Page 25 - Palliative Care, Trials and COVID-19 Tribulations: First-hand experience shared by the experts at ground zero

So, in situations like this, I think many of you may be familiar with the need to have to
restrain patients in a bed. If you look at this, just think about it and consider, do you think that
this is a very dignified way for yourself or your loved ones to be at the end of one’s life?

So, if we can, we should try and treat the delirium and restlessness. Hopefully then, we may
be able to take off those restraints. For delirium, we commonly use Haloperidol 0.5 - 1 mg at
night and PRN, you can give it every 30 minutes to 1 hour. You can actually titrate up the
dose 1 - 2 mg at night depending on how many PRN doses they take. Most of the time,
patients do not need more than 5 mg in 24 hours. It is much less than those with
schizophrenia or severe psychosis.

If they are very restless, I would normally prefer to try to get the patient calm immediately by
using intravenous Midazolam 0.5 - 1 mg and titrate it every 5 - 10 minutes until the patient is
calm. After that, put them on subcutaneous Midazolam 2.5 mg PRN. If they have very
persistent restlessness and are still very distressed, then I would consider using an infusion of
10 - 20 mg over 24 hours.

Other Symptoms

Now, other symptoms like pain. If they have got pre-existing pain because they got cancer or
something else, I do hope that patients could continue all of their pain medications even while
they are in the COVID-19 wards. If the patient is on Morphine, and they develop renal
failure, then you can convert to transdermal Fentanyl. For further guidance on the dosages
and how to treat, please refer to the CPG on “Management of Cancer Pain” and “Pain
Management Handbook” that are available.

Secondly, coughing can sometimes be distressing. Initially, you can use some simple cough
syrups, but if it is very persistent, aqueous Morphine 2 - 3 mg TDS/QID is something that can
be helpful. Sometimes patients get very distressed at night because they are coughing, and
they cannot sleep, so you can give a night dose.

Thirdly, respiratory secretions can also be distressing. We normally use an anticholinergic
like Buscopan or Glycopyrrolate, whichever you can actually get.