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Renal Disease in the Last Days of Life

Introduction

This guideline applies to patients with stage 4 to 5 acute or chronic kidney disease (eGFR <30ml/min) whether receiving dialysis or not.

Plan end-of-life care in advance if a patient is likely to stop dialysis soon. Median survival after renal dialysis withdrawal is 9 days, but some patients with residual renal function may live much longer and need continuing care.  If they pass urine they are likely to live longer than if they have minimal urine output.

Other relevant guidelines include: Last days of life, Subcutaneous medication, Alfentanil and Fentanyl.

Assessment

Diagnosis of the terminal phase can be difficult. Potentially reversible causes of deterioration include hypercalcaemia, infection, and opioid toxicity. Clinical signs include:

  • bed-bound and drowsy or semicomatose
  • only able to take sips of fluid or having difficulty swallowing tablets
  • poor tolerance of renal replacement therapy
  • background of deterioration.

 

Management

Plan and document care of the patient and family; consider using an individualised care plan or checklist.

  • Discuss prognosis (patient is dying), goals of care (maintaining comfort), and preferred place of death with patient and family, as appropriate.
  • Clarify resuscitation status; check DNACPR form has been completed. (See national policy)
  • Reassure the patient and family that full supportive care will continue.
  • Stop unnecessary investigations and monitoring (blood pressure, pulse, temperature).
  • Discontinue medication not needed for symptom control, and review daily.
  • Prescribe anticipatory medications for symptom control ('Just in case' box in community).

Some patients may still benefit from oral diuretics, adjuvant analgesics and bicarbonate.

  • If able to swallow, consider liquid formulations. Otherwise use the subcutaneous (SC) or rectal route.
  • Offer oral fluids, maintaining any fluid restriction; review the patient’s requirement for clinically assisted hydration in order to maintain comfort.
  • Comfort nursing care (pressure relieving mattress, reposition for comfort only), eye care, mouth care (sips of fluid, oral gel), bladder and bowel care.

 

Medication

Anticipatory prescribing

All patients should have medication for symptom control available as required. Drugs in a 'Just in case' box will need to be adapted to take renal function into account:

  • Opioid analgesic: alfentanil SC as required hourly (100 micrograms, if not on a regular opioid). If ‘as required’ doses needed, consider using a syringe pump with, for example, alfentanil 500 micrograms over 24 hours (1mg of alfentanil≈30mg oral morphine) and titrate according to response.
  • Anxiolytic sedative: midazolam SC 2mg as required hourly.
  • Antisecretory medication: hyoscine butylbromide (Buscopan) SC 20mg as required hourly.
  • Anti-emetic: haloperidol SC 500 micrograms to 1mg, 8 hourly or levomepromazine SC 2.5 to 5mg, 12 hourly.

If using three or more doses consider starting a syringe pump which can be titrated according to response and use of breakthrough medication.

Pain

  • Paracetamol or an NSAID (benefits may outweigh risks in a dying patient) can help bone, joint, pressure sore, inflammatory pain.
  • Alfentanil is the opioid of choice – less renal excretion of parent drug and the metabolites are not active.
    • Morphine, diamorphine and oxycodone are renally excreted, as are their active metabolites and repeated doses can lead to significant toxicity.
  • Oxycodone can be given if the patient is not opioid toxic while a supply of alfentanil is obtained. Use the lowest effective dose on an as required basis and monitor for toxicity.
  • No regular opioid: alfentanil SC 100 micrograms as required hourly.
  • Fentanyl patch: continue patch, use correct SC alfentanil dose for breakthrough pain.
  • If stable on current opioid and very close to end of life (24 to 48 hours) it may be appropriate to continue current opioid but monitor closely for signs of toxicity and have a low threshold for switching to alfentanil (please seek specialist advice).
  • If pain significant or difficult to control, please seek specialist advice.

Myoclonus or muscle stiffness or spasm

  • Midazolam SC infusion, 5 to 10mg over 24 hours (could be titrated to 20mg if necessary).
  • Clonazepam 500 micrograms orally or SC at night may be useful.
  • Consider opioid toxicity and rotation to alfentanil if not already done.

Anxiety and distress

  • Midazolam SC 2mg as required hourly or 5 to 10mg over 24 hours via syringe pump.
  • Lorazepam sublingual 500 micrograms 8 hourly as required.
  • If agitation worsening despite midazolam, consider haloperidol 500 micrograms to 1mg 8 hourly or levomepromazine 2.5 to 5mg 12 hourly.

Delirium

  • Delirium is common and may worsen as uraemia increases – drug of choice is haloperidol 500micrograms to 2mg 8 hourly.
  • Try to address psychological and family concerns causing patient anxiety.

Terminal agitation

  • Seek specialist advice if delirium or agitation worsening.
  • Try haloperidol 2mg and midazolam 5mg SC.
  • If this is ineffective try levomepromazine 12.5mg SC. Start a syringe pump with 10mg midazolam over 24hours and seek specialist advice.

Breathlessness

  • May be due to pulmonary oedema, acidosis, anxiety or lung disease.
  • Follow guidelines above for anxiety and distress, use opioid as per pain guidelines above and consider syringe pump.

Respiratory tract secretions

  • Consider repositioning.
  • Try to avoid suction in case this stimulates distress or more secretions.
  • First line: hyoscine butylbromide SC 20mg, hourly as required (up to 120mg in 24hours).
  • Second line: glycopyrronium bromide SC 100 micrograms, 6 to 8 hourly as required.

Nausea and vomiting (see Nausea and vomiting and Subcutaneous medication guidelines)

  • Nausea is common due to uraemia and comorbidity.
  • If already controlled with an oral antiemetic, continue it as a subcutaneous infusion or use a long acting anti-emetic:
    • haloperidol SC 500 micrograms to 1mg 8 hourly
    • levomepromazine SC 2.5 to 5mg 12 hourly.

Practice Points

  • Opioid analgesics should not be used to sedate dying patients.
  • Avoid renally excreted opioids (codeine, dihydrocodeine, morphine, diamorphine, oxycodone).
  • Subcutaneous infusions provide maintenance treatment only; additional SC doses of medication will be needed if the patient’s symptoms are not controlled.
  • Midazolam is titrated in 5 to 10 mg steps. Up to 5mg can be given in a single SC injection (1ml). Single SC doses can last 2 to 4 hours. Useful as an anticonvulsant.
  • A marked increase in pain in the dying patient is unusual; reassess and seek advice.

Resources

Professional
NHS End of life care Programme 

 

 

References