Background A crisis pack, of one or more medications, is prescribed in anticipation of a terminal haemorrhage with the goal of alleviating patient distress.¹ A challenge in the prescription and administration of crisis packs is the lack of data to allow for evidence-based management. The literature published is largely case reports. Hence there is significant variability in which medications are used, including which dosage and route.

Objectives Establish current practice among senior palliative medicine physicians, regarding anticipatory prescribing to manage a terminal hemorrhage.

Review prescribing and administration of crisis packs in a specialist inpatient hospice unit (IPU) in Galway Hospice Foundation.

Generate a guideline informed by data collected.

Methods Part a) Questionnaire

An electronic questionnaire was sent to palliative medicine consultants and specialist registrars (SpRs) in the Republic of Ireland. Data was analysed using the online survey software and excel.

Part b) Prescribing in one IPU

A chart review of all patients admitted to a single IPU over a 3-month period (June 2023 – August 2023 inclusive) was conducted. Basic demographic data and prescription data was collected. Results were analysed using Stata/SE 18.0.

Results Part a) Questionnaire

The questionnaire was sent to 96 individuals. Response rate was 50%. 100% of participants prescribed crisis packs. The most prescribed medications were morphine (89.6%) and midazolam (100%). Over 95% prescribed medication via the subcutaneous route. Most participants 70.8% vary the dose of crisis medication charted based on if the patient is on a baseline anxiolytic/opioid. The calculations used for dose variation were inconsistent between participants. The most common inclusion criterion for prescribing by malignancy type was head and neck cancer. 65% of participants did not follow a guideline when prescribing.

Part b) Prescribing in one IPU

Study included 75 separate admissions. Three quarters of patients had a malignant diagnosis. No patients died due to an external haemorrhage. Crisis medications were prescribed in 17% of admissions but none were administered. All crisis packs were prescribed as a combination of midazolam and an opioid via subcutaneous route. There was little variation in dosing relative to baseline opioid/anxiolytic, with 76.9% of patients prescribed 10mg of both midazolam and morphine sulfate. In 2 cases the breakthrough (as needed) dose of opioid was greater than the dose of the opioid in the crisis pack.

Disussion Results demonstrate that there is little variation in the medications prescribed or the route. There is significant variation in the doses of medications prescribed and the indications for prescribing. To standardise crisis pack prescribing a guideline should be used. Given the concerns around the use of opioids for an event that is not thought to be painful and the use of subcutaneous route in the setting of a haemorrhage the use of intramuscular midazolam is recommended. Dosage of midazolam recommended is relative to baseline benzodiazepine. Recommendations are described further in the guideline.

Reference

1. Harris DG, Noble SIR. Management of terminal hemorrhage in patients with advanced cancer: a systematic literature review. Journal of Pain and Symptom Management 2009;38(6):913–27. doi:10.1016/j.jpainsymman.2009.04.027