Abstract

The audit compared frequency of use of injectable sedatives at end of life (including range and mean doses) with the EAPC recommended start doses for actual sedation (as defined by EAPC, October 2009). The authors also looked at documentation of intent in using these medicines, and sharing of intent with patient and family. The authors looked retrospectively at notes of all patients dying in our hospice over 3 months. 53 patients died. 47 died on the Liverpool Care Pathway. Midazolam was used in 48/53 patients; levomepromazine in 18/53; phenobarbitone in 1/53. The mean dose of midazolam was 10.8 mg/24 h (range 5–30mg) and of levomepromazine was 16.1mg/24 h (r6.25–31.25mg). The dose of phenobarbitone used was 1000 mg/24 h. The mean 24 h doses, even in the last day of life, were at the lower end of the starting range for sedation (EAPC guidance). However on average two breakthrough injections were needed in that last day. The LCP documented restlessness as reason for giving. Documentation of intent was best for breakthrough injectables in patients on the LCP but poor for syringe driver choices. Documentation of explanation of intent, including (if relevant) intent to sedate was poor. In 17/53 there was documented discussion with the patient alone: some of these included family discussion too. In 21/53 there was no documentation of any discussion. Our audit shows breakthrough restlessness as common on the last day of life, and raises concern that we are too cautious in our syringe driver dosing. We do not document intent and discussion of intent well. Better articulation of intent in using these drugs, with patients, families and in the notes may help more confident prescribing. The authors plan to improve documentation, including hopes for (intent in using) these drugs, and sharing of intent as our standard, with hope that better symptom control is achieved.