Clinical Decision Support
Symptom Navigator
Select a symptom spoke for management guidance, or tap the hub for JIC anticipatory prescribing. Opioid calculator in the next tab.
📄
JIC Anticipatory Prescription
CMAC format — NHS Grampian. Reference only. Prescriber must sign original.
ℹ️
Scottish Palliative Care Guidelines
Opioid Conversion Calculator
Based on SPCG Choosing & Changing Opioids tables. Decision-support aid — always apply clinical judgement.
Current drug
mg /
Specialist Palliative Care
Roxburghe House
Specialist Palliative Care · Aberdeen
📞 01224 557057
⚙ Configurable via CDMtools Admin → Practice Settings → Palliative Team
Refer when
- →Complex or refractory pain after dose titration
- →Opioid switch — especially in renal failure
- →Fentanyl or alfentanil initiation
- →Palliative sedation / refractory distress
- →Complex family or ethical situations
Breakthrough & CSCI
JIC PRN dose1/6 of total 24hr SC opioid — give up to hourly.T34 CSCITotal 24hr SC dose in driver over 24hr. Verify drug compatibility before combining.
⚡ Urgent Guidance
Palliative Emergencies
Check ACP/DNACPR before acting. Weigh benefits and burdens against prognosis and patient wishes.
🚨For all emergencies: check ACP/DNACPR status first. Involve patient and family. Specialist palliative care on-call via Roxburghe House 01224 557057.
⚡ Malignant Spinal Cord Compression (MSCC)
⏱️Time-critical. Neurological deterioration may be irreversible within hours.
- 1Suspect: thoracic back pain + weakness, numbness or bladder/bowel dysfunction
- 2Dexamethasone 16 mg IV/oral stat — do not delay for imaging
- 3Urgent MRI whole spine. Same-day referral to oncology/spinal surgery
- 4If prognosis poor or treatment declined: comfort care — analgesia, bladder care, positioning
⚡ Hypercalcaemia
- 1Suspect: confusion, polyuria, nausea, constipation, bone pain. Common in myeloma, breast, renal, lung cancers
- 2Corrected calcium: mild <3.0 mmol/L; moderate/severe ≥3.0 mmol/L
- 3IV rehydration 0.9% saline 3–4 L/24hr — admit for moderate/severe
- 4Zoledronic acid 4 mg IV (dose-adjust in renal impairment). Effect peaks 5–7 days
- 5If last days of life: comfort measures only may be appropriate
⚡ Catastrophic Bleeding
🔴Anticipate in head/neck cancers and lung tumours — prepare in advance where possible.
- 1If anticipated: pre-prescribe midazolam 10 mg SC/buccal. Dark towels available. Family forewarned.
- 2Acute: lay patient on side (bleeding side down). Apply pressure.
- 3Midazolam 10 mg SC/IM immediately. Repeat if needed. Morphine for pain/distress.
- 4Remain with patient. 999 only if resuscitation in line with ACP wishes.
- 5Family support. Document and debrief.
⚡ Raised ICP
- 1Morning headache, nausea, vomiting, drowsiness, focal neurology
- 2Dexamethasone 8–16 mg oral/IV stat then 4–8 mg BD. PPI cover.
- 3Head of bed 30°. Avoid Valsalva.
- 4Refer oncology for whole brain radiotherapy if appropriate
⚡ SVCO
- 1Facial/arm swelling, distended neck veins, dyspnoea, headache
- 2Dexamethasone 16 mg oral/IV stat then 8 mg BD
- 3Urgent CT chest. Refer for stenting if appropriate.
- 4Radiotherapy/chemo by tumour type. Anticoagulate if thrombus.
⚡ Seizures
- 1Protect airway. Time the seizure. Recovery position. Do not restrain.
- 2>5 min or status: midazolam 10 mg buccal (Epistatus) or diazepam 10 mg PR
- 3Ongoing: midazolam CSCI. Pre-prescribe in known risk patients.
⚡ Opioid Toxicity
⚠️Titrate naloxone carefully — precipitates acute pain and distress.
- 1Pinpoint pupils, drowsiness, respiratory depression, myoclonus
- 2Stop opioid. Identify cause: renal failure, dehydration, dose error.
- 3If RR <8 or unconscious: naloxone 0.4 mg diluted to 4 ml, give 0.5 ml IV every 2 min — do not fully reverse
Care Around Dying
Last Days of Life
Recognition, comfort care and management of special circumstances in the last hours and days.
📊 Palliative Performance Scale (PPS)
ℹ️PPS assesses functional status across five domains. Use alongside clinical judgement for prognosis conversations and care planning. PPS ≤40% suggests weeks; ≤20% suggests days.
| PPS % | Ambulation | Activity & Evidence of Disease | Self-Care | Intake | Consciousness |
|---|---|---|---|---|---|
| 100% | Full | Normal activity, no evidence of disease | Full | Normal | Full |
| 90% | Full | Normal activity, some evidence of disease | Full | Normal | Full |
| 80% | Full | Normal activity with effort, some evidence of disease | Full | Normal or reduced | Full |
| 70% | Reduced | Unable to do normal job/work, significant disease | Full | Normal or reduced | Full |
| 60% | Reduced | Unable to do hobby/housework, significant disease | Occasional assistance | Normal or reduced | Full or confusion |
| 50% | Mainly sit/lie | Unable to do any work, extensive disease | Considerable assistance required | Normal or reduced | Full or confusion |
| 40% | Mainly in bed | Unable to do most activity, extensive disease | Mainly assistance | Normal or reduced | Full or drowsy ± confusion |
| 30% | Bed bound | Unable to do any activity, extensive disease | Total care | Normal or reduced | Full or drowsy ± confusion |
| 20% | Bed bound | Unable to do any activity, extensive disease | Total care | Minimal sips | Full or drowsy ± confusion |
| 10% | Bed bound | Unable to do any activity, extensive disease | Total care | Mouth care only | Drowsy or coma ± confusion |
100–70% — Functional, community
60–40% — Declining, likely weeks–months
30–10% — Last days–weeks, trigger ACP/JIC/DNACPR
⚠️PPS ≤40% — Consider ACP conversation, DNACPR, GSF register, JIC medications, KIS update. Likely weeks prognosis.
🔴PPS ≤20% — Last days of life likely. Initiate comfort care, syringe driver, OOH handover, rapid transfer home if preferred.
PPS adapted from Victoria Hospice Society (Anderson et al, 1996). Used with permission in SPCG. Score based on worst applicable description across all five domains for each level.
🕊️ Recognising the Last Days
ℹ️Recognising dying is a clinical skill — it is not always certain. Communicate uncertainty honestly with patient and family.
Functional decline
Bed-bound, only sips of fluid, drowsy for most of the day, minimal communication
Physical signs
Mottling (peripheries then trunk), Cheyne-Stokes breathing, cold extremities, altered consciousness, inability to swallow
Respiratory secretions
Noisy breathing (“death rattle”) — reassure family this does not cause suffering. Hyoscine butylbromide 20 mg SC PRN / 60 mg/24hr CSCI.
Communication
Explain to family what is happening and what to expect. Spiritual/religious needs. Who to call when death occurs.
💙 Comfort Care Priorities
- 1Mouth care: Every 2–4 hr. Foam swabs, lip balm, small sips if tolerated.
- 2Medications via CSCI: Continue opioid, antiemetic, anxiolytic, antisecretory. Stop non-essential drugs.
- 3Hydration: IV/SC fluids rarely appropriate. If offered: hypodermoclysis max 500–1000 ml/24hr SC.
- 4Pressure care: Reposition 2-hourly if not distressing. Pressure-relieving mattress.
- 5Urinary: Catheter if retention causing distress.
- 6Documentation: DNACPR in place. ACP documented. Preferred place of death confirmed.
🩸 Diabetes in Last Days
- 1Stop all hypoglycaemics when oral intake has ceased
- 2Stop routine blood glucose monitoring unless symptomatic
- 3T1DM: small background insulin may prevent DKA — specialist advice
- 4Hypo/hyper symptoms managed symptomatically
🫘 Renal Disease in Last Days
⚠️Morphine accumulates — switch to alfentanil SC.
- 1Preferred opioid: Alfentanil SC — no active metabolites. Specialist initiation.
- 2Midazolam and haloperidol generally safe in renal failure
- 3Avoid NSAIDs. Reduce all doses. Monitor closely.
⚠️ Severe Uncontrolled Distress — Palliative Sedation
⚠️Clinical and ethical decision. Involve senior clinician, patient (if able), family and specialist palliative care.
- 1Refractory suffering despite all reasonable symptom control measures
- 2Midazolam CSCI: 20–40 mg/24hr starting. Titrate. PRN available alongside.
- 3Levomepromazine for refractory agitation: 25–100 mg/24hr CSCI
- 4Goal is relief of suffering — proportionate sedation, not hastening death
🏠 Rapid Transfer Home
- 1Confirm patient’s wish to die at home. Family/carer willing and able to support.
- 2JIC medications prescribed, dispensed and physically at home before discharge
- 3Community nursing notified — visit within hours of arrival home
- 4OOH GP informed. DNACPR paperwork in patient’s home.
- 5Equipment: hospital bed, pressure mattress, commode — arrange via community nursing/OT
- 6Family: who to call, what to expect, do not call 999 unless agreed in ACP
Medicines Reference
Medicines & Syringe Driver
Common palliative medications, T34 CSCI guidance and renal prescribing. Many drugs used off-label — document clinical rationale.
⚗️ T34 Syringe Driver — Key Principles
ℹ️T34 is the standard CSCI device in NHS Grampian. Nurses set up and monitor. GP role: prescribe 24hr CSCI dose + PRN SC doses on CMAC.
- 1Diluent: Water for injection preferred. 0.9% NaCl for some drugs. Always verify.
- 2Volume: Draw up to approximately 17 ml in a 20 ml syringe
- 3Site: Anterior chest, upper arm, anterior thigh, abdomen. Avoid oedematous areas.
- 4Change every 24 hours. Check site for erythema, induration or leakage.
Common Compatibility (T34)
| Drugs | Diluent | Compatibility |
|---|---|---|
| Morphine + Midazolam | WFI | ✓ Compatible |
| Morphine + Haloperidol | WFI | ✓ Compatible |
| Morphine + Hyoscine butylbromide | WFI | ✓ Compatible |
| Morphine + Midazolam + Haloperidol | WFI | ✓ Compatible |
| Morphine + Levomepromazine | WFI | ✓ Compatible |
| Cyclizine + Morphine (high dose) | WFI | ⚠ Precipitation risk |
| Cyclizine + Haloperidol | — | ✗ Incompatible |
💊 Key Drug Reference
| Drug | Indications | Typical doses | Notes |
|---|---|---|---|
| Morphine | Pain, dyspnoea | 2.5–5 mg SC PRN | Avoid in renal failure |
| Oxycodone | Pain (morphine intolerant) | 2.5 mg SC PRN | Caution in renal failure |
| Alfentanil | Pain in renal failure | Specialist initiation only | No active metabolites |
| Midazolam | Agitation, seizures, dyspnoea | 2.5–5 mg SC PRN CSCI 10–60 mg | Titrate carefully in elderly |
| Haloperidol | Nausea, delirium | 0.5–1 mg SC PRN CSCI 1.5–5 mg | QT prolonging |
| Levomepromazine | Refractory N&V, agitation | 5–6.25 mg SC 12-hrly PRN CSCI 6.25–50 mg | Sedating. Broad antiemetic. |
| Hyoscine butylbr. | Secretions, bowel colic | 20 mg SC PRN CSCI 60–120 mg | Does not cross BBB |
| Dexamethasone | ICP, SVCO, MSCC, appetite | 8–16 mg OD SC/oral | Morning dose. PPI cover. |
| Cyclizine | Nausea (vestibular) | 50 mg SC TDS CSCI 150 mg | Incompatible with haloperidol |
⚠️ Renal Prescribing Quick Guide
Avoid / extreme caution
MorphineHydromorphoneNSAIDsCodeine
Preferred in renal failure
Alfentanil SCFentanyl patchMidazolamHaloperidol (low dose)Hyoscine butylbromide
Care Coordination
Handover, KIS & ACP
OOH handover, referral pathways and ACP documentation for patients approaching end of life.
Roxburghe House
Specialist Palliative Care · Aberdeen
📞 01224 557057
⚙ Team name and number configurable via CDMtools Admin → Practice Settings → Palliative Team
📋 OOH Handover — What to Communicate
Complete in EMIS/Vision. Ensure accessible via KIS and palliative care flag.
- Diagnosis and prognosis — primary diagnosis, stage, expected trajectory
- Preferred place of death — documented and family aware
- DNACPR status — in place, signed, copy in patient’s home, family aware
- JIC medications — prescribed, dispensed, physically at home. CMAC completed.
- Current symptoms and management — active issues, what is working, recent dose changes
- What to do if patient deteriorates — admission appropriate? Which hospital? Or comfort at home?
- Family contact — primary carer name and number
- Community nursing team — key nurse, visit frequency
- Specialist palliative care team — if involved, contact details included
- KIS updated — accessible to NHS 24, SAS and OOH GP services
📞 NHS Grampian Referral Pathways
| Service | When to refer | How |
|---|---|---|
| Roxburghe House 01224 557057 | Complex symptoms, refractory pain, ethical dilemmas, palliative sedation | SCI Gateway. OOH: ARI switchboard → bleep palliative care CNS |
| Community Palliative Nursing | Syringe driver setup, JIC administration, monitoring at home | Via district nursing. Flag as palliative on referral. |
| Marie Curie Nursing | Overnight nursing at home in last days of life | Via community nursing or Marie Curie booking line |
| Social Work | Increased care package, equipment, carer support | SCI referral or direct contact. |
📝 ACP & Documentation Checklist
- Prognosis discussed with patient — honest, sensitive, with uncertainty acknowledged
- Preferred place of death documented in EMIS/Vision
- DNACPR decision made, documented, signed and copy in patient’s home
- KIS updated on EMIS — accessible to SAS and OOH
- Palliative care / GSF register updated
- Power of Attorney / welfare guardianship checked if patient lacks capacity
- Anticipated problems documented (bleeding risk, seizure risk) with contingency plan
- After-death guidance given to family (who to call, Certification of Death)
ℹ️KIS reminder: Update before every weekend and bank holiday. This is the primary mechanism for communicating palliative status to NHS 24, SAS and OOH GP.
📖 SPCG OOH Handover Guidance