COVID-19 Rapid Guideline: Managing Symptoms (Including at The End of Life) in The Community

COVID-19 rapid guideline:
managing symptoms
(including at the end of life) in
the community
NICE guideline
Published: 3 April 2020
www.nice.org.uk/guidance/ng163
© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

rights).
COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community
(NG163)
Your responsibility
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual needs,
preferences and values of their patients or the people using their service. It is not mandatory to
apply the recommendations, and the guideline does not override the responsibility to make
decisions appropriate to the circumstances of the individual, in consultation with them and their
families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be
applied when individual professionals and people using services wish to use it. They should do so in
the context of local and national priorities for funding and developing services, and in light of their
duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a
way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of implementing
NICE recommendations wherever possible.
© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- Page 2 of
conditions#notice-of-rights). 19
(NG163)
Contents
Overview ............................................................................................................................................................................. 4
1 Communicating with patients and minimising risk ......................................................................................... 5
2 Treatment and care planning ................................................................................................................................... 6
3 General advice for managing COVID-19 symptoms ...................................................................................... 7
4 Managing cough ............................................................................................................................................................ 8
5 Managing fever .............................................................................................................................................................. 10
6 Managing breathlessness .......................................................................................................................................... 11
7 Managing anxiety, delirium and agitation ........................................................................................................... 15
8 Managing medicines for patients with COVID-19 .......................................................................................... 17
9 Prescribing anticipatory medicines for patients with COVID-19 ............................................................. 18
10 Healthcare workers .................................................................................................................................................. 19
(NG163)
Overview
The purpose of this guideline is to provide recommendations for managing COVID-19 symptoms
for patients in the community, including at the end of life. It also includes recommendations about
managing medicines for these patients, and protecting staff from infection.
This guideline is for:
• health and care practitioners
• health and care staff involved in planning and delivering services
• commissioners.
The recommendations bring together
• existing national and international guidance and policies
• advice from specialists working in the NHS from across the UK. These include people with
expertise and experience of treating patients for the specific health conditions covered by the
guidance during the current COVID-19 pandemic.
NICE has developed these recommendations in direct response to the rapidly evolving situation
and so could not follow the standard process for guidance development. The guideline has been
developed using the interim process and methods for developing rapid guidelines on COVID-19.
The recommendations are based on evidence and expert opinion and have been verified as far as
possible. We will review and update the recommendations as the knowledge base and expert
experience develops.
(NG163)
1 Communicating with patients and minimising

risk
1.1 For patients with COVID-19 symptoms explain:
• that the key symptoms are cough, fever, breathlessness, anxiety, delirium and agitation
but they may also have fatigue, muscle aches and headache
• that they and people caring for them should follow the UK guidance on self-isolation
and the UK guidance on protecting vulnerable people
• that if the symptoms are mild they are likely to feel much better in a week
• who to contact if their symptoms get worse, for example NHS 111 online.
1.2 Communicate with patients and support their mental wellbeing, signposting to
charities and support groups where available, to help alleviate any anxiety and
fear they may have about COVID-19.
1.3 Minimise face-to-face contact by:
• offering telephone or video consultations (see BMJ guidance on Covid-19: a remote

assessment in primary care for a useful guide including a visual summary for remote
consultations)
• cutting non-essential face-to-face follow up
• using electronic prescriptions rather than paper
• using different methods to deliver medicines to patients, for example pharmacy

deliveries, postal services, NHS volunteers or introducing drive-through pick-up points
for medicines.
(NG163)
2 Treatment and care planning

2.1 When possible, discuss the risks, benefits and possible likely outcomes of the
treatment options with patients with COVID-19, and their families and carers,
so that they can express their preferences about their treatment and escalation
plans. Use decision support tools (when available). Bear in mind that these
discussions may need to take place remotely (see recommendation 1.3).
2.2 Put treatment escalation plans in place because patients with COVID-19 may
deteriorate rapidly and need urgent hospital admission (see
recommendation 3.1).
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.
2.4 For patients who are being considered for admission to critical care in line with
the NICE COVID-19 rapid guideline on critical care in adults bear in mind that
this may need to happen urgently.
(NG163)
3 General advice for managing COVID-19

symptoms
We will review and update these recommendations on a regular basis.
3.1 When managing COVID-19 symptoms, take into account:
• that not all patients will have COVID-19
• the patient's underlying health conditions, severity of the acute illness and if they are
taking multiple medicines
• that older patients with comorbidities, such as chronic obstructive pulmonary disease
(COPD), asthma, hypertension, cardiovascular disease and diabetes, may have a higher
risk of deteriorating and need monitoring or more intensive management, including
hospital admission
• that patients with severe symptoms of COVID-19 may deteriorate rapidly and need
urgent hospital admission (see the NICE COVID-19 rapid guideline on managing
suspected or confirmed pneumonia in adults in the community).
3.2 When managing key symptoms of COVID-19 in the last hours and days of life,
follow the relevant parts of NICE guideline on care of dying adults in the last
days of life. This includes pharmacological interventions and anticipatory
prescribing. Note that symptoms can change, and patients can deteriorate
rapidly in a few hours or less.
(NG163)
4 Managing cough
4.1 Be aware that older patients or those with comorbidities, frailty, impaired
immunity or a reduced ability to cough and clear secretions are more likely to
develop severe pneumonia. This could lead to respiratory failure and death.
4.2 If possible, encourage patients with cough to avoid lying on their back because
this makes coughing ineffective.
4.3 Use simple measures first, including getting patients with cough to take honey
(for patients aged over 1 year). See table 1 for treatments for managing cough.
4.4 For patients with COVID-19 consider short-term use of codeine linctus, codeine
phosphate tablets or morphine sulfate oral solution to suppress coughing if it is
distressing.
Table 1 Treatments for managing cough in adults aged 18 years and over
Treatment Dosage
Initial management: use simple non-drug

A teaspoon of honey
measures, for example taking honey
15 mg to 30 mg every 4 hours as required, up

First choice, only if cough is distressing: codeine to 4 doses in 24 hours
linctus (15 mg/5 ml) or codeine phosphate If necessary, increase dose to a maximum of
tablets (15 mg, 30 mg) 30 mg to 60 mg 4 times a day (maximum
240 mg in 24 hours)
2.5 mg to 5 mg when required every 4 hours

Increase up to 5 mg to 10 mg every 4 hours
Second choice, only if cough is distressing: as required
morphine sulfate oral solution (10 mg/5 ml) If the patient is already taking regular
morphine increase the regular dose by a
third
(NG163)
Notes: See BNF and MHRA advice for appropriate use and dosing in specific populations.
All doses are for oral administration.
Consider addiction potential of codeine linctus, codeine phosphate and morphine sulfate. Issue as
an 'acute' prescription with a limited supply. Advise the person of the risks of constipation and
consider prescribing a regular stimulant laxative.
Avoid cough suppressants in chronic bronchitis and bronchiectasis because they can cause sputum
retention.
Seek specialist advice for patients under 18 years old.
(NG163)
5 Managing fever
5.1 Be aware that, on average, fever is most common 5 days after exposure to the
infection.
5.2 Advise patients to drink fluids regularly to avoid dehydration (no more than
2 litres per day).
5.3 Do not use antipyretics with the sole aim of reducing body temperature (see
table 2 for treatments for managing fever).
5.4 Advise patients to take paracetamol if they have fever and other symptoms that
antipyretics would help treat. Tell them to continue only while the symptoms of
fever and the other symptoms are present. Until there is more evidence,
paracetamol is preferred to non-steroidal anti-inflammatory drugs (NSAIDs) for
patients with COVID-19 (see Central Alerting System: novel coronavirus - anti-
inflammatory medications).
Table 2 Antipyretics for managing fever in adults and children
Treatment Dosage
0.5 g to 1 g every 4 to 6 hours, maximum

Adults (18 years and over)
over): paracetamol
4 g per day
Children and young people over 1 month and See the dosing information on the pack or
under 18 years
years: paracetamol the BNF for children
Notes: See BNF and MHRA advice for appropriate use and dosing in specific populations.
All doses are for oral administration. Rectal paracetamol, if available, can be used as an alternative.
Please see the BNF and BNF for children for rectal dosing information.
Continue only while the symptoms of fever and the other symptoms are present.
(NG163)
6 Managing breathlessness
6.1 Be aware that severe breathlessness often causes anxiety, which can then
increase breathlessness further.
6.2 As part of supportive care the following may help to manage breathlessness:
• keeping the room cool
• encouraging relaxation and breathing techniques and changing body positioning (see
table 3 for techniques to help manage breathlessness)
• encouraging patients who are self-isolating alone, to improve air circulation by opening
a window or door (do not use a fan because this can spread infection)
• when oxygen is available, consider a trial of oxygen therapy and assess whether
breathlessness improves.
Table 3 Techniques to help manage breathlessness
Controlled breathing techniques include positioning, pursed-lip breathing, breathing exercises

and coordinated breathing training.
In pursed-lip breathing, people inhale through their nose for several seconds with their mouth
closed, then exhale slowly through pursed lips for 4 to 6 seconds. This can help to relieve the
perception of breathlessness during exercise or when it is triggered.
Relaxing and dropping the shoulders reduces the 'hunched' posture that comes with anxiety.
Sitting upright increases peak ventilation and reduces airway obstruction.
Leaning forward with arms bracing a chair or knees and the upper body supported has been
shown to improve ventilatory capacity.
Breathing retraining aims to help the person regain a sense of control and improve respiratory
muscle strength. Physiotherapists and clinical nurse specialists can help patients learn how to
do this (bearing in mind that this support may need to be done remotely).
6.3 For patients with signs or symptoms of pneumonia see the NICE COVID-19
rapid guideline on managing suspected or confirmed pneumonia in adults in the
(NG163)
community.
6.4 Identify and treat reversible causes of breathlessness, for example pulmonary
oedema.
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).
Table 4 End-of-life treatments for managing breathlessness for patients aged 18 years and over
Clinical scenario Treatment
Oral treatment
Opioid naive (not
Morphine sulfate immediate-release 2.5 mg to 5 mg every 2 to 4 hours as
currently taking
required or
opioids) and able to
swallow morphine sulfate modified-release 5 mg twice a day, increased as
necessary (maximum 30 mg daily)
Already taking Oral treatment

regular opioids for Morphine sulfate immediate-release 5 mg to 10 mg every 2 to 4 hours as
other reasons (for required or
example, pain relief) one twelfth of the 24-hour dose for pain, whichever is greater
(NG163)
Parenteral treatment
Morphine sulfate 1 mg to 2 mg subcutaneously every 2 to 4 hours as
required, increasing the dose as necessary
Unable to swallow
If needed frequently (more than twice daily), a subcutaneous infusion via a
syringe driver may be considered (if available), starting with morphine
sulfate 10 mg over 24 hours
Special considerations
See BNF for more details on formulations and dosages of morphine
sulfate. If breathlessness is not continuous, intermittent opioid dosing
may be appropriate
If estimated glomerular filtration rate (eGFR) is less than 30 ml per
minute, use equivalent doses of oxycodone instead of morphine sulfate
(see Prescribing in palliative care in the BNF for more details)
Consider concomitant use of an antiemetic (such as haloperidol) and a
regular stimulant laxative (such as senna)
Continue with non-pharmacological strategies for managing
breathlessness when starting an opioid
Opioid patches should not routinely be used in patients who are opioid
naive because of the time it takes for the medicine to get to steady state
for clinical effect and the high morphine equivalence (see Prescribing in
palliative care in the BNF for more details)
Add a benzodiazepine if required
For breathlessness and anxiety: lorazepam 0.5 mg sublingually when
required (maximum 4 mg daily)
Reduce the dose to 0.25 mg to 0.5 mg in elderly or debilitated patients
(maximum 2 mg in 24 hours)
For associated agitation or distress: midazolam 2.5 mg to 5 mg
subcutaneously when required (see BNF for more details on dosages)
Sedation and opioid use should not be withheld because of a fear of
causing respiratory depression
Notes: At the time of publication (April 2020), opioids and benzodiazepines did not have a UK
marketing authorisation for this indication or route of administration (see General Medical
Council's guidance on prescribing unlicensed medicines for further information).
(NG163)
Dosages may need to be adjusted because some patients dying of COVID-19 may need higher
doses to achieve symptom relief. Others may need lower doses because of their size or frailty.
Table 5 Treatments in the last days and hours of life for managing breathlessness for patients aged
18 years and over
Treatment Dosage
Morphine sulfate 10 mg over 24 hours via a syringe driver,

Opioid increasing stepwise to morphine sulfate 30 mg over 24 hours as
required
Benzodiazepine if
Midazolam 10 mg over 24 hours via the syringe driver, increasing
required in addition to
stepwise to midazolam 60 mg over 24 hours as required
opioid
Morphine sulfate 2.5 mg to 5 mg subcutaneously as required

Add parenteral
parenteralmorphine
morphine
Midazolam 2.5 mg subcutaneously as required.
or midazolam if required
(See BNF for more details on dosages).
Special considerations
Consider concomitant use of an antiemetic (such as haloperidol) and
a regular stimulant laxative (such as senna).
Continue with non-pharmacological strategies for managing
breathlessness when starting an opioid.
Sedation and opioid use should not be withheld because of an
inappropriate fear of causing respiratory depression.
Notes: At the time of publication (April 2020), opioids and benzodiazepines did not have a UK
(NG163)
7 Managing anxiety, delirium and agitation

7.1 Address reversible causes of anxiety, delirium and agitation first by:
• exploring the patient's concerns and anxieties
• ensuring effective communication and orientation (for example explaining where the
person is, who they are, and what your role is)
• ensuring adequate lighting
• explaining to those providing care how they can help.
7.2 Treat reversible causes of anxiety or delirium, with or without agitation, for
example hypoxia, urinary retention and constipation.
7.3 Consider trying a benzodiazepine to manage anxiety or agitation (see table 6 for
treatments for managing anxiety, delirium and agitation).
Table 6 Treatments for managing anxiety, delirium and agitation in patients aged 18 years and
over
Treatment Dosage
Lorazepam 0.5 mg to 1 mg 4 times a day as required (maximum 4 mg in

Anxiety or agitation 24 hours)
and able to swallow
swallow: Reduce the dose to 0.25 mg to 0.5 mg in elderly or debilitated patients
lorazepam tablets (maximum 2 mg in 24 hours)
Oral tablets can be used sublingually (off-label use)
(NG163)
Midazolam 2.5 mg to 5 mg subcutaneously every 2 to 4 hours as

required
Anxiety or agitation If needed frequently (more than twice daily), a subcutaneous infusion
and unable to swallow: via a syringe driver may be considered (if available) starting with
midazolam injection midazolam 10 mg over 24 hours
Reduce dose to 5 mg over 24 hours if estimated glomerular filtration
rate is less than 30 ml per minute
Haloperidol 0.5 mg to 1 mg at night and every 2 hours when required.

Increase dose in 0.5-mg to 1-mg increments as required (maximum
10 mg daily, or 5 mg daily in elderly patients)
The same dose of haloperidol may be administered subcutaneously as
Delirium and able to
required rather than orally, or a subcutaneous infusion of 2.5 mg to
swallow: haloperidol
10 mg over 24 hours
tablets
Consider a higher starting dose (1.5 mg to 3 mg) if the patient is
severely distressed or causing immediate danger to others
Consider adding a benzodiazepine such as lorazepam or midazolam if
the patient remains agitated (see dosages above)
Levomepromazine 12.5 mg to 25 mg subcutaneously as a starting dose

and then hourly as required (use 6.25 mg to 12.5 mg in the elderly)
Delirium and unable to
Maintain with subcutaneous infusion of 50 mg to 200 mg over
swallow:
24 hours, increased according to response (doses greater than 100 mg
levomepromazine
over 24 hours should be given under specialist supervision)
injection
Consider midazolam alone or in combination with levomepromazine if
the patient also has anxiety (see dosages above)
Notes: At the time of publication (April 2020), midazolam and levomepromazine did not have a UK
See BNF and MHRA advice for appropriate use and dosing in specific populations.
(NG163)
8 Managing medicines for patients with

COVID-19
8.1 Follow UK government legislation on prescribing, ordering, supplying,
transporting, storing and disposing of medicines.
8.2 After a patient with COVID-19 has died, follow UK government guidance for
infection prevention and control, particularly if taking medicines for safe
removal and destruction.
8.3 When returning medicines, tell the community pharmacy staff that they are
from a patient with COVID-19 so that infection prevention and control
precautions can be taken.
8.4 When supporting patients with symptoms of COVID-19 who are having social
care in the community, follow the NICE guideline on managing medicines for
adults receiving social care in the community. This includes processes for
ordering and supplying medicines and transporting, storing and disposing of
medicines.
8.5 When prescribing, handling and administering medicines for patients with
symptoms of COVID-19 in a care home, follow the NICE guideline on managing
medicines in care homes. This includes processes for storing and disposing of
medicines.
(NG163)
9 Prescribing anticipatory medicines for

patients with COVID-19
For information about prescribing medicines at the end of life see the BNF's prescribing in
palliative care.
9.1 When prescribing and supplying anticipatory medicines at the end of life:
• Take into account potential waste, medicines shortages and lack of administration
equipment by prescribing smaller quantities or by prescribing a different medicine,
formulation or route of administration when appropriate.
• If there are fewer health and care staff you may need to prescribe subcutaneous, rectal
or long-acting formulations, and carers or family members may need to administer
them.
9.2 Consider different routes for administering medicines if the patient is unable to
take or tolerate oral medicines, such as sublingual or rectal routes, or
subcutaneous injections.
(NG163)
10 Healthcare workers
10.1 All healthcare workers involved in receiving, assessing and caring for patients
who have known or suspected or COVID-19 should follow UK government
guidance for infection prevention and control. This contains information on
using personal protective equipment (PPE), including visual and quick guides for
putting on and taking off PPE.
ISBN: 978-1-4731-3754-7

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COVID-19 rapid guideline:

© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

Commissioners and providers have a responsibility to promote an environmentally sustainable

1 Communicating with patients and minimising risk ......................................................................................... 5

2 Treatment and care planning ................................................................................................................................... 6

3 General advice for managing COVID-19 symptoms ...................................................................................... 7

4 Managing cough ............................................................................................................................................................ 8

5 Managing fever .............................................................................................................................................................. 10

6 Managing breathlessness .......................................................................................................................................... 11

7 Managing anxiety, delirium and agitation ........................................................................................................... 15

8 Managing medicines for patients with COVID-19 .......................................................................................... 17

9 Prescribing anticipatory medicines for patients with COVID-19 ............................................................. 18

10 Healthcare workers .................................................................................................................................................. 19

This guideline is for:

• health and care practitioners

• health and care staff involved in planning and delivering services

The recommendations bring together

• existing national and international guidance and policies

1 Communicating with patients and minimising

1.3 Minimise face-to-face contact by:

• offering telephone or video consultations (see BMJ guidance on Covid-19: a remote

• cutting non-essential face-to-face follow up

• using electronic prescriptions rather than paper

• using different methods to deliver medicines to patients, for example pharmacy

2 Treatment and care planning

3 General advice for managing COVID-19

3.1 When managing COVID-19 symptoms, take into account:

• that not all patients will have COVID-19

Initial management: use simple non-drug

15 mg to 30 mg every 4 hours as required, up

2.5 mg to 5 mg when required every 4 hours

All doses are for oral administration.

Seek specialist advice for patients under 18 years old.

Table 2 Antipyretics for managing fever in adults and children

0.5 g to 1 g every 4 to 6 hours, maximum

• keeping the room cool

Table 3 Techniques to help manage breathlessness

Controlled breathing techniques include positioning, pursed-lip breathing, breathing exercises

• are at the end of life and

• have moderate to severe breathlessness and

Consider concomitant use of an antiemetic and a regular stimulant laxative. At the

Clinical scenario Treatment

Already taking Oral treatment

Seek specialist advice for patients under 18 years old.

Morphine sulfate 10 mg over 24 hours via a syringe driver,

Morphine sulfate 2.5 mg to 5 mg subcutaneously as required

Seek specialist advice for patients under 18 years old.

7 Managing anxiety, delirium and agitation

• exploring the patient's concerns and anxieties

• ensuring adequate lighting

• explaining to those providing care how they can help.

Lorazepam 0.5 mg to 1 mg 4 times a day as required (maximum 4 mg in

Midazolam 2.5 mg to 5 mg subcutaneously every 2 to 4 hours as

Haloperidol 0.5 mg to 1 mg at night and every 2 hours when required.

Levomepromazine 12.5 mg to 25 mg subcutaneously as a starting dose

Seek specialist advice for patients under 18 years old.

8 Managing medicines for patients with

9 Prescribing anticipatory medicines for