Pain in the dying phase


When the patient is no longer able to swallow oral morphine, change to:

•  Continuous diamorphine (or morphine) infusion via a syringe driver (see Relative doses of Opiods).

•  Prescribe a PRN dose of subcutaneous diamorphine (or morphine) for breakthrough pain one sixth of the total 24- hour dose of diamorphine. This can be given as frequently as necessary and increased in proportion to any increase in 24-hour dose.

•  If the patient is still in pain and the PRN diamorphine (or morphine) has been found to be effective, the 24-hour dose of subcutaneous diamorphine (or morphine) may be increased by the sum of the PRN doses given in the previous 24 hours. For patients requiring rapidly escalating doses of opioids, contact the Specialist Palliative Care Team for advice.

•  If the patient does not currently have pain, prescribe subcutaneous diamorphine 2.5–5 mg (or morphine 2.5–5 mg) PRN. If after review at 24 hours two or more doses have been required, set up a syringe driver containing diamorphine (or morphine).

If the patient is on an alternative strong opioid and needs to switch to a syringe driver, see Pain ( see Relative doses of Opiods; and Discontinuing transdermal Fentanyl) or seek Specialist Palliative Care Team advice.