Symptom control in the last days of life

Owner Anne Garry

Contributions from Specialist Palliative Care teams in York and Scarborough Jane Crewe, Lynn Ridley
and Diabetes team.
Version 4
Date of issue: June 2019
Review date: June 2021
 2

Principles of symptom management in last days of life

These principles are applicable to the care of patients who may be dying from any cause
Recognise that death is approaching
Studies have found that dying patients will manifest some or all of the following:
 Profound weakness - usually bedbound
 Drowsy or reduced cognition - semi-comatose
 Diminished intake of food and fluids - only able to take sips of fluid
 Difficulty in swallowing medication - no longer able to take tablets

Treatment of symptoms
The prime aim of all treatment at this stage is the control of symptoms current and potential.
 Discontinue any medication which is not essential
 Prescribe medication necessary to control current distressing symptoms
 All patients who may be dying would benefit from having ANTICIPATORY subcutaneous
medication prescribed JUST IN CASE distressing symptoms develop
 All medication needs should be reviewed every 24 hours
 Prn medications may be administered via a Saf -T- intima line
 If two or more doses of prn medication have been required, then consider the use of a syringe
driver for continuous subcutaneous infusion (CSCI)

The most frequently reported symptoms are:-

 Pain
 Nausea / Vomiting
 Excessive secretions / Noisy breathing
 Agitation / Restlessness
 Dyspnoea

Opioid choice and syringe drivers

Morphine sulphate is the injectable opioid of choice in the majority of patients.
Alternative opioids (when morphine is not tolerated or in patients with severe renal failure e.g. GFR<
30mL /min) include oxycodone or alfentanil.

Both morphine sulphate and oxycodone are compatible with all the medications that are
recommended in the following guidelines (cyclizine, haloperidol, levomepromazine, hyoscine
butylbromide, glycopyrronium, metoclopramide, ondansetron and midazolam).
Incompatibility may occur when higher doses of oxycodone >150mg are mixed with cyclizine.
Alfentanil is compatible with all the above medications that are recommended, with exception of
cyclizine.

Use either water for injection or sodium chloride 0.9 % as the diluent, unless mixing with cyclizine,
when water for injection must be used.
Use sodium chloride 0.9 % for levomepromazine by itself or syringe driver combinations containing
octreotide, methadone, ketorolac, ketamine or furosemide
.
With the introduction of the T34 McKinley syringe drivers use a 20mL syringe as standard and if a
larger volume is required use a 30mL syringe.

For information on the usual doses of drugs used in a syringe driver see inside of back cover.
For guidance on converting between opioids see the coloured opioid conversion chart.
For further information on compatibility in a syringe driver contact:
York and Scarborough Hospital enquiries GP enquiries
York Medicines Information Newcastle Medicines Information

01904 725960 0191 2824631

The algorithms will support you in your management of the most frequently reported symptoms
 3

Mouth care guidelines

General principles of mouth care

Assess the whole mouth daily.

Clean the teeth and tongue using a toothbrush and toothpaste, morning and night.
If patients have apthous ulcers avoid toothpastes containing sodium lauryl sulphate
Ensure all toothpaste is rinsed away.

Offer mouth care every 3 to 4 hours using a soft toothbrush.

Use lip salve for dry lips. Care when using oxygen mask.

Note any history of pain, dry mouth, change of taste, medications and respond if required.

Document findings

Mouth care Guidelines

Problem Action
Dry mouth Consider discontinuing contributing factors, e.g.
medication.
If required, consider humidifying oxygen.
Implement general mouth care principles.
Offer fluids hourly if appropriate.
Consider topical saliva substitutes, e.g. Oralieve
spray or gel
Coated tongue Implement general mouth care principles.
Rinse the mouth after food with water.
Encourage fluids as appropriate.
If no improvement in 24 hours consider infection as a
cause.
Pain / mucositis / ulceration Implement general mouth care principles.
Consider analgesia – topical/systemic.
Use soft toothbrush for hygiene.
Consider diluting mouthwash if the patient finds their
use painful.
Seek specialist advice if symptoms continue.
Infection Rinse mouth 3 times per day with chlorhexidine 0.2%
(Corsodyl) or sodium chloride 0.9%.
Implement general mouth care principles.
Check for thrush and treat with antifungal, if
appropriate. e.g. fluconazole or nystatin
 4

Pain Control
(Non renal pathway – see next page for patients with renal failure)

Is the patient already

Yes No
taking an opioid?

Prescribe
Convert to 24 hour sc syringe driver plus MORPHINE
sc dose every 2 to 4 hours prn 3 to 5mg sc every 2 to 4 hours prn
(to be administered only if the
If possible continue with the same opioid the patient has pain)
patient was already taking (ie. morphine or NB if patient sensitive to morphine
oxycodone) – refer to the opioid conversion use alternative opioid
table for equivalent dose

If the patient is on an opioid patch

Leave the patch on and top up with prn Have more than
opioid. (usually morphine but oxycodone, if Yes
Convert to 2 prn doses been
sensitive to morphine ) given in 24 hours
syringe driver
If over the next 24 hours 2 or more prn doses
are required set up a 24 hour sc syringe driver
with appropriate opioid. No Review
Pain Control

The prn dose of morphine (or oxycodone)

used should take account of both the patch
and the syringe driver – see table below Continue with MORPHINE
3 to 5mg sc every 2 to 4 hours
prn

Remember :
Any change in the syringe driver dose should take account of the number of
sc prn doses given over the last 24 hours. If you change the syringe driver
dose remember to also change the 4 hourly prn dose

To calculate the prn dose of sc morphine

Prescribe 1/6th of the 24 hour dose in the driver
e.g 20mg sc via driver over 24 hours will require 3 to 5mg sc every 4 hours prn

 Use the chart on the back of this booklet to help in converting between opioids
 If in doubt please seek advice from the palliative care team
 It is good practice to document calculations in notes and check dose conversions with a
colleague.
 Patients on opioid patches - if a patient requires a syringe driver the patch should
continue to be prescribed at the usual dose and the syringe driver used as a top up and
titrated as necessary. The prn dose of opioid should be calculated from the dose of
opioid in the syringe driver and the equivalent given by patch.
 5

Pain control in renal failure

(Patients with severe renal failure i.e. GFR < 30mL/min use oxycodone or <15mL/min use Alfentanil
if unable to tolerate oxycodone)

Is the patient already

Yes No
taking an opioid?

If patient is already taking and tolerating oral

GFR >/= 15mL/min
OXYCODONE and GFR >/= 15mL/min convert
Prescribe OXYCODONE
to 24 hour sc syringe driver plus sc dose every 2
1 to 2mg sc every 2 to 4 hours prn if patient has pain
to 4 hours prn
GFR <15mL/min
OTHERWISE
Prescribe ALFENTANIL
Convert to ALFENTANIL
250 micrograms sc every 2 to 4 hours prn if the
in a 24 hour sc syringe driver
patient has pain
using the conversion table. Prescribe sc opioid
every 2 to 4 hours prn (up to a maximum of 6
prn doses in 24 hours)
(Note alfentanil sc can be prescribed prn Yes Have more than
alongside the syringe driver, but as it has a short Convert to 2 prn doses been
duration of action oxycodone is sometimes used syringe driver given in 24 hours
instead. If this is the case take EXTRA care Review
when calculating and amending doses for

Pain control in renal failure

syringe driver and prn use.
No

If the patient is on a opioid patch

Leave the patch on and top up with prn Continue with OXYCODONE or ALFENTANIL
oxycodone or alfentanil as initiated above
If over the next 24 hours 2 or more prn doses
are required set up a 24 hour sc syringe driver
with oxycodone or alfentanil .
The prn dose of oxycodone or alfentanil used
should take account of both the patch and the
syringe driver

Remember :
Any change in the syringe driver (SD) dose should take account of the number of sc prn doses given
over the last 24 hours. If you change the SD dose remember to also change the prn dose

To calculate the prn dose of oxycodone or alfentanil

For prn dose prescribe 1/6th of the 24 hour syringe driver dose
e.g 3mg alfentanil sc via driver over 24 hours will require 500 microgram alfentanil sc prn every 2 to 4
hours prn (up to a maximum of 6 prn dose in 24 hours) OR 3mg oxycodone sc every 2 to 4 hours prn
e.g. 20mg oxycodone sc via driver over 24 hours will require 3mg oxycodone sc prn every 2 to 4 hours
(If the patient is also on a patch you must calculate how much alfentanil or oxycodone this is equivalent to
and include this in the 24 hour dose which you use as a basis for your prn dose)

 Use the chart on the back of this booklet to help in converting between opioids
 If in doubt please seek advice from the palliative care team
 It is good practice to document calculations in notes and check dose conversions with a
colleague.
 Patients on opioid patches - if a patient requires a syringe driver the patch should
continue to be prescribed at the usual dose and the syringe driver used a top up and
titrated as necessary. The prn dose of opioid should be calculated from the dose of opioid
in the syringe driver and the equivalent given by patch.
 6

Respiratory tract secretions

(Remember you cannot clear existing secretions, but you can help stop further production)
These drugs only reduce upper airways secretions and not lower collections from e.g. infectionor
pulmonary oedema)

Are respiratory tract

Yes No
secretions present?

Prescribe and administer

HYOSCINE BUTYLBROMIDE Prescribe
HYOSCINE BUTYLBROMIDE
10 to 20mg sc STAT
and 10 to 20mg sc every 4 hours prn
10 to 20mg sc every 4 hours prn (to be administered only if the
(caution in ischaemic heart patient develops symptoms)
disease, heart failure or heart rate (caution in heart disease)
>100 bpm)
Respiratory tract secretions

Review
every 24 hours

Have more than

2 prn doses been given No
in 24 hours

Yes
Convert to a syringe driver starting with Continue with HYOSCINE
total prn doses over previous 24 hours BUTYLBROMIDE

Titrate 10 to 20mg sc every 4 hours

HYOSCINE BUTYLBROMIDE prn
dependant on doses given previously.
If symptoms persist increase up to maximum of
120mg sc via syringe driver
and
10 to 20mg sc every 4 hours prn

Maximum dose is 120mg in 24 hours

HYOSCINE BUTYLBROMIDE (BUSCOPAN) above 60mg in 24 hours may precipitate when mixed with
CYCLIZINE. If problems discontinue cyclizine and switch to levomepromazine. Caution in heart disease

GLYCOPYRRONIUM may be used as an alternative if hyoscine butylbromide not effective (reduced

doses in renal failure).

HYOSCINE HYDROBROMIDE is not recommended in patients with renal failure because of

excessive drowsiness or paradoxical agitation.
 7

Agitation / Terminal restlessness

Before prescribing have all reversible causes been excluded? e.g. urinary retention

Is agitation/ terminal
Yes No
restlessness present?

Prescribe
Prescribe and adminster MIDAZOLAM
MIDAZOLAM
2 to 5mg sc
2 to 5mg sc every 2 to 4 hours prn every 2 to 4 hours prn
(to be administered only if the
patient develops symptoms)

Review

Agitation / Terminal restlessness

every 24 hours

Have more than

2 prn doses been given
in 24 hours? Calculate
amount of MIDAZOLAM administered
Yes
over the last 24 hours and set up a
Convert to a
syringe driver with this dose
syringe driver
and
2 to 5mg sc every 2 to 4 hours prn
No

Continue with
Is the patient’s
MIDAZOLAM
agitation controlled?
2 to 5mg sc
every 2 to 4 hours prn
Yes

No
Increase dose of
MIDAZOLAM in syringe driver to
Review maximum of 60mg
every 24 hours (30mg in renal failure) in 24 hours
Continue with and
current 2 to 5mg sc every 2 to 4 hours prn
prescription
Maximum dose in 24 hours is 60mg
(NB 30mg in renal failure)
which includes both prn doses and
syringe driver
Seek advice if more required

NB if uncontrolled on a maximum of 60mg midazolam (30mg in renal failure) consider

levomepromazine starting at 6.25mg prn. Further doses may need to be added to the syringe driver.
If symptoms continue contact the Specialist Palliative Care Team.
 8

Nausea and Vomiting (see note below for patients with parkinson’s disease)

Is nausea and
Yes No
vomiting present ?

What might be the

Bowel
cause of any nausea Is the patient already
obstruction Chemically induced No
experienced? taking an antiemetic?
(opioid, renal failure,
hypercalcaemia)

Follow the flow diagram for

nausea present but only
Increased
Contact the administer if symptoms
intracranial pressure
Palliative care develop.
Team for advice Yes Most commonly prescribe
Haloperidol (1st line) and
levomepromazine (for 2nd line)
Prescribe CYCLIZINE Prescribe
50mg sc HALOPERIDOL
every 8 hours prn 500 microgram to 1mg sc Use the same antiemetic via the
Avoid or use cautiously in every 8 hours prn syringe driver - if this is possible
renal/heart/liver failure May need lower starting dose (i.e cyclizine, haloperidol,
(e.g. 25mg dose) in renal failure metoclopramide,
(e.g. 500 micrograms) levomepromazine)
(See note in shaded box re If opting for cyclizine prescribe
compatibility) cautiously and at lower dose in
renal/heart/liver failure
(75mg to 100mg sc over 24 hours
plus 25mg sc every 8 hours prn –
Nausea and vomiting

NB. maximum total dose in

Have more than 2 doses Have more than 2 doses 24 hours =100mg in renal failure).
been administered been administered
in 24 hours? in 24 hours? (See note in shaded box re
compatibility)

Yes No Yes
No

Consider use of 24
Consider use of 24 hour sc hour sc infusion
infusion
CYCLIZINE HALOPERIDOL
100 to 150mg Continue with 1 to 3mg Remember :
over 24 hours current over 24 hours
(75mg to 100mg in renal prescription Haloperidol (H) – Good for chemically induced nausea
impairment) Levomepromazine (L) – Broad spectrum antiemetic
Metoclopramide (M) – prokinetic, pushes gut contents
Cyclizine (C) – Good for increased intracranial pressure

Is nausea Not prescribed together

Is nausea controlled? M & C as opposing kinetic effect
controlled? Yes H & L as both dopaminergic (but can prescribe both prn
Continue with
Yes as 1st and 2nd lline options respectively)
current
H & M as both dopaminergic
prescription
No
No Can be prescribed together
H&C
M & L as prokinetic added to broad spectrum antiemetic,
but note both are dopaminergic
H&L if 1st (H) and 2nd (L) line prn choices, but not
together in syringe driver
LEVOMEPROMAZINE 2.5 to 12.5 mg sc infusion over 24 hours
PLUS
LEVOMEPROZAMAZINE 2.5 to 5mg sc every 4 hours prn
Note cyclizine is not compatible with alfentanil and may
(Seek help from palliative care if higher dose in SD required)
be incompatible with hyoscine butylbromide if dose is
greater than 60mg)

Patients with Parkinson’s disease - the above choices are best avoided - 5HT3 receptor-antagonist
are preferred (eg ondansetron – see syringe driver chart and if unsure seek advice from palliative care).
Avoid if possible all dopamine antagonists (e.g haloperidol and levomepromazine)
 9

Dyspnoea (Breathlessness)
(Non renal pathway –see next page for patients with renal failure)
Opioids are more useful for patients who are breathless at rest than those who are breathless on exertion - PCF6.

Is the patient
Yes No
breathless?

Treat reversible causes

appropriately and consider non
pharmacological management such
as positioning, cool air,
reassurance
Prescribe
MORPHINE 2 to 5mg sc every 2 to 4 hours prn
Is the patient already (to be administered only if the patient
taking an opioid (oral or develops breathlessness)
patch)?
No
(If concurrent anxiety consider also prescribing
MIDAZOLAM 2mg sc every 2 to 4 hours prn)
Yes
NB if patient sensitive to morphine use alternative –
Use prn doses for breathlessness even if not in pain

Dyspnoea (Breathlessness)
but note lack of evidence for other opioids
Opioid doses required to relieve breathlessness may be less
than the prn dose used for pain
Look at the foot note

Convert to MORPHINE (or alternative opioid) Have more than

24 hour sc infusion using the opioid conversion table 2 prn doses been given
plus sc prn doses in 24 hours?

If the patient is on an opioid patch

Leave the patch on and initially top up with prn morphine or No Review
alternative opioid. See footnote

If over the next 24 hours 2 or more prn doses are required Yes Continue with
set up a 24 hour sc syringe driver with appropriate opioid. MORPHINE
2 to 5mg sc every 4 hours
The prn dose of morphine (or alternative opioid) used for prn +/- MIDAZOLAM
breathlessnes may be much less than the dose used for
pain. See footnote
To calculate the prn dose of morphine or
If concurrent anxiety alternative opioid
Consider also prescribing MIDAZOLAM 2mg sc every Look at the foot note
2 to 4 hours prn. Severe breathlessness
100% analgesic dose is 1/6th of the 24 hour dose
If more than 2 prn doses required in Moderate breathlessness
24 hours put total dose given in 24 hours into syringe driver 50% analagesic is the 1/12 of the 24 hour dose
Maximum MIDAZOLAM dose 60mg in 24 hours
Mild breathlessness
If symptoms continue contact the specialist palliative care 25% analgesic dose is 1/24 of the 24 hour dose
team

Note :
Severe breathlessness >7/10 a dose that is 100% of 4 hourly analgesic dose may be needed
Moderate breathlessness 4 to 6/10 a dose that is 50 to 100% of 4 hourly analgesic dose may be needed
Mild breathlessness < 3/10 a dose that is 25 to 50% of 4 hourly analgesic dose may be needed
Morphine is normally used for breathlessness. This is the opioid which has the best evidence base for treatment of
breathlessness. In renal impairment however morphine accumulates and alfentanil or oxycodone is preferred for this
reason.
 10

Dyspnoea (Breathlessness) in Renal Failure

(Patients with severe renal failure i.e. GFR < 30mL/m use oxycodone or <15mL/min use
Alfentanil if unable to tolerate oxycodone )
Opioids are more useful for patients who are breathless at rest than those who are breathless on exertion PCF6.

Is the patient
Yes No
breathless?

Treat reversible causes appropriately

and consider non pharmacological GFR >/= 15mL/min
management such as positioning, Prescribe OXYCODONE
cool air, reassurance 1 to 2mg sc every 2 to 4 hours prn to adminster if
patient develops breathlessness

GFR <15mL/min
Prescribe ALFENTANIL
Dyspnoea (breathlessness) Renal Failure

Is the patient already No

250 micrograms sc every 2 to 4 hours prn to
taking an opioid (oral or
administer if the patient develops breathlessness
patch)?

Yes
(If concurrent anxiety consider also prescribing
Use prn doses for breathlessness even if not in pain MIDAZOLAM 2 mg sc every 2 to 4 hours prn)
Opioid doses required to relieve breathlessness may be less
than the prn dose used for pain. See footnote

If patient is already taking and tolerating oral OXYCODONE and

GFR >15mL/min convert to OXYCODONE 24 hour sc syringe
driver plus sc dose ever 2 to 4 hours prn Yes Have more than
Convert to 2 prn doses been given
OTHERWISE syringe driver in 24 hours?
Convert to ALFENTANIL
24 hour sc infusion using the opioid conversion table plus
No
sc dose every 2 to 4 hours prn (up to a maximum of 6 prn Review
doses in 24 hours)
(Note oxycodone may sometimes be used as the prn opioid – Continue with
see pain flow chart in renal patients). ALFENTANIL 100 to 250 micrograms sc
every 2 to 4 hours prn
If the patient is on a opioid patch (up to a maximum of 6 prn doses in 24 hours)
Leave the patch on and initially top up with prn oxycodone or +/- MIDAZOLAM
alfentanil.
If over the next 24 hours 2 or more prn doses are required set
up a 24 hour sc syringe driver with oxycodone or alfentanil

The prn dose of oxycodone or alfentanil used should take To calculate the prn dose of opioid for
account of both the patch and the syringe driver breathlessness
Look at the foot note
If concurrent anxiety Severe breathlessness
Consider also prescribing MIDAZOLAM 2mg 100% analgesic dose is 1/6th of the 24 hour dose
sc every 2 to 4 hours prn. Moderate breathlessness
If more than 2 prn doses required in 50% analagesic is the 1/12 of the 24 hour dose
24 hours put total dose given in 24 hours into syringe driver
Mild breathlessness
Maximum MIDAZOLAM dose 30mg in 24 hours
25% analgesic dose is 1/24 of the 24 hour dose
If symptoms continue contact the specialist palliative care team

Note :
Severe breathlessness > 7/10 a dose that is 100% of 4 hourly analgesic dose may be needed
Moderate breathlessness 4 to 6/10 a dose that is 50 to 100% of 4 hourly analgesic dose
Mild breathlessness < 3/10 a dose that is 25 to 50% of 4 hourly analgesic dose may be needed
Morphine would normally be used for breathlessness. This is the opioid which has the best evidence base for treatment
of breathlessness. In renal impairment however morphine accumulates and alfentanil or oxycodone is preferred for this
reason.
11
 12

Guidance for prescribing anticipatory medicines subcutaneously

If your patient has renal failure look at the cautions in red

Usual max
24 hours sc
dose in
Drug Use Stat dose sc dose in syringe
24 hours
driver (SD)
(prn + SD)
Medication for nausea and vomiting
Centrally acting on vomiting centre. 50mg 100 to 150mg 150mg
Good for nausea associated with (25mg in patients (75 to 100mg in (75 to 100mg in
bowel obstruction or increased with renal/heart/ renal/heart/liver renal/heart/liver
CYCLIZINE intracranial pressure liver failure.) failure) failure)
50mg in 1mL Dilute with water Do not use if
Note Dose reduction may be patient has two or
necessary in renal, cardiac or liver more of above
failure e.g. 25mg risk factors
Good for chemically induced nausea 500microgram to 1 to 3mg 5mg
1mg
HALOPERIDOL May need lower
5mg in 1mL dose in
elderly/renal failure
500microgram
Antiemetic action 10mg 30 to 60mg 100mg
METOCLOPRAMIDE 1. Prokinetic (accelerates GI transit) (5 to 10mg) (30mg in (30mg in
10mg in 2mL 2. Centrally acting on chemo- renal failure) renal failure)
receptor trigger zone (CTZ),
NB MHRA caution blocking transmission to vomiting
centre
Broad spectrum antiemetic, works on 2.5 to 5mg 2.5 to 12.5mg 12.5mg
LEVOMEPROMAZINE chemo-receptor trigger zone (CTZ) If require higher
25mg in 1mL and vomiting centre (at lower doses) doses consult
Dilute with sodium chloride 0.9% palliative care
when used alone
Medication for agitation
Sedative/anxiolytic (terminal 2 to 5mg 5 to 60mg 60mg
MIDAZOLAM agitation). Also anticonvulsant and Always start low (30mg in renal (30mg in renal
10mg in 2mL muscle relaxant For major bleeds failure) failure)
use 10mg im Start with lower
dose & titrate

LEVOMEPROMAZINE Antipsychotic used for terminal 5 to 12.5mg 5 to 50mg 200mg

nd
25mg in 1mL agitation (2 line to midazolam) Start with lower Seek help with (25mg to 50mg
dose & titrate higher doses in renal failure)
Medication for respiratory secretions
Antisecretory - useful in reducing 10 to 20mg 40 to 120mg 120mg
respiratory tract secretions.
HYOSCINE Has antispasmodic properties Caution in heart
BUTYLBROMIDE May precipitate when mixed with disease
20mg in 1mL cyclizine or haloperidol.
Less sedating than HYOSCINE
HYDROBROMIDE as does not
cross the blood brain barrier
Antisecretory - useful in reducing 200microgram 400 to1200 1200
GLYCOPYRRONIUM respiratory tract secretions (100microgram) microgram micrograms
200microgram in 1mL Also has antispasmodic properties (1.2mg) (1.2mg)
(200 to 600 (600 microgram
microgram) in renal failure)
 If more information is required please seek help from specialist palliative care
Opioid dose conversion chart, syringe driver doses, rescue / prn doses and opioid patches 13
Use the conversion chart to work out the equivalent doses of different opioid drugs by different routes.
The formula to work out the dose is under each drug name. Examples are given as a guide

Oral opioid mg /24 hour Subcutaneous infusion of opioid Subcutaneous prn opioid Opioid by patch
(Divide 24 hour dose by six Syringe driver (SD) dose in mg per 24 hours Dose in mg every 4 hours injected as required prn Dose microgram/hour
for 4 hourly prn oral dose) (or micrograms for alfentanil where stated) NB Alfentanil in lower doses in micrograms
Morphine Oxycodone Diamorphine Morphine Oxycodone Alfentanil Diamorphine Morphine Oxycodone Alfentanil Fentanyl Buprenorphine
4 hour B=Butec change
24 hour 24 hour sc 24 hour sc 24 hour sc 24 hour sc 24 hour 4 hour 4 hour 2 to 4 hour normally change
every 7 days
(500microgram/ every 72 hours
(500microgram/mL) T = Transtec change
mL)
96 hrs (4 days)
Calculated by Calculated by Calculated by Calculated by Calculated by Prn dose is one sixth (1/6th) of 24 hour subcutaneous (sc) Conversions use UK SPC
dividing 24 hour dividing oral dividing oral dividing oral dividing 24 hour syringe driver dose plus opioid patches if in situ.
oral morphine morphine morphine oxycodone dose oral morphine NB Alfentanil injection is short acting. Maximum 6 prn
dose by 2 dose by 3 dose by 2 by 2 dose by 30 doses in 24 hours. If require more seek help
20 10 5 10 5 500mcg 1 2 1 100mcg (6) B 10
45 20 15 20 10 1500mcg 2 3 2 250mcg 12 B 20
90 45 30 45 20 3mg 5 7 3 500mcg 25 T 35
140 70 45 70 35 4500mcg 8 10 5 750mcg 37 T 52.5
180 90 60 90 45 6mg 10 15 8 1mg 50 T 70
230 115 75 115 60 7500mcg 12 20 10 1.25mg 62 T 70 + 35
270 140 90 140 70 9mg 15 25 10 1.5mg 75 T70 + 52.5
360 180 120 180 90 12mg 20 30 15 2mg 100 T 140
450 225 150 225 110 15mg 25 35 20 2.5mg 125 -
540 270 180 270 135 18mg 30 45 20 3mg 150 -
630 315 210 315 160 21mg 35 50 25 3.5mg 175 -
720 360 240 360 180 24mg 40 60 30 4mg 200 -

Fentanyl and buprenorphine patches in the dying/moribund patient

Equivalent doses if converting from oral to sc opioid  Continue fentanyl and buprenorphine patches in these patients.
o Remember to change the patch(es) as occasionally this is forgotten!
Calculation of breakthrough/ rescue / Renal failure/impairment GFR<30mL/min: o Fentanyl patches are more potent than you may think
prn doses Morphine/Diamorphine metabolites If pain occurs whilst patch in situ
accumulate and should be avoided.  Prescribe 4 hourly prn doses of subcutaneous (sc) morphine unless contraindicated.
Oral prn doses:
 Fentanyl patch if pain is stable.  Use an alternative sc opioid e.g. alfentanil or oxycodone in patients with

th
Morphine or Oxycodone: 1/6 of 24 hour oral
 Oxycodone orally or by infusion if mild o poor renal function,
dose
renal impairment o morphine intolerance
Subcutaneous: o where morphine is contraindicated
 If patient is dying & on a fentanyl or

th
Morphine & Oxycodone: 1/6 of 24 hour sc
buprenorphine patch top up with  Consult pink table when prescribing 4 hourly prn subcutaneous opioids
syringe driver (SD) dose Adding a syringe driver (SD) to a fentanyl or buprenorphine patch
appropriate sc oxycodone or

th
Alfentanil: 1/6 of 24 hour sc SD dose alfentanil dose & if necessary, add into If 2 or more rescue/ prn doses are needed in 24 hours, start a syringe driver with appropriate opioid and
o Short action of up to 2 hours syringe driver as per renal guidance continue patch(es). The opioid dose in the SD should equal the total prn doses given in the previous 24
o Seek help If reach maximum of 6 prn  If GFR<15mL/min and unable to
hours up to a maximum of 50% of the existing regular opioid dose. Providing the pain is opioid sensitive
doses in 24 hours continue to give prn sc opioid dose and review SD dose daily.
tolerate oxycodone use alfentanil sc E.g. Patient on 50 micrograms/hour fentanyl patch, unable to take prn oral opioid and in last days of life.
Keep patch on. Use appropriate opioid for situation or care setting. If 2 extra doses of 15 mg sc
(For ease of administration, opioid doses over morphine are required over the previous 24 hours, the initial syringe driver prescription will be morphine
10mg, prescribe to nearest 5mg) If unsure please seek help 30mg/24 hour. Remember to look at the dose of the patch and the dose in the syringe driver to
work out the new opioid breakthrough dose each time a change is made.
from palliative care Always use the chart above to help calculate the correct doses.

Copyright Owner: Anne Garry, Palliative Care Team & Pharmacy Group September 2017 Version 7. Review date September 2020. Approved by York D&T Committee. Modified from Northern Cancer Network EOLC
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