Breathlessness For general information on the assessment and management of breathlessness see factsheet 14. In the terminal phase patients may be very anxious and dyspnoeic: this may be controlled by midazolam (2.5 to 5 mg subcutaneously four hourly) and diamorphine (2.5 to 5mg subcutaneously four hourly) as a subcutaneous bolus or as a continuous subcutaneous infusion via a syringe driver (e.g. midazolam 10mg with diamorphine 10mg over 24 hours), monitoring response to determine dose adjustment. Seizures Patients may be at increased risk of seizures because they are no longer able to take oral medication. A subcutaneous syringe driver containing midazolam (10 to 60 mg/24hour) should prevent seizures. Subcutaneous or buccal midazolam (5 to 10mg) or rectal diazepam (10mg) can be used if seizures occur. Hydration There is often concern amongst patients, family and healthcare workers about fluid intake towards the end of life. Drinking and eating less are universal in the terminal phase and are a normal part of dying. There is evidence that there is no correlation between fluid intake, serum biochemistry and patient comfort. There are reasons why parenteral fluids might impair patient comfort: Increased peritumour oedema may lead to more pain. Increased urinary flow may lead to more episodes of retention or urinary incontinence. Increased intestinal secretions can exacerbate vomiting. Increased respiratory secretions can worsen noisy breathing/death rattle. Some patients / families find that the presence of infusion equipment can be a barrier to physical contact. Patients (or family) will often correlate lack of fluid with dry mouth. However, this symptom is best treated with local measures (see below). However, the decision should be individualised. If fluids are likely to do little harm, consideration may be given to a distressed family wanting to see ‘everything done’. Mouth care Many patients have a dry mouth toward the end of life, often exacerbated by mouth breathing. Regular mouth care can help relieve this symptom. 1 to 2ml of fluid placed in the mouth, or the frequent use of moist applications (e.g. KY Jelly, or continuation of saliva replacement if already in use), swabs or ice chips, can help. Is this what the "new" version will still say, business as usual!
Posted on: Wed, 17 Jul 2013 15:02:22 +0000