Advanced Palliative Care & Symptom Management

WHO Definition of Palliative Care

Palliative care is an approach that improves quality of life of patients and their families facing life-threatening illness, through prevention and relief of suffering by means of early identification and assessment and treatment of pain and other physical, psychosocial and spiritual problems.

Core Affirmations

Affirms life; regards dying as a normal process
Intends neither to hasten nor postpone death
Integrates psychological & spiritual aspects
Offers support to live as actively as possible
Enhances quality of life; may positively influence the course of illness
Applicable early in illness alongside curative treatment

Palliative vs Curative Intent

Curative	Palliative
Eliminate disease	Relieve suffering
Quantity of life primary	Quality of life primary
Aggressive interventions common	Burdensome tx avoided
Cure-focused goals	Comfort & dignity goals

Total Pain Concept (Cicely Saunders)

Physical Pain

Cancer invasion, nerve compression
Treatment side effects
Co-morbidities
Fatigue, nausea, breathlessness

Psychological Pain

Fear of death, disfigurement, dependency
Anxiety, depression, anger
Loss of control, identity
Unfinished business

Social Pain

Loss of role/employment
Financial worries
Family relationships/conflicts
Social isolation

Spiritual/Existential Pain

"Why me?" — search for meaning
Religious doubt or crisis of faith
Fear of punishment after death
Unresolved guilt, need for forgiveness

Total pain must be assessed and addressed holistically — analgesics alone will not adequately control pain if psychological, social or spiritual components are unaddressed.

Palliative Care Referral Triggers

SPICT Tool (Supportive & Palliative Care Indicators)

General Indicators:

Unplanned hospital admissions (2+ in 6 months)
Declining performance status (Karnofsky <50%)
Weight loss >10% over 6 months
Persistent troublesome symptoms despite treatment
Patient/family concern about future

Disease-specific indicators: advanced cancer, end-stage organ failure (heart, respiratory, renal, hepatic), neurological, dementia, frailty.

The Surprise Question

"Would you be surprised if this patient died in the next 12 months?"

If NO — consider palliative care referral. Validated in cancer AND non-cancer populations. Simple, quick, widely applicable. Sensitivity ~67%, Specificity ~80%.

Gold Standards Framework (GSF)

Prognostic Indicator Guidance: uses 3 triggers:

A: Years — advanced disease (COPD/Heart failure/Dementia)
B: Months — deteriorating, increasing need
C: Weeks/Days — rapidly deteriorating, near death

Prognosis Communication — SPIKES Protocol

S — Setting

Private room, sit down, ensure support person present, silence phone

P — Perception

"What do you understand about your illness?" — assess current knowledge

I — Invitation

"How much information would you like me to share?" — check readiness

K — Knowledge

Give information in small chunks; use plain language; avoid jargon; fire a warning shot: "I have some difficult news…"

E — Emotions

Acknowledge emotional response. Use NURSE: Name, Understand, Respect, Support, Explore. Allow silence.

S — Strategy/Summary

Summarise, agree a plan, ensure follow-up. Check understanding. Provide written information.

Goals of Care Conversations & DNACPR

Goals of Care Framework

Elicit patient values: "What matters most to you?"
Clarify understanding of prognosis
Discuss trade-offs (treatment burden vs benefit)
Document agreed goals clearly in notes
Share across multidisciplinary team
Review as condition changes

Remember: Goals of care conversation ≠ DNACPR discussion. Goals of care is broader and includes all treatment decisions.

DNACPR Process

Decision is medical — clinician makes the decision
Consultation required (not consent): discuss with patient & family where appropriate
Document: reason, date, review date, who was consulted
Communicate to all team members and on handover
DNACPR does NOT mean "do not treat" — all other care continues
Nurse role: advocate for patient, ensure documentation visible, implement on arrest

GCC Note: DNR documentation in GCC hospitals requires senior physician signature and family notification per institutional policy. See Tab 6.

WHO Analgesic Ladder

Step 1 — Mild Pain (NRS 1–3)

Non-Opioid

Paracetamol 1g QDS (max 4g/day)
NSAIDs (with gastroprotection)
± Adjuvants

Step 2 — Moderate Pain (NRS 4–6)

Weak Opioid

Codeine 30–60mg QDS
Tramadol 50–100mg QDS (max 400mg/day)
Low-dose strong opioid (now preferred)
± Non-opioid ± Adjuvants

Step 3 — Severe Pain (NRS 7–10)

Strong Opioid

Morphine (drug of choice)
Oxycodone, Hydromorphone
Fentanyl (transdermal)
± Non-opioid ± Adjuvants

Principle: Analgesics should be given "by the mouth, by the clock, by the ladder." Regular dosing prevents pain; PRN doses treat breakthrough. Reassess every 24h during titration.

Strong Opioid Initiation — Morphine Titration

Starting Morphine (Opioid-naive)

Start oral morphine immediate-release (IR) 2.5–5mg every 4 hours in elderly/frail; 5–10mg in younger adults

Prescribe PRN breakthrough: same dose as regular 4-hourly dose (or 1/6 total daily dose) every 1 hour PRN

Review after 24h: add total opioid (regular + breakthrough) used in 24h

Increase regular dose by 30–50% if pain uncontrolled; set new breakthrough as 1/6 of new total

When stable on IR morphine, convert to modified-release (MR) morphine 12-hourly

Always co-prescribe: Laxative (senna/lactulose), anti-emetic PRN for first week, mouth care

Opioid Rotation (Equianalgesic Conversion)

Drug/Route	Oral Morphine Equivalent
Morphine oral	1 : 1 (reference)
Morphine SC/IV	Oral ÷ 2 (SC), ÷ 3 (IV)
Oxycodone oral	Oral morphine ÷ 1.5
Oxycodone SC	Oral morphine ÷ 3
Hydromorphone oral	Oral morphine ÷ 5
Tramadol oral	Oral morphine ÷ 10 (approx)
Codeine oral	Oral morphine ÷ 10
Fentanyl patch (mcg/h)	Oral morphine 24h ÷ 2.4 ≈ patch dose in mcg/h

Safety: Reduce new opioid dose by 25–30% when rotating (incomplete cross-tolerance). Reduce by 50% in renal impairment, elderly, or frailty.

Breakthrough Dose Calculation

Formula: Breakthrough dose = Total daily opioid dose ÷ 6

Example: Patient on MST 60mg BD (total 120mg/24h oral morphine) → Breakthrough = 120 ÷ 6 = 20mg oral morphine IR
If converting to SC: 20mg oral ÷ 2 = 10mg SC morphine PRN
Allow breakthrough every 1 hour (oral) or 30 minutes (SC)

Syringe Driver in Palliative Care

Indications for Syringe Driver

Unable to swallow (dysphagia, unconscious)
Persistent nausea/vomiting
Malabsorption
Patient preference
Last days of life

Setup Principles

Calculate 24h SC dose for all drugs
Use water for injection as diluent (avoid normal saline with cyclizine)
Change syringe every 24h
Check site 4-hourly for inflammation/extravasation
Document drug, dose, diluent, rate, site, time

Syringe Driver Drug Compatibility ▼

Drug	Compatible With	Incompatible With
Morphine	Midazolam, Haloperidol, Metoclopramide, Hyoscine HBr, Dexamethasone (separate)	High-conc dexamethasone (precipitate risk)
Midazolam	Morphine, Oxycodone, Haloperidol, Hyoscine HBr	Dexamethasone, Cyclizine (at higher doses)
Haloperidol	Morphine, Midazolam, Metoclopramide	Cyclizine, Dexamethasone
Cyclizine	Morphine, Diamorphine (low conc)	Hyoscine HBr, Haloperidol, Metoclopramide, Ketorolac
Metoclopramide	Morphine, Midazolam, Haloperidol	Cyclizine, Dexamethasone, Ketorolac
Dexamethasone	Dilute alone (best in separate syringe)	Midazolam, Cyclizine, Metoclopramide
Hyoscine HBr	Morphine, Midazolam, Haloperidol	Cyclizine
Levomepromazine	Morphine, Midazolam, Hyoscine HBr	Ketorolac, high-dose Cyclizine

Always check: Visual compatibility — if cloudiness/precipitate appears, do NOT use. Check current Palliative Care Formulary or equivalent for exact combinations.

Adjuvant Analgesics

Drug Class	Examples	Indication	Nursing Points
Corticosteroids	Dexamethasone 4–8mg/day	Nerve compression, raised ICP, hepatomegaly	Give morning dose; monitor BG; PPI cover; taper on discontinuation
NSAIDs	Ibuprofen, Naproxen, Diclofenac	Bone pain, inflammatory pain	Use lowest dose; co-prescribe PPI; avoid in renal impairment
TCAs	Amitriptyline 10–75mg nocte	Neuropathic pain (burning/tingling)	Sedating — give at night; anticholinergic SEs; ECG if cardiac history
Gabapentinoids	Gabapentin 300–900mg TDS; Pregabalin 75–150mg BD	Neuropathic pain, allodynia	Titrate slowly; sedation; dose reduce in renal impairment; fall risk
Ketamine	Specialist use only, SC infusion	Refractory neuropathic/cancer pain	Psychomimetic SEs; monitor vitals; specialist supervision
Bisphosphonates	Zoledronic acid IV monthly	Bone metastases pain	Pre-hydrate; monitor renal function; jaw osteonecrosis risk

Opioid-Induced Constipation (OIC): Affects >90% of patients on opioids. ALWAYS co-prescribe a laxative from day 1. Start stimulant laxative (Senna 2–4 tabs BD or Bisacodyl). Add osmotic agent (Lactulose/Macrogol) if needed. Unlike other opioid SEs, constipation does NOT resolve with time. Naloxegol or Methylnaltrexone for refractory OIC.

Opioid Conversion Calculator

Current Opioid

Total Daily Dose (mg) — or mcg/h for fentanyl patch

Patient Factors

Oral Morphine Equivalent (24h)—

SC Morphine Equivalent (24h)—

Breakthrough Dose (1/6 oral morphine 24h)—

Breakthrough SC Morphine—

Approximate Fentanyl Patch Equivalence—

Dyspnoea Management

Non-pharmacological

Fan directed at face — stimulates V2 branch of trigeminal nerve, reduces breathlessness perception (strong evidence)
Upright/forward-leaning positioning
Open window, cool room
Relaxation techniques, breathing exercises
Anxiety management — reduce panic cycle
Oxygen only if hypoxic (SpO2 <90%); not routinely beneficial in normoxic patients

Pharmacological

Drug	Dose	Note
Morphine SC/oral	2.5–5mg SC PRN	First-line; reduces ventilatory drive & perception of breathlessness
Midazolam SC	2.5–5mg SC PRN	For anxiety component; not first-line alone
Lorazepam SL	0.5–1mg SL	Useful in acute dyspnoea panic

Low-dose opioids for dyspnoea do NOT hasten death when used correctly. Reassure patients and families.

Nausea & Vomiting — Antiemetic Selection by Cause

Antiemetic Selection by Cause (Click to Expand) ▼

Cause	Pathway/Receptor	First-line Antiemetic	Dose
Opioid-induced	CTZ — D2 receptor	Haloperidol	0.5–1.5mg SC/oral nocte or BD
Gastric stasis / functional	GI motility — D2 peripheral	Metoclopramide	10mg TDS–QDS oral/SC
Raised intracranial pressure	Vomiting centre	Cyclizine	50mg TDS oral/SC
Motion / vestibular	H1 + muscarinic	Cyclizine or Hyoscine HBr	Cyclizine 50mg TDS
Metabolic (hypercalcaemia, uraemia)	CTZ — D2 + 5HT3	Haloperidol or Ondansetron	Haloperidol 1.5–3mg nocte
Chemotherapy/radiation	5HT3 — gut & CTZ	Ondansetron/Granisetron	8mg BD–TDS
Bowel obstruction	Multiple	Cyclizine + Hyoscine HBr (reduce secretions)	Cyclizine 50mg TDS; Hyoscine HBr 60–120mg/24h SC
Refractory/multi-factorial	Broad receptor block	Levomepromazine	6.25–12.5mg SC nocte or BD

Note: Avoid metoclopramide in bowel obstruction (pro-kinetic — may worsen colic). Ondansetron causes constipation — use cautiously in palliative patients.

Constipation in Palliative Care

Laxative Ladder

Stimulant laxative: Senna 2–4 tabs BD or Bisacodyl 5–10mg BD. Always first-line for opioid-induced constipation.

Add osmotic laxative: Lactulose 15ml BD or Macrogol (Movicol) 1–2 sachets daily. For harder stool.

Rectal intervention: Glycerine suppository (softener) or Bisacodyl suppository (stimulant). For loaded rectum.

Phosphate enema: For hard impacted stool. Check contraindications (bowel obstruction, low platelet).

Manual evacuation: Last resort. Under sedation/analgesia if needed. Requires 2-nurse check & documentation.

PR Examination Protocol

Explain procedure, obtain verbal consent
Left lateral position, knees to chest
Visual inspection before digital examination
Lubricate index finger; gentle insertion
Assess: stool present (hard/soft), rectal loading, blood, masses
Document: findings, consistency, patient tolerance

Contraindications to PR: Bowel obstruction, neutropenic (ANC <500), thrombocytopenic (platelets <50k), recent rectal/anal surgery, known rectal tumour — seek specialist advice.

Secretions / Death Rattle

Occurs in ~50% dying patients. Noisy breathing from pooled secretions the patient cannot clear. Patient is usually unconscious and not distressed — but distressing for family.

Management

Repositioning: Semi-prone or lateral — gravity drainage. First-line.
Hyoscine Butylbromide (Buscopan) SC: 20mg SC PRN or 60–120mg/24h syringe driver. Reduces new secretion production — does NOT clear existing secretions.
Glycopyrronium SC: 0.2mg PRN / 0.6–1.2mg/24h — less sedating than hyoscine hydrobromide.
Avoid oropharyngeal suctioning in dying patients — distressing and ineffective.

Family Communication

Explain to family: "The noise is caused by relaxed throat muscles and secretions. Your relative is not aware of it and is not choking or suffocating. We are giving medication to help reduce this."

Terminal Agitation & Restlessness

Causes (ALWAYS Exclude)

Urinary retention / constipation
Uncontrolled pain
Opioid toxicity (hyperalgesia, myoclonus)
Hypoxia
Metabolic disturbance
Medication side effects
Psychological/existential distress

Pharmacological Management

Drug	Dose	Indication
Midazolam SC	2.5–5mg SC PRN; 10–30mg/24h CSCI	Agitation, anxiety, seizures
Haloperidol SC	0.5–2mg SC PRN; 2–10mg/24h CSCI	Delirium, hallucinations, agitation
Levomepromazine SC	6.25–25mg SC PRN; 25–200mg/24h CSCI	Refractory agitation (broad sedation)

Palliative Sedation: When all reversible causes addressed and symptom control inadequate, proportionate sedation is ethically acceptable. Requires MDT discussion, documentation, family communication and senior physician prescribing.

Malignant Wounds & Lymphoedema

Malignant Wound Management

Goals: Symptom control (odour, exudate, bleeding, pain) not wound healing.

Problem	Management
Odour	Metronidazole gel topical (anaerobic bacteria); activated charcoal dressings (Clinisorb); room odour eliminators
Exudate	Foam dressings (Allevyn); alginate if heavy; avoid frequent dressing changes — traumatic
Bleeding	Mepitel/silicone dressings (non-adherent); adrenaline 1:1000 soaked gauze; tranexamic acid topical; radiation referral
Pain at dressing change	Pre-medicate 30min before (opioid PRN); Mepitel/silicone primary layer; Entonox if available
Infection	Wound swab only if changing; antimicrobials topically or systemically if cellulitis

Lymphoedema Management

Complete Decongestive Therapy (CDT):

MLD (Manual Lymphatic Drainage): Specialist technique — light pressure redirects lymph via collateral pathways
Compression bandaging: Multi-layer during intensive phase, then compression garments maintenance phase
Skin care: Daily moisturising (aqueous cream), avoid trauma, prompt infection treatment
Exercise: Active movement within compression

Avoid BP cuffs, venepuncture, injections in affected limb. Educate patient on cellulitis risk signs (redness, warmth, fever).

Recognition of Dying

Recognition of Dying Checklist (Click to Expand) ▼

Clinical Signs — Patient is Likely in Last Hours/Days

Circulatory changes:

Mottled, cyanosed peripheries (mottling ascending above knees = very close to death)
Cold extremities, colour changes
Weak, thready or absent peripheral pulse
Hypotension; BP may be unrecordable

Respiratory changes:

Cheyne-Stokes breathing pattern
Long periods of apnoea (>20 seconds)
Accessory muscle use, jaw breathing
Death rattle (secretions)

Neurological changes:

Unconscious or unresponsive
Fixed, partially dilated pupils
Loss of swallow reflex (cannot take oral meds)
Reduced or absent urine output

AMBER Care Bundle triggers:

Patient acutely unwell AND may not recover
Uncertain about appropriateness of current treatment
Patient/family not fully aware of uncertainty
No plan in place if patient deteriorates

Comfort-Focused Care in Last Days

Stop non-essential medications (statins, antihypertensives, vitamins)
Continue: analgesia, antiemetics, anxiolytics, antisecretories, anticonvulsants
Convert all oral medications to SC route
Remove non-essential monitoring (routine BG, obs may be reduced)
Ensure syringe driver running with anticipatory medications
Ensure patient comfortable: repositioning 2-4hrly, pressure area care

Mouth Care Protocol

2-4 hourly (or more frequently if mouth breathing)
Moist foam swabs moistened with water
Lip balm/petroleum jelly to prevent cracking
Mouth wash if tolerated (no alcohol-based)
Oral suction for comfort only (gentle)
Document condition of mouth at each assessment

Pressure Area Care

Reposition 2–4 hourly minimum (or use dynamic mattress)
Skin assessment at each turn
Protective dressings to bony prominences
Accept unavoidable pressure injury in final hours

Anticipatory Prescribing Protocol

Anticipatory Prescribing — 4 PRN SC Drugs (Click to Expand) ▼

Prescribe BEFORE the patient deteriorates so medications are immediately available. Avoids delays at end of life.

Category	Drug (first choice)	Standard PRN SC Dose	Indication	Review
1. Opioid (Analgesia/Dyspnoea)	Morphine SC	2.5–5mg SC PRN q1h (opioid naïve) Or 1/6 current 24h dose if on opioids	Pain, breathlessness	After 3+ doses in 24h → titrate syringe driver
2. Antiemetic	Metoclopramide or Haloperidol SC	Metoclopramide 10mg SC PRN q4h Haloperidol 0.5–1.5mg SC PRN q4h	Nausea, vomiting	If >2 doses/24h → add to syringe driver
3. Anxiolytic (Agitation/Dyspnoea)	Midazolam SC	2.5–5mg SC PRN q1h	Agitation, anxiety, breathlessness	If >3 doses/24h → review syringe driver dose
4. Antisecretory	Hyoscine Butylbromide SC	20mg SC PRN q4h	Secretions (death rattle)	If persistent → 60–120mg/24h CSCI

Additional drugs to consider: Anticonvulsant (Midazolam 10mg SC PRN/Diazepam PR) if seizure history; Dexamethasone if raised ICP; Ondansetron if refractory nausea.

Documentation required: Prescription signed by senior physician, route (SC), indication, dose, frequency, maximum doses/24h, and review plan. Nurse administers on clinical assessment.

Family Communication at End of Life

Key Communication Points

Inform sensitively that patient is in the dying phase
Encourage presence — sitting with patient, holding hands
Explain what to expect: breathing changes, colour, sounds
Reassure that patient is not in pain
Discuss what happens at moment of death
Cultural and religious needs assessment (see Tab 6)
Pastoral/chaplaincy referral if appropriate
Provide written bereavement information

Withdrawing / Withholding Treatment

Ethically equivalent — there is no moral distinction between withholding and withdrawing a treatment that is no longer of benefit.

Treatment is withdrawn when burdens outweigh benefits
Withdrawal of clinically assisted nutrition/hydration (CANH) — senior clinical decision, MDT, family consultation
Document clearly: rationale, discussions, decision maker
Withdrawal ≠ abandonment — comfort care continues

Nurse Role: Advocate for patient dignity and comfort throughout withdrawal process. Provide sensitive family support. Ensure anticipatory medications prescribed and available.

Verification of Death

Nursing Verification Procedure

Note time called to patient. Approach respectfully.

Confirm absence of response to verbal and pain stimuli (sternal rub).

Check absence of pupillary response to light (fixed, dilated pupils).

Listen for heart sounds: absent for minimum 2 minutes.

Check for absent respiratory effort: observe for minimum 2 minutes.

Absent carotid pulse confirmed.

Document time of death verification (not time of death — that is certified by physician).

Notify: next of kin, physician for death certification, bed manager. Begin last offices per cultural/religious preference.

Post-Death Care

Close eyes (use moist gauze if resistant)
Position naturally: supine, head on pillow, limbs straightened (rigor mortis begins ~2h)
Remove monitoring lines/tubes unless coroner involved
Maintain dignity at all times
Cultural needs: enquire about religious requirements before last offices (see Tab 6 — Ghusl)
Label body correctly per institutional policy
Support family if present — offer private time
Document all actions with times

Psychological Assessment in Palliative Care

Anxiety & Depression Screening

Distress Thermometer: Single-item 0–10 scale. Score ≥4 = significant distress → further assessment needed.

PHQ-9: 9-item depression screen. Score ≥10 = moderate depression. Validated in palliative populations.

GAD-7: 7-item anxiety screen. Score ≥10 = moderate anxiety.

Existential Distress Features

Loss of meaning and purpose
Fear of the future / uncertainty
"Why me?" / "What was the point of my life?"
Loss of dignity or self-concept
Desire for hastened death

Desire for hastened death requires immediate senior review — assess for undertreated pain, depression, or delirium before assuming existential choice.

Therapeutic Communication in Palliative Care

Active listening: Full attention, no interrupting, reflecting back
Open questions: "Tell me what's worrying you most"
Silence: Therapeutic — allows processing
Empathic statements: "That sounds incredibly hard"
Normalising: "Many people with your illness feel that way"
Avoiding platitudes: Not "everything happens for a reason"
Presence: Sitting with someone in distress without needing to fix it

SAGE & THYME model: S-etting, A-sk, G-ather, E-mpathy & T-hink, H-elp needed?, Y-our help?, M-ore, E-nd. A structured listening model for nurses — not therapy, but good supportive communication.

Spiritual Care — FICA Tool

Letter	Question Domain	Example Questions
F	Faith / Belief	"Do you have spiritual beliefs that help you cope with illness?"
I	Importance	"How important is spirituality/religion to you right now?"
C	Community	"Are you part of a religious or spiritual community?"
A	Address in Care	"How would you like us to address your spiritual needs?"

Spiritual care is the responsibility of ALL health professionals, not just chaplains. Referral to chaplain/religious leader appropriate for specific religious needs or complex spiritual distress.

Spiritual Needs & Interventions

Facilitate access to religious leaders/clergy/imam/priest/rabbi
Enable religious practices: prayer, ablution (wudu), Quran recitation
Allow religious items at bedside
Facilitate confession, last rites, sacraments as appropriate
For Muslim patients — offer facing Mecca (Qibla direction)
Sensitive, non-judgmental approach regardless of nurse's own beliefs

Bereavement Support

Grief Models

Kübler-Ross Stages (1969)

Denial → Anger → Bargaining → Depression → Acceptance. Note: not linear, not all stages occur.

Worden's Tasks of Mourning

Accept the reality of the loss
Work through the pain of grief
Adjust to a world without the deceased
Find an enduring connection while embarking on new life

Dual Process Model (Stroebe & Schut)

Oscillation between loss-orientation (grief work) and restoration-orientation (adapting to new roles/life). Both necessary for healthy grief.

Complicated Grief — Referral Criteria

Refer to specialist bereavement/psychology if:

Prolonged grief disorder — grief-specific symptoms >12 months
Persistent inability to accept death
Significant functional impairment
Suicidal ideation
Substance misuse as coping mechanism
Pre-existing mental health disorder exacerbated

Family Support During Illness

Family meetings — regular, structured, with MDT
Carer needs assessment — separate from patient
Young children/dependants — specialist support
Anticipatory grief support before death

Paediatric Palliative Care Principles

Key Differences from Adult Palliative Care

Long-term life-limiting conditions (not just end-of-life)
Prognostic uncertainty — some children outlive prognosis
Family-centred care — parents as primary decision-makers
Pain assessment adapted to age: FLACC, Faces Scale, Wong-Baker
Opioid dosing weight-based; involve pharmacy
Sibling support essential
Schooling, play, normalcy maintained where possible

Communication with Children & Families

Age-appropriate language about illness and dying
Children understand more than adults often assume
Do not exclude children from information about their own illness
Involve play therapists, child psychologists
Legacy work — memory boxes, recordings, letters
Bereavement support for siblings and parents long-term

Specialist Paediatric Palliative Care referral for all children with life-limiting conditions — do not manage alone on a general ward.

Islamic Perspectives on Death & Dying — GCC Context

The Good Death — Khusnul Khatimah

Islam teaches that every soul will return to Allah (Inna lillahi wa inna ilayhi raji'un — Quran 2:156). The concept of Khusnul Khatimah (dying in a good state) guides patient and family wishes:

Shahada (declaration of faith) at time of death
Presence of family reciting Quran (Surah Yaseen is tradition)
Facing Mecca (Qibla) — nurses should assist with positioning
Pain relief is permitted and encouraged — suffering has no spiritual benefit
Wudu (ablution) maintained if possible

Reciting the Shahada is the highest priority for Muslim patients near death — facilitate, do not interrupt, family recitation.

Family Decision-Making in GCC

Collective family decision-making is cultural norm — elder male family member (father/husband/eldest son) often presents as decision-maker
Patient autonomy respected in Islamic ethics but family involvement expected
Truth-telling: family may request "protect" patient from diagnosis — navigate sensitively; patient has right to know if they wish
Advance care planning is developing in GCC — not yet widely normalised
Social workers and Arabic-speaking interpreters essential for complex family meetings

Islamic Bioethics — Withholding vs Withdrawing

Islamic Bioethical Principles

La darar wa la dirar (no harm, no harming) — treatment causing undue suffering may be withdrawn
Prolonging the dying process artificially is not required in Islamic scholarship
Majority of Islamic scholars: withdrawing futile treatment is permissible
Active euthanasia/assisted dying: prohibited in Islam
Palliative sedation: permissible if intent is comfort, not hastening death (doctrine of double effect)
DNACPR: permissible — Islamic scholars support allowing natural death

Practical Guidance for GCC Nurses

Engage hospital Islamic scholar/chaplain (imam) for complex ethical decisions
Document religious needs in care plan
DNR documentation: requires senior physician + family consultation per DHA/MOH policy; imam consultation may be requested
Medication in Ramadan: SC/IV medications are generally permitted by Islamic scholars during Ramadan as they are not oral intake; discuss with patient and family; confirm with hospital imam if uncertainty

Ramadan SC medications: Subcutaneous medications (including syringe drivers) are considered medically necessary and do not invalidate the fast according to most Islamic scholarly opinions. Reassure patients.

Ghusl & Body Preparation Post-Death

Nursing Actions After Muslim Death

Do not perform last offices without family/imam guidance
Wear gloves; handle body with utmost respect
Do not remove tubes, lines if family/family physician not yet notified
Close eyes; close mouth (support with rolled towel under chin)
Turn head towards right shoulder (towards Mecca if possible)
Straighten the body; arms alongside body (not folded)
Cover with white sheet
Notify family immediately — burial should occur as soon as possible (within 24h ideally)

Ghusl (Islamic Ritual Washing)

Performed by Muslims of same sex (or spouse)
Ideally done by family or designated Muslim washers
Hospital should facilitate ghusl room if available
After ghusl: wrapped in white kafan (shroud) — 3 layers for women, 3 for men
Post-mortem examinations: acceptable only if legally required — family must be informed; delay burial accordingly
Organ donation: permissible under many Islamic scholars' opinions when brain death criteria met and to save a life

Note for non-Muslim nurses: Do not apply perfumes, embalm, or dress body in non-Islamic clothing. Ask the family for guidance in all post-death care.

GCC Healthcare Context — Opioids & Hospice

Opioid Availability in GCC

Historically, opioid access was a significant barrier to palliative care in the GCC:

Morphine access improving — now available in UAE, KSA, Qatar hospital formularies
Controlled drug regulations: strict documentation (Class A equivalent in most GCC states)
Community/home opioid prescribing: limited but developing
Opioid phobia remains among some clinicians and families — education critical
Fentanyl patches increasing availability
Methadone: limited availability in GCC

Advocating for adequate pain control is a professional nursing obligation — under-treatment of pain is an ethical violation. Escalate if opioids are inappropriately withheld.

DHA / DOH Hospice & Palliative Development

Dubai Health Authority (DHA): Palliative care strategy developed post-2015; Palliative Care Centre of Excellence at Latifa Hospital
DOH (Abu Dhabi): HAAD/DOH palliative care framework; Sheikh Khalifa Medical City palliative unit
KSA — SCFHS: Palliative medicine as specialty; Saudi Society of Palliative Medicine active; King Hussein Cancer Center model referenced
Home-based palliative care services expanding in UAE and KSA
Integration of palliative care into oncology and ICU pathways ongoing

DHA / DOH / SCFHS Exam Preparation

High-Yield Opioid Conversion Topics

Scenario	Calculation	Answer
Patient on Codeine 60mg QDS — convert to oral morphine	(60×4) ÷ 10 = 240 ÷ 10	24mg oral morphine/24h
Patient on oral morphine 60mg/24h — convert to SC morphine	60 ÷ 2	30mg SC morphine/24h
Patient on oral morphine 120mg/24h — breakthrough dose	120 ÷ 6	20mg oral morphine PRN
Patient on oral morphine 90mg/24h — fentanyl patch	90 ÷ 2.4 = 37.5 → round	Fentanyl 37.5 mcg/h (round to 25 or 50)
Patient on oxycodone oral 40mg BD — oral morphine equivalent	(40×2) × 1.5	120mg oral morphine/24h
Fentanyl patch 50 mcg/h — oral morphine equivalent	50 × 2.4	120mg oral morphine/24h

Syringe Driver Exam Questions — Key Facts

Diluent: Water for Injection (not saline — cyclizine precipitates in saline)
Cyclizine incompatible with: haloperidol, metoclopramide, hyoscine HBr, ketorolac
Dexamethasone: best prescribed in separate syringe
Change syringe every 24 hours
Check site 4-hourly
Morphine oral to SC: divide by 2

DNACPR & Anticipatory Prescribing — Exam Summary ▼

DNACPR Key Facts

Medical decision — nurse does NOT make DNACPR decision independently
Requires senior physician signature
Consultation (not consent) with family required
Document: date, reason, who consulted, review plan
DNACPR = no CPR only; all other treatment continues unless separately decided
In GCC: family notification mandatory per DHA/DOH policy; some institutions require family signature as acknowledgment

4 Anticipatory Drugs — Memorise

Morphine SC — pain & dyspnoea
Midazolam SC — agitation & anxiety
Metoclopramide/Haloperidol SC — nausea
Hyoscine Butylbromide SC — secretions

Surprise Question Answer

If you would NOT be surprised if patient died in 12 months → consider palliative care referral

Total Pain — 4 Components

Physical, Psychological, Social, Spiritual