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"There is a silence into which the world cannot intrude.
There is an ancient peace you carry in your heart and have not lost."

A COURSE IN MIRACLES

Morphine or Diamorphine* prescribing at the end of life

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Morphine or diamorphine are frequently prescribed in the in the last few days of life. In the wake of the Shipman trial it is even more important for patients, families and the general practitioner and primary health care team to be confident they are being prescribed correctly. This means prescribing appropriate and defensible doses for appropriate and documented indications. Clear discussion with the patient and the family about the indication and dosage is vital.

Morphine and diamorphine are primarily a strong analgesics. They are cough suppressants and in the absence of pain are respiratory sedatives. This side effect can be utilised to relieve distressing breathlessness at the end of life.

Morphine and diamorphine are NOT a strong sedatives. They are generally unsuitable for terminal agitation, anguish or distress and if used inappropriately, it may cause or exacerbate these problems. In the absence of pain or in excessive doses morphine or diamorphine can cause nightmares, hallucinations, sweating, confusion and myoclonic jerks. If a patient needs sedation, benzodiazepines are a better choice.

Clinical situation at the end of life Subcutaneous (S/C) morphine dose over 24 hours As required subcutaneous (S/C) morphine dose
No previous opioid
No pain
Not indicated 5-10mg S/C prn
No previous opioid
In pain
20-30mg/24 hours (Halve dose if less than 70 years or frail) 5-10mg S/C prn
On oral morphine
No pain
Oral morphine dose in mg/24 hours divided by TWO One sixth 24 hour dose in mg S/C
On oral morphine
In pain
Oral morphine dose in mg/24 hours INCLUDING BREAKTHROUGH DOSES divided by two One sixth 24 hour dose in mg S/C

Sometimes if a patient is in severe pain and near death, it can be tempting to put a much larger dose of morphine or diamorphine in the syringe driver. This is unsatisfactory for two reasons:

* NHS Cumbria recommends morphine as the first line parenteral strong opioid for palliative care patients. For high doses (>morphine 180mg/24h SC) use diamorphine, which is more soluble.

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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

21/03/2011

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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.

1/3/2011

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