KISS: COVID-19 Webinar – Module 3 – End of Life Care with COVID-19

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Advanced care planning:
  • Consider using excellent resources from NHS Scotland on effective communication (click here for more detail); use the REDMAP approach:
    • Ready - Can we talk about how coronavirus might affect you?
    • Expect - What do you know? What do you expect?
    • Diagnosis - We know that coronavirus...What we aren't sure is...
    • Matters - What matters to you?
    • Actions - What we can do to help is...This does not work/help...
    • Plan - Let's make a plan for you and your family.
  • Avoid words/language that can make people feel abandoned or deprived of treatment or care:
    • There is nothing more we can do...Further treatment is futile...
Specifics on dying from COVID-19:
  • Often involves a lung disease profile with high breathlessness ('air hunger'), high distress, high delirium/agitation, high fever; pain is not a prominent feature.
  • A proportion of people will have severe symptoms and may decline rapidly (within hours).
  • Look for and treat other reversible causes of symptoms e.g. SOB ?pulmonary oedema, ?anxiety; agitation/delirium ?hypoxia, ?urine retention ?constipation.
Non-drug management:
  • Breathlessness: Keep the room cool, open windows, breathing exercises and techniques (click here for more detail); do NOT use fans (increases risk of droplet spread).
  • Cough: a teaspoon of honey.
Drug management (for more detail including syringe driver doses click on links at the top of the page):
  • Breathlessness:
    • 1st line - Oramorph 2.5-5mg 2-4 hrly (double dose if already on opiates) +/- lorazepam 0.5mg S/L
    • 2nd line (or not able to swallow) - morphine sulphate 2.5-5mg S/C PRN +/- midazolam 2.5mg S/C PRN
    • Usual drugs/delivery not available - fentanyl patch 12-25 mcg/hr (replace every 48 hrs); buprenorphine patch 15-35mcg/hr (change as per drug info); morphine MR tablet 10-30mg RECTALLY
  • Anxiety/agitation:
    • 1st line - lorazepam 0.5-1mg S/L PRN (max 4mg daily) 
    • 2nd line (or unable to swallow) - midazolam 2.5-5mg S/C 2-4 hrly
  • Delirium:
    • 1st line - haloperidol 0.5-1mg PO 2 hrly (consider higher starting dose e.g. 1.5-3mg if severe distress) +/- lorazepam 0.5-1mg S/L 
    • 2nd line (or not able to swallow) - haloperidol S/C (doses as above) or levomepromazine 12.5-25mg S/C hourly +/- midazolam 2.5-5mg S/C 2-4 hrly
    • Usual drugs/delivery not available in agitated delirium oro-dispersible olanzapine 5mg buccal 4 hrly
  • Fever:
    • Paracetamol 1g QDS; if unable to swallow diclofenac 75-150mg daily PR in divided doses 
  • Cough:
    • Codeine linctus or if distress consider Oramorph 2.5-5mg 4 hrly 

Changes in legislation following death (click here for more detail):
  • The MCCD can be signed by a doctor who has never met the patient in life providing that a) the usual doctor is unavailable, b) the signing doctor is able to state to the best of their knowledge and belief the cause of death and, c) that a doctor saw the patient within 28 days of death or after death.
  • Cremation forms - Form 4 may now be filled in by any doctor (given the same situation as for MCCD above) and Form 5 (colloquially known as 'part 2') does not need to be completed. 
Published on 15th April 2020

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