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How is agitation and restlessness managed in the last 24 h of life in patients whose care is supported by the Liverpool Care Pathway for the Dying Patient?
  1. M Gambles1,
  2. T McGlinchey1,
  3. R Latten2,
  4. A Dickman3,
  5. D Lowe4 and
  6. J E Ellershaw4
  1. 1Marie Curie Palliative Care Institute Liverpool, University of Liverpool, Liverpool, UK
  2. 2Marie Curie Hospice Liverpool, Liverpool, UK
  3. 3Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
  4. 4Marie Curie Palliative Care Institute Liverpool (MCPCIL), Liverpool, UK
  1. Correspondence to M Gambles, Marie Curie Palliative Care Institute Liverpool, University of Liverpool, Prescot Street, Liverpool L7 8XP, UK; mgambles{at}liverpool.ac.uk

Abstract

Background Guidance regarding the patient centred management of agitation and restlessness reinforces the importance of considering underlying causes, non-pharmacological approaches to treatment and judicious use of medications titrated to patient need. In contrast, recent reports in the literature suggest that the practice of continuous deep sedation until death is prevalent in the UK.

Aim To use data from the National Care of the Dying Audit - Hospitals (NCDAH) to explore the administration of medication for management of agitation and restlessness in the last 24 h of life.

Methods Hospitals submitted data from up to 30 consecutive adult patients whose care in the final hours/days of life was supported by the Liverpool Care Pathway for the Dying Patient (LCP). Data on the total dose received in the last 24 h of life PRN and the last dose prescribed for administration via continuous subcutaneous infusion (CSCI) for agitation and restlessness were submitted.

Results 155 hospitals provided data from 3893 patients. Median total doses in the last 24 h for midazolam, haloperidol and levomepromazine, respectively, were: PRN only, 2.5, 1.5 and 6.25 mg; CSCI only, 10, 3 and 6.25 mg; PRN+CSCI, 15, 3 and 12.5 mg.

Conclusion Only 51% of patients received medication to alleviate agitation and restlessness in the last 24 h of life. Median doses were low in comparison to doses recommended for continuous deep sedation, suggesting that there is no ‘blanket’ policy for continuous deep sedation at the end of life for patients whose care is supported by the LCP.

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  • Received 21 June 2011.
  • Accepted 1 October 2011.
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Footnotes

  • Funding The second round of the National Care of the Dying Audit - Hospitals (NCDAH) was funded by Marie Curie Cancer Care and the Department of Health End of Life Care Programme.

  • Competing interests At the time that this study was undertaken MG, TM, RL, AD and JE were employed by the Marie Curie Palliative Care Institute Liverpool and the Liverpool Care Pathway for the Dying Patient (LCP) is an important programme of work within the Institute's portfolio. The LCP has been recommended by the Department of Health to improve the quality of care in the final hours or days of life. In addition, AD has contributed to the advisory boards of a range of pharmaceutical companies; he has recently been awarded a grant from Marie Curie Cancer Care and Cancer Research UK to research the chemical compatibility of drugs for continuous subcutaneous infusion; he has provided non-promotional educational sessions for a range of pharmaceutical companies; he has received payment for preparation of a manuscript on breakthrough cancer pain from a public relations company; and he has received royalties for work published by Oxford University Press, including information on syringe drivers and cancer pain.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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