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COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community https://web.archive.org/web/20200409054527/https://www.nice.org.uk/guidance/ng163/resources/covid19-rapid-guideline-managing-symptoms-including-at-the-end-of-life-in-the-community-pdf-66141899069893 Correlate the use of these drugs with ‘covid’ deaths https://coronavirus.data.gov.uk/details/deaths?areaType=nation&areaName=England Spike in deaths, spring 2020 2 Treatment and care planning 2.3 For patients with pre-existing advanced comorbidities, find out if they have advance care plans or advance decisions to refuse treatment, including do not attempt resuscitation decisions. Document this clearly and take account of these in planning care. Table 1 Treatments for managing cough in adults aged 18 years and over only if cough is distressing: morphine sulfate oral solution (10 mg/5 ml) 2.5 mg to 5 mg when required every 4 hours Increase up to 5 mg to 10 mg every 4 hours as required Table 4 End-of-life treatments for managing breathlessness for patients aged 18 years and over For associated agitation or distress: midazolam 2.5 mg to 5 mg subcutaneously when required Sedation and opioid use should not be withheld because of a fear of causing respiratory depression 6 Managing breathlessness 6.5 Consider an opioid and benzodiazepine combination (see tables 4 and 5) for patients with COVID-19 who: are at the end of life and have moderate to severe breathlessness and are distressed. Consider concomitant use of an antiemetic and a regular stimulant laxative. At the time of publication (April 2020), opioids and benzodiazepines did not have a UK marketing authorisation for moderate to severe breathlessness (see the General Medical Council's guidance on prescribing unlicensed medicines for further information). Midazolam https://openprescribing.net/analyse/#org=regional_team&numIds=0408020W0,1501041T0,0408020V0,0401010Q0&denom=nothing&selectedTab=chart Spike in midazolam use, spring 2020 Increased levels of use through to Autumn 2022 https://bnf.nice.org.uk/drugs/midazolam/ Important safety information For all benzodiazepines MHRA/CHM advice: Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression (March 2020) Levomepromazine https://openprescribing.net/analyse/#org=CCG&numIds=0402010L0AAAAAA&denom=nothing&selectedTab=chart Spike in use, spring 2020 Somewhat increased levels of use through to Autumn 2022 phenothiazine neuroleptic https://bnf.nice.org.uk/drugs/levomepromazine/ Restlessness and confusion in palliative care Nausea and vomiting in palliative care Schizophrenia Haloperidol https://openprescribing.net/analyse/#org=CCG&numIds=0402010J0AAACAC&denom=nothing&selectedTab=chart Spike in use, spring 2020 Increased levels of use through to Autumn 2022 https://bnf.nice.org.uk/drugs/haloperidol/ Nausea and vomiting in palliative care Schizophrenia and schizoaffective disorder Acute delirium [when non-pharmacological treatments ineffective] So How many of these deaths were covid? How many of these deaths were iatrogenic? To precisely what degree did this make covid look more deadly that in was? How did this artificially inflated death date influence national policy?

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