rpmg covid-19 guidance final (april 2020) · 2020. 4. 10. · ts t ils in ec ®) rix ®) h ® olu!...

COVID

-19 EOLC Sym

ptom m

anagement guidance 2 April 2020

Guidance for the M

anagement of

Symptom

s in Adults in the Last D

ays of Lifeprofessionals on m

anaging comm

only experienced sym

ptoms at the end of life.

Updated Jan 2018 Peter Arm

strong & D

r Kiran Kaur on behalf of the

Public Health

Agency

COVID

-19: Symptom

Managem

ent in Last D

ays of Life (For use in Secondary and Prim

ary Care Se!ngs)

(April 2020)

CORONAVIR

US

COVID

-19 EOLC Sym

ptom m


COVID

-19: Symptom

Managem

ent in Last Days of Life (2 April 2020)

This guidance is a supplement to the RPM

G “G

uidance for the Managem

ent of Symptom

s in Adults in the Last Days of life” w

hich should s!ll be used as a reference. h"p://w

ww

.professionalpallia!vehub.com/sites/default/files/RPM

G%

20End%20of%

20Life%20G

uidance%202018.pdf

This guidance has been developed given the extreme challenges that m

ay arise as a result of COVID

-19 pandemic. It is specifically for use in

pa!ents in the last days of life and is applicable in both Secondary and Primary care se!

ngs.

The subcutaneous route of medica!on adm

inistra!on remains the preferred route as pa!ents w

ill o$en have difficulty or be unable to sw

allow

in the last days of life. If there are issues with drug availability, please refer to 3rd line op!ons - these should only be considered as a last resort

where all other op!ons have been exhausted.

Please seek advice from the local H

ospital Specialist Pallia!ve Care team or H

ospice if needed:

Belfast HSC Trust

028 9615 1900

Northern H

SC Trust

028 9442 4000

South Eastern HSC Trust

028 4483 8388 ext 2222

Southern HSC Trust

028 3026 7711

Western H

SC Trust (North Sector )

028 7134 5171 (Altnagelvin Hospital Sw

itchboard)

Western H

SC Trust (South Sector)

028 6638 2000 (SW

AH)

STAFF SHO

ULD

BE AWARE TH

AT THIS GU

IDAN

CE IS SUBJECT TO

CHAN

GE AS DEVELO

PMEN

TS OCCU

R. CHECK FO

R UPD

ATES ON

THE

PALLIATIVE CARE IN PARTN

ERSHIP W

EBSITE: ww

w.pcip.hscni.net

COVID

-19 EOLC Sym

ptom m


For pa"ents who are seriously ill w

ith Covid-19, honest and sensi"ve conversa"ons about goals of care and treatment escala"on planning

should be ini"ated as early as possible.

Ac"on

Consider

Establish a clear ceiling of care at admission

DN

ACPR discussions Review

route of administra!on of m

edicines for symptom

control - con!nue oral if tolerated and prescribe PRN

SC alterna!ves as appropriate U

sual SC medicines are not available or cannot be adm

inistered

Consider stopping regular observa!ons and inverven!ons including BM

s and fluids An!cipatory Prescribing

Consider mouth care

Ra!onalise all medicines

A"end to the social, psychological and spiritual care of the pa!ent

See 3rd line medicine choices

Ra!onalise diabetes treatment and BM

monitoring in line w

ith diabetes U

K End-of- Life-Care; h"ps://ww

w.diabetes.org.uk/

resources-s3/2018-03/EoL_Guidance_2018_Final.pdf

Consider stopping parenteral fluids

Ensure an!cipatory medica!on is prescribed for all pa!ents - please

prescribe oral and SC op!ons as appropriate

Consider regular Biotene Gel four !m

es a day

Avoid mouthw

ashes

Consider stopping non-cri!cal medicines and if necessary, review

ing the route of adm

inistra!on for cri!cal medicines e.g. an!-epilep!cs,

Parkinson’s medica!on

COVID

-19 EOLC Sym

ptom m


General points•

In all cases consider posi!oning and other non-pharmacological m

easures. Seek physio advice if required.

• For pa!ents already on opioid m

edica!ons adjust the breakthrough dose to one sixth of the pa!ent’s regular total opioid dose.

• For all sym

ptoms, consider star"ng at low

er end of ranges given, especially in pa"ents who are opioid-naïve, elderly or have a low

BM

I, and !tra!ng up rapidly as needed (usually 30-50% every 12 hours, using clinical judgem

ent. Reassess symptom

s if pa!ent is not

responding).

• For pa!ents w

ho are very symptom

a!c or distressed, consider star!ng higher doses in the range and !tra!ng up rapidly if needed. The

pa!ents m

ay benefit from a dose range being prescribed to allow

nursing staff more flexibility eg M

orphine Sulfate 2mg-5m

g SC PRN (TW

O

m

g to FIVE mg) for pain or dyspnoea 2 hourly to a m

aximum

of 30mg/24hrs PRN

.

• A shorter dose interval eg 1-2 hourly PRN

with a clear m

aximum

permissible dose in 24hrs m

ay also allow flexibility

• The pa!ents m

ay deteriorate very quickly and may require com

bina!ons of 2 or 3 SC PRNs at one !m

e eg if SOB/agitated and having

secre!ons - consider giving the pa!ent Morphine Sulfate SC for SO

B; Midazolam

SC for anxiety and a SC an!secretory.

• Consider using a subcutaneous line to allow

for stat dosing, par!cularly if repeated stat doses are required for symptom

s. Consider using a

‘Saf-T-In!ma’ for this purpose at end of life.

• U

nless stated these drugs are compa!ble in a CSCI w

ith 0.9% Sodium

Chloride. Up to 4 drugs can be added to a CSCI.

• FO

R LOW

VOLU

ME O

RAL DRU

GS GIVEN e.g. 0.5m

l, ENSU

RE 1 ML SYRIN

GES ARE AVAILABLE FOR CARER / PATIEN

TS.

COVID

-19 EOLC Sym

ptom m


Injectable op"on

Non-

injectable Alterna"ve

Dyspnoea/Pain/Cough

Consider reversible causes and treat if appropriate. Consider posi"oning; relaxa"on techniques; reduce room tem

perature; cool cloth for face; psychological support. Avoid all fans. Consider cough hygiene (‘Catch it/ Bin it/ Kill it’) and m

easures eg oral fluids/cough remedies/

humidified air.

For pa"ents already on opioid medica"ons adjust the breakthrough dose to one sixth of the pa"ent’s regular total opioid dose.

1st line – Ini"a"on of therapy

eGFR>45M

orphine Sulfate injec!on 2mg-5m

g every 2-4 hours PRN by SC Inj

eGFR15-45O

xycodone injec!on 1mg-2m

g every 2-4 hours PRN by SC Inj

eGFR<15or concern re opioid toxicityO

xycodone injec!on 1mg every 2-4 hours PRN

by SC Inj and Contact Specialist Pallia!ve Care Team

for advice

eGFR>45M

orphine Sulfate Oral Solu!on (O

ramorph

®) 5mg every 2-4 hours PRN

eGFR15-45Shortec®

Oral Solu!on 1m

g-2mg every 2-4 hours PRN

eGFR<15Shortec

® Oral Solu!on 1m


and Contact Specialist Pallia!ve Care Team

for advice

2nd line – Alterna"ve or progression of symptom

s

eGFR>45M

orphine Sulfate injec!on 10mg +/-M

idazolam 10m

gover 24 hours via CSCI (Con!nuous Sub-Cutaneous Infusion) and con!nue PRN

SC Inj for breakthrough

eGFR15-45O

xycodone injec!on 5mg +/-M

idazolam 10m

gover 24 hours via CSCI and con!nue PRN


eGFR<15or concern re opioid toxicityO

xycodone injec!on 1mg every 2-4 hours PRN

by SC InjConsider Alfentanil 1m

g +/- Midazolam

5mg-10m

g over 24hrs via CSCIContact Specialist Pallia!ve Care Team

for advice

Use available short-ac!ng opioid eg O

ramorph

® or Shortec® at

equivalent dose, regularly every 4 hours and 2hourly PRN.

Consider use of long-ac!ng opioid at appropriate star!ng dose according to previous opioid use eg M

ST® BD

while con!nuing

Oram

orph® PRN

OR Longtec

® BD w

hile con!nuing Shortec® PRN

. See Regional O

pioid Conversion Guidance

h"p://ww

w.professionalpallia!vehub.com

/resource-centre/northern-ireland-guidelines-conver!ng-doses-opioid-analgesics-adult-use-2018

Please exercise cau!on if prescribing long-ac!ng opioid medica!on

in pa!ents with renal im

pairment.

For use in Secondary and Primary Care

COVID

-19 EOLC Sym

ptom m


Injectable op"on

Non-injectable

Alterna"ve

Injectable op"on

Non-injectable

Alterna"ve

Midazolam

injec!on 2mg-5m

g every 2 hours PRN by SC Inj

And either H

aloperidol 0.5mg-1m


OR

Levomeprom

azine 5mg-10m


Lorazepam sublingual tablets 0.5-1m

g every 4 hours PRN (M

ax 4mg/24

hours) (Suitable brands – Genus, Teva, Lexon or M

ylan)O

RD

iazepam 2m

g-5mg every 4 hours PRN

Glycopyrronium

injec!on 200 microgram

s every 4 hours PRN by SC Inj

and/orG

lycopyrronium injec!on 600-1200 m

icrograms over 24 hours by CSCI

(Max dose 1200 m

icrograms in 24 hours)

OR

Hyoscine Butylbrom

ide injec!on 20mg every 4 hours PRN

by SC InjAnd/O

rH

yoscine Butylbromide injec!on 60-120m

g over 24 hours by CSCI

Hyoscine H

ydrobromide sublingual tablets (Kw

ells®)

300 microgram

s every 6 hours PRN (M

ax 3 doses/24 hours)

Midazolam

10mg over 24 hours via CSCI

And add eitherLevom

epromazine 10-25m

g O

R H

aloperidol 3-5mgand con!nue PRN


Haloperidol 0.5-1m

g every 4-6 hours PRNO

RLevom

epromazine tablets 6m


(Max TD

S)(25m

g tablets can be used and split to appropriate dose and dissolved in w

ater if 6mg tablets are unavailable)

Hyoscine H

ydrobromide injec!on 400 m

icrograms every 4 hours PRN

by SC Injand/orH

yoscine Hydrobrom

ide injec!on 1200-2400 microgram

s over 24 hours by CSCI

NB: First line choice of an!secretory m

ay be affected by availability of m

edica!ons.

Hyoscine H

ydrobromide 1m

g Patch (Scopoderm®

) every 72 hours

Delirium

/Agita"on/ Anxiety Consider reversible causes and treat if appropriate. eg: superadded infec"on; drugs; urinary reten"on; dehydra"on; cons"pa"on; hypoxia. Consider usual non-pharm

acological approaches.

Respiratory Secre"ons Consider reposi"oning on side or sem

i-prone posi"on; reassurance of family that secre"ons are not likely to be causing the pa"ent

discomfort.

COVID

-19 EOLC Sym

ptom m


Can use IV Paracetamol if cannula in situ

Dose according to w

eight:>50kg 1g Q

DS or every 4-6 hours PRN

<50kg 15mg/kg Q


Paracetamol O

ral tablets 1g QD

S or every 4-6 hours PRN

Also consider cooling the face using a cool cloth and Oral fluids if able.

Avoid all fans

NSAID

s are NO

T recomm

ended in COVID

-19 but may be an op"on

at end of life where there is diffi

cult to control pyrexia and limited

alterna"vesConsider:Parecoxib injec!on 20m

g BD PRN

by SC Inj or 40-80mg over 24 hours by

CSCI(Parecoxib should not be m

ixed in syringe pump w

ith any other medicine)

Paracetamol Suppositories 1g Q


And/Or

Diclofenac Suppositories 50-100m

g every 8 hours PRN (M

ax 150mg/24

hours)

Injectable op"on

Non-injectable

Alterna"ve

Pyrexia Consider cool cloth for face; oral fluids if able. Avoid all fans.

COVID

-19 EOLC Sym

ptom m


3rd line medicine choices

To be used only if 1st and 2

nd line choices are not suitable or not available. These are considered less well established prac"ce.

Exercise cau"on when prescribing as m

ay lead to an increased risk of adverse events.N

ote: Transdermal prepara"ons m

ay be absorbed more rapidly in pyrexic pa"ents

Product

Prescribing details

Dyspnoea/Pain

Buprenorphine Patch* – BuTec®

10-20 m

icrogram/hour every 7 days (N

B Equivalent to 20-50mg O

ral Morphine/24 hours)

Fentanyl Patch* – Mezolar M

atrix®

12-25 m

icrogram/hour every 72 hours (N

B Equivalent to 30-90mg O

ral Morphine/24 hours)

Oram

orph® CO

NCEN

TRATED 20m

g/ml O

ral Solu!on

10mg every 4 hours via buccal route PRN

(NB 0.5m

l volume – high risk of overdose if inaccurate m

easure)Shortec®

CON

CENTRATED

10mg/m

l Oral Solu!on

5m

g every 4 hours via buccal route PRN (N

B 0.5ml volum

e – high risk of overdose if inaccurate measure)

Agita"on/Anxiety/Delirium

Epistatus® Buccal Solu!on O

R

5-10m

g every 4 hours PRN via buccal adm

inistra!onBuccolam

®Prefilled Syringes (in the absence of the above being available, m

idazolam

solu!on for injec!on can be administered via buccal m

ucosa)

Diazepam

Enema

5-10m

g OD

PRN via rectum

Olanzapine O

rodispersible tablets

5-10mg O

D (Can increase to 20m

g/day as required)Risperidone tablets

500 m

icrograms BD

regularly or PRN

If CSCI not available but DN

able to administer SC injec"on:

Consider Haloperidol 1-3m

g sc daily or

Levom

epromazine 10m

g sc od /bd

Respiratory Secre"onsIf CSCI not available but D

N able to adm

inister SC injec"on: Consider H

yoscine Butylbromide 40m

g SC BD O

R

G

lycopyrronium 400m

cg BD or TID

Atropine 1% Eye D

rops

Sublingually 1-2 drops every 6-8 hours PRN

*Note topical opioid patches w

ill take 24-48 hours to establish efficacy in m

ost pa!ents and PRN opioids/alterna!ve strategies w

ill need to be used in mean!m

e.

COVID

-19 EOLC Sym

ptom m


CORONAVIR

US

This guidance has been prepared by the Regional Pallia"ve M

edicine Group (RPMG) in N

orthern Ireland w

ith input from the N

I Specialist Pallia"ve Care Pharm

acy Group and supported by the Pallia"ve Care in Partnership Program

me.

WA

SH

HA

ND

SK

EE

P D

ISTA

NC

ES

TAY

HO

ME

Prescribing Opioid A

nalgesicsM

orphine is the first line choice of strong opioid in non-specialist settings.

*In severe renal impairm

ent or dialysis patients, buprenorphine, fentanyl or alfentanil m

ay be the preferred opioid.

Prescribe oral, transdermal and transm

ucosal opioids by brand nam

e and injections generically.

Remem

ber to ensure you are clear on the duration of action w

hen prescribing branded products:

• Short-acting preparations e.g. O

ramorph

®, Sevredol ®, Shortec

®, Oxynorm

® or Palladone

® approximately 4 hours.

• Long-acting preparations e.g. M

ST®,

Longtec®, O

xyContin

® or Palladone® SR

approximately 12 hours.

• O

pioid patches e.g. Mezolar ®, D

urogesic®,

replace every 3 days. Butec®, BuTrans

®, replace every 7 days. Transtec

® replace twice

weekly (every 3 or 4 days).

Northern Ireland guidelines on converting

doses of opioid analgesics for adult use 2018

Disclaim

er: Conversion ratios vary and these are an approxim

ate guide only. They m

ay differ from other published

conversions but have been chosen to reflect best evidence and safety. U

sers are advised to m

onitor patients carefully for pain and side effects. Responsibility for the use of these recom

mendations lies w

ith the healthcare professional(s) m

anaging each patient. Seek specialist palliative care advice w

hen necessary, especially at higher doses.

ReferencesBritish N

ational Formulary 74 (Septem

ber 2017)Palliative C

are Formulary 5th Edition (2014)

Palliative Adult N

etwork G

uidelines (PAN

G) 2016.

ww

w.book.pallcare.info

Health and Social C

are Board NI Form

ulary http://niformulary.hscni.net

Royal College of A

naesthetists. Opioids A

ware: A

resource for patients and healthcare professionals. w

ww

.rcoa.ac.uk/faculty-of-pain-m

edicine/opioids-aware

National Patient Safety A

gency. 2008. Reducing dosing errors with

opioid medicines. N

PSA/2008/RRR005

Electronic Medicines C

ompendium

2017. Summ

ary of Product C

haracteristics Tapentadol. Personal com

munication. G

runenthal June 2017

Developed w

ith input from the H

ealth and Social Care Board Pharmacy and M

edicines M

anagement Team

January 2018. For review January 2021

• Ensure you are fam

iliar with the follow

ing characteristics of that medicine and

formulation: usual starting dose, frequency of adm

inistration, standard dosing increments,

symptom

s of overdose, comm

on side effects.

• C

onfirm the m

ost recent opioid dose, formulation, frequency of adm

inistration and any other analgesic m

edicines prescribed for the patient.

• Ensure w

here a dose increase is intended, the calculated dose is safe for the patient (e.g. generally by a third but not norm

ally more than 50%

higher than the previous dose). U

se caution in higher doses.

• W

hen making a planned opioid sw

itch, if there is no stated opioid equivalent, usual practice is to convert to the oral m

orphine equivalent and then to the chosen opioid.

• C

onsider reduced doses in elderly, cachectic and debilitated patients. In renal or significant hepatic im

pairment, seek further advice.*

• W

hen switching opioids it is recom

mended that a 25 - 50%

reduction of the calculated dose of the new

opioid should occur. This is to allow for cross tolerance, w

here tolerance to a currently adm

inistered opioid may not extend com

pletely to other opioids. The new

regimen m

ay need to be increased or decreased accordingly. Monitor patients closely,

especially at higher doses.

• The addition of adjuvant analgesia m

ay require reduction of the opioid dose.•

Before prescribing opioids or increasing doses:

• All patients should be m

ade aware of the potential risks, side-effects and potency of

opioids. Patient information available at http://niform

ulary.hscni.net

• W

hen considering prescribing opioids for persistent non-malignant pain, m

edication w

ill achieve a 30-50% pain reduction at best. The risk of harm

increases substantially above daily doses of oral m

orphine sulfate 120mg (or equivalent), w

ithout significant benefit. Suitable pain self m

anagement should also be explored w

ww

.paintoolkit.org

• Transderm

al Opioid Conversion

• Transdermal patches are N

OT appropriate w

hen rapid titration of opioids is required e.g. acute pain. U

se in stable pain. • O

n first applying or increasing patch, systemic therapeutic levels are not reached for at

least 12 hours. Doses should not be changed m

ore regularly than every 48 hours.

• On rem

oval of an opioid patch a reservoir of the drug remains under the skin w

ith levels falling by 50%

(half-life) approximately every 18 to 24 hours.

• For inform

ation on initiating, changing or stopping transdermal opioids refer to

Palliative Adult N

etwork G

uidelines ww

w.book.pallcare.info

Health and Social Care

in Northern Ireland

Breakth

rou

gh

An

algesia in

Palliative C

areIn palliative care the standard dose of a strong opioid for breakthrough pain is usually one-sixth of the regular 24 hour dose, repeated every 4 to 6 hours as required.

The BNF prescribing in palliative care guidance

also supports use (outside the product licence) every 2 to 4 hours as required (up to hourly m

ay be needed if pain is severe or in the last days of life).

14

In persistent non-malignant pain, patients

should not routinely require breakthrough analgesia except prior to events likely to cause pain e.g. dressing changes.

Buprenorphine Patch e.g. Butec®, BuTrans

® Replace patch EV

ERY 7 D

AY

S

Patch strength(m

icrograms per hr)

Oral dose over 24 hours (m

g)

Morphine

Tramadol

Codeine/

Dihydrocodeine

5 microgram

s/hr~10 - 12

~100~120m

g/day

10 microgram

s/hr~20 - 24

~200~240m

g/day

20 microgram

s/hr ~40 - 48

~400

Oral M

orphine to Oral O

xycodone – Divide by 2

E.g. 30mg O

ral Morphine = 15m

g Oral O

xycodone

Oral M

orphine to Oral H

ydromorphone – D

ivide by 7.5 E.g. 30m

g Oral M

orphine = 4mg O

ral Hydrom

orphone

Oral Tapentadol ‡ to O

ral Morphine – D

ivide by 2.5 E.g. 50m

g Oral Tapentadol = 20m

g Oral M

orphine

Oral Tapentadol ‡ to O

ral Oxycodone – D

ivide by 5 E.g. 50m

g Oral Tapentadol = 10m

g Oral O

xycodone

Oral Tram

adol ‡ to Oral M

orphine – D

ivide by 10 E.g. 100 m

g Oral Tram

adol = 10 mg O

ral Morphine

Oral Tram

adol ‡ to Oral Tapentadol ‡ – D

ivide by 4E.g. 200m

g Oral Tram

adol modified release = 50m

g Oral Tapentadol

modified release

Oral Codeine / D

ihydrocodeine to Oral M

orphine – Divide by 10

E.g. 240 mg O

ral Codeine / D

ihydrocodeine = 24 mg O

ral Morphine

Oral M

orphine to Subcutaneous (SC) Diam

orphine – Divide by 3

E.g. 30 mg O

ral Morphine = 10 m

g SC D

iamorphine

Oral M

orphine to SC Morphine – D


g Oral M

orphine = 15 mg SC

Morphine

Oral M

orphine to SC Alfentanil – D


g Oral M

orphine = 1 mg SC

Alfentanil

Oral O

xycodone to SC Oxycodone – D


g Oral O

xycodone = 5 mg SC

Oxycodone

Oral H

ydromorphone to SC H

ydromorphone – D

ivide by 2 E.g. 4 m

g Oral H

ydromorphone = 2 m

g SC H

ydromorphone

PO (O

ral) to PO

PO (O

ral) to SC (Subcutaneous)SC (Subcutaneous) to SC

SC Diam

orphine to SC Alfentanil – D

ivide by 10E.g. 10 m

g SC D

iamorphine = 1 m

g SC A

lfentanil

SC Morphine to SC D

iamorphine – D

ivide by 1.5 E.g. 15 m

g SC M

orphine = 10 mg SC

Diam

orphine

SC Morphine to SC O

xycodone – D

ivide by 2E.g. 20 m

g SC M

orphine = 10 mg SC

Oxycodone

Note this m

ay differ from other available conversions

SC Morphine to SC A

lfentanil – Divide by 15

E.g. 15mg SC

Morphine = 1m

g SC A

lfentanil

Buprenorphine Patch e.g. Transtec®

PatchReplace patch TW

ICE WEEK

LY (every 3 or 4 days)

Transtec®

Patch (microgram

s/hr)24 hour O

ral M

orphine Dose

35 microgram

s/hr~ 63 - 97m

g

52.5 microgram

s/hr~ 95 - 145m

g

The doses below are not recom

mended for persistent non-

malignant pain

70 microgram

s/hr~ 126 - 193m

g

140 microgram

s/hr~ 252 - 386m

g

Fentanyl Patch e.g. Mezolar

®, D

urogesic®

Replace patch every 3 days

Fentanyl Patch (m

icrogram/hr)

Equivalent 24 hourly Oral

Morphine D

ose (mg)

1230-59

2560-89

3790-119

50120-149

The doses below are not recom

mended for

persistent non-malignant pain.

62150-179

75180-239

100240-299

125300-359

150360-419

175420-479

200480-539

225540-599

250600-659

275660-719

300720-779

Transdermal to O

ral

Transdermal to O

ral

32

Specialist Palliative Care only. Oral M

orphine to SC Fentanyl D

ivide by 150 e.g. 15mg O

ral Morphine = 100 m

icrograms SC

Fentanyl

‡Analgesia only partly opioid-m

ediated. Potential for increased opioid-related side effects w

hen switching

to other opioids.

Approxim

ate equivalent doses of opioid analgesics for adult use Read page1 before using these equivalence tables

The following medicines are stocked by all network pharmacies DRUG STOCK DRUG STOCK

Alfentanil 1mg/2ml Injection 1 x 10 Lorazepam 1mg Tablets (Brands

Genus, Teva, Mylan, Lexon) NEW

1 x 28

Cyclizine 50mg/ml Injection 2 x 5 Metoclopramide 10mg/2ml Injection 1 x 10

Cyclizine 50mg Tablets NEW 1 x 100 Metoclopramide 10mg Tablets NEW 2 x 28

Dexamethasone 3.3mg/ml Injection 1 x 10 Midazolam 10mg/2ml Injection 2 x 10

Diamorphine 5mg Injection 1 x 5 Midazolam Buccal Solution (Epistatus®)

10mg/ml NEW

1 x 5ml

Diamorphine 10mg Injection 2 x 5 Morphine Sulfate (Oramorph®)

10mg/5ml Solution VOLUME

INCREASED

3x100ml and 1x300ml

Diamorphine 30mg Injection 2 x 5 Morphine Sulfate 10mg/ml Injection 1 x 10

Diamorphine 100mg Injection 1 x 5 Morphine Sulfate 30mg/ml Injection 1 x 10

Diazepam 2mg Tablets NEW 1 x 28 Ondansetron 4mg/2ml Injection 1 x 5

Diazepam Oral 10mg/5ml

Suspension/Solution NEW

2 x 200ml Ondansetron Orodispersible Films 4mg

NEW

1 x 10

Furosemide 50mg/5mls Injection 1 x 10 Oxycodone 5mg/5ml Syrup 1 x 250ml

Glycopyrronium 200micrograms/ml Injection

1 x 10 Oxycodone 10mg/1ml Injection 2 x 5

Haloperidol 5mg/ml Injection 1 x 10 Oxycodone 20mg/2ml Injection 2 x 5

Haloperidol Caps or Tabs 500mcg

NEW

3 x 28 Oxycodone 50mg/1ml Injection 1 x 5

Haloperidol Oral Solution 5mg/5ml

NEW

1 x 100ml Oxygen Cylinders and one giving set 2 x Size AF

Hyoscine Butylbromide 20mg/ml (Buscopan®) Injection

1 x 10 Paracetamol 500mg Tablets NEW 100

Hyoscine Hydrobromide 400micrograms/ml Injection

1 x 10 Paracetamol Soluble Tablets 500mg

NEW

100

Hyoscine Hydrobromide (Kwells®)

Sublingual Tablets 300mcg NEW

2 x 12 Paracetamol Suppositories 500mg

NEW

2 x 10

Hyoscine Hydrobromide Patch 1mg

(Scopoderm®) NEW

1 x 2 Paracetamol Suspension/Solution

250mg/5ml NEW

2x 500ml

Levomepromazine 25mg/ml Injection

1 x 10 Prochlorperazine Buccal Tablets 3mg

NEW

1 x 50

Levomepromazine 6mg Tablets 1 x 28 Sodium Chloride 0.9% 10ml Injection 1 x 10

Levomepromazine 25mg Tablets (if

6mg unavailable) NEW

1 x 28 Water for Injection 10ml

2 x 10

Information correct as of April 2020. For review January 2022.

Community Pharmacy Palliative Care

Network Information for Healthcare Professionals 2020

Palliative care is provided by all community pharmacies and patients and carers

should always be encouraged to use their regular pharmacy to obtain medicines. If

they cannot supply a medication within the required timeframe, contact a network

pharmacy.

Network pharmacies are spread throughout Northern Ireland and aim to increase

access to community pharmacy palliative care services. They can supply medicines

from the palliative stock list (see back page) or be contacted for advice.

Please note:

Outside normal working hours, local arrangements for the supply of

medicines may exist. Contact your local GP Out of Hours Centre.

‘Anticipatory prescribing’ for patients approaching end of life ensures

medicines are available to relieve symptoms as soon as they occur. This can

greatly improve patient comfort and prevent delays accessing medicines.

Information on symptom control at the end of life is available at:

http://niformulary.hscni.net/Formulary/Adult/PalliativeCare

Prescribe sufficient quantities of medicines to cover weekends and out of hours. Prescriptions for controlled drugs must meet the legal requirements:

Drug name, form, strength, dose and frequency.

Total quantity in words and figures, prescriber’s signature

e.g. Morphine Sulfate injection 5mg to be given subcutaneously every four hours

when required for breakthrough pain. Supply Ten (10) x 10mg/ml injection

http://niformulary.hscni.net/Formulary/Adult/PalliativeCare

Southern Area

Armagh

McKeevers Chemists,

33-37 Ogle Street

Mon-Fri 9am-6.00pm

Sat 9am-5.30pm

Tel. 3752 2685

Lurgan

McKeagney Chemist,

10 Edward Street

Mon-Fri 9am-6pm, Sat

9am-5.30pm

Tel. 3832 2295

Aughnacloy

Aughnacloy Pharmacy

67-69 Moore Street

Mon-Sat 9am-6pm

Tel. 8555 7943

Moy

Gordons Chemists,

1 Killyman Street


9.00am-5.30pm

Tel. 8778 4248

Banbridge

Clear Pharmacy,

19-21 Bridge Street

Mon-Sat 9am - 5.30pm

Thur 9.00am - 5.00pm

Tel. 4066 2622

Newry

Cherrymount

Healthcare Ltd, 5 John

Mitchel Place

Mon-Fri 9am-6pm

Sat 9am-5.30pm

Tel. 3026 2606

Crossmaglen

Health Centre

Pharmacy McCormick

Place

Mon-Fri 9am-1pm and

2pm-5.30pm

Tel. 3086 8314

Portadown

Hamill’s Pharmacy

17 Thomas Street

Mon-Fri 9am-6 pm, Sat

9am-1pm

Tel. 3835 2471

Stock list also available from the following pharmacies with extended opening hours:

Dungannon Boots Pharmacy, Oaks Centre, Mon-Wed 9am-5.30pm, Thurs-Fri 9am-9pm, Sat 9am-

5.30pm, Sun 1pm-6pm. Tel. 8772 6626

Craigavon Boots Pharmacy, Rushmere Shopping Centre, Mon-Fri 8.45am-9pm, Sat 8.45am-6pm,

Sun 1pm-6pm Tel. 3834 6885

Newry Medical Hall, The Quays Centre. Mon-Tues 9am-6pm, Wed-Fri 9am-9pm, Sat 9am-6pm,

Sun 1pm-6pm Tel. 3083 3781

Western Area

Belleek

McGuinness

Pharmacy, 4 Main

Street

Mon-Sat 9.30am-6pm

Tel. 6865 8218

Limavady

Gormley Medicare Ltd,

171 Irish Green Street

Mon-Sat 9am-5.30pm

Tel. 7772 2508

Castlederg

Corrys Chemist

11-12 The Diamond


9am-5.30pm

Tel. 8167 1974

Lisnaskea

Armstrongs Pharmacy,

119 Main Street

Mon-Sat 9am-6pm

Tel. 6772 1231

Derry

Murphy's Chemist,

165 Spencer Road

Mon-Sat 9am-9pm,

Sun 12.30pm-1.30pm

Tel. 7131 1720

Omagh

Kelly’s Chemist

41 High Street

Mon-Sat 9am-6pm

(Wed to 5.30pm)

Tel. 8224 2030

Derry

Medicare Pharmacy,

43 Great James Street

Mon-Fri 9.15am–

6.15pm

Tel. 7126 7004

Strabane

Medicare Pharmacy,

340a Ballycolman

Estate

Mon-Fri 9am-6pm,

Tel. 7138 2252

Enniskillen

Erne Pharmacy, 12

Church Street


9am-5.30pm

Tel. 6632 2291

Stock list also available from the following pharmacies with extended opening hours:

Derry Whitehouse Pharmacy, 65 Buncrana Road, Mon-Thurs 9am-6pm, Fri 9am-9pm, Sat 9am-

6pm Tel. 7136 7191

Omagh Boots Pharmacy, 43-47 High Street, Mon-Thurs 8.45am-5.45pm, Fri 8.45am-9pm, Sat 9am-

5.45pm, Sun 1pm-5pm Tel. 8224 5455

Belfast & South Eastern Areas

Belfast

Gordons Chemists 13 Greenway, Cregagh Road

Mon-Fri 9am-6pm Sat 9am-5.30pm Tel. 9040 1023

Downpatrick Gordons Chemists 37 Market Street

Mon-Sat 9am-5.30pm Tel. 4461 2014

Belfast

Crossin Chemist 267 Antrim Road

Mon-Fri 9am-6pm Sat 9.30-5.30 Tel. 9035 1084

Holywood

Sweeney’s Pharmacy 52 High Street

Mon-Sat 9am-5.30pm Tel. 9042 2222

Belfast

McCoubrey Chemists 154 Cavehill Road

Mon-Fri 9am-6pm Sat 9am-1pm Tel. 9039 1169

Kircubbin McKeevers Chemists 40 Main Street

Mon-Sat 9am- 5.45pm Tel. 4273 8235

Belfast

Dohertys Pharmacy 115-117 Andersonstown Rd


Lisburn

Boots Pharmacy 57-59 Bow Street

Mon-Wed 9am-5.30. Thurs 9am-9pm, Fri-Sat 9am-6pm. Sun 1pm- 5pm Tel. 9266 2193

Belfast

McMullans Pharmacy 165 Lisburn Road

Mon-Sat 9am- 5.30pm Tel. 9038 1882

Newcastle Gordons Chemists 16 Railway Street


Bangor

Gordons Chemists 110 Abbey Street

Mon-Fri 9am-6pm. Sat 9am-1pm and 2pm- 5.30pm Tel. 9127 0408

Newtownards Boots Pharmacy 104-108 Frances St

Mon-Fri 9am-9pm Sat 9am-6pm Tel. 9182 3700

Stock list also available from the following pharmacies with extended opening hours

Newtownards Boots Pharmacy, Ards Shopping Centre.

Mon-Fri 9am-9pm, Sat 9am-5.30pm, Sun 1pm-5.30pm Tel. 9181 1297

Northern Area

Antrim Clear Pharmacy, The Health Centre

Mon-Fri 9am-6pm Tel. 9446 3495

Draperstown O’Kane’s Pharmacy, 6 Tobermore Road

Mon-Fri 9am-6pm, Sat 9am-5.30pm Tel. 7962 8209

Ballycastle McMullan’s Pharmacy, 63 Castle Street

Mon-Sat 9am-6pm Tel. 2076 3135

Larne

Larne Chemists The Health Centre

Mon-Fri 9am-6pm, Sun 1-2 pm Tel. 2826 0696

Ballymoney Mathewson’s Pharmacy 51-53 Queen Street

Mon & Thurs 8.30am- 7pm, Tues, Wed, Fri & Sat 8.30-6pm Tel. 2766 4600

Sat 9am-5.30pm, Sun 2-5pm from McFarlane’s Pharmacy 86-88 Main Street, Larne Tel. 2826 0768

Magherafelt O’Briens Pharmacy, 5 Broad Street

Mon-Sat 9am-6pm Tel. 7963 3333

Coleraine

Boots Pharmacy,

Asda Shopping Centre, Ring Road

Mon- Fri 9am-9pm, Sat 9am-5.30pm, Sun 1pm- 6pm Tel. 7032 1596

Randalstown Randalstown Pharmacy, Medical Centre, 5 Neillsbrook Road

Mon-Fri 8.30-6pm. Tel. 9447 2245

Sat 9am-5.30pm operating from 46/48 High St, Randalstown Tel. 9447 2751

Carrickfergus Carrickfergus Chemists, The Health Centre

Stewartstown

F P Kelly,

12 The Square

Mon-Fri 9am-6pm, Sat 9am-1pm Tel. 8773 8241

Mon- Fri 8.45am - 8pm Tel. 93365111

Stock list also available from the following pharmacies with extended opening hours

Ballymena LLoyds Pharmacy (in Sainsburys), Braidwater

Retail Park, Mon-Fri 8am-10pm Sat 8am-8pm Sun 1-6pm

Tel. 2565 3420

Newtownabbey Boots Pharmacy, Abbeycentre,

Mon-Fri 9am-9pm, Sat 9am-6pm, Sun 1pm-6pm Tel. 9036 5910

Consider

Discussions about goals of care

COVID-19 Outbreak

Talking to patients and those close to them about prognosis, ceilings of treatment and possible end of life care is often challenging but, in the current COVID-19 outbreak, such conversations with the population described may become even more difficult, as health professionals may have to triage patients, often in emergency or urgent situations, and prioritise certain interventions and ceilings of treatment.

Background

The UK population is ageing and many more people are living with chronic illness and multiple comorbidities. A third of patients admitted unexpectedly to hospital (rising to 80% in those living in 24-hour care) are in the last year of their lives. Despite such facts, few have ever had discussions about ceilings of treatment or resuscitation. Such conversations, which constitute advance care planning, are useful during normal times, but even more so during the COVID-19 outbreak. Open, honest discussions regarding ceilings of treatment and overall goals of care are not only essential to ensure that those with significant potential to recover receive appropriate care, but also that those who are very unlikely to survive also receive appropriate, end of life care. Such decisions may have to be made when health professionals have not had the opportunity to get to know their patient as well as they would usually like, or may involve discussion with those close to the patient over the telephone or via internet-based communication facilities. While this is less than ideal, honest conversations are often what patients and those close to them actually want. While palliative, end of life and bereavement care professionals cannot take over responsibility for this aspect of care and have the conversations for you, they should be able to support, advise and provide follow up care.

don’t make things more complicated than they need to be; use a framework such as SPIKES: o Setting / situation

read clinical records, ensure privacy, no interruptions

o Perception what do they know already?; no assumptions

o Invitation how much do they want to know?

o Knowledge explain the situation; avoid jargon; take it slow

o Empathy even if busy, show that you care

o Summary / strategy summarise what you’ve said; explain next steps

should ceilings of treatment conversations include ethical issues, for example where escalation to Level 3 care is thought not to be appropriate due to frailty, comorbidity or other reasons, health professionals should be prepared for anger / upset / questions o these are usually not aimed directly at you,

but you may have to absorb these emotions and react professionally, even if they are upsetting / difficult at the time

o patients or those close to them may request a ‘second opinion’ – this should be facilitated wherever possible

be honest and clear o don’t use jargon; use words patients and

those close to them will understand o sit down; take time; measured pace and tone;

use silences to allow people to process information

o avoid using phrases such as “very poorly” on their own – is the patient “sick enough that they may die”? If they are – say it

Source: COVID-19 and Palliative, End of Life and Bereavement Care (27 March 2020) https://apmonline.org/

https://apmonline.org/

Grievingin exceptional

timesWhat is Grief?A death in your family or in your circle of friends is always difficult. You may feelshocked, upset, tearful or distressed. You may find it difficult to concentrate andto realise what has happened. You may be angry or frightened. Theseexperiences are particularly confusing and intense in the early days and weeksof a bereavement. In Ireland, we have a long tradition of coming together in the days after a death.We all understand the rituals that happen around a death, and they oftenprovide comfort. These may involve a wake, a funeral, a burial or cremation.There may be a gathering or meal after the funeral and later, a month’s mind. People have found arranging a funeral, meeting with family and friends to behelpful. We share stories and memories about the person who died. We laughand we cry. We pay tribute to the person who died through our mourning. The Covid-19 pandemic has changed the traditional ways we mark our grief. For themoment, it is not possible to come together and to gather in one location. It isnot possible to have a large funeral. It may not be possible to receive thecompany of those who wish to offer condolences. However, we can support ourselves and each other in different ways.

20TH MARCH 2020 - VER 1 The Irish Hospice Foundation Care & Inform Series

Try not to become emotionally isolated. Even if people cannot visit you, allowthem to offer their condolences and support in different ways; you mayreceive texts, emails and messages through social media as well as phonecalls. Try to allow yourself to feel and react in a way that is natural to you. Wesometimes say that ‘grief is the price we pay for love’, and there is no doubtbut it is painful. Keep conversations going with the people who are closest to you, yourfamily or close circle of friends. Even if those closest to you are not physically near, reach out to them andmake sure to telephone someone each day. Having ‘conversations’ through WhatsApp or through Facebook can meanthere is a regular flow of communication through the day. They can remindyou that people are thinking about you. Remember to eat and to keep hydrated. Your body has needs and grief ishard work. Keeping some routine can be helpful and mealtimes play an important partin this. So too, does bed-time and getting-up time. Try to stick to yournormal routine as much as possible. Try getting out in the garden, if possible. If there are children in your family, check-in with them often. Answer theirquestions honestly. Don’t ‘fob them off’. There are some useful resourcesbelow. Children may appear sad and happy in the space of minutes. It can belikened to jumping in an out of the puddles. Let children set their own pace. Try to limit how much news and social media you consume – when you arefeeling very sad, regular news can be distressing.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Remember: In grief you can only do the best you can, try to be tolerant

and kind to yourself.

Ten ways to support yourselfwhen you are grieving

www.bereaved.ie#IHFsupportingyou #Covid19Ireland

To help a grieving friend, think about how you might send your condolences

– write a card, complete an online condolence such as on RIP.ie, send a text

or telephone. You might share photos or drop food and little gifts at a

person’s door to offer comfort.

Reach out, make yourself available not just in the short term but in the weeks

and months to come.

Ask your friend how they are doing, ask what might help, listen carefully.

Offer practical help, for example with meals, shopping etc.

Offer to help with technology, for example with setting up video calls, What’s

App or other ways of keeping in touch.

1.

2.

3.

4.

5.

Five ways to help others who aregrieving

Call Message Write Conference


Bereaved.ie |www.bereaved.ie

What’s Your Grief |https://whatsyourgrief.com/mental-health-and-

coronavirus/

HSE minding your mental health| https://www2.hse.ie/wellbeing/mental-

health/minding-your-mental-health-during-the-coronavirus-outbreak.html

Department of Education and Skills |https://www.education.ie/en/The-

Department/Announcements/talking-to-children-and-young-people-about-

covid-19-coronavirus-advice-for-parents-and-schools.pdf

Irish Childhood Bereavement Network|

https://www.childhoodbereavement.ie

If you have questions or worries about Covid-19 listen to the advice of the

professionals as offered through the HSE. https://www2.hse.ie/coronavirus/

You might find it useful to look at bereavement websites or resources or videos.

Some useful websites and resources include;

Talking to children about Corona virus|https://krisepsykologi.no/what-can-we-

say-to-children-about-coronavirus/

Useful Resources

This leaflet is brought to you by The Irish Hospice FoundationIf you would like to support us you can do so online at www.hospicefoundation.ie


http://www.bereaved.ie/

https://whatsyourgrief.com/mental-health-and-coronavirus/

https://www2.hse.ie/wellbeing/mental-health/minding-your-mental-health-during-the-coronavirus-outbreak.html

https://www.education.ie/en/The-Department/Announcements/talking-to-children-and-young-people-about-covid-19-coronavirus-advice-for-parents-and-schools.pdf

https://www.childhoodbereavement.ie/

https://www2.hse.ie/coronavirus/

https://krisepsykologi.no/what-can-we-say-to-children-about-coronavirus/

http://www.hospicefoundation.ie/

rpmg covid-19 guidance final (april 2020) · 2020. 4. 10. · ts t ils in ec ®) rix ®) h ® olu!...

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