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return to Activity 3.
Adjusting medication
First, think of Michael's drugs you know you can
stop. For example, laxatives can be stopped. If you have
been ensuring a comfortable stool before the deterioration, most people
can manage for up to 2 weeks without a laxative.
Next, think of those drugs you know Michael needs
to continue:
- Morphine needs to continue, but by a different
route. The subcutaneous route is the commonest, but for
convenience, diamorphine is used since it is very soluble and can be
used in low volumes. Divide the total daily morphine dose by 3
to find out the 24 hour diamorphine dose. Some dying patients
need a lower dose - reduce if they become more unsettled on switching
to diamorphine. See the CLIP tutorial:
Changing opioids.
- Cyclizine would be helpful to control any
continuing nausea or vomiting. It can be given in suppository
form, or mixed with diamorphine and given subcutaneously
(concentrations of cyclizine above 10 mg/ml will precipitate).
This leaves the drugs you might not be sure about:
- Amitriptyline can be stopped if he is
deteriorating rapidly since its effects will last at least a further
24-36 hours.
- Dexamethasone is usually stopped in a rapidly
deteriorating patient, regardless of the length of previous treatment.
In patients deteriorating more slowly, steroids can be safely stopped
if the treatment has been for less than 3 weeks, but if they have been
taking steroids for 1 month or more it may be necessary to continue
the dexamethasone by SC infusion to avoid the "washed out" feeling of
adrenocortical insufficiency.
- Temazepam can be stopped if the treatment has
been less than 3 weeks. In many patients, however, treatment has
been much longer and a benzodiazepine will need to be continued to avoid
agitation due to withdrawal.
- Cigarettes are rarely continued by very ill
patients. Beware, however, of agitation due to nicotine
withdrawal. This is simply treated by using a nicotine patch.
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