Pain

To convert from other strong opioids, contact the Palliative Care team or hospital pharmacy.
Conversion data is also available in CueDoc cars and in the palliative care formulary http://www.palliativedrugs.com/
DO NOT DISCONTINUE FENTANYL PATCH IN DYING PATIENT. If patient in pain, see below Using Fentanyl in the dying patient

References: 1,2 & 3

Using Fentanyl in the dying patient

Sometimes there is confusion about how best to manage a patient who has been using Fentanyl patches for pain control but who is dying and can no longer take oral medication for breakthrough pain.

These Guidelines are intended to clarify and simplify good practice.

Continue to change the Fentanyl patch every three days
If additional analgesia is necessary s/c Diamorphine should be given. This can be given in a syringe driver with additional 4 hourly s/c injections available for immediate relief of breakthrough pain

Appropriate doses are:

Fentanyl Patch strength mcg/hr	Diamorphine mg/24 hrs s/c	Diamorphine mg/4 hrs s/c for Breakthrough pain
25	15	5 - 10
50	30	5 - 10
75	40	10 - 20
100	60	20 - 30
200	100	25 - 50

The Diamorphine is given in addition to the Fentanyl patch.

The Fentanyl patch should only be dicontinued in exceptional circumstances by practitioners with a good working knowledge of the pharmacodynamics of Fentanyl. Many practitioners may prefer to seek expert advice first from a member of the Palliative Care Team

References

1. British National Formulary 56 (September 2008). There is excellent additional information in the section at the front of the BNF - Prescribing in Palliative Care

2. Twycross R, Wilcock A, - Palliative Care Formulary Third Edition (2007) Palliative drugs.com Ltd. (Also on www.palliativedrugs.com with latest updates)

3. Changing Gear - Guidelines for managing the last days of life in adults. National Council for Hospice and Specialist Palliative Care Services. Northamptonshire, Land & Unwin (Data Sciences) Ltd 1997.