Table 3

Mrs A's end-of-life care programme

Preparation Her subcutaneous infusion of morphine (20 mg/24 hours) and midazolam (15 mg/24 hours) via a syringe driver was re-instated after confirming the diagnosis of coma.
These were continued while a midlength intravenous line was requested.
Day 1Clinically assisted nutrition and hydration was discontinued
Her gastrotomy tube was sealed and covered with an occlusive dressing
Day 2Once the intravenous line was in place, she was changed over to intravenous infusion (morphine (30 mg/24 hours) and midazolam (20 mg/24 hours)), with bolus doses of 5 mg each as required
Day 3Glycopyrronium 600 µg/24 hours and cyclizine 50 mg prn were added to the regimen. These were given subcutaneously
Day 4Her suprapubic catheter blocked and a urethral catheter was inserted to keep her dry
Day 6Because changing her tracheostomy inner tube continued to cause coughing and abnormal posturing, the tracheostomy was removed on January 11 2016. The stoma was allowed to remain open to facilitate breathing and sputum clearance, and was just loosely covered with protective sterile gauze, changed as necessary
Her medications were adjusted to morphine (40 mg/24 hours) and midazolam (30 mg/24 hours). After this she appeared more settled
Day 8There was a slight increase in her breathing rate and sweating and she had required two additional bolus doses, so the infusion rates were increased to morphine (50 mg/24 hours) and midazolam (35 mg/24 hours)
Day 9Her breathing had become more laboured and her medication was increased further to morphine (60 mg/24 hours) and midazolam (50 mg/24 hours) after which she settled
Day 10She died peacefully in the early hours of the morning