Breathlessness

Consider whether the patient is benefiting from any oxygen prescribed. If not, consider discontinuing non-beneficial oxygen and using medication and non-pharmacological measures for symptom control.

If the patient has significant distress associated with breathlessness, consider early addition of levomepromazine.

Patients who are receiving medication via nebulisers may continue to do so in the context of COVID-19 lung disease. Currently corticosteroids are not recommended for managing the symptoms of dying of COVID-19 lung disease.

Non-pharmacological measures to manage breathlessness should also be considered, these include positioning, relaxation techniques, wiping the face with cool wipes.

Fans must not be used in the context of COVID-19 infection as they increase aerosol spread of the virus.

Early commencement of syringe pump, if available, is strongly recommended.

Morphine sulfate

Subcutaneous or slow intravenous injection

Start with 2mg to 5mg as required; can be titrated to resolution of symptoms

• Titration frequency: subcutaneous 10-15mins; intravenous 3-5mins
• Consider using the higher dose if the patient is very distressed with breathlessness
• Consider using lower doses in elderly patients
• In patients who are already receiving regular opioid, use 1/6 of total daily opioid dose for as required dose

Subcutaneous infusion

Start with 10mg to 20mg over 24h

If the patient has known renal impairment (eGFR <30), consider using equivalent and equipotent doses of oxycodone, if immediately available, as required and alfentanil or oxycodone in an infusion. Refer to Choosing and changing opioids for conversions. If only one opioid is available, this should be used to relieve suffering in the setting of COVID-19 lung disease rapid dying.

 Midazolam

Subcutaneous or slow intravenous injection 

Start with 2mg to 5mg as required; can be titrated to resolution of symptoms

• Titration frequency: subcutaneous 10-15mins; intravenous 3-5mins
• Consider using the higher dose if the patient is very distressed with breathlessness
• Consider using lower doses in elderly patients
• Maximum dose 100mg over 24h

Subcutaneous infusion 

Start with 10mg to 20mg over 24h 

Levomepromazine

Subcutaneous injection 

Start with 10 to 25mg every hour as required 

• Doses over 100mg/day may be given under specialist advice
• Better for agitation due to delirium
• Consider using lower doses in elderly patients
• Consider early addition for significant breathlessness-associated distress

Cough

Morphine sulfate

Oral

5mg every hour as required

• Consider using lower doses in elderly patients
• In patients who are already receiving regular opioid, use 1/6 of total daily opioid dose for as required dose

Subcutaneous injection

2mg every hour as required

Subcutaneous infusion

10mg to 20mg over 24h

Codeine linctus

Oral

60mg every 6 hours as required

If the patient has known renal impairment (eGFR <30), consider using equivalent and equipotent doses of oxycodone, if immediately available, as required and alfentanil or oxycodone in an infusion. Refer to: Choosing and changing opioids for conversions. If only one opioid is available, this should be used to relieve suffering in the setting of COVID-19 lung disease rapid dying.

Terminal delirium/terminal agitation/terminal restlessness/breathlessness with associated distress

A combination of midazolam and levomepromazine should be considered in terminal agitation/restlessness/delirium/breathlessness with associated distress.

Early commencement of syringe pump, if available, is strongly recommended.

Midazolam

Subcutaneous or slow intravenous injection

Start with 2mg to 5mg as required; can be titrated to resolution of symptoms

• Titration frequency: subcutaneous 10-15mins; intravenous 3-5mins
• Maximum dose 100mg over 24h
• Better for agitation due to distress and anxiety
• Consider using lower doses in elderly patients
• High doses may be required in patients who have severe agitation

Subcutaneous infusion

Start with 10mg to 20mg over 24h

Levomepromazine

Subcutaneous injection

Start with 10 to 25mg every hour as required

• Doses over 100mg/day may be given under specialist advice
• Better for agitation due to delirium
• Consider using lower doses in elderly patients
• Consider early addition for significant breathlessness-associated distress

Subcutaneous infusion

Start with 50mg over 24h (can be given as bd injections)

Haloperidol

Use where levomepromazine is not available

Subcutaneous injection

1mg every 2 hours as required

Subcutaneous infusion

Start with 5mg to 10mg over 24h

If the patient remains agitated, please contact your local palliative care team for further advice.

Respiratory Secretions

Suction is not recommended for patients dying rapidly with COVID-19 lung disease. Focus should be on treatment of distress related to secretions, or medical treatment of secretions. Outwith this context, if suction is being used for symptomatic relief in a palliative care setting, an appropriate level of PPE is required. Refer to: Health Protection Scotland COVID-19 - guidance for infection prevention and control in healthcare settings

Hyoscine butylbromide

Subcutaneous injection

20mg every hour as required

• Alternative drugs and routes of administration are also available – Refer to Alternatives to regular medication normally given via a syringe pump when this is not available

Subcutaneous infusion

Up to 180mg over 24h

Glycopyrronium

Subcutaneous injection

200micrograms every hour as required

Subcutaneous infusion

1.2mg over 24h

Hyoscine Hydrobromide

Subcutaneous injection

400micrograms every hour as required

Subcutaneous infusion

2.4mg over 24h

Pyrexia

Paracetamol

Oral, rectal or intravenous

1g every 4 to 6 hours; maximum 4g per day

• Use 500mg dose if:
  • weight <50kg
  • hepatic impairment
  • history of alcohol excess

Diclofenac

Oral or rectal

75mg to 150mg daily in divided doses

• Dilute in saline

Subcutaneous or intramuscular injection

50mg every 8 hours as required

Subcutaneous infusion

150mg over 24h

Ketorolac

Subcutaneous infusion

60mg over 24h

• Dilute in saline

Subcutaneous injection

15mg every 8 hours as required

Remember non-pharmacological measures such as reducing room temperature, removing excess bedding, and cooling forehead with tepid sponging (if PPE is available).