In this section : Palliative Care
Deactivation of Implantable Cardioverter Defibrillator
Palliative Care – How to Refer
Conversion Charts
Anticipatory ‘As Required’ Medications
Syringe Driver Chart
Scottish Palliative Care Guidelines
Breaking Bad News by Telephone
End of Life Diabetes Care
Fentanyl Patches in the Last Days of Life
Care in the Last Days of Life
Symptom Control
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Fentanyl Patches in the Last Days of Life
Last updated 7th January 2021
Referral
- The Hospital Palliative Care Team introduced a new referral phone line in July 2019 for DGRI patients you wish to be reviewed.
- The contact number is 33400.
- Messages will be checked between 9am and 4pm Monday to Friday.
- You should give patient name, CHI number, ward, and reason for referral, along with your contact details.
- Urgent advice will still be available on their usual numbers, with on call available through switchboard.
General Principles
- In patients who are expected to die within a few days, fentanyl patches should be continued not converted to another opiate. They should be changed every 72 hours as before.
- Breakthrough analgesia should be given prn SC (usually morphine but use oxycodone in renal failure).
- If 2 or more breakthrough doses are given within 24 hours then start a syringe driver SC, starting with the sum of breakthrough doses given in preceding 24 hours.
- The breakthrough dose is then calculated as the sum of the breakthrough dose for the patch plus the breakthrough dose for the syringe driver.
- Example:
- Patient is established on 25 microgram/hr patch (this is equivalent to 60 mg morphine orally over 24 hours).
- Continue patch with 5mg subcutaneous morphine prescribed prn (from table below).
- After 24 hours they have had 3 breakthrough doses of 5mg morphine SC. The 25 microgram/hr patch continues as before, and a syringe driver with 15mg morphine (3 x 5mg) over 24 hours is started with 7.5mg (5 (from patch) + 2.5mg (from syringe driver)) morphine as breakthrough.
- Occasionally a patient may be in severe pain in a setting where there is likely to be a delay in getting breakthrough medication. In this case a syringe driver could be started with the equivalent of two breakthrough doses alongside the patch. However, best practice is to use prn medication for 24 hours and then start a syringe driver with the total breakthrough given.
- If in doubt, please seek specialist advice.
Fentanyl Patch Breakthrough Conversion Table
This is a chart for calculating breakthrough doses. Please note, there is a range of conversion doses (not illustrated) – please discuss with a specialist if you are considering switching back from a patch to long acting PO medication.
Fentanyl patch strength | Morphine | Oxycodone | Breakthrough Morphine Dose | Breakthrough Oxycodone Dose | ||||
---|---|---|---|---|---|---|---|---|
in microgrammes/hour | 24h PO dose (mg) | 24h SC dose (mg) | 24h PO dose (mg) | 24h SC dose (mg) | PO (mg) | SC (mg) | PO (mg) | SC (mg) |
12 | 30 | 15 | 15 | 7 | 5 | 2 | 2 | 1 |
25 | 60 | 30 | 30 | 15 | 10 | 5 | 5 | 2 |
37 | 90 | 45 | 45 | 20 | 15 | 7 | 7 | 3 |
50 | 120 | 60 | 60 | 30 | 20 | 10 | 10 | 5 |
75 | 180 | 90 | 90 | 45 | 30 | 15 | 15 | 7 |
100 | 240 | 120 | 120 | 60 | 40 | 20 | 20 | 10 |