: value of bedside instruments. Long surgeries or repeated procedures pose the highest risks. Full Fact fights for good, reliable information in the media, online, and in politics. Article J Pain Symptom Manag. 1992;7:948. 1988;1:678. Wiffen PJ and McQuay HJ. J Palliat Med. Three classes were prescribed more frequently at Td than at Ta: analgesics, psycholeptics and drugs for functional gastrointestinal disorders. Only a few studies in palliative care units [1719] and services for mainly outpatients groups [2023] have described medication use in palliative care. Only later did I discover that midazolam has no analgesic properties. Our higher figures may be explained by the difference in the studied patient population; we only included patients who died in the palliative centre. They found our father sitting in an armchair, unresponsive, with his tongue pushing out of his mouth, eyes partially open and rolled back. 2004;18:195201. A few papers have inventoried drug prescriptions in palliative care settings, but none has reported the frequency of use in combination with doses and route of administration. This staff member was not a registered nurse. For the purposes of that scheme, weve rated this claim as false Drugs were prescribed according to the symptom-specific Dutch national palliative guidelines [5]. Without assistance Dad would not have been able to feed himself. 2003;163:3414. Oral bioavailability of morphine and haloperidol is 30 and 50%, respectively, versus almost 100% after subcutaneous, intravenous and intramuscular administration. I was concerned about this too. Significantly, it appears that the prescription of midazolam has spiked during the COVID-19 pandemic, leading to allegations in the press that the drug is being used to control elderly patients in stretched care homes or even to hasten their deaths. Nauck F, Ostgathe C, Klaschik E, Bausewein C, Fuchs M, Lindena G, et al. Thank you so much. 2005;19:20819. Now and then he would jerk and let out a harsh cry as if in pain before lapsing back into inertia. This seemed borne out by one incident when we were talking about the fate of Dads ashes. After a short search I located him at Bond University in Queensland, and told him our stories. He told me he was thirsty and I asked a nurse if there was thickened water as he was still unable to handle water well. Kidney or liver impairments may slow down the elimination of midazolam leading to prolonged and enhanced effects.. Lorazepam and diazepam can help to reduce anxiety associated with breathlessness. We remain deeply dissatisfied with Dads care at the hospice and continue to believe that, among a number of major failings, the insistence on routinely administering midazolam was a significant factor in his rapid decline, and added a layer of unnecessary suffering to his death. PubMed Central Medicines Evaluation Board; the Dutch data bank for human medicines. Instead he said he knew exactly what I was talking about and he told me that he had personally insisted that no such sedatives be used on his mother when she was dying. Curtis EB, Walsh TD. This combination can slow breathing and heart rate, and may make it impossible for the patient to eat or drink. Two top-10s of individual drugs prescribed were constructed: One covering the day of admission (Ta), the other the day of death (Td). Midazolam can be used for anxiolysis and hypnosis during the maintenance phase of general anesthesia and is also superior to thiopental in the maintenance of anesthesia because of the less need for adjunct medications. I will briefly address some of the specific issues raised: 2013;182:10712. I was shocked to learn this. McLean S, Sheehy-Skeffington B, OLeary N, OGorman A. Pharmacological management of co-morbid conditions at the end of life: is less more? We requested a different doctor be put in charge of Dads care and this was agreed to. He claims that midazolam was used to facilitate the culling of old people, and that Covid-19 is a faked pandemic used as a guise to allow this. The governments top priority throughout this pandemic has always been doing everything possible to save lives.. Next morning, as an inquiry into Dads fall got underway and as we awaited the changeover in care personnel we had requested, he was given an injection which the lone person administering told us was a steroid. Seizure management in the palliative care setting Development of seizures at the end of life can often be distressing for patients, their families and healthcare staff. On the other hand, it has been argued that palliative sedation can be distinguished from euthanasia by clinician intent, and proportionality of dose to symptoms. Oral morphine for cancer pain. Article Article The ATC system groups the drugs into 5 different levels according to the organ or system on which they act and according to their chemical, pharmacological and therapeutic properties. Pharmacokinetic drug interactions in palliative care: focus on opioids. Midazolam has no analgesic properties it may actually increase perceptions of pain: My thinking has been that Midazolam can settle the firing of nerves and thereby ease some neuropathic pains; as a muscle relaxant it can help ease muscle tension associated with pain; anxiety often amplifies pain, and midazolam can dampen anxiety; and in severe, refractory pain the only way to ease distress may be to sedate the patient. What are the essential medications in pallative care?a survey of Australian palliative care doctors. Midazolam can be continuously infused subcutaneously (under the skin rather than into a vein) via syringe driver (pump), to give a steady level of effect to prevent restlessness, anxiety or distress. (It later emerged that he had been given no anti-constipation medication during his entire stay to that point, despite being on high doses of opiates which are known to interfere with bowel function.). This study compares breakthrough medication requirements of patients treated with the novel agent dexmedetomidine compared with patients treated with standard-care sedatives. Doses of these three drugs at the day of death were statistically significantly higher than at admission. The three most prescribed drugs were morphine, midazolam and haloperidol, to 21, 11 and 23% of patients at admission, respectively. Systematic review of the role of alternative application routes for opioid treatment for moderate to severe cancer pain: an EPCRC opioid guidelines project. Midazolam is a type of benzodiazepine medication, used as a conscious sedative, anaesthetic agent, anticonvulsant and is also licensed to help manage restlessness and agitation in palliative care. 2009;38:36571. We also know that tests for Covid-19 are largely accurate. The aim of this study was to evaluate what drugs were administered, and at what dose and route of administration, from admission to day of death in patients admitted to a single palliative care centre. That afternoon two of my brothers and a number of other family members visited. Percentages of patients with prescriptions of solid oral drugs declined from 89.2% (n=173) at Ta to 21.3% (n=43) at Td. The phrase "terminal sedation" was initially used to describe the practice of sedation at end of life, but was changed due to ambiguity as to what the word 'terminal' meant. The daily dose was calculated as the dose of the prescribed patch divided by the number of days the patch was in place. A DHSC spokesperson previously told Full Fact that: To manage increases in demand, we have been building UK stockpiles of key medicines, including midazolam. 2009;10:16472. CAS Intermediate-acting GABA A agonist. 2007;55:5905. A p value of <0.05 (two-sided) was deemed statistically significant. Note: There are a number of different strengths of midazolam injection available (1mg/ml, 2mg/ml, 5mg/ml).In palliative care the most concentrated form of the injection is prescribed to maximise dosing options for single site subcutaneous injection where the volume limit is approximately 2ml i.e. A prospective multicenter assessment of the Edmonton staging system for cancer pain. We believe this terminology is highly misleading. 2007; (2): CD005594. He was communicating normally. 1 The reasons for use vary between reports and include difficulties in controlling such symptoms as pain and breathlessness, but probably the most common indication for sedation in palliative care is delirium in an extremely ill patient. Midazolam may harm an unborn baby, and generally should not be used during pregnancy. First, this was a single-centre study of which the results cannot be extrapolated to other palliative care settings or other countries as prescription practices may differ. or if eGFR <30mL/min or older than 65years of age or frail: Morphine 5mg plus Midazolam 5mg subcut infusion over 24 hours. Midazolam may also be used for purposes not listed in this medication guide. Dose adjustment may be needed because liver and kidney function undergo changes at the end of life [13, 14]. Methadone and Midazolam: Methadone is long-acting and one dose can have effects for several days, whereas Midazolam mainly wears off within a few hours. Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Data were analysed using descriptive statistics. Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited. The first, a letter published in the Journal of Palliative Medicine in 2015, notes that midazolam is indeed a very prolifically administered drug in Australian palliative care practice. Accessed Nov 2014. It is suggested that physicians start with opioids, 3 which do not impair respiratory status or hasten death when used appropriately with a symptom focus (e.g., hydromorphone 0.5 mg subcutaneously every 4 h, and 0.5 mg subcutaneously every 30 min, as needed). Therefore, while midazolam was included as a symptom control option in the LCP, its use has continued as a tenet of good end of life care. You have spoken out against establishment out of love and indignation with what happened to your fathers. Relatively slow onset. Become a Photo Time Tunnel member and receive deep discounts, subscriber-only content and a FREE BOOK with new 1-year subscriptions*! The paper goes on to describe the belief on the part of many practitioners that adding a sedative like midazolam is a solution when pain relief medications arent quite achieving the desired level of relief. People have died in care homes during the Covid-19 pandemic. Ensor BR, Middlemiss TP. The goal of palliative care is symptom control by a combination of non-pharmacological measures and drugs. The article also reports that: Retired neurologist Professor Patrick Pullicino, who was instrumental in raising concerns a decade ago that the Liverpool Care Pathway was bringing forward patients deaths, believes the jump indicated something similar had happened. All patient data were handled and processed in accordance with the recommendations of Good Clinical Practice. Objective To describe doses and routes of administration of the most frequently used drugs at admission and at day of death. While I was talking to one of my sisters-in-law in the corridor, two different nurses came to check on Dad. Acting on the benzodiazepine receptor, it promotes the action of gamma-aminobutyric acid. Subcutaneous midazolam infusion in palliative care. I asked her if she had given my father midazolam. Mentally fuzzy: Benzodiazepines reduce mental acuity, even in low doses, and impair memory. [We were later to learn that the nurse failed to tell us she had also given him another two injections of midazolam, one at 4am when he was found on the floor and another at 6.20am only 10 minutes before she called me. Higher doses are required if tolerance has developed to benzodiazepines. We were shocked and disappointed at what appeared to be dishonesty and evasiveness.]. You can email us at water_gums@bigpond.com. She had given midazolam because she felt the methadone had not eased his pain and he was still attempting to sit up. The COL has 4 oncology medical departments (with a total of 48 beds) and an 11-bed palliative care unit (PCU). 2007;34:94104. Regarding haloperidol, only retrospective descriptive studies or overview articles are available, even without addressing the administration route [4548]. A second item shared by Professor Henry was an article in the journal Anesthesiology, in March 2013, by Michael Frolich, Kui Zhang and Timothy Ness of the University of Alabama. There is no evidence that the LCP has been reinstated. He never regained consciousness. The frequencies of combinations of prescriptions of non-opioids, NSAIDs and opioids are given in supplementary Table S3. Google Scholar. Midazolam is often stopped in the last days before death, to avoid that patients become comatose. Are powerful sedatives being over-used in palliative care and aged care? Equivalent subcutaneous doses of oral drugs were calculated by dividing oral morphine doses by 3 and oral haloperidol doses by 2 [5, 25, 26]. J Pain Symptom Manage. She relayed this to a doctor who prescribed what the nurse referred to as a breakthrough drug to ease Dads pain. Midazolam is a commonly used benzodiazepine in palliative care and is considered one of the four essential drugs needed for the promotion of quality care in dying patients. An explanation for this wide range could be the studied time frame. https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2034567&resultclick=1, Carrington Slipways and the Laverick family, A shopping coupon prize took him to the Titanic, Pillar of the community quietly disappeared. He said he was, so I helped him out of bed and into an armchair. It changes end-of-life care into euthanasia.. LeGrand SB. Nauck and co-workers [17] in a similar study found that 26% of patients received morphine at admission (versus 21% in the present study), but corresponding figures at the end of treatment were 42 versus 87%. Regarding opioids, only small and mostly non-randomized controlled clinical trials have compared the subcutaneous route with another route of administration [12, 42]. Midazolam undergoes metabolism in the liver by hydroxylation into three major metabolites. She urged us to stay, to hold Dads hand and talk to him because, she said, hearing was usually the last thing to go. The median subcutaneous midazolam dose (60mg/24h) at the day of death in the present study fits within the range found in other studies; mean midazolam doses of 2670mg/24h during the last days of life [30, 31, 39]. In a conversation later that morning with the doctor overseeing Dads treatment, I expressed concern about midazolam. Not long after this my father died, as expected. These effects are accentuated with concurrent use of opioids and other drugs. Midazolam is a commonly used benzodiazepine in palliative care and is considered one of the four essential drugs needed for the promotion of quality care in dying patients. ISBN 978-0-9552547-5-8. 2004;101:14737. A. Matht, Palliative Care Centre, Laurens Cadenza, Rotterdam, The Netherlands, Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Childrens Hospital, Room SK 1276, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands, Anniek D. Masman,Monique van Dijk&Dick Tibboel, Hospital Pharmacy - Clinical Pharmacology, Academic Medical Centre, Amsterdam, The Netherlands, You can also search for this author in Below is the link to the electronic supplementary material. We asked Professor Pullicino (quoted early in this post) to comment on our accounts. Midazolam injection may cause serious or life-threatening breathing problems such as shallow, slowed, or temporarily stopped breathing that may lead to permanent brain injury or death. Thanks for your thoughtful and detailed reply Roger. He asked me for water when he was thirsty and at one time he even wanted to watch TV. It seems apparent from much that has been written that this impression may not be accurate and that the drug might merely tend to prevent prisoners from expressing their pain although it is evidently not always successful even in this. Throughout the day Dad remained unresponsive. He encouraged me to ask the hard questions and to ask them publicly. Greg and Sylvia, Belated condolences to you both and thanks for sharing what must have been troubling memories of that time and the impact of the drug. We have written more about tests for Covid-19 previously. Mr. Oltzik was also receiving morphine, to kill pain. Prescriptions of lactoluse-senna mix, rabeprazole, acetaminophen, metoclopramide, temazepam, dexamethasone, macrogol/salts and metoprolol had been discontinued before Td. At the day of death these percentages had increased to 87, 58 and 50%, respectively. 2019 Photo Time Tunnel. Fonzo-Christe C, Vukasovic C, Wasilewski-Rasca AF, Bonnabry P. Subcutaneous administration of drugs in the elderly: survey of practice and systematic literature review. Lonergan E, Britton AM, Luxenberg J and Wyller T. Antipsychotics for delirium. Up until the week ending 28 May 2021, the Office for National Statistics data shows there have been 138,367 deaths in England and Wales involving Covid-19 (where Covid-19 is mentioned anywhere on the death certificate), and 123,717 with Covid-19 documented as the underlying cause of death on the death certificate. being injected with midazolam after refusing an order to stop eating biscuits. So he had been given three injections in a six hour period. He also ate all his evening meal. Doses of these drugs were statistically significantly higher than those at the day of admission. The nightmare drug, he said, had robbed him of any power over his body. The Liverpool Care Pathway (LCP) was a generic approach to care for the dying, intended to improve end of life care and allow some of the essentials of palliative medicine and hospice model end of life practices into hospitals and other healthcare settings. With the assistance of a nurse we managed to get Dad onto a mobile commode chair and wheeled him into the bathroom. Myself, my husband and stepmother arrived shortly after. We believe it can reduce the ability of patients to communicate important facts about their pain and other aspects of their condition. She made me feel like I was over-reacting, ignorant and creating problems over nothing. In conclusion, strict monitoring of the efficacy of subcutaneous morphine, midazolam and haloperidol is essential and more pharmacokinetic and pharmacodynamics studies are needed. Objectives Infused sedatives are often utilised to alleviate distress at the end of life. Accessed Nov 2014. His sleep was fitful. The Dutch national guideline for delirium treatment, however, recommends a maximum parenteral maintenance dose of 10mg/day [5]. According to one recent article in the UK Daily Mail, whistleblowers have claimed they were told to administer the drug to stop confused patients wandering. Palliat Med. Two studies of patients at the end . This is the largest palliative care centre in the Netherlands, with 20 beds for terminal care and symptom management; from 200 to 250 patients are admitted annually. In our centre, as needed prescriptions mainly serve to increase the already prescribed doses of the medications, for example when worsening of symptoms is expected. [36, 37]. For Dad it was not like that. morphine) have been repeatedly raised. J Am Geriatr Soc. I stayed with Dad all that night. A multidisciplinary team of health care professionals is available 24h per day. I returned in the afternoon and stayed for a third night. Semin Oncol Nurs. This allows admitting staff to ensure that the treatment and care they provide are . Guidelines for diagnosis and treatment in palliative care. It has a half-life of 2-5 hours, although the half-life is prolonged up to three times in people older than 60 years of age. What we have seen has led us to question the use of this powerful drug. being turned in bed, washed, or having a catheter inserted). 2,3 The use of sedation near the end of life has aroused ethical controversy, and . We have written many times before about the Covid-19 pandemic, and the evidence behind proof of its existence. In two other studies more than 90% of the patients received low-to-moderate morphine doses either upon admission [27] or in the last 24h before death [28] . At one point he awoke and became quite distressed and insisted on going to the bathroom to use his bowels. Dad died shortly after this injection at about 1pm. I didnt feel reassured so I turned to a person I knew and respected from my years as health reporter with The Newcastle Herald. 2012;51:9961008. They are sometimes used with other agents in anaesthesia, on ventilated patients and to induce coma.
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