TABLE 1

Example clinical guidelines for the management of the severe/dying COVID-19 patient

Symptom/needClinical indicationRecommendation
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)

Monitor patients receiving opioids for undesirable effects, particularly nausea and vomiting, and constipation. Depending on individual circumstances, prescribe a regular or p.r.n anti-emetic and a regular laxative.
AnxietyMild

  • 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)

If needed regularly, consider a CSCI/IV infusion (starting dose midazolam 10 mg /24 h- reduce to 5 mg if eGFR<30 or elderly)
CoughIf 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).

Monitor patients receiving opioids for undesirable effects, particularly nausea and vomiting, and constipation. Depending on individual circumstances, prescribe a regular or p.r.n anti-emetic and a regular laxative.
Fever

  • Paracetamol 1 g QDS PO/IV (avoid NSAIDs unless end of life)

DeliriumMild 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).

If needed regularly, consider CSCI/IV infusion (either levomepromazine 50 mg or midazolam 15 mg /24 h- reduce to levomepromazine 25 mg or midazolam 7.5 mg (if eGFR<20 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 opioid
CommunicationPatients

  • “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.