Figures
- FIGURE 1
Example information sheet for COVID-19 patients admitted to hospital (downloadable WORD document available in supplementary files).
- FIGURE 2
Example information sheet for familes/friends of COVID-19 patients admitted to hospital (downloadable WORD document available in supplementary files).
Tables
- TABLE 1
Example clinical guidelines for the management of the severe/dying COVID-19 patient
Symptom/need Clinical indication Recommendation Distressing breathlessness at rest Stat dose morphine 2.5 mg SC/IV+ midazolam 2.5 mg SC/IV (reduce both to 1.25 mg if eGFR <30 or elderly)
If continuous infusion is available Morphine 10 mg + midazolam 10 mg CSCI/ IV over 24 hs OR morphine 5 mg+midazolam 5 mg CSCI/IV over 24 h (if eGFR <30 or in the elderly).
In addition, prescribe morphine 2.5 mg+midazolam 2.5 mg SC/IV p.r.n. 4 hourly (1.25 mg for both if eGFR<30 or in the elderly)
If continuous infusion is not available Morphine 2.5 mg SC/IV+midazolam 2.5 mg SC/IV 4 hourly (1.25 mg for both if eGFR<30 or in the elderly).
In addition, prescribe morphine 2.5 mg SC/IV+midazolam 2.5 mg SC/IV p.r.n. 4 hourly (1.25 mg for both if eGFR<30 or in the elderly)
Anxiety Mild Relaxation techniques and breathing exercises
Moderate/severe Midazolam 2.5 mg SC/IV p.r.n (1.25 mg for both if eGFR<30 or in the elderly)
Cough If continuous infusion is available Morphine 10 mg CSCI/ IV over 24 h (5 mg CSCI/IV if eGFR<30 or elderly)
If continuous infusion is not available Morphine 2.5 mg SC/IV SC/IV 4 hourly (1.25 mg for both if eGFR<30 or in the elderly).
Fever Paracetamol 1 g QDS PO/IV (avoid NSAIDs unless end of life)
Delirium Mild confusion Orientation to time and place
Delirium with distress Orientation to time and place, if ineffective haloperidol 1–10 mg SC/IV in 1–3 divided doses over 24 h; maximum 10 mg/day (halve all doses in elderly; maximum 5 mg/day)
Delirium/agitation at end of life Stat dose levomepromazine 25 mg SC/IV or midazolam 5 mg (reduce to levomepromazine 12.5 mg and midazolam 2.5 mg if eGFR<30 or elderly).
NB May need to titrate rapidly if ongoing agitation. Where on both opioid and sedative - titrate the sedative up for terminal delirium NOT the opioidCommunication Patients “I understand that this is an emotional time, anyone would be scared/anxious…it is normal to be worried and scared.”
“We do not think recovery from this illness is possible and [you/they] may die over the next [few hours / days / short weeks].”
“I am very sorry that you cannot have your loved ones around you, but as you can see, you are here with us, you are not alone, we will stay with you.”
Family “What concerns you the most?” “It's understandable you feel this way / This must be really hard for you / It is upsetting.” “Who is around to support you?” “Is there something we can do to help?”
“We are concerned about the condition of your [relative] and think that they are ‘sick enough to die’”
Further information/resources available at: https://www.vitaltalk.org/guides/covid-19-communication-skills/, SIGN delirium guidance https://www.sign.ac.uk/sign-157-delirium.
CSCI: continuous subcutaneous infusion; SC: subcutaneous; IV: intravenous; PO: per oral; BD: twice daily; GFR: glomerular filtration rate.
