Apologies for the delay since my last post. It was busy.
There were many learning experiences I want to share. Perhaps the most poignant one was writing up the Liverpool Care Pathway for an elderly woman with multiple co morbidities and a likely terminal episode of pneumonia. The consultant made a decision to start the LCP, and I was asked to write the relevant medications.
My stream of consciousness went something like this: What dose of morphine should we use? I don’t know if she is opiate naive…does it matter at this stage? Can an F1 write big doses of morphine up? Oh, she’s on oxygen. Does that have to stop? It’s symptom relief only…but does the oxygen make her feel less breathless? Maybe we could monitor her sats and see if she needs it…but hold on, is that invasive monitoring? She looks dry, and I’m pretty sure the LCP says that actually you can use artificial hydration, I remember a case study on the GMC website. How can I tell if she is agitated, or in pain? Do the family decide…
As ever, when in doubt with a prescription, I speak to a pharmacist. These are the most amazing people in the hospital. They are fountains of knowledge raining on the gasping fish out of water that is the F1 asked to make a decision about which drug to use.
“Hi. I need help.”
“What is it?”
“I’ve been asked to prescribe the LCP to a terminally ill patient. How do I write up a syringe driver? How do I decide the rate and dose? How do I…”
She produced a LCP booklet that was about 30 pages long. I started reading from the front, which felt like opening a new TV and reading the company propaganda from Sony when it’s pretty clear that the things I really need are going to be later in the booklet. I never understand why companies insist on selling you the product in the first few pages after you have clearly just bought it.
I skipped forward to the prescribing section. There were five pharmaceutical targets to the care:
1. No pain
2. No vomiting/nausea
3. No agitation/restlessness
4. No respiratory distress
5. No respiratory secretions
The management of each of these depended on whether or not the patient was already experiencing the symptom. If the patient had the symptom, an appropriate drug should be written up as a syringe driver with a PRN subcut breakthrough dose. If the patient were not yet experiencing this symptom, then a PRN dose should be prescribed. As I began attempting to fill in the prescription chart, I realised I could not write anything unless I knew what the particular needs of my patient were. I decided to see the patient.
The patient was a tall woman who had clearly lost weight recently. Folds of skin hung loosely off bones that are not meant to be so easily visible. She was breathing rapidly but with shallow breaths, with each inspiration accompanied by what sounded like basal crepitations but amplified and coming out the mouth. She did not seem to be in pain, but how do you tell in a patient who is not verbalising or even vocalising? She was as peaceful as he could be with all the secretions in her respiratory tract, and her respiratory rate was around 16.
I asked the nurse looking after her what she thought about her symptom control over the last few hours. I also spoke with her daughters to work out what symptoms (if any) were bothering her most in the last few days.
For pain, we looked through the notes, including her previous prescriptions, and there was no suggestion of any pain nor any history of painkillers above PRN paracetamol. I decided to use PRN diamorphine 10mg s/c for pain control based on the LCP recommendation.
The patient had not been vomiting or expressed any nausea. PRN haloperidol 1mg s/c was the medication of choice for this scenario. As the patient appeared to be opiate naive, and 10mg diamorphine is a pretty big first dose of opiate, there was a significant risk of inducing vomiting in her last few moments alive, which needed antiemetic cover.
The advantage of haloperidol was that is was also useful for agitation and restlessness. The patient had none of that at the moment, so a PRN dose was all that was needed. The other option recommended was midazolam, which would be more sedating. As her daughters were around and presumably wanted to speak with her, I preferred the less sedating option.
I have since learnt that respiratory distress is often tied to anxiety in the dying patient, and both should be treated together. Relaxation exercises and physiotherapy, as well as basic treatment like sitting the patient up if tolerated, can be helpful. Medically, morphine can be used PRN. There was no need to write up any additional medication in this case. We decided that oxygen was not needed, as the mask was probably uncomfortable and as the respiratory rate did not increase with the oxygen off, the patient probably was not in respiratory distress. I realise that I am making the assumption that respiratory rate and respiratory distress have the usual relationship that they have in non palliative medicine. If anyone has anything to add on this I would be really grateful.
Finally, the respiratory secretions. The patient had symptoms, so needed hyoscine hydrobromide. I gave this as a subcut syringe driver over 24 hours, with a PRN top up as needed.
I didn’t have long before I was back to my usual on call routine of pretending to be in 3 places at once. But just for a few minutes, I felt like a doctor who was independent from the chaos in the rest of the hospital. I was making the care of my patient my one and only priority, and it was rewarding.