palliative care NICE guidance with respect to COVID-19
Last edited 03/2021 and last reviewed 11/2021
For full details then see:
NICE guideline [NG191].COVID-19 rapid guideline: managing COVID-19
Summary:
For people who are nearing the end of their life, see:
- The NICE guideline on care of dying adults in the last days of life: this includes recommendations on recognising when a person may be in the last days of life, communication and shared decision making.
- The NICE guideline on end of life care for adults: service delivery: this includes recommendations for service providers on systems to help identify adults who may be at the end of their life, providing information and advanced care planning.
- The NICE guideline on care and support of people growing older with learning disabilities: this includes recommendations on accessing end-of-life care services, person-centred care, and involving families and support networks in end-of-life care planning
Medicines for end-of-life care
Consider an opioid and benzodiazepine combination. See the table in practical info for managing breathlessness in the last days and hours of life for people 18 years and over with COVID-19 who:
- are at the end of life and
- have moderate to severe breathlessness and
- are distressed.
Consider concomitant use of an antiemetic and a regular stimulant laxative. Seek specialist advice for children and young people under 18 years.
Treatments in the last days and hours of life for managing breathlessness for people 18 years and over
| Treatment | Dosage Higher doses may be needed for symptom relief in people with COVID-19. Lower doses may be needed because of the person's size or frailty The doses are based on the BNF and the Palliative care formulary |
| Opioid | Morphine sulfate 10 mg over 24 hours via a syringe driver, increasing stepwise to morphine sulfate 30 mg over 24 hours as required |
| Benzodiazepine if required in addition to opioid | Midazolam 10 mg over 24 hours via the syringe driver, increasing stepwise to midazolam 60 mg over 24 hours as required |
| Add parenteral morphine or midazolam if required | Morphine sulfate 2.5 mg to 5 mg subcutaneously as required Midazolam 2.5 mg subcutaneously as required (See the BNF for more details on dosages) |
| Special considerations | Consider concomitant use of an antiemetic and a regular stimulant laxative Continue with non-pharmacological strategies for managing breathlessness when starting an opioid Sedation and opioid use should not be withheld because of a fear of causing respiratory depression |
For people with COVID-19 who are out of hospital, when prescribing and supplying anticipatory medicines at the end of life:
- Take into account potential waste, medicines shortages and lack of administration equipment by prescribing smaller quantities or by prescribing a different medicine, formulation or route of administration when appropriate.
- If there are fewer health and care staff, you may need to prescribe subcutaneous, rectal or long-acting formulations. Family members could be considered as an alternative option to administer medications if they so wish and have been provided with appropriate training.
For people with COVID-19 who are out of hospital, consider different routes for administering medicines if the person is unable to take or tolerate oral medicines, such as sublingual or rectal routes, subcutaneous injections or continual subcutaneous infusions.
COVID - summary of NICE COVID-19 rapid guideline: Managing COVID-19