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Palliative care NICE guidance with respect to COVID-19

Authoring team

Palliative care - summary

For full details then see:

NICE guideline [NG191].COVID-19 rapid guideline: managing COVID-19

Summary:

For people who are nearing the end of their life, see:

Medicines for end-of-life care

Consider an opioid and benzodiazepine combination. See the table in practical info for managing breathlessness in the last days and hours of life for people 18 years and over with COVID-19 who:

  • are at the end of life and
  • have moderate to severe breathlessness and
  • are distressed.


Consider concomitant use of an antiemetic and a regular stimulant laxative. Seek specialist advice for children and young people under 18 years.

Treatments in the last days and hours of life for managing breathlessness for people 18 years and over

Treatment

Dosage
Higher doses may be needed for symptom relief in people with COVID-19. Lower doses may be needed because of the person's size or frailty
The doses are based on the BNF and the Palliative care formulary

Opioid

Morphine sulfate 10 mg over 24 hours via a syringe driver, increasing stepwise to morphine sulfate 30 mg over 24 hours as required

Benzodiazepine if required in addition to opioid

Midazolam 10 mg over 24 hours via the syringe driver, increasing stepwise to midazolam 60 mg over 24 hours as required

Add parenteral morphine or midazolam if required

Morphine sulfate 2.5 mg to 5 mg subcutaneously as required
Midazolam 2.5 mg subcutaneously as required
(See the BNF for more details on dosages)

Special considerations


Consider concomitant use of an antiemetic and a regular stimulant laxative
Continue with non-pharmacological strategies for managing breathlessness when starting an opioid
Sedation and opioid use should not be withheld because of a fear of causing respiratory depression

For more recommendations on pharmacological interventions and anticipatory prescribing, see the NICE guideline on care of dying adults in the last days of life and prescribing information in the BNF's prescribing in palliative care.

For people with COVID-19 who are out of hospital, when prescribing and supplying anticipatory medicines at the end of life:

  • Take into account potential waste, medicines shortages and lack of administration equipment by prescribing smaller quantities or by prescribing a different medicine, formulation or route of administration when appropriate.
  • If there are fewer health and care staff, you may need to prescribe subcutaneous, rectal or long-acting formulations. Family members could be considered as an alternative option to administer medications if they so wish and have been provided with appropriate training.

For people with COVID-19 who are out of hospital, consider different routes for administering medicines if the person is unable to take or tolerate oral medicines, such as sublingual or rectal routes, subcutaneous injections or continual subcutaneous infusions.


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The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

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