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"Seeing death as the end of life is like seeing the horizon as the end of the ocean."


Anticipating & Planning for Common Problems at Home

Many problems in the last days of life can be predicted and prepared for:
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Anticipated Problem Consider & Plan

Loss of mobility. Unable to transfer safely

Generally safer and more manageable to nurse in bed

Consider loan of hospital bed/monkey pole/cot sides/commode/ urine bottles

Assess for pressure area care and implement appropriate strategy

Indwelling urinary catheter/sheath for men is more acceptable if incontinent/unable to transfer to commode

Bowel care

Loss of ability to eat

Prepare family and patient for this happening

Explain it is a natural process

Forcing food may create discomfort if too weak to swallow/digest

Loss of ability to drink

Prepare family and patient for this happening

Explain it is a natural process and may aid comfort by reducing secretions/gastric secretions and chance of vomiting/urine output

Encourage sips/mouth care

If still distressed by thirst consider S/C fluids (N.saline 1 litre over 12 hour via a butterfly into anterior abdominal wall or thigh)*

Loss of ability to shallow

Convert essential medications to subcutaneous route (if no syringe driver available)

Delirium and agitation

Common at the end of life: Distressing and frightening for everyone involved

Haloperidol 1.5-30mg/24h SC and/or midazolam 5-60mg/24h SC (if agitation only)


Morphine SC prn in proportion to overall opioid requirement (can be administered orally if injection not appropriate)

Leave pre drawn-up syringes: leave an indwelling butterfly needle SC


Cyclizine 50mg tds SC or

Buccastem 3mg sublingual or

Transdermal hyoscine


Common and frightening

Morphine preferably SC (or orally) titrated up as for pain

Midazolam 2-10mg SC or buccal prn or 5-30mg SC/24h for breathlessness/fear or


Excess respiratory secretions

Positioning/portable suction (if available)

Hyoscine 0.4mg sublingual or SC 4h prn or

Hyoscine 1.6-2.4mg/24h SC

Hyoscine transdermal patch

Changing breathing pattern

Explanation to family "He may appear to stop breathing for a time, then draw another breath"

Table: Anticipating & Planning for Common Problems at Home
Adapted from Guidelines on managing predictable problems in home death with permission from Dr. Mike Harlos, Manitoba, Canada.

*N. saline, 4% dextrose/0.18% saline or 5% dextrose are all suitable. No more than 2 litres/24 hours should be infused into any one site. Fluid should not be pumped in.

Our knowledge of the likely problems allows us to anticipate and plan for appropriate medical and nursing interventions. Each day or each visit aim as you leave to anticipate what might happen over the next day or two.

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© Dr. Eileen Palmer, Dr John Howarth Palliative Care for the Primary Health Care Team Quay Books ISBN 1856422291

Important News

Important Changes in Cumbria Palliative Care Prescribing Practice

Cumbria is changing practice, from 1st April 2011.

The Area Prescribing Committee has recommended the following changes:

  • All strong opioids are to be prescribed by brand name
  • "Just in Case" prescribing is to be encouraged and promoted
  • Morphine is to replace diamorphine as the subcutaneous injectable strong opioid of choice for palliative care patients in Cumbria


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North Cumbria Pallative Care website

The award winning North Cumbria Palliative Care website continues to receive around 30,000 page views a year. This is 82 page views every single day of the year, 2,500 hits every month, without any publicity or advertising program.


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