Evidence to support use of alternative drugs and routes of administration for management of End of Life symptoms
Reviewed and changed January 2021 Levomepromazine changed to first line, in advance of Haloperidol, for agitated delirium driven by breathlessness, hypoxia and fear. This change is based upon anecdotal evidence of significant restlessness and distress in a proportion of patients; generally younger and fitter before their illness.
The chart above, may, in full, part or adapted, be used in any country to support provision of care. It should not be used in any form for profit. The A3 version is the easiest to read.
Evidence Base for some of the more unusual suggestions in the “COVID-19 management of EoL symptoms" chart. March 2020
Morphine via the rectal route. There appears to be some reasonable evidence that morphine injection, modified and immediate release tablets and suppositories are all absorbed rectally with almost equal (or better) efficacy to morphine pain relief given by the oral route. With regards breathlessness there is no evidence for use of the rectal route, though there seems no reason to think that morphine absorbed into the blood stream will give any regard to the route by which it arrived there. Hence, its actions once in the system should provide the same relief, which many studies have shown, of pain, breathless and to some extent anxiety. Clearly, this ignores many arguments that could be made about different pharmacokinetics and pharmacodynamics that may impact upon efficacy. It seems reasonable to assume however that some morphine in the system at whatever level, via whatever route is better than none in the face of End of Life symptoms. The best review paper appears to be that by Dr Matt Kestenbaum, who has kindly given his permission for any use of his paper. Matthew G. Kestenbaum, MD, et al., Alternative Routes to Oral Opioid Administration in Palliative Care: A Review and Clinical Summary, Pain Medicine, Volume 15, Issue 7, July 2014, Pages 1129–1153, https://doi.org/10.1111/pme.12464
Further relevant papers and Fentanyl Patch references.