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Liverpool Care Pathway (LCP)

First line drugs Second line drugs Specialist drugs Secondary care drugs

Introduced for patients in the last days of life when all possible reversible causes for their current condition have been considered, and the multi-professional team have agreed that the patient is dying.        

Two or more of the following criteria may apply: the patient is bed bound, is only able to take sips of fluids, is semi-comatose, are no longer able to take oral medication.

  • Review medication and stop all unnecessary drugs. Consider setting up a syringe driver. It is recommended that fentanyl patches remain in situ, and if further analgesia is needed, then a syringe driver is set up in addition to the patch.
  • One important aspect of the LCP is the provision of anticipatory drugs for pain, vomiting, agitation and respiratory tract secretions.

Pain: opioid naïve patients, suggest diamorphine 2.5mg-5mg sc prn. In patients already on morphine or oxycodone, prescribe appropriate breakthrough dose

Nausea and vomiting: levomepromazine  2.5mg-6.25mg sc prn
Agitation: midazolam 2.5mg-5mg prn (higher doses may be needed for patients previously on benzodiazepines)

Respiratory tract secretions: hyoscine hydrobromide 400 micrograms sc prn 

If patient is not on regular opioid analgesic, anti-emetic or benzodiazepine suggest that GPs write up stat doses as above, and supply a prescription for the following (basic pack):       

  • Diamorphine: 10mg x 5 ampoules
  • Midazolam: 10mg in 2mls x 5 ampoules
  • Levomepromazine: 25mg in 1ml x 5 ampoules
  • Water for injection: 10ml x 10 ampoules 

Please refer to the LCP flow chart for further advice or contact your local specialist palliative care team or St Luke’s Hospice (24hr advice line) if unsure about drug doses.

Guidelines for prescribing at end of life in severe renal failure: Please seek advice from local specialist palliative care team

Pain: alfentanil recommended. Suggested starting dose alfentanil 250 micrograms sc prn
Morphine and oxycodone and their active metabolites accumulate in severe renal failure and this can cause profound sleepiness, myoclonic jerks, and respiratory depression. Alfentanil and fentanyl accumulate significantly less.

Nausea and vomiting: haloperidol recommended, suggested starting dose 0.5mg-1mg sc prn. Use levomepromazine second line.
Agitation: midazolam and diazepam recommended but lower doses are indicated eg midazolam 2.5mg sc prn

Respiratory tract secretions: glycopyrronium recommended, suggested dose 200 micrograms sc prn. (hyoscine hydrobromide accumulates in severe renal failure; it also has a central effect and high levels can cause deeper sedation and worsen terminal agitation)

Return to Chapter: 16. Palliative Care Guidelines

Last updated by: on 01-12-2009 15:14