75 Symptom control medication for patients dying in critical care: systematic review of the literature and current practice in cheshire and merseyside

Background Symptom control at the end of life within Critical Care settings varies. Within the literature there is no consensus for titration of infusion rates, the use of PRN medications or subcutaneous infusions. Methods A literature review was performed, the databases MedLINE, EMBASE and CiNAHL searched using relevant terms and results independently reviewed. A case note review was undertaken via an electronic proforma sent to Acute and Specialist Trusts with Critical Care units in Cheshire and Merseyside. Results 633 articles were identified from the literature search, 66 having full text review, 14 accepted. These highlighted a wide range of doses prescribed, including 0–217 mg/hr of Morphine being reported. 95 case notes reviewed. Mean age was 69, 60% were male. 63% had Specialist Palliative Care input and 80% remained in Critical Care until death. There were discussions relating to dying in 96% of cases, 80% had a documented assessment of symptoms at the time dying was recognised. There was a wide range of time from recognising dying to death, 5 minutes to 9 days. When dying was recognised, 52% of patients were receiving intravenous infusions for sedation, symptom control or inotropes. After dying was recognised, 64% received medications via continuous infusion, 30% intravenous, 28% subcutaneous, 6% both. 65% of patients had anticipatory medication prescribed which increased to 83% when SPCT were involved. The mean dose of Morphine administered when dying recognised was 4.5 mg/hour, vs 5.9 mg/hour at the time of death, for Midazolam 1.5 mg/hour vs 3 mg/hour. Conclusions Within Critical Care we found a wide range in time from withdrawal of life sustaining interventions to death. Routes and doses changed over this period and patients were more likely to have PRN medications prescribed when SPCT were involved. Doses of medication given by intravenous infusion were lower than the average doses reported in the literature.