Symptom control can be a complex process, requiring the use of multiple medications in differing doses and combinations, depending on the unique needs of each patient.
In our efforts to keep you as comfortable and peaceful as possible, it may be that you become a lot sleepier which may be as a result of the medications being used. At all times we will try to include you and your family in decision making about the medications we are prescribing and how these might affect the patient.
Nurses and/or doctors are always available to answer your questions and discuss the options available in the care of your loved one.
Routes of administration
Most people take their medications by mouth. As people become weaker because of their illness, they may experience some difficulties in swallowing them, particularly when there are many different drugs to be taken.
Where possible we will try our best to continue giving them by mouth. We may decide to change the form of the medication, such as changing from capsules or tablets to a liquid preparation.
We may also decide to stop certain medications which are not essential for the patient’s comfort, such as:
– Thyroid treatments
– Blood pressure treatment
– Cholesterol lowering drugs
– Hormone treatment
We may also reduce the dose of medications or the frequency of administration. This is because the need for certain medications may become less because of reduced appetite, weight loss and reduced mobility. Such medications may include Insulin (and other treatments for diabetes) and medications for angina.
In order to avoid giving medications by mouth, some medications may be given in the form of a skin patch. These may include Fentanyl or Buprenorphine (for pain) and Hyoscine (to reduce saliva or for sickness).
The most common alternative to the oral route is the use of syringe pumps. A syringe pump is a device used to administer drugs continuously under the skin. The placement of small plastic tubes(cannulae) under the skin for syringe pumps is seldom of any discomfort to patients. The drugs are delivered continuously from a syringe which is attached to a battery operated device. We have a separate leaflet which explains syringe pumps. Medical and nursing staff will usually explain these to patients and family members.
There are a number of other unusual routes for giving medications. Occasionally drugs may be given through the rectum. This may include drugs such as Paracetamol or other pain killers, treatment to promote bowel motions or medications for nausea and vomiting. Sometimes medications are given intravenously.
Drugs used in syringe pumps
In general there are five groups of drugs used:
Diamorphine is the pain relieving drug most commonly used in syringe pumps. Occasionally patients may be given an alternative strong pain relieving drug such as Morphine, Oxycodone or Methadone. In many cases we simply convert to an equivalent dose of the patient’s oral medication that they have already been taking, in which case there should be no change in either the beneficial effects or the side effects. However if the patient is experiencing pain problems it may be necessary to gradually increase the drugs to control the pain.
Sometimes the doses used may cause drowsiness as a side effect. Other side effects such as confusion, sickness or constipation may occur but are usually controlled very well with other drugs.
Drugs normally used for pain relief may also be used for other symptoms such as breathlessness, cough and diarrhoea.
The drugs used most commonly for sickness include Metoclopramide, Cyclizine, Haloperidol and Levomepromazine. Some of these medications, particularly Levomepromazine and Haloperidol, may cause drowsiness, but where possible we will use the lowest appropriate dose and perhaps use combinations of drugs to minimise the side effects.
Tranquillisers and sedatives
Drugs such as Midazolam are used to reduce restlessness, anxiety or agitation. Midazolam also has a beneficial effect on muscle tension and in treating and preventing convulsions (epileptic fits). Midazolam may also be used to treat the symptom of breathlessness. A number of anti-sickness medications, including Levomepromazine and Haloperidol may also be used for their tranquillising effects.
Again we will try to use the minimum possible dose and/or the use of combinations of drugs to keep side effects to the minimum.
Drugs to reduce chest secretions
Hyoscine Butylbromide (Buscopan) is commonly used to reduce secretions in the back of the throat. Such secretions are usually caused by extreme weakness of the chest muscles and can sound very distressing if untreated. Other medications such as Hyoscine Hydrobromide or Glycopyrronium may be used.
Drugs to prevent syringe pump site problems
Certain drugs such as Dexamethasone may be helpful in reducing the chances of syringe pump medications causing skin reactions. We may also try various other strategies including diluting drugs into larger volumes.