Red Flags
- Acute reversible cause of deterioration (sepsis, electrolyte, hypercalcaemia, drug toxicity, urinary retention) — investigate and treat where consistent with care goals[1]
- Severe uncontrolled symptoms (pain, dyspnoea, agitation) — anticipatory medications urgently administered; specialist palliative care[1]
- Distress, family conflict, or unaddressed psychosocial / spiritual concerns — multidisciplinary palliative care input[1]
- Suspected over-sedation or paradoxical agitation — review medication doses; consider switching agent or rotating opioid[1]
First-line treatment
Interventions
- Communication and shared decision making[1]Sensitive disclosure of dying phase; ascertain patient and family priorities; agree on goals of care, place of care, and DNACPR status; document; revisit as needed
- Anticipatory prescribing (5 essentials)[1]Prescribe in advance for: pain (morphine), dyspnoea (morphine), nausea (haloperidol or levomepromazine), agitation/restlessness (midazolam), respiratory secretions (hyoscine butylbromide or glycopyrronium); 4-hourly PRN with breakthrough doses; subcutaneous route preferred when oral not tolerated
- Symptom control with continuous subcutaneous infusion (CSCI / syringe driver)[1]When PRN doses ≥3 in 24 h or oral route not tolerated; titrate based on prior 24-h requirements; monitor and adjust daily; combine appropriate agents (analgesic + antiemetic + anxiolytic) per local protocol
- Hydration and nutrition (individualised)[1]Discuss with patient and family; clinically assisted hydration neither routinely beneficial nor harmful in last days; small volumes may improve comfort or worsen secretions; review regularly; avoid forced oral intake
- Family and carer support[1]Information about expected changes, bereavement support, practical guidance (registration of death, funeral arrangements); involve faith leaders per family preference; access to palliative care helpline 24/7
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Morphine sulfate (pain or dyspnoea)[1] | Opioid analgesic | Opioid-naive: 2.5–5 mg SC PRN every 4 h; titrate per response. Established opioid: convert oral total dose to SC equivalent (oral:SC = 2:1) | — | First-line for pain and dyspnoea; subcutaneous route via butterfly needle; convert to CSCI for steady control; counsel about constipation, drowsiness, nausea |
| Midazolam (agitation, restlessness, terminal seizures)[1] | Benzodiazepine | 2.5–5 mg SC PRN every 1 h; CSCI 10–60 mg/24 h titrated | — | First-line for anxiety, restlessness, terminal restlessness, seizures; 1:1 PRN to CSCI titration; sedation expected |
| Haloperidol (nausea, delirium)[1] | Typical antipsychotic / antiemetic | 0.5–1.5 mg SC every 4 h PRN; CSCI 1.5–5 mg/24 h; max 10 mg/24 h | — | First-line antiemetic and for delirium; lower dose for elderly; QTc consideration; alternative metoclopramide unless complete bowel obstruction |
| Levomepromazine (multimodal antiemetic + sedation)[1] | Phenothiazine | 6.25–12.5 mg SC every 8 h PRN; CSCI 12.5–25 mg/24 h, titrate to 200 mg | — | Useful when haloperidol insufficient; sedating; multimodal antiemetic effect; postural hypotension |
| Hyoscine butylbromide or glycopyrronium (secretions)[1] | Anticholinergic | Hyoscine butylbromide 20 mg SC PRN; CSCI 60–240 mg/24 h. Glycopyrronium 200 µg SC PRN; CSCI 600–1200 µg/24 h | — | For respiratory secretions; positioning and reassurance also help; glycopyrronium does not cross BBB (less sedation/confusion) |
Morphine sulfate (pain or dyspnoea)[1]
Opioid analgesic
- Adult
- Opioid-naive: 2.5–5 mg SC PRN every 4 h; titrate per response. Established opioid: convert oral total dose to SC equivalent (oral:SC = 2:1)
- Paediatric
- —
First-line for pain and dyspnoea; subcutaneous route via butterfly needle; convert to CSCI for steady control; counsel about constipation, drowsiness, nausea
Midazolam (agitation, restlessness, terminal seizures)[1]
Benzodiazepine
- Adult
- 2.5–5 mg SC PRN every 1 h; CSCI 10–60 mg/24 h titrated
- Paediatric
- —
First-line for anxiety, restlessness, terminal restlessness, seizures; 1:1 PRN to CSCI titration; sedation expected
Haloperidol (nausea, delirium)[1]
Typical antipsychotic / antiemetic
- Adult
- 0.5–1.5 mg SC every 4 h PRN; CSCI 1.5–5 mg/24 h; max 10 mg/24 h
- Paediatric
- —
First-line antiemetic and for delirium; lower dose for elderly; QTc consideration; alternative metoclopramide unless complete bowel obstruction
Levomepromazine (multimodal antiemetic + sedation)[1]
Phenothiazine
- Adult
- 6.25–12.5 mg SC every 8 h PRN; CSCI 12.5–25 mg/24 h, titrate to 200 mg
- Paediatric
- —
Useful when haloperidol insufficient; sedating; multimodal antiemetic effect; postural hypotension
Hyoscine butylbromide or glycopyrronium (secretions)[1]
Anticholinergic
- Adult
- Hyoscine butylbromide 20 mg SC PRN; CSCI 60–240 mg/24 h. Glycopyrronium 200 µg SC PRN; CSCI 600–1200 µg/24 h
- Paediatric
- —
For respiratory secretions; positioning and reassurance also help; glycopyrronium does not cross BBB (less sedation/confusion)
Safety-net
- Anticipatory medications mean we are prepared, not that we expect rapid deterioration; we will reassess regularly and discuss any concerns[1]
- Family contact information for the palliative care team should be visible at home; out-of-hours support exists for urgent symptom control[1]
- Bereavement support and follow-up after death is part of palliative care; ask about local bereavement services[1]
Referral criteria
- Complex symptoms not controlled with anticipatory prescribingSpecialist palliative care[1]
- Existential distress, family conflict, or complex psychosocial needsMultidisciplinary palliative care with social work, chaplaincy[1]
- Death at home and out-of-hours supportLocal palliative care helpline; community nursing[1]
- Bereavement support for familyBereavement service or counselling per local provision[1]
Clinical summary
Recognising the dying phase, anticipatory prescribing, symptom control, and family support for adults in the last days of life.