Benchmarking opioids in the last 24 hours of life

Opioid dosages are titrated against symptoms with large variations between patients. For self-assessment of prescribing, and for clinical governance, it is important to know the normal prescribing patterns across New Zealand (NZ). The aims of this study were to document opioids and dosages given to patients in the last 24 h of life to identify normal practice and allow prescribers to reflect on their own practice.

A cross-sectional benchmarking design with retrospective chart review was carried out among 14 NZ hospices. Data (n = 352) on opioid dosages were analysed for inter-hospice variability (ANOVA). Parenteral morphine equivalent daily dose was used to analyse the dosage of different opioids.

Overall, 95% of dying patients received an opioid. Of these 71% received morphine, 17% fentanyl, 10% methadone 9.5% oxycodone. The dosages delivered are conservative compared with international data, with a geometric mean of 47.8 mg. There was no significant difference in mean dosages of opioids prescribed between hospice teams. There was, however, a significant difference between the dosage of opioid for those on the Liverpool Care Pathway for the Care of the Dying and those who were not (63.1-44.4 mg), and between those with malignant and non-malignant disease (53.8-26.0 mg). Opioid footprints show different hospices have different patterns of opioid use.

The parameters of what normal opioid prescribing is in the last days of life in NZ can be described from these data. There is value in repeating this exercise both for clinical governance and for professional reflection and self-assessment.