from: https://www.palliativecareguidelines.scot.nhs.uk (22
October 2021).
38.
Gomes, B., Calanzani, N., Koffman, J., and Higginson, I.J.
(2015). Is dying in hospital better than home in incurable
cancer and what factors influence this? A population-based
study. BMC Medicine 13 (1): 1.
39.
Cross, S., Wesley, E., Kavalieratos, D., Tulsky, J., and Warraich,
H. (2020 August). Place of death for individuals with chronic
lung disease: Trends and associated factors from 2003–2017
in the United States. Chest 158 (2): 670–680.
40.
Krawczyk, M. and Gallagher, R. (2016). Communicating
prognostic uncertainty in potential end-of-life contexts:
Experiences of family members. BMC Palliative Care 15 (1):
59. Available from: https://bmcpalliatcare.biomedcentral.com/
articles/10.1186/s12904-016-0133-4 (11 November 2021).
41.
Marcolini, E., Putnam, A., and History, A.A. (2018 June).
Perspectives on Nutrition and Hydration at the end of life.
Yale Journal of Biology and Medicine 91 (2): 173–176.
42. GMC. (2010). Treatment and care towards the end of life: good
practice in decision making. GMC. Available from: Treatment
and care towards the end of life - ethical guidance summary
- GMC (gmc-uk.org) (11 November 2021).
43.
Diabetes UK. (2021 Available from). End of Life Guidance for
Diabetes Care. Diabetes UK. EoL_TREND_FINAL2_0.pdf
(amazonaws.com) (25 October 2022).
44.
Wilson, J., Laverty, D., Mann, T. et al. (2020 Available from).
Care after Death, Guidance for Staff Responsible for Care
after Death, 3e. Hospice UK. https://www.hospiceuk.org/what-
we-offer/clinical-and-care-support/clinical-
https://t.me/med1917
Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
299
Appendix A – Managing Pain in
the Last Days of Life for Opioid
Naïve Patients
Assess the patient:
Identify likely source and triggers
Consider Abbey pain score if unconscious
Consider non-pharmacological measures:
Repositioning
Use of heat/cold
Urinary catheter if pain related to micturition
Pharmacological:
In last days of life swallowing often compromised
Therefore, SC route preferred
SC morphine sulfate 2.5mg – 5mg 4
hourly PRN [26]
Reduced dose if elderly or renal
impairment [26] (e.g. 1.25mg - 2.5mg 4
hourly) PRN
Reassess:
Check eect of drug on pain
If unsure how to proceed or medication
appears ineffective then contact local
specialist palliative care team for advice
and guidance.
If needed 3+ doses in the last 24 hrs and are effective, then consider
CSCI
Starting dose of CSCI would be total ofdoses used in last 24 hrs
https://t.me/med1917
Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
300
Appendix B – Managing
Breathlessness in the Last Days
of Life
Assess the patient:
Consider aetiology – e.g. extension of disease (lung
metastases or heart failure) or acute new pathology
(infection)
Consider non-pharmacological measures:
Remaining calm
Providing reassurance
Fans
Distraction
Opening windows
Repositioning
Pharmacological:
Oxygen could be considered depending on
the situation (may require assessment prior
to this)
In the last days of life swallowing often
compromised
Therefore, SC route preferred
SC morphine sulfate 1mg –2mg hourly PRN for
dyspnoea and opiate naïve (reduce to 1.25mg - 2.5mg if
eGFR <30)[48]. If not opiate naïve then can use normal
breakthrough dose [48]
SC midazolam 2mg -5mg 4 hourly PRN for anxiety
(reduce to 1.25-2.5mg if eGFR <30) [48]
Reassess:
Check eect of drug on breathlessness
If unsure how to proceed or medication
appears ineffective then contact local
specialist palliative care team for advice
and guidance.
If needed 3+ doses in the last 24 hrs and are effective, then consider
CSCI
Starting dose of CSCI would be total of doses used in last 24 hrs
NB: Furosemide cannot be mixed with other drugs in a CSCI
https://t.me/med1917
Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
301
Appendix C – Management of
Respiratory Secretions in the Last
Days of Life
Assess the patient:
Consider potential risk of secretions – may be more likely in someone still
being fed in the last days of life or in those with conditions causing fluid
accumulation e.g. liver or renal failure
Consider non-pharmacological measures:
Repositioning
Oral suctioning if unconscious and
available in your setting
Reassurance to family members that
patient likely unaware of secretions/noise
of breathing
Pharmacological:
At end-of-life swallowing often compromised
Therefore SC route preferred. Choice of drug
may be affected by local preference.
SC hyoscine butylbromide 20mg hourly
max 120mg/24 hrs [26]
SC glycopyrronium 200 micrograms
hourly max 1.2mg/24 hours [26]
Reassess:
Check effect of drug on secretions
If unsure how to proceed or medication
appears ineffective then contact local
specialist palliative care team for advice
and guidance.
If needed 3+ doses in the last 24 hrs and are effective, then consider
CSCI.
Starting dose of CSCI would be total of doses used in last 24 hrs
https://t.me/med1917
Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
302
Appendix D – Management of
Nausea and Vomiting in Last
Days of Life
Assess the patient:
Identify likely source and triggers
Consider underlying cause: Bowel obstruction, brain
metastases etc. which may influence management
Consider non-pharmacological measures:
If Ryles tube present consider aspiration when
managing bowel obstruction
If not present consider appropriateness of
insertion.
Remove olfactory triggers if appropriate
Pharmacological:
At end-of-life swallowing often compromised
Therefore, SC route preferred.
Reassess:
Check effect of drug on nausea/vomiting
If unsure how to proceed or medication
appears ineffective then contact local
specialist palliative care team for advice
and guidance.
If needed 3+ doses in the last 24 hrs and are effective, then consider
CSCI.
Starting dose of CSCI would be total of doses used in last 24 hrs.
Broad spectrum antiemetic often advised
in the last days of life
SC levomepromazine 2.5mg – 6.25mg
PRN. Max 25mg/24 hours [26]
https://t.me/med1917
Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
303
Appendix E – Management of
Terminal Agitation in the Last
Days of Life
Assess the patient:
Identify likely source and triggers: pain, retention
Treat accordingly
Consider non-pharmacological measures:
Reassurance
Pharmacological:
At end-of-life swallowing often compromised
Therefore SC route preferred. However in
some settings IV route may also be available
(e.g. hospice/hospital setting)
First line:
SC midazolam 2.5mg - 5mg [26]
Repeat after 30 minutes if still agitated
Reassess:
Check effect of drug on agitation.
If ongoing call 999 and discuss with on-
call palliative care team
If unsure how to proceed or medication
appears ineffective then contact local
specialist palliative care team for advice
and guidance.
If needed 3+ doses in the last 24 hrs and are effective, then consider
CSCI.
Starting dose of CSCI would be total of doses used in last 24 hrs. Note
that doses for agitation may be higher than for other symptoms.
Second line:
SC levomepromazine 2.5mg -12.5mg 1
hourly max 50mg in 24 hours [26]
If agitation continuing then next steps
may involve phenobarbital but this would
be initiated by/with specialist advice
Involve family/friends where possible and
if they wish to be involved
https://t.me/med1917
Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
304
Appendix F – Management of
Bleeding in Last Days of Life
Assess the patient:
Identify the point of bleeding
Consider non-pharmacological measures:
Remain calm
Provide reassurance
Call for help but someone should remain
with patient
Use dark towels to apply pressure to
bleeding point
In reality catastrophic bleeds are rare but
when they occur it is unlikely a trained
professional will be present therefore
management is mainly non-
pharmacological
Pharmacological:
At end-of-life swallowing often compromised
Therefore, SC route preferred
If bleeding likely to be terminal event:
IM midazolam 10mg repeated as
required at 10 minute intervals to
alleviate distress [26]
Reassess:
If survives bleed then review any medication that may be
contributing to bleed i.e. anticoagulation
If unsure how to proceed or medication
appears ineffective then contact local
specialist palliative care team for advice
and guidance.
https://t.me/med1917
Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
305
Appendix G – Management of
Seizures in Last Days of Life
Assess the patient:
Consider underlying cause – previously
known epilepsy or new symptom?
Previously known epilepsy:
Consult palliative care team as to
appropriate replacement for oral
anticonvulsants
New symptom in the dying phase:
If seizures continuing for >5 minutes then
give 5mg midazolam via SC injection or
buccally [48]
If ongoing then repeat midazolam 5mg after
10 minutes [48]
Reassess:
Check eect of drug
If unsure how to proceed or medication
appears ineffective then contact local
specialist palliative care team for advice
and guidance.
If seizures are ongoing call 999 and discuss with on-call palliative
care team. Next steps may involve phenobarbital but this would be
initiated by/with specialist advice
If medication has been effective then commence CSCI with dose
required to control seizures.
https://t.me/med1917
Handbook of Palliative Care, Fourth Edition. Edited by Richard Kitchen, Christina Faull, Sarah Russell and Jo Wilson.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
306
Introduction
A large proportion of patients requiring palliative care
have symptom control needs and will require medicines to
manage them, often alongside any regular medicines they
are already prescribed. With palliative care encompassing
non-malignant conditions, the complexity of medicines
management is just as challenging as those with a cancer
diagnosis undergoing advanced treatments or living longer
with their disease.
Medicines management concerns all those involved in
the prescribing, supply, administration, and guidance of
drugs, and healthcare professionals within palliative care
will vary with the differing responsibilities they have to
contribute to the safe and effective use of medicines.
Definition of Medicines Management
and How This Applies to Palliative Care
Medicines management and medicines optimisation has
been defined as “the clinical, cost-effective and safe use of
medicines to ensure patients get the maximum benefit
from the medicines they need, while at the same time min-
imising potential harm” [1] and as a “system of processes
and behaviours that determine how medicines are used by
the NHS and patients” [2].
Medicines Management incorporates the clinical and
legal approaches of the pharmacy team and learning from
medicines related incidents, specifically related to medi-
cines usage, which could have, or did, lead to patient harm.
Examples of medicines-related incidents include:
• Prescribing errors
•
Administration errors
•
Unintentional omissions
•
Near misses (preventable medicines-related patient
safety incidents which could have led to patient harm)
This may involve local-level working with teams to address
practice and processes or may be national and involving
the Medicines Health Regulatory Agency (MHRA) via the
yellow card scheme.
Medicines optimisation is ensuring that the right patients
get the right choice of medicine, at the right time [3].
The goal is to help patients to:
• improve outcomes/experience with their medicines;
•
take medicines correctly for maximum benefit without
impacting their quality of life, for example, having to
reconfigure mealtimes;
•
avoid taking unnecessary medicines and reduce wastage;
•
improve medicines safety.
Ultimately medicines optimisation can help encourage
patients to take ownership of their treatment [4]. This
ethos matches that of palliative care where the patient is at
the centre and supported to make informed decisions.
Pharmacy Teams in Palliative Care: A
Key Member
Palliative care requires a multidisciplinary approach –
National Institute for Health and Care Excellence (NICE)
guidance specifically recommends that an effective spe-
cialist palliative care team incorporates the range of exper-
tise provided by pharmacy teams. Palliative care is
delivered in a variety of healthcare settings so patients and
21
Medicines Management in Palliative
Care Including Syringe Pumps
Kerry Parker and Michelle Aslett
https://t.me/med1917
Medicines Management in Palliative Care Including Syringe Pumps 307
healthcare professionals may interact with different mem-
bers of the pharmacy team.
Pharmacists are registered with the General
Pharmaceutical Council (GPhC) to work in the UK. Their
main role and responsibilities ensure:
•
the quality of medicines supplied to patients
•
supplies of medicines are within the law
•
medicines prescribed to patients are suitable
•
advising patients about medicines including how to take
them, what reactions may occur, and answering patients’
questions
•
advising other healthcare professionals about safe and
effective medicines use, and safe and secure supply of
medicines.
Pharmacy technicians work under the supervision of a
pharmacist and are registered professionals (GPhC). Their
roles span all areas of pharmacy practice, from the pur-
chasing, manufacture, preparation, supply, and final check
of medicines to assisting medicines use reviews and
administration of medicines.
Traditionally roles were within hospital, community,
industry, and academia but now wider reaching and cross-
interface pharmacy teams work within GP practices, care
homes, Clinical Commissioning Groups (CCGs)/
Integrated Care Boards (ICBs), Primary Care Networks
(PCNs), and hospices.
The role of a palliative care pharmacy team comprises
“clinical, educational, administrative and supportive”
responsibilities. Many pharmacists are independent/non-
medical prescribers, whose skills are best placed to support
patients particularly where specialist medicines are
required including managing their own patient caseloads.
On average, palliative care patients take 8 (range 0–17)
different medications [5]. Changing formulations, reducing
medicines burden, education, and support helps patients as
well as their family/carers. Where compliance or lack of
usual administration routes become an issue, the pharma-
cist can advise on alternative options for symptom control.
Pharmacists working in the palliative care MDT can
help to address psychological and social circumstances
that influence a patient’s approach to medicines. This may
be anxiety over the use of opioids and fear it is hastening
death, patients trying to maintain their independence for
as long as possible but being told medicines may affect
their driving, or it may be family members with addiction
issues which affect availability of medicines in the home. A
partnership between the pharmacy team and patient as
well as the wider MDT is essential.
The pharmacy team can help their healthcare settings
with education, guideline development, audit, incident
reviews, and reflections. They support the controlled drug
accountable officers (CDAOs) who will feed into the con-
trolled drug local intelligence network (CDLIN). There are
regional and national pharmacist specialist interest groups
that provide education catered for the team working at a
higher level as well as sharing of practice, research, and
networking.
Use of Drugs beyond Their Licence
In palliative care, medications are often prescribed outside
the terms of their marketing authorisation (previously
called a product license). A marketing authorisation is
granted by a regulatory body to a pharmaceutical company
for a specific medicinal product. It stipulates the terms of
use, including indications, doses, routes, and patient popu-
lations for which it can be marketed [6].
“Off-label” is a term commonly used to describe the use
of a medicinal product beyond the specifications of its
marketing authorization, that is, using a licensed medicine
for a purpose not covered by its marketing authorisation
[6]; examples include antidepressants for neuropathic
pain, subcutaneous administration of some medicines, and
administration of medication via feeding tubes. Surveys
suggest that up to one quarter of prescriptions in palliative
care come into this category [7, 8].
An unauthorised (unlicensed) medicinal product is a
product that does not have a marketing authorization
granted for medicinal use in humans. These include:
•
“specials” – special order products made in the UK by a
manufacturer
• trial drugs
•
“manipulated products” where two or more medicinal
products have been mixed for administration, for example,
syringe pump.
In the UK, doctors and independent prescribers may
legally prescribe off-label and unlicensed products where
it is accepted clinical practice and within their clinical
competence. This will be backed up by local organisation
governance and policies which will also determine any
requirements around administration, dispensing and
documentation [9–11]. The prescriber must be fully
informed about the actions and uses of the medicinal
product, be assured of the quality of the particular prod-
uct, and in the light of published evidence, balance both
the potential good and the potential harm which might
ensue [9–11].
It is recommended that the patient (or their advocate if
no capacity) are made aware why a medicine is being used
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