Copyright © Diane Gainey -

"Courage is being scared to death - but saddling up anyway."


Management of symptoms in the last few days of life

Principles of management

These guidelines have been developed for the use of health care professionals. The principles are applicable to the care of patients dying from cancer and indeed non-malignant disease.

Recognise that death is approaching

Studies have found that dying patients will manifest some or all of the following:

Treatment of symptoms

The prime aim of all treatment at this stage is the control of symptoms the patient has or may develop.

Many medications, which until now have been regarded as essential, can and should be discontinued.

The most common reported symptoms are:

All patients who are dying should have subcutaneous medication prescribed for all these symptoms, to be given as the need arises.

The algorithms attached will support you in your management.

All medication needs must be reviewed after 24 hours. If two or more doses of prn medication have been required, then consider the use of a syringe driver over 24 hours. See A brief guide to drugs for the syringe driver.

If there is difficulty obtaining a syringe driver please contact the palliative care team. Out of hours, syringe drivers are available in all the CueDoc cars, as are emergency palliative care drug boxes.

For advice and support please contact your local palliative care team.



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.

1. Continue to change the Fentanyl patch every three days

2. If additional analgesia is necessary, S/C diamorphine or S/C morphine 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:

Download this table

Fentanyl patch strength mcg/hr Morphine mg/24 hrs S/C Morphine mg/4 hrs S/C for breakthrough pain
25 10 - 20 5 - 10
50 30 - 40 10 - 15
75 40 - 60 10 - 20
100 60 - 90 15 - 30
200 90 - 180 30 - 60

The Morphine is given in addition to the Fentanyl patch.

For diamorphine, approximate doses are:

Fentanyl patch strength mcg/hrDiamorphine mg/24 hrs s/cDiamorphine mg/4 hrs s/c for breakthrough pain
25 10 - 15 5 - 10
50 20 - 30 5 - 10
75 30 - 40 10 - 20
100 50 20 - 30
200 100 25 - 50

3. The Fentanyl patch should only be discontinued 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:

Nausea & Vomiting


N.B. Always use water for injection whenmaking up Cyclizine to correct volume.

References: 1,2 & 3

Respiratory Tract Secretions


References: 1,2 & 3

Terminal Restlessness and Agitation


References: 1,2 & 3


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 Ltd. (Also on 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.

Updated February 2011

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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