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Pain in the Dying Phase

When the patient is no longer able to swallow oral morphine, change to:

  • Continuous morphine (or diamorphine) infusion via a syringe driver/pump (see conversion table).
  • Prescribe a p.r.n. dose of subcutaneous morphine (or diamorphine) for breakthrough pain one sixth of the total 24-hour dose of morphine (or diamorphine). This can be given as frequently as necessary,up to 1 hourly when pain severe,  and increased in proportion to any increase in 24-hour dose.
  • If the patient is still in pain and the p.r.n. morphine (or diamorphine) has been found to be effective, the 24-hour dose of subcutaneous morphine (or diamorphine) may be increased by the sum of the PRN doses given in the previous 24 hours.
    For patients requiring rapidly escalating doses of opioids or frequent use of p.r.n. doses, i.e. ≥2 a day, should prompt a review of pain management plan and consider contacting the Specialist Palliative Care Team for advice.
  • If an opioid naïve patient does not currently have pain, prescribe subcutaneous morphine 2.5–5 mg (consider starting at 1.25mg for frail elderly) p.r.n. If after review at 24 hours two or more doses have been required, set up a syringe driver/pump containing morphine (or diamorphine).

If the patient is on an alternative strong opioid and needs to switch to a syringe driver/pump, see here for conversion doses or seek Specialist Palliative Care Team advice.

NEXT: nausea and vomiting in the dying phase

DISCLAIMER

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.
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