Terry's story: prescribing opioids at the end of life
The hospice have stabilised Terry’s pain by converting him to oral oxycodone and reducing the dose. He is now at home, approaching the very end of life.
He’s struggling to take oral medications but has been managing his breakthrough opioids. The District Nurse feels he won’t be able to take oral medication much longer and calls you for advice.
Starting a Continuous Subcutaneous Infusion (CSCI)
If a patient is unable to reliably swallow their oral opioid, they are at risk of poor pain control and opioid withdrawal. We covered the process for converting an opioid from the oral to subcutaneous route in previous steps (links are provided below). You may wish to revisit these steps before proceding to the next step.
Fentanyl patches in the last days of life
Terry is no longer prescribed a fentanyl patch but if he were this should continue. It is best to do this because the drug has reached steady state. If the patient requires 2 or more doses of an IR opioid in a 24 hour period, the background (MR) opioid dose needs to be increased. To do this safely you should set up a CSCI in addition to the patch. Don’t forget to continue to change the patch at the prescribed intervals.
In this situation, the dose of opioid in the CSCI is the same as the total amount of IR opioid taken in the 24 hour period concerned. The maximum dose should be no more than 50% of the equivalent patch dose - seek specialist advice if it exceeds this. The dose of IR opioid for breakthrough pain is 1/6th - 1/10th of the total daily opioid dose - that is the infusion plus the patch equivalent. This can be a complex calculation so always check the final dose before prescribing and seek specialist support if necessary. Any subsequent dose adjustments are made to the CSCI.
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