Symptom management
Pain, nausea, dyspnoea, agitation, catastrophic haemorrhage and troublesome respiratory secretions should all be expected. Simple measures and anticipatory medications should be prescribed to manage them.
Non-pharmacological
Pain: explanations of the cause of pain and expectations for its treatment can be helpful. Covering open wounds or splinting fractures can provide additional relief. If pain is due to a full bladder, full rectum or a wet bed, addressing these causes is important.
Dyspnoea: opening a window or providing a bedside fan to move air can help with breathlessness.
Agitation: a calm, quiet environment with low lighting levels can help ease agitation. Playing a patients favourite music or having a relative present can also be calming.
Catastrophic haemorrhage: a dark room with dark towels and bed linen can reduce the distress caused to patients and families by significant blood loss.
Respiratory secretions: repositioning and oropharyngeal suctioning can help reduce secretion burden.
Pharmacological
This is a sample of possible pharmacological prescribing options4,5,13. Your own hospital or trust should have comprehensive guidelines on anticipatory prescribing approved for use in your ED which you should refer to.
| Symptom | Medication Option | Starting dose |
| Pain | ||
| Normal renal function | Morphine or equivalent | 2.5mg S/C, 2-4hrly/PRN |
| eGFR <30ml/min | Fentanyl | 25mcg S/C, 1-2hrly/PRN |
| Agitation | ||
| No delirium | Midazolam | 2.5mg S/C, hourly/PRN |
| With delirium | Add haloperidol | 0.5-1mg S/C, 2-4hrly/PRN |
| Or levomepromazine | 6.25mg S/C, 4hrly/PRN | |
| Nausea | ||
| Chemical cause | Levomepromazine | 2.5-6.25mg S/C, 6hrly/PRN |
| Or Haloperidol | 0.5-3mg S/C, daily | |
| Alternative | Cyclizine | 50mg S/C, 8hrly/PRN |
| Bowel obstruction | Hyoscine butylbromide | 20mg S/C, hourly/PRN |
| Respiratory secretions | ||
| Hyoscine butylbromide | 20mg S/C, hourly/PRN | |
| Or Hyoscine hydrobromide | 400mcg S/C, hourly/PRN | |
| Or Glycopyrronium | 200-400mcg S/C, hourly/PRN | |
| Breathlessness | ||
| Morphine | 2.5mg S/C, hourly/PRN | |
| And/or Midazolam | 2.5mg S/C, hourly/PRN |
Patients already on oral opioids or anti-emetics may have their medication continued by subcutaneous infusion if needed. If three or more doses of as required subcutaneous medication are given, consider changing to a continuous infusion through a syringe driver.
Timely discharge
Depending on the clinical situation, patient preference and community resources in your area, it may be possible to arrange a timely discharge for those who wish to die at home.
NHS Continuing Healthcare in England may provide fast track funding for equipment such as a commode, hospital bed or home oxygen through the community nurse4.
A comprehensive handover to the patients GP and the community nurse, the local hospice or to the domiciliary palliative care nursing care team is essential to prevent the patient deteriorating unsupported at home causing distress and an unplanned reattendance at the ED.
Learning Bite
A range of options exist to manage the symptoms associated with dying. The drug-based options should be prescribed early so they can be administered promptly as required.