title: Four essential drugs needed for quality care of the dying: a Delphi-study based international expert consensus opinion.
abstract: OBJECTIVE
  The majority of dying patients do not have access to necessary drugs to alleviate their most common symptoms, despite evidence of drug efficacy. Our aim was to explore the degree of consensus about appropriate pharmacological treatment for common symptoms in the last days of life for patients with cancer, among physicians working in specialist palliative care.
  
  
  METHODS
  Within OPCARE9, a European Union seventh framework project aiming to optimize end-of-life cancer care, we conducted a Delphi survey among 135 palliative care clinicians in nine countries. Physicians were initially asked about first and second choice of drugs to alleviate anxiety, dyspnea, nausea and vomiting, pain, respiratory tract secretions (RTS), as well as terminal restlessness.
  
  
  RESULTS
  Based on a list of 35 drugs mentioned at least twice in the first round (n=93), a second Delphi round was performed to determine ≤ 5 essential drugs for symptom alleviation in the last 48 hours of life that should be available even outside specialist palliative care. There was ≥ 80% consensus among the participants (n=90) regarding morphine, midazolam, and haloperidol as essential drugs. For RTS, there was consensus about use of an antimuscarinic drug, with 9%-27% of the physicians each choosing one of four different drugs.
  
  
  CONCLUSIONS
  Based on this consensus opinion and other literature, we suggest four drugs that should be made available in all settings caring for dying patients with cancer, to decrease the gap between knowledge and practice: morphine (i.e., an opioid), midazolam (a benzodiazepine), haloperidol (a neuroleptic), and an antimuscarinic.
authors.affiliation: R&D Unit in Palliative Care, Stockholms Sjukhem Foundation, Stockholm, Sweden. olav.lindqvist@ki.se
authors.forename: Olav
authors.initials: O
authors.lastname: Lindqvist
authors.forename: Gunilla
authors.initials: G
authors.lastname: Lundquist
authors.forename: Andrew
authors.initials: A
authors.lastname: Dickman
authors.forename: Johannes
authors.initials: J
authors.lastname: Bükki
authors.forename: Urska
authors.initials: U
authors.lastname: Lunder
authors.forename: Carina Lundh
authors.initials: CL
authors.lastname: Hagelin
authors.forename: Birgit H
authors.initials: BH
authors.lastname: Rasmussen
authors.forename: Sylvia
authors.initials: S
authors.lastname: Sauter
authors.forename: Carol
authors.initials: C
authors.lastname: Tishelman
authors.forename: Carl Johan
authors.initials: CJ
authors.lastname: Fürst
mesh_terms: D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use; D014151:Anti-Anxiety Agents / Q000627:therapeutic use; D014150:Antipsychotic Agents / Q000627:therapeutic use; D003697:Delphi Technique; D018954:Drugs, Essential; D005062:European Union; D005260:Female; D006024:Glycopyrrolate / Q000627:therapeutic use; D006220:Haloperidol / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008874:Midazolam / Q000627:therapeutic use; D008875:Middle Aged; D009020:Morphine / Q000627:therapeutic use; D018727:Muscarinic Antagonists / Q000627:therapeutic use; D010166:Palliative Care; D011595:Psychomotor Agitation / Q000188:drug therapy; D012601:Scopolamine / Q000627:therapeutic use
chemical_list: D000701:Analgesics, Opioid; D014151:Anti-Anxiety Agents; D014150:Antipsychotic Agents; D018954:Drugs, Essential; D018727:Muscarinic Antagonists; D009020:Morphine; D012601:Scopolamine; D006220:Haloperidol; D008874:Midazolam; D006024:Glycopyrrolate