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Palliative care guidelines

Palliative Care Guidelines: Introduction Introduction: Palliative Care Guidelines Third Edition
Palliative care
• aims to improve the quality of life of patients and their families facing the problems associated
with any life limiting illness.
• provides relief from pain and other distressing symptoms. • integrates the psychological and spiritual aspects of patient care. • offers a support system to help patients live as actively as possible until death. • offers a support system to help the family cope during the patient's illness and in their own • uses a team approach to address the needs of patients and their families. • affirms life and regards dying as a normal process. • intends neither to hasten or postpone death. • is relevant in combination with many other treatments directed at the underlying illness.
Palliative care is part of the care delivered by a wide range of health and social care professionals working in the community, in care homes and in hospitals. Some patients with more complex problems will benefit from advice, assessment or care from a palliative care specialist. Details of how to access local specialist services are included in the Guidelines and are available online.
These Guidelines reflect a consensus of opinion about good practice in the management of adults with a life limiting illness. They have been developed by a multidisciplinary group of professionals working in the community, hospitals and specialist palliative care services and approved by local Formulary and Clinical Policy Committees. There is a separate section on the website covering paediatric palliative care.
Every effort has been made to ensure the accuracy of the text and that evidence informed information has been included. Adherence to guideline recommendations will not ensure a successful outcome in every case. It is the responsibility of all professionals to exercise clinical judgement in the management of individual patients. Palliative care specialists occasionally use or recommend other drugs, doses or drug combinations than those given here. NHS Lothian holds copyright for these materials. Please acknowledge authorship if you copy or disseminate them. The Guidelines Group members would like to thank all those involved in preparation of these resources.
Palliative Care Guidelines: websites
The printed Palliative Care Guidelines, additional guidelines, more information about specialist
services, information for patients and further professional resources are available online.
Correspondence and enquiries to:
Dr Kirsty Boyd (Palliative Care Guidelines Group Chair)
Palliative Care Service
Royal Infirmary of Edinburgh
Little France Crescent,
Edinburgh EH16 4SA
Tel: 0131 242 1990e-mail: kirsty.boyd@luht.scot.nhs.uk Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Specialist Palliative Care Services in NHS Lanarkshire Specialist Palliative Care Services in NHS Lanarkshire
Services
• Inpatient
• Outpatient
• Day care, home assessment, home care and telephone advice.
Referral
A referral form is required for inpatient care for patients with life limiting illness and uncontrolled
symptoms or complex physical, psychological, spiritual or family needs.
A referral form can be downloaded from www.st-andrews-hospice.com
Hospice Inpatient Units
Community Palliative Care Services
St Andrew's Hospice, Airdrie
Available Monday to Friday, 9am-4:30pm Henderson Street, ML6 6DJ Macmillan Community Nursing Team
Tel: 01236 766951 Calder Unit, Udston Hospital Fax: 01236 748786http://st-andrews-hospice.com North Team
Strathcarron Hospice, Denny
Tel: 01698 723278Fax: 01698 723282 (Cumbernauld/ Kilsyth area)
Randolph Hill, FK6 5HJ
South Team
Tel: 01324 826222 Tel: 01698 723297 Fax: 01698 723282 Clydesdale Palliative Care Service
Hospital Palliative Care Teams
Roadmeetings HospitalTel: 07880 787213 Macmillan Palliative Care CNS
Palliative Care Day Services
Hairmyres Hospital
Direct line 01355 584656
St Andrew's Hospice Day Unit
Monklands District General Hospital
Tel: 01236 766951Fax: 01236 748786 Direct line: 01236 712156 Dalziel Centre Day Unit
Wishaw General Hospital
Tel: 01698 245026 Direct line: 01698 366053 Fax: 01698 245044 Palliative Care Pharmacist
Kilbryde Day Hospice- Day Unit
Macmillan Area Lead Pharmacist-
Tel: 01355 593484 Fax: 01355 593496 St Andrew's Hospice Palliative Care Out of Hours
Tel: 01236 772021
Senior Clinical Pharmacist-
Contact St Andrew's Hospice for medical/ nursing advice on complex patients. Community pharmacy palliative care Hairmyres Hospital network stocks essential medications.
Tel: 01355 584887 Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Alfentanil Alfentanil in Palliative Care
Description
Potent, short-acting opioid analgesic; used 3rd line so seek specialist advice.
Used as a subcutaneous infusion or 500 micrograms/ml sublingually/ subcutaneously.
A higher concentration preparation can be ordered, but is only for named patient use with specialist supervision.
Sublingual/ buccal spray Pharmacist can order spray on a named 5mg/5ml (1 metered dose = 140 patient basis if advised by a palliative care Indications
Third line injectable opioid for moderate to severe opioid responsive pain in patients unable
to tolerate morphine, diamorphine or oxycodone due to persistent side effects (eg. sedation, confusion, hallucinations, itch).
• Injectable analgesic for moderate to severe, opioid responsive pain in patients with Stage 4-5 chronic kidney disease (eGFR <30ml/min), or severe acute renal impairment. • Episodic/ incident pain o Pain often related to a particular event (eg. movement, dressing changes); sudden in onset, can be severe, but may not last long.
o Different from breakthrough pain occurring when the dose of regular analgesic has worn off. Assessed and treated independently of the regimen used to manage any continuous/ background pain.
Cautions
• Liver impairment:
reduced clearance
Dose reduction of 30-50% may be necessary.
• Renal impairment:
No dose reduction needed. Not removed by dialysis.
Drug interactions
• Diltiazem, fluconazole, clarithromycin, erythromycin slow clearance of alfentanil.
Anticonvulsants may reduce its effect. See BNF.
Side effects
Drowsiness, skin rash.
Dose & Administration
• Alfentanil for moderate to severe opioid responsive pain
o Continuous subcutaneous infusion in a syringe driver/ pump over 24 hours.
o o Titrate larger doses in multiples of 250 micrograms.
o Prescribe doses of over 1000 micrograms in milligrams (mg).
o Prescribe about 1/6th of the 24hour dose hourly for breakthrough pain as alfentanil
has a very short duration of action. The same dose can be given subcutaneously or sublingually.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Alfentanil Dose & Administration
Alfentanil for episodic/ incident pain
• Starting dose: 100-250 micrograms.
• Give a dose five minutes before an event likely to cause pain; repeat if needed
• Increase dose up to 500 micrograms according to response.
• Give by subcutaneous injection or sublingually. The dose is the same.
• Consider an alfentanil spray if the patient is being discharged home.
Dose Conversions
• Alfentanil is approximately thirty times more potent than oral morphine
Oral morphine 30mg ≈ subcutaneous alfentanil 1mg (1000 micrograms) Subcutaneous morphine 15mg ≈ subcutaneous alfentanil 1mg (1000 micrograms) Subcutaneous diamorphine 10mg ≈ subcutaneous alfentanil 1mg (1000 micrograms) Oral oxycodone 15mg ≈ subcutaneous alfentanil 1mg (1000 micrograms) Subcutaneous oxycodone 7.5mg ≈ subcutaneous alfentanil 1mg (1000 micrograms) • Alfentanil is approximately four times less potent than fentanyl.
A patient whose pain is controlled on a subcutaneous alfentanil infusion can be converted to a fentanyl patch. Apply the patch and stop the infusion 12 hours later.
Alfentanil SC 24 hour Alfentanil SC hourly as Fentanyl patch dose given 100-200 micrograms Do not use a patch 1 mg (1000 micrograms) 200-250 micrograms 12 micrograms / hour 300-500 micrograms 25 micrograms / hour 37 micrograms / hour 50 micrograms / hour 62 micrograms / hour 75 micrograms / hour • As with all opioid conversions, these are approximate doses.
• Dose conversions should be conservative and doses rounded down.
• Monitor the patient carefully so that the dose can be adjusted if necessary. • If the patient has opioid toxicity, reduce dose by 1/3rd when changing opioid.
Resources
Professional
Palliative Care Drug Information online: http://www.palliativedrugs.com
Patient
Patient leaflet on website: Alfentanil
Discharge planning/ Community use:
• The community pharmacist, GP, and community nurse should be informed.
• The unscheduled care service should be informed that the patient is receiving this third line opioid.
• The Community Pharmacy Palliative Care Network stocks a limited supply of alfentanil injection
for emergency use.
• Alfentanil can be prescribed by the patient's GP for the indications listed in liaison with local palliative care specialists.
Key references
1. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Management 2004:25(5): 497-504
2. Urch CE, Carr S, Minton O. A retrospective review of the use of alfentanil in a hospital palliative care setting.
Palliative Medicine 2004; 18:516-9 Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Anorexia Anorexia / Cachexia in Palliative Care
Introduction
Anorexia / cachexia syndrome is a complex metabolic process found in many end-stage illnesses.
Characterised by loss of appetite, weight loss and tissue wasting, it impacts significantly on
quality of life. It causes anxiety and distress for patients and, perhaps even more, for carers.
Assessment
• Look for any reversible problems that may exacerbate anorexia including:
• oral problems: dry mouth, ill fitting dentures, ulcers, candidiasis etc.
• odours – fungating lesion, fistulae, cooking smells, and incontinence can contribute to • delayed gastric emptying (eg. due to local disease, autonomic neuropathy) causing early satiety, and vomiting of undigested foods that relieves nausea • Find out about patient and carer perspectives on weight, body image, nutrition, dietary intake. Psychosocial aspects are very important.
• Prevention or early identification and treatment of contributory symptoms.
• Acknowledge the psychological impact on the patient and carer; ongoing discussion and support are needed.
Medication
Limited benefit, but worth considering, as may improve quality of life.
Corticosteroids
• Established role in short-term improvement of appetite.
• Rapid effect, but tends to decrease after 3-4 weeks.
• May also reduce nausea, and improve energy/ general feeling of well being.
• No significant effect on nutritional status.
• Starting dose: oral dexamethasone 4mg or prednisolone 30mg in the morning. Consider
need for a proton pump inhibitor. • Side-effects: fluid retention, candidiasis, myopathy, insomnia, gastritis.
• Prescribe for 1 week, if no benefit, stop. If helpful, reduce to lowest effective dose; review regularly and withdraw if no longer improving symptoms.
Progestogens
• Improve appetite and increase weight in patients with cancer.
• Take a few weeks to take effect but benefit more prolonged than steroids.
• More appropriate for patients with a longer prognosis.
• Megestrol acetate - starting dose 160mg orally daily for one month, then review. Dose range
(160-800mg). No evidence for optimal dose.
• Side effects: nausea, fluid retention, increased risk of thromboembolism.
• Reduce dose gradually if used for more than 3 weeks (adrenal suppression).
Prokinetics
• Used for early satiety, delayed gastric emptying, gastroparesis or nausea.
• Metoclopramide 10mg or domperidone 10-20mg (less long term side-effects) given three
times a day half an hour before meals. Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Anorexia Non-drug
• Address concerns about the importance to the patient and carer of giving nourishment,
refusing food, and eating as a social activity.
• Explain that a gradual reduction in oral intake is natural as part of the illness.
• Offer information and practical advice about nutrition in advanced illness, diet and management of anorexia. Practice Points
• Supplementary drinks are expensive but can help selected patients after careful assessment of
nutritional status, prognosis, and alternative options.
• See local Formulary for recommended preparations and advice. Patient / carer advice points
• Gently encourage the patient to take what he or she can manage.
• Offer soft, easy to swallow foods; soup, pudding, nutritious drinks/ snacks.
• Small portions, attractively presented, offered more often through the day.
• Try not to talk about food all the time but keep the person involved in the social aspects of
Resources
Professional
Macmil an Cancer Support (including Cancerbacup resources) http://www.macmil an.org.uk
Patient
Patient leaflet on website: Managing a poor appetite
Key references
1. Templeton A. Treating cancer patients with anorexia-cachexia syndrome. European J Palliative Care 2007; 14(5):
2. Shragge J E. The management of anorexia by patients with advanced cancer: a critical review of the literature. Palliative Medicine 2006; 20: 623-629 3. Poole K. Loss of weight & loss of appetite in advanced cancer: a problem for the patient, the carer or the health professional? Palliative Medicine 2002; 16: 499-506 4. Fainsinger R. Clinical assessment & decision making in cachexia and anorexia. In Oxford Textbook of Palliative Medicine 3rd Edition 2004, p533-546 5. Bruera E. Pharmacological interventions in cachexia and anorexia. In Oxford Textbook of Palliative Medicine, 3rd Edition 2004, p552-560 6. Strasser F. Pathophysiology of the anorexia/cachexia syndrome. In Oxford Textbook of Palliative Medicine, 3rd Edition 2004, p520-533 7. Davis MP. Appetite and cancer associated anorexia: a review. Journal of Clinical Oncology 2004; 22 (8): 1510-1517 Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Bowel Obstruction Bowel Obstruction in Palliative Care
Introduction
Is due to mechanical obstruction (partial or complete) of the bowel lumen and/or peristaltic failure.
Can be complex to manage and require specialist advice.
Assessment
• Exclude faecal impaction from history, rectal examination, abdominal X-ray. Can complicate or
mimic any type of bowel obstruction.
• Some patients with a localised obstruction can benefit from surgery.
• Assess each patient on the basis of their clinical condition, likely benefits/ risks and patient Contraindications to surgery
• Diffuse intra-abdominal cancer seen at previous surgery, or shown radiologically.
• Diffuse, palpable intra-abdominal masses.
• Massive ascites which recurs rapidly after drainage.
• High obstruction involving the proximal stomach.
Relative contraindications to surgery
• Non-symptomatic but extensive metastatic disease outside the abdomen.
• Frail or elderly patient with poor performance status or nutritional status.
• Previous radiotherapy to the abdomen or pelvis.
• Small bowel obstruction at multiple sites.
Clinical picture
Depends on the level, type and duration of bowel obstruction but may include:
• Constipation.
• Intermittent nausea, often relieved by vomiting undigested food.
• Worsening nausea and/ or faeculent vomiting (as obstruction progresses and small bowel
contents are colonised by colonic bacteria). • Continuous abdominal pain due to tumour and/ or nerve infiltration (eg. coeliac plexus • Colic (in mechanical obstruction); altered bowel sounds. • Abdominal distension (may be absent in gastro-duodenal obstruction or patients with extensive peritoneal spread).
• Faecal incontinence.
Management
General
• • Offer ice to suck, small amounts of food and drinks as wanted. Low fibre diet.
• If the patient is dehydrated and not dying, IV rehydration may be appropriate initially.
• SC fluids may be required for longer-term management of symptomatic dehydration or for a
patient not wanting hospital admission. Hydration of 1-1.5 litres/ 24hours may reduce nausea but more fluid than this can result in increased bowel secretions and worsen vomiting. • Interventional treatment
• Stenting (gastric outlet, proximal small bowel, colon) or laser treatment can palliate localised
• NG tube may be appropriate to control vomiting initially; try to avoid long-term use.
• Venting gastrostomy in a fit patient with gastroduodenal or jejunal obstruction and persistent vomiting may relieve symptoms. • TPN is only appropriate for a very small group of patients with a longer prognosis. Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Bowel Obstruction Medication
Peristaltic failure
May be due to autonomic neuropathy or intra-abdominal carcinomatosis.
Partial obstruction, reduced bowel sounds, no colic.
• Stop medication reducing peristalsis. (cyclizine, hyoscine, 5HT antagonists, amitriptyline).
• Use a prokinetic antiemetic (SC metoclopramide (30-120mg /24hrs); stop if colic develops).
).
• Fentanyl patch for controlling stable, moderate to severe pain in patients with/ or at risk of Mechanical obstruction
Target treatment at the predominant symptom(s).
• Laxatives (+/- rectal treatment) to treat/ prevent co-existent constipation.
Movicol (if volume of fluid is tolerated) is effective. Docusate sodium is an alternative.
Avoid stimulant laxatives (senna, bisacodyl, danthron) if patient has colic.
Stop all oral laxatives in complete obstruction.
• Dexamethasone (6-16mg) SC, IM or IV for 4-7 days may reverse partial obstruction.
24 hour SC
Tumour pain/ colic Morphine or diamorphine Titrate dose.
See: Fentanyl patches Adjuvant analgesic Seek specialist advice.
Hyoscine butylbromide Reduces peristalsis Anticholinergic antiemetic; hyoscine butylbromide Add to the subcutaneous infusion or give as a single SC dose for persistent nausea.
Use in a SC infusion or as a once or twice daily SC injection. Monitor for hypotension.
Hyoscine butylbromide Anti-secretory action. (If nausea and pain are controlled, the Second line anti-secretory. patient may cope with More effective than occasional vomits) hyoscine but expensive. Practice points
• Most patients need a SC infusion of medication as oral absorption is unreliable.
• Review treatment regularly; symptoms often change and can resolve spontaneously.
• Do not combine anticholinergic antiemetics (cyclizine, hyoscine) with metoclopramide.

Resources
Professional:
Palliative Care Drug Information online: http://www.palliativedrugs.com/
Patient: Patient leaflet on website: Managing sickness and vomiting
Key References
1. Mercadante S. Medical treatment for inoperable malignant bowel obstruction: a qualitative systematic review.
J Pain Symptom Management 2007; 33(2): 217-223 2. Ripamonti C. Pathophysiology and management of malignant bowel obstruction. In Oxford Textbook of Palliative Medicine 3rd Edition, 2004, p496-507 Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Breathlessness Breathlessness in Palliative Care
Introduction
Breathlessness is a common and distressing symptom in advanced cancer, chronic obstructive
pulmonary disease, lung fibrosis and heart failure.
Assessment
• Clarify pattern of breathlessness, precipitating / alleviating factors and associated symptoms.
• Is treatment of the underlying disease appropriate? Seek advice if in doubt.
• Look for any reversible causes of breathlessness: infection, pleural effusion, anaemia,
arrhythmia, pulmonary embolism, or bronchospasm.
• Check oxygen saturation (if pulse oximeter available). • Ask the patient to rate symptom severity and level of associated distress/ anxiety.
• Explore fears, impact on functional abilities, and quality of life.
Management
• Treat any reversible causes, if appropriate.
• If stridor or signs of superior vena cava obstruction - emergency referral to hospital.
• Give high dose steroids in divided doses: dexamethasone 16mg, or prednisolone 60mg.
• Oxygen: careful individual patient assessment. Important to avoid psychological dependence.
A fan or air from a window may be just as effective.
If oxygen saturation is less than 90%, consider a trial of oxygen.
• Nebulised sodium chloride 0.9%, 5ml as required may help loosen secretions.
Medication
Bronchodilators: by inhaler or spacer: Stop if no symptomatic benefit.
Steroids: trial of dexamethasone oral 8-16mg daily for lymphangitis or airways obstruction that
has responded to steroids before. Unless starting emergency therapy, give steroids in the morning.
Stop if no effect after a week, or reduce gradually to lowest effective dose.
Opioids: can reduce breathlessness, particularly at rest and in the terminal phase.
Give as a therapeutic trial; monitor patient response and side effects.
• No opioid before: o Immediate release morphine oral 2mg, 4-6 hourly or as required.
Increase slowly in steps of about 30%, if tolerated. o If unable to take oral medication: morphine SC 2mg, 4-6 hourly and/or 2 hourly as required. or diamorphine SC 2.5mg, 4-6 hourly and/or 2 hourly as required. • Elderly, frail patient or impaired renal function: o Morphine oral 1-2mg, 6-8 hourly as required; monitor closely for side effects. • Opioid taken regularly for pain: o 25% of the 4 hourly breakthrough analgesic dose, given as required, may be adequate for breathlessness. Titrate according to response.
• Continuous breathlessness: o Consider using modified release (long acting) morphine. o If the patient is dying, give morphine as a continuous SC infusion. Dose is based on previous regular dose and any as required doses. Usually combined with midazolam SC in the infusion. • Second line opioid: o Second line opioids can be used for breathlessness if the patient is unable to • Anxiolytics: Start with a low dose and increase gradually as required and tolerated.
o Lorazepam sublingually 0.5mg, as required for episodic anxiety, panic attacks.
o Diazepam oral 5mg, at night if more continuous anxiety.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Breathlessness Breathlessness in the last days of life • If unable to take an oral opioid, convert to the subcutaneous route. Prescribe the opioid SC,
• Midazolam SC 2.5-5mg, hourly as required for anxiety/distress.
• Add midazolam SC 5-20mg over 24 hours to the subcutaneous infusion of opioid; titrate
midazolam dose in 5-10mg steps according to the level of distress.
• Noisy breathing or respiratory secretions: hyoscine butylbromide SC 20mg, hourly as required (up to 120mg/ 24hours).
Non-drug management
• Holistic assessment and a multi-professional approach are essential.
• Enhance coping and functional ability using controlled breathing and anxiety management
techniques, and by planning and pacing activities.
• Consider need for equipment/aids and a package of care. • If prognosis is longer, a breathlessness support service, if available, may help. Practice points
• Starting opioids at a low dose and titrating carefully is safe and does not cause respiratory
depression in patients with cancer, airways obstruction or heart failure.
• Non-drug measures that maximise patient coping are essential. As the illness progresses, medication to relieve breathlessness becomes more necessary.
• Plan management of breathlessness in the last days of life with patient and family. o Discuss the option of sedation in the event of uncontrolled distress.
o Anticipatory prescribing of as required medication for symptom control. o Complete a handover for the unscheduled care service or hospital at night team.
Patient/ carer advice points
• Keep the room well ventilated: open a window, use a fan, keep face cool.
• Anxiety /panic are distressing but do not cause harm or worsen the patient's condition.
Resources
Professional
Palliative Care Drug Information online http://www.palliativedrugs.com/
Patient
Patient leaflet on website: Managing breathlessness
Macmillan Cancer Support (including Cancerbackup resources) http://www.macmillan.org.uk
Roy Castle Lung Foundation http://www.roycastle.org
Cancer Research UK http://www.cancerhelp.orgChest Heart and Stroke Scotland http://www.chss.org.uk/British Lung Foundation Breathe Easy Support Network http://www.lunguk.org/ Key references
1. Chan K-S. Palliative medicine in malignant respiratory diseases. Oxford Textbook of Palliative Medicine 3rd
Edition, 2004, page: 587-618 2. Jennings A. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database of Systematic Reviews 2001, Issue 3 http://www.cochrane.org/reviews/en/ab002066.html Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Choosing and Changing Opioids Choosing and Changing Opioids in Palliative Care
Introduction
• Opioids are used for pain and breathlessness.
• Most palliative care patients respond well to titrated oral morphine.
• A small number of patients may need to be changed to another opioid:
o Oral route is not available.
o Pain is responding but patient has persistent, intolerable side effects. (Consider reducing the dose and titrating more slowly or adding an adjuvant analgesic before changing opioid) o Moderate to severe liver or renal impairment. o Poor compliance with oral medication.
o Complex pain (consider adjuvant analgesics/ other pain treatments).
Choosing an opioid for moderate to severe pain
First line opioids: Morphine
• Range of oral preparations; SC injection and in a syringe driver/ pump.
• Renally excreted, active metabolites – titrate morphine slowly and monitor carefully in
chronic kidney disease.
• Consider other opioids in stage 4-5 chronic kidney disease, dialysis patients.
• Low doses and slow titration in liver impairment.
Diamorphine
• Highly soluble opioid used for SC injection and in a syringe driver/ pump.
• Use for high dose SC breakthrough injections (above 180mg SC morphine/ 24hrs).
Powder preparation is diluted in a small volume of water for injections.
• As with morphine, cautious use in renal and liver impairment.
Second line opioids:
• For moderate to severe pain if morphine/ diamorphine are not tolerated.
• Immediate and modified release oral preparations; SC injection; syringe driver/ pump.
• Low concentration of preparation limits dose for SC injection to 10mg (1ml).
• Avoid in moderate to severe liver impairment, clearance is much reduced.
• Mild to moderate renal impairment: reduced clearance so titrate slowly and monitor
carefully. Avoid in stage 4-5 chronic kidney disease.
• Topical patch lasting 72 hours; use if oral and SC routes unsuitable.
• For stable pain if morphine is not tolerated; dose cannot be changed quickly.
• No initial dose reduction in renal impairment but may accumulate over time.
• Liver impairment; dose reduction may be needed in severe liver disease.
Third line opioid: (seek specialist advice)
• Short acting, injectable opioid for SC injection and in syringe driver/ pump.
• In episodic/ incident pain can be given sublingually or subcutaneously.
• Standard dose in renal disease including stage 4-5 chronic kidney disease.
• Clearance may be reduced in liver impairment; reduce dose and titrate.
Fourth line opioid: (specialist use only)
Methadone
• Oral methadone is used by specialists for complex pain; dosing is difficult due to the long
half life; no renal excretion so standard dose in chronic kidney disease, half life prolonged in severe liver disease. Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Choosing and Changing Opioids Opioid toxicity
• Wide variation in the dose of opioid that causes symptoms of toxicity.
• Prompt recognition and treatment are needed. Symptoms include:
o Persistent sedation (exclude other causes)o Vivid dreams/ hallucinations; shadows at the edge of visual fieldo Deliriumo Muscle twitching/ myoclonus/ jerkingo Abnormal skin sensitivity to touch • Reduce the opioid by a third. Ensure the patient is well hydrated. Seek advice.
• Consider adjuvant analgesics and/or alternative opioids if still in pain.
• Naloxone (in small titrated doses) is only needed for life-threatening respiratory depression.

Changing opioid
• These doses / ratios are approximate (≈) and should be used as a guide.
• Dose conversions should be conservative and doses usually rounded down.
• Monitor closely; extra care if frail, elderly patient; renal or hepatic impairment.
• Always prescribe an appropriate drug and dose for breakthrough pain:
1/6th of the 24 hour regular opioid dose.
Equivalent doses of opioids recommended for use in palliative care
Immediate release morphine
Opioid dose
Oral morphine: opioid
Oral morphine 5 mg ≈ Oral codeine 60mg or oral dihydrocodeine 60mg Oral morphine 10mg ≈ SC morphine 5mg Oral morphine 10mg ≈ SC diamorphine 3mg Oral morphine 10mg ≈ Oral oxycodone 5mg Oral morphine 10mg ≈ SC oxycodone 2-3mg Oral morphine 60-90mg in ≈ Fentanyl patch 25 micrograms/ hour Oral morphine 30mg ≈ SC alfentanil 1mg (1000 micrograms) Immediate release oxycodone Oxycodone potency ratio
Oral oxycodone 5mg ≈ SC oxycodone 2-3mg Equivalent doses of opioids not generally recommended for palliative care
Opioid dose
Immediate release morphine
Morphine: opioid
Oral tramadol 50mg ≈ Oral morphine 5-10mg Oral nefopam 30mg ≈ Oral morphine 10mg Buprenorphine patches 10 micrograms/ hour ≈ Oral morphine 10mg/ 24 hrs 35 micrograms/ hour ≈ Oral morphine 30-60mg/ 24 hrs 52.5 micrograms/ hour ≈ Oral morphine 60-90mg/ 24 hrs 70 micrograms/ hour ≈ Oral morphine 90-120mg/ 24 hrs Oral hydromorphone 1.3mg ≈ Oral morphine 5-10mg Issue date: January 2009 Review date: March 2012 A guide to dose conversions FROM morphine TO second line opioid analgesics used for moderate to severe pain
• Use this chart as a guide. The doses are approximate and not exact equivalent doses.
• Opioid bioavailability (particularly for oral morphine) and response are highly variable.
• Always prescribe an appropriate drug and dose for breakthrough pain: 1/6th of the 24hour regular opioid dose.
Reduce the dose by up to 30% when changing opioid if the patient is opioid toxic, frail or elderly and re-titrate.
Reduce the dose by up to 30% when converting from a second line opioid back to morphine and re-titrate.
• Check the information about individual drugs if the patient has renal or liver impairment.
• Particular care is needed when changing between opioids at higher doses or when the dose of the first opioid has been rapidly increased as these patients are at greater risk of adverse effects.
• Morphine and oxycodone doses can be measured accurately in 1mg dose increments. Decimal places are not recommended.
• Fentanyl: dose conversions from oral morphine are usually given as a range for each patch dose. The minimum dose of oral morphine when it Monitor the patient carefully
If in doubt – seek advice
Issue date: January 2009 A guide to dose conversions FROM morphine TO second line opioid analgesics used for moderate to severe pain Palliative Care Guidelines: Choosing and Changing Opioids Fentanyl
12-hr 24-hr total MR dose total dose total dose (micrograms) Review date: March 2012 MR = modified release (long acting)
∗ Morphine injection is available in a maximum concentration of 30mg/ml. Oxycodone injection is only available as 10mg/ml.
Another SC opioid will be needed for breakthrough pain if patient needs a dose that is in an injection volume above 1ml – Seek advice
Palliative Care Guidelines: Constipation Constipation in Palliative Care
Introduction
Constipation is the passage of small, hard faeces infrequently or with difficulty, and less often than
is normal for that individual.
Assessment
• Normal and current bowel pattern (frequency, consistency, ease of passage, blood present,
pain on passing stool).
• Current and previous laxatives taken regularly or as needed, and their effectiveness.
• Clinical features may mimic bowel obstruction or intra-abdominal disease.
o Paino Nausea/ vomiting, anorexiao Flatulence, bloating, malaiseo Overflow diarrhoeao Urinary retention • Cause of the constipation.
o Medication: opioids, anticholinergics (hyoscine, cyclizine, tricyclic antidepressants), antacids, diuretics, iron, 5HT antagonists.
o Secondary effects of illness (dehydration, immobility, poor diet, anorexia).
o Tumour in, or compressing, bowel wall.
o Damage to lumbosacral spinal cord, cauda equina or pelvic nerves.
o Hypercalcaemia. o Concurrent disease e.g. diabetes, hypothyroidism, diverticular disease, anal fissure, haemorrhoids, Parkinson's disease, hypokalaemia.
• Clarify cause before starting treatment of constipation.
o Abdominal and rectal examination are essential.
o To exclude bowel obstruction/ assess extent of faecal loading, an X-ray may be needed.
Management
General
• Encourage a good oral fluid intake (2 litres a day, if able); review diet.
• Ensure patient has privacy and access to toilet facilities.
• Address any reversible factors causing constipation.
• If current regimen satisfactory and well tolerated, continue it but review patient regularly and
explain importance of preventing constipation.
Oral Medication
• Use oral laxatives if possible.
• Rectal treatment may be needed for faecal impaction, and for paraplegic or bedbound
• If rectum is ballooned and empty, do not give rectal treatment.
Option A (combination of stimulant and softener)
Senna 2-4 tablets or bisacodyl 5-10mg, at bedtime in combination with docusate sodium 100mg
capsule, twice daily
Option B (osmotic laxative)
Macrogol (Movicol®) 1-3 sachets daily
• Severe constipation; consider a higher dose for three days.
Option C (combined stimulant / softener, licensed for terminally ill patients)
Co-danthramer 1-2 capsules or co-danthramer suspension 5-10ml; at bedtime.
Co-danthramer strong 2 capsules or co-danthramer strong suspension 5ml; at bedtime.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Constipation Rectal Treatment
Soft loading: bisacodyl suppository, sodium citrate or phosphate enema.
Hard loading: glycerol suppository as lubricant/ stimulant; then treat as above.
Very hard loading: arachis oil enema overnight, followed by phosphate enema.
Paraplegic or bedbound patient
• Titrate laxatives or loperamide to keep stool firm, but not hard.
• Use rectal treatment every 1-3 days to avoid incontinence or an anal fissure.
Practice points
• Do not use an arachis oil enema if patient has nut allergy.
• Avoid co-danthramer if patient is incontinent as it may cause a local skin reaction.
• Frail or nauseated patients may not be able to tolerate the fluid volume needed with Movicol®.
• Bulk forming laxatives are not suitable if patient has a poor fluid intake and reduced bowel
• Lactulose is not effective without a high fluid intake; causes flatulence and abdominal cramps in some patients.
• Almost all palliative care patients on opioids need a regular oral laxative.
• Review laxative regimen when opioid medication or dose is changed. • If maximal laxative therapy fails, consider changing opioid to fentanyl.
Patient/ carer advice points
• Co-danthramer colours the urine red.
Resources
Professional
Palliative Care Drug Information online: http://www.palliativedrugs.com/
Patient
Patient leaflet on website: Managing constipation
Key references
1. Larkin PJ, Sykes NP, Centeno C. et al. The management of constipation in palliative care: clinical practice
recommendations. Palliative Medicine 2008:22; 796-807.
2. Miles CL, Goodman ML, Wilkinson S. Laxatives for the management of constipation in palliative care patients (Systematic Review) 2006; Issue 4. The Cochrane Collaboration 3. Sykes N. Constipation. Oxford Textbook of Palliative Medicine 3rd Edition 2004: 483-4934. Scottish Intercollegiate Guideline Network. Control of pain in patients with cancer. Edinburgh, 2008. SIGN Secretariat (SIGN 106) 5. Goodman S, Wilkinson S. Constipation management in palliative care. Journal Pain Symptom Management 6. Campbell T et al. The management of constipation in people with advanced cancer. International Journal Advanced Nursing 2001; 7(3): 110-119 Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Constipation Laxative drug information chart
Time to act
Bisacodyl tablets • Can cause abdominal cramps.
• Tablets may be difficult to swallow.
• Can cause abdominal cramps.
• Combination laxative containing dantron and a softener.
• Colours the urine red.
• Licensed for use in terminally ill patients.
(1 capsule = 5ml) • Avoid if patient is incontinent as can cause a local skin reaction.
strong capsulesCodanthramer strong suspension(2 capsules = 5ml) • Mainly a softener.
• Liquid preparation very unpalatable.
• Made up in 125ml of water per sachet.
• High dose (up to 8 sachets per day for 1-3 days in impaction).
• Available in half strength sachets.
Rectal preparations Starting dose
Time to act
• Must be in contact with bowel wall to be • Can cause local irritation. • Warm to body temperature.
Glycerol suppository • Combined irritant and softener.
Arachis oil enema • Contains peanut oil; contraindicated in nut allergy.
• Warm to body temperature.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Cough Cough in Palliative Care
Introduction
Cough has a useful protective function but symptomatic treatment may be indicated when it is
distressing or affecting sleep/ activity.
Reversible causes should be identified and treated.
Management
• Ensure adequate analgesia – pain may be inhibiting effective coughing.
• Physiotherapy assessment if difficulty coughing retained secretions.
Management of common causes of cough in palliative care
Cancer related causes Stridor due to airway obstruction Dexamethasone 16mg or prednisolone 60mg (if dexamethasone not available) orally.
Seek oncology/ respiratory medicine advice.
Lymphangitis, disease progression Seek oncology advice; consider a trial of steroids.
Tracheo-oesophageal fistula with Seek specialist advice – stenting may be possible.
aspiration (cough after swallowing)Ineffective cough (eg due to recurrent Supportive care.
laryngeal nerve palsy, weakness, pain) Vocal cord injection may help a patient with laryngeal nerve palsy – refer to ENT.
Malignant pleural effusion Consider pleural drainage +/- pleurodesis.
Seek oncology advice; corticosteroids.
Other causesSmoking Smoking cessation advice if appropriate.
Antibiotics if infection, or an antisecretory such as hyoscine butylbromide (see: Last days of life).
Proton pump inhibitorProkinetic eg. metoclopramide, domperidone.
Antibiotics – see local guidelines.
Stop or switch to alternative medication.
Nasal decongestant spray, nasal corticosteroid, antihistamine.
Cardiac failure, COPD, asthma Optimise treatment.
Simple linctus BP 5ml, 3 times daily.
Nebulised 0.9% sodium chloride 2.5-5ml can help loosen secretions.
Opioid: titrate according to response, monitor for side effects (eg constipation).
o Codeine linctus BP (15mg/ 5ml) 5-10ml, 6-8 hourly and/or at bedtime.
o Oral morphine liquid 2mg, 6-8hourly or at bedtime.
o Methadone linctus (2mg/5ml) 2.5ml at bedtime (specialist advice only).
Non-drug
• Posture - it is impossible to cough effectively when lying flat.
Key References
1. Morrice AH. British Thoracic Society recommendations for the management of cough in adults. Thorax 2006;
2. Leach M. Cough. Oxford Textbook of Palliative Medicine, 3rd Edition 2004, p 899-901 Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Delirium Delirium in Palliative Care
Definition
Disturbed consciousness and inattention with cognitive impairment; acute onset and fluctuating
course as a physiological consequence of disease or treatment.
(Other terms: acute confusional state, agitation, terminal restlessness)
Assessment
• Common (30-85% of hospice inpatients), often reversible but diagnosed late.
• Three types:
o Hyperactive – increased arousal and agitation.
o Hypoactive – quiet, withdrawn and inactive: more common but often missed or misdiagnosed as depression.
o Mixed pattern.
• Diagnosis depends mainly on careful clinical assessment; consider using Mini-Mental State Examination or Abbreviated Mental Test.
• Causes include: o Drugs (including: opioids, anticholinergics, steroids, benzodiazepines, antidepressants, o Drug withdrawal (alcohol, sedatives, antidepressants, nicotine).
o Dehydration, constipation, urinary retention, uncontrolled pain.
o Liver or renal impairment, electrolyte disturbance (Na, Ca, glucose), infection, hypoxia, cerebral tumour or cerebrovascular disease.
o Visual impairment and deafness are risk factors.
Differential diagnosis: depression, dementia (increased risk of developing delirium).
Management (treat underlying causes)
• • Review all medication and stop any non-essential drugs.
• Maintain hydration, oral nutrition and mobility.
• Check for opioid toxicity (drowsiness, agitation, myoclonus, hypersensitivity to touch), reduce
opioid dose by 1/3. Consider switching to another opioid if delirium persists. • Check for constipation, urinary retention or catheter problems.
• Check full blood count and biochemistry, including calcium.
• Check for infection (urine infection in the elderly).
• If nicotine dependent, consider using replacement patches.
Medication (if essential to control symptoms)
• Review regularly and withdraw medication as soon as the patient recovers.
First choice: haloperidol
• Dose: 0.5-3mg oral or subcutaneous (start with a low, oral dose).
• Repeat after 2 hours, if necessary.
• Maintenance treatment may be needed if cause cannot be reversed; use lowest effective dose:
0.5-3mg oral or 2.5mg SC, once daily.
Second choice: benzodiazepines
• Benzodiazepines do not improve cognition; may help anxiety.
• Used in alcohol withdrawal (often at higher doses), sedative and antidepressant withdrawal;
preferred in Parkinson's disease.
• Lorazepam 0.5-1mg oral or sublingually.
• Midazolam SC 2.5-5mg, 1-2 hourly OR diazepam oral or PR 5mg, 8-12 hourly.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Delirium Medication (cont):
If more sedation is desirable and appropriate:
• Add or increase benzodiazepine (midazolam SC infusion 10-30mg/ 24hours in a syringe driver /
pump or diazepam PR 5-10mg, 6-8 hourly).
• Change haloperidol to levomepromazine SC 12.5-25mg, once or twice daily by injection or as a subcutaneous infusion in a syringe driver/pump.
Non-drug
• Explain cause and likely course to patient, relatives and carers.
• Address anxiety; patients with delirium are often very frightened.
• Quiet area or side room; limit staff changes.
• Adequate lighting, minimise noise, provide a clock the patient can see.
• Gentle repeated reorientation and avoid confronting deficits.
• Try to maintain normal sleep-wake cycle.
• Patients who recover recall their experiences; explain the organic cause of their behaviour and
Practice points
• Attention to the environment is essential.
• Opioid toxicity is a common cause of delirium, particularly in the elderly.
• Corticosteroids can cause florid delirium.
• Hypoactive delirium is frequently missed or misdiagnosed.
• Atypical antipsychotics offer no advantage over haloperidol.
• Adults with Incapacity Act covers the medical treatment of patients with cognitive impairment.
See: Adults with Incapacity Act on website. • In the acute situation, emergency treatment can be given without an Incapacity certificate if this is in the patient's best interest.
Patient / carer advice points
• Encourage the patient to keep taking oral fluids if able.
• The presence of a close relative or friend can help reassure the patient.
Resources
Professional
British Geriatrics Society Guidelines: http://www.bgs.org.uk
Key references
1. Young J, Inouye SK. Delirium in Older People. BMJ 2007; 334:842-6
2. Siddiqi N, House A. Delirium: an update on diagnosis, treatment and prevention. Clinical Medicine 2006; 6:540-543
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Depression Depression in Palliative Care
Introduction
• All patients should be assessed for depression.
• Depression
o is strongly and consistently associated with a poor quality of life.
o causes more reduction in role and social functioning than would be due to the physical illness alone.
o reduces physical functioning.
o is often associated with symptoms that are difficult to control.
o has a major impact on the patient's family.
• Treatment of depression can significantly improve quality of life and is as effective in palliative care as in other situations.
Assessment
• Physical symptoms commonly associated with depression may be due to physical illness or
treatment so are less helpful in making a diagnosis.
o Weight/appetite changeo Insomniao Loss of energyo Fatigueo Psychomotor slowingo Loss of libido • Depressive symptoms in palliative care patients include: o Greater severity of dysphoric mood.
o Excessive feelings of hopelessness, guilt, worthlessness.
o Social withdrawal; loss of pleasure in daily activities.
o A wish for earlier death (or suicidal thoughts).
o A positive response to the question "Do you feel depressed?" • Risk factors: o Personal or family history of depression.
o Concurrent life stresses.
o Absence of social support.
o Oropharyngeal, pancreatic, breast and lung cancers (more common).
• Additional barriers to diagnosis: o Patient/family feeling that a "fighting spirit" is needed to maximise active treatment/ support from health professionals. o Difficulty deciding if depression is a primary problem or whether improving other symptoms would improve mood.
o Concerns about polypharmacy and drug interactions.
o Other physical/ psychological conditions mimicking depression.
  Review medication (haloperidol can cause motor retardation).
o Complex care packages; many staff involved and lack of continuity.
Assessment tools:
• In primary care, the PHQ-9 is used as a screening tool.
• The Brief Edinburgh Depression Scale is suited to palliative care patients.
• The Hospital Anxiety and Depression questionnaire is widely available but relies on physical
symptoms so may be less helpful.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Depression Management
General
• In mild depression, psychological support can be as effective as medication.
• Adequate pain control may improve depressive symptoms significantly.
• Spiritual distress may be a component of depression, or distinct from it.
• Consider supportive psychotherapy or cognitive behavioural therapy.
• Patients with severe depression and/or suicidal ideation are uncommon but should be referred
to psychological medicine / psychiatry for assessment.
Medication
• There is little difference in efficacy between antidepressants.
• Consider side effects and any co-morbid illnesses; check for drug interactions.
• A current or previously effective antidepressant should be used unless contraindicated.
Selective serotonin reuptake inhibitors (SSRI)
 1st choice if recent cardiac event; normal dose in renal failure. o Citalopram: tablet and oral suspension  few drug interactions; useful for agitated depression/ anxiety; relatively safe if patient is at risk of seizures.
 long acting so low withdrawal risk; many drug interactions so may not be suitable in palliative care patients.
 nausea, vomiting, anorexia, dyspepsia, diarrhoea.
 risk of gastrointestinal bleeding – avoid or use with caution if history of GI bleeding, patient over 80 or taking NSAID/ aspirin.
 insomnia, sweating, impaired sexual function.
 vivid dreams, agitation, hyponatraemia.
 tablet and oro-dispersible tablet.
 sedative, particularly at lower doses; appetite stimulant.
 well tolerated in the elderly and patients with heart failure or diabetes.
o Amitriptyline: also treats nerve pain.
o Lofepramine: better tolerated than other tricyclics.
Side effects:  avoid if cardiac disease or risk of seizures.  dry mouth, hypotension and confusion limit dose.  sedative/ anxiolytic action may be helpful.
Practice point
Antidepressants should be withdrawn gradually, if possible.
Key reference
1. Lloyd-Wil iams M. Diagnosis and treatment of depression in pal iative care. European J Pal Care 2002; 9(5): 186-8
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Patient information leaflet What happens when someone is dying?
This leaflet aims to answer some of the questions you may have about the changes
that happen when someone is close to death.

The process of dying is unique to each person. It can last a few hours or several days. Do ask your nurse or doctor if you need more help or information.
Everyone is different, but in most cases there are common signs and changes that show a person may be close to death.
1. Less need for food and drink
• As people get more unwell, it is normal for them not to feel like eating or drinking. When this happens it can be upsetting because we want to do everything to help the people we care for.
• Eating and drinking becomes more of an effort. The person needs help to take sips of fluid. A drinking beaker or straw can make sipping fluid easier. Moistening the person's lips and tongue with water or oral gel helps keep them comfortable. • A drip is occasionally used to give people fluid into a vein or under the skin. As the process of dying continues the body does not need the same amount of fluid and cannot cope with it. Fluid from a drip can make breathlessness worse as it tends to build up in the lungs, and staff may advise that a drip is stopped.
2. Changes in breathing
• When someone is dying their need for oxygen may lessen and the way they breathe changes. People who have been breathless may feel less breathless at this time.
• As people get more unwell, their breathing may pause for a while and then start again. They use different muscles to breathe, which means their breathing will look different. Sometimes breathing can sound noisy or "rattling" because the person is no longer able to cough or clear their throat. This can sound distressing but is generally not upsetting for the person. Often changing the person's position can reduce the noise of breathing or an injection of medicine may be given.
3. Changes in how the person looks and behaves
• During the process of dying a person's skin may become pale and moist. Their hands and feet can feel very cold and sometimes look bluish in colour.
• Dying people often feel very tired and will sleep more. Even when they are awake, they may be drowsier than they have been. As people get more unwell they will be awake less and less. They will eventually not waken up at all. They may still be aware of the presence of family and friends so you can still talk to them.
• If you are worried about what is happening or have any questions, do ask.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Emergencies in Palliative Care Emergencies in Palliative Care
Introduction
• Patients receiving palliative care may deteriorate suddenly due to their illness or another acute
medical or surgical problem. • Management options depend on life expectancy, level of intervention needed, and an assessment of risks, benefits, side effects and likely outcome.
• Symptom control and supportive care may be the most appropriate management if the patient • Discuss treatment options with the patient and family. If possible discuss and document the patient's wishes in advance including those about resuscitation, hospital admission and transfer to an intensive care unit.
• Emergency treatment can be given but ongoing treatment in a patient lacking capacity to consent requires a Section 47 Certificate. (see: Adults with Incapacity Act on website) • This guideline covers the following palliative care emergencies: • Bleeding events• Hypercalcaemia• Seizures• Spinal cord compression Bleeding
• Acute haemorrhage can be very distressing for the patient and family.
• It is usually best to discuss the possibility with the patient and their family.
• An anticipatory care plan is helpful. This includes having sedative medication prescribed for
• If the patient is at home, discuss options for sedation if family carers feel able to use these.
• Discuss resuscitation; document and communicate resuscitation status.
• Make sure all professionals / services involved are aware of the care plan, including out of hours services.
Management of severe, acute bleeding
Non-drug
• Call for help. Ensure carers at home have an emergency contact number.
• Put the patient in the recovery position.
• Apply direct pressure to any bleeding area; dark coloured towels are best.
• If resuscitation is appropriate, admit to hospital and manage according to local protocols for
• If the patient has a massive haemorrhage and is clearly dying, support and non-drug interventions are more important until help arrives than trying to give sedative medication as the patient will usually lose consciousness rapidly.
Sedative medication
• If the patient is distressed, titrated doses of a rapidly acting benzodiazepine are indicated. The
route of administration guides the choice of drug.
o IV access available: midazolam 5-20mg IV or diazepam (emulsion for IV injection) 5-20mg IV in small boluses until settled.
o IM injection: midazolam IM 5-10mg can be given into the deltoid muscle. o Rectal route or via a stoma: diazepam rectal solution 5-10mg.
o Sublingual: midazolam 10mg can be given using the parenteral preparation or the buccal liquid (special order product).
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Emergencies in Palliative Care Hypercalcaemia in Palliative Care
Introduction
• Hypercalcaemia is the commonest life-threatening metabolic disorder in cancer patients.
• Occurs most frequently in myeloma, and in breast, renal, lung and thyroid cancer.
• 20% of patients with hypercalcaemia do not have bone metastases.
• Common symptoms: malaise, thirst, nausea, constipation, polyuria, delirium.
• Treatment may not be appropriate in a dying patient at the end of life – seek advice.
• To reduce risk of renal toxicity from bisphosphonate treatment, consider withholding
medication that affects renal function (eg. NSAIDs, diuretics, ACE inhibitors).
Patient presents with symptoms suggestive of hypercalcaemia.
Check calcium + urea & electrolytes, eGFR, albumin Corrected calcium ∗ Corrected calcium ∗ Corrected calcium Severe hypercalcaemia can cause seizures Rehydrate with 1-3litres 0.9% NaCl IV Monitor calcium if or arrhythmias - seek -check calcium, U & E next morning patient at risk of consultant advice Calcium is still raised – treat with pamidronate IV (reduce dose in renal impairment)♦ Corrected calcium (mmol/L) Diluent & maximum infusion rate 500mls NaCl 0.9% over > 60 minutes 500mls NaCl 0.9% over > 60 minutes 500mls NaCl 0.9% over > 90 minutes 500mls NaCl 0.9% over > 90 minutes If calcium >3.0mmol/l, some units routinely give pamidronate 90mg as a higher dose may increase response and delay relapse.
Review treatment of Continue IV fluids until patient able underlying cancer. to maintain oral hydration.
Monitor renal function. pre-treatment level after rehydration Recheck calcium after 5 days.
and pamidronate. Maintain good hydration; recheck calcium after 2-3 Seek advice; review Calcium has decreased from days. Do not repeat pre-treatment level but is pamidronate until 7 days after first dose to avoid ♦ Pamidronate in renal impairment: seek advice
• GFR >20ml/min: give pamidronate over at least 90 minutes. ∗ Corrected calcium = • GFR <20ml/min: consider risks & benefits of pamidronate. measured calcium + Maximum infusion rate 20mg/hr; consider dose reduction. (40 - serum albumin) X 0.02 Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Emergencies in Palliative Care Seizures in Palliative Care
Introduction
• Seizures (generalised or partial) occur in 10-15% of palliative care patients most often due
to primary or secondary brain tumours, cerebrovascular disease, epilepsy, or biochemical abnormalities (eg. low sodium, hypercalcaemia, uraemia).
• An advance care plan is needed if the patient wishes to avoid hospital admission.
Assessment
• Exclude other causes of loss of consciousness or abnormal limb/ facial movement. (eg
vasovagal episode (faint), postural hypotension, arrhythmia, hypoglycaemia, extrapyramidal side effects from dopamine antagonists, alcohol).
• Find out if the patient has had previous seizures or is at risk - history of epilepsy, previous secondary seizure, known cerebral disease.
• Is there a problem with usual antiepileptic drug therapy – unable to take oral medication, drug interactions – check BNF (eg.corticosteroids reduce the effect of carbamazepine, phenytoin).
Management
Acute seizure management
• Put the patient in the recovery position; move any objects that might cause injury.
• If seizure does not resolve quickly, anticonvulsant medication is needed.
Treatment options
• In hospital, diazepam (emulsion) IV in 2mg bolus doses up to 10mg or lorazepam 4mg by slow
IV injection are used. • Diazepam rectal solution 10-30mg given PR or via a stoma.
• Midazolam SC 5mg, repeated after 5 minutes.
• Buccal midazolam 10mg can be given using the parenteral preparation or the buccal liquid (special order product).
Persistent seizures
• IV phenytoin is used in hospital settings.
• Phenobarbital can be given as 100mg IM bolus dose followed, if needed, by a subcutaneous
infusion of phenobarbital 200-400mg diluted in water for injection over 24 hrs. Seek advice from a palliative care specialist.
Chronic seizure control
• Most patients with a structural cause for seizures benefit from treatment.
• Follow SIGN guideline recommendations. Check BNF for drug interactions.
o Partial or secondary generalised seizures - sodium valproate, carbamazepine or lamotrigine.
o Primary generalised seizures – sodium valproate or lamotrigine. • Dying patient unable to take oral medication - antiepileptics have a long half life so additional anticonvulsant treatment may not be needed. o Midazolam SC 5mg or diazepam rectal solution PR 10mg, if required.
o Midazolam SC 20-30mg infusion over 24 hrs can be used as maintenance therapy.
Practice points
• Phenytoin is no longer a first line drug for chronic seizure control. It interacts with many drugs,
and is prone to cause side effects including sedation in palliative care patients.
Professional resource
SIGN Guideline 70 (Epilepsy in Adults): http://www.sign.ac.uk/
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Emergencies in Palliative Care Spinal Cord Compression
Definition
Malignant spinal cord compression occurs when the dural sac and its contents are compressed at
the level of the cord or cauda equina.
• It affects about 5% of patients with cancer. Lung, breast, and prostate cancer are the
commonest causes but it occurs in other cancers.
• Cord compression can be the initial presentation of cancer.
• Late diagnosis is common causing permanent loss of function and significant morbidity. Assessment
• Consider cord compression in any patient with cancer.
• Thoracic cord compression is commonest but any part of the spine and multiple sites can be
• Sites of pain and level of compression do not always correlate; X-rays and bone scans can be • Key signs and symptoms
• New, progressively severe back pain (particularly thoracic). • New spinal nerve root pain (burning, shooting, numbness) – may radiate down anterior or posterior thigh (like sciatica), or like a band around the chest or abdomen.
• Coughing, straining or lying flat may aggravate pain.
• New difficulty walking or climbing stairs; reduced power (motor weakness), sensory impairment or altered sensation in limbs. • Bowel or bladder disturbance - loss of sphincter control is a late sign with a poor prognosis.
• A full neurological examination should be done but may be normal initially.
• MRI is the correct investigation - images the whole spine.
Cauda equina syndrome
Compression of lumbosacral nerve roots below the level of the cord itself results in a different
clinical picture.
• New, severe root pain affecting low back, buttocks, perineum, thighs, legs.
• Loss of sensation often with tingling or numbness in the saddle area.
• Leg weakness, often asymmetrical.
• Bladder, bowel and sexual dysfunction – occur earlier than in cord compression. Loss of anal
Management
Emergency referral is essential – see local protocol for your NHS Board.
• High dose dexamethasone, unless contraindicated, should be started as soon as a diagnosis
of cord compression is suspected: 16mg orally and then daily in the morning. Withdraw gradually after radiotherapy treatment.
• If clinical suspicion of spinal instability, transport as a spinal injury.
• • If there is complete paraplegia and loss of sphincter control, radiotherapy may improve pain control but is unlikely to restore function. • Patients with residual disability need a full multidisciplinary assessment and continuing supportive care including physiotherapy, occupational therapy, pressure area care, bladder and bowel care; social care, psychological and family support.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Fatigue Fatigue in Palliative Care
Introduction
A persistent, subjective feeling of tiredness, weakness or lack of energy (physical or mental)
related to cancer or advanced chronic illness.
• Common (70-100% of patients receiving cancer treatment).
• Not related to level of activity. Not alleviated by rest or sleep.
• Affects physical function, cognitive ability, emotional and spiritual well-being.
• Multiple contributory causes but exact aetiology poorly understood.
• Fatigue is common in the last days of life and part of a normal dying process.
Assessment
Palliative care patients should be screened for fatigue and its impact.
• Symptom pattern, duration; associated or alleviating factors.
• Interference with function and quality of life.
• Severity: mild, moderate or severe, or rated on a 0-10 scale.
Disease status and treatment:
• Exclude cancer recurrence or progression.
• Hormone treatment often causes fatigue.
• Review medication - beta-blockers, sedative drugs, corticosteroids, opioids.
Contributing factors and associated symptoms: (see: relevant guidelines)
• • • sleep disturbance
• anaemia
• poor nutrition or absorption
• fluid /electrolyte imbalance: check sodium, potassium, calcium, magnesium
• de-conditioning due to reduced activity level/ fitness or muscle wasting
• co-morbidities
o chronic infection o cardiac or respiratory diseaseo renal or hepatic impairmento hypothyroidism, adrenal insufficiency, hypogonadism Management
Combination of approaches tailored to the individual patient is likely to be required.
• Acknowledge the reality of the symptoms, and their effect on the patient /family.
• Explore understanding of the illness/treatment; explain possible causes of fatigue.
• An activity/ fatigue diary may help identify precipitants/ timing of symptoms.
Physical activity:
Graded exercise, both aerobic and strength training; consider physiotherapy referral.
Energy conservation: set priorities; pace; schedule activities at times of peak energy; eliminate
non-essential activities; short daytime naps if sleep at night is not affected; attend to one activity
at a time; conserve energy for valued activities.
Psychosocial interventions: stress management; relaxation therapy; sleep hygiene.
Medication:
• • Insufficient evidence to support the use of psychostimulants by non-specialists.
Resources
National Comprehensive Cancer Network Guideline: www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf
Patient leaflet on website: Managing fatigue
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Fentanyl patches Fentanyl Patches in Palliative Care
Description
Potent opioid analgesic in a topical patch lasting 72 hours.
12, 25, 50, 75,100 Durogesic D-Trans® Matrifen® Reservoir patch Durogesic® Tilofyl® Patients should stay on the same preparation and not switch formulation/ brand.
Indications
Second line opioid for moderate to severe opioid responsive pain.
• Pain that is stable.
• Oral and subcutaneous routes are not suitable.
• Patient unable to tolerate morphine/ diamorphine due to persistent side effects.
• Compliance is poor, but supervised patch application is possible.
Cautions
• Fentanyl is a potent opioid analgesic; check the dose carefully.
25 microgram fentanyl patch is equivalent to about 60-90mg of oral morphine in 24 hours.
• Frail or elderly patients may need lower doses and slower titration.
• Heat increases the rate of fentanyl absorption. This can occur if patient is febrile or the skin under the patch is heated. Avoid direct heat sources, use anti-pyretic measures.
Liver impairment: dose reduction may be needed in severe liver disease.
Renal impairment: no initial dose reduction. May accumulate gradually over time. Monitor
patient and reduce dose. Fentanyl is not usually removed by dialysis.
• If the patient has unstable pain or pain likely to change following treatment, do not start fentanyl. Seek advice and consider alternative opioids.
Side effects
• Similar to morphine but less constipation, nausea.
• If signs of opioid toxicity (eg sedation, delirium), remove the patch and seek advice. Fentanyl
will be released from the site for up to 24 hours. Monitor the patient for 24-48 hours.
• Titrated naloxone is only needed for life-threatening, opioid induced respiratory depression o A low respiratory rate < 8 respirations/minute.
o Oxygen saturation <85%, patient cyanosed.
• An allergic reaction to the patch adhesive can occur – change opioid.
Dose & Administration
Starting a fentanyl patch
1. Choose a suitable patch - matrix patch allows titration in smaller increments.
2. Calculate the dose of fentanyl from the conversion chart given here or seek advice. Patch
strengths can be combined to provide an appropriate dose.
3. The 12 microgram patch is licensed for dose titration, but may be used for patients needing a lower starting dose if recommended by a specialist.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Fentanyl patches Starting a fentanyl patch (continued)
4. Make sure the patient takes another regular opioid for the first 12 hours after the patch is first
applied to allow the fentanyl to reach therapeutic levels: Immediate release (quick acting)
Apply patch; continue the immediate release morphine or oxycodone opioid 4 hourly for the next 12 hours.
Modified release (long acting) 12 hourly
Apply patch when the last dose of a 12 morphine or oxycodone hourly, modified release opioid is given.
Subcutaneous infusion of morphine,
Apply the patch and continue the infusion diamorphine, oxycodone or alfentanil for the next 12 hours, then stop the infusion.
5. An immediate release opioid (e.g. oral morphine or morphine SC) must be available 1-2 hourly, as required, for breakthrough pain or to treat any opioid withdrawal symptoms (diarrhoea, abdominal pain, nausea, sweating). These can occur during the fentanyl initiation period due to the variable time to reach steady state. The correct 4 hourly equivalent dose should be used.
6. Change the patches every third day (72 hours) at about the same time. 7. Fentanyl is often less constipating than morphine; half dose of any laxative and titrate. Adjusting the fentanyl patch dose
Review the fentanyl patch dose after 72 hours; drug levels will be at steady state.
a) If the patient shows signs of opioid toxicity (drowsiness, confusion), reduce the dose and reassess the pain. Seek advice.
b) If the patient still has pain which is opioid responsive, titrate the fentanyl dose in 12-25microgram/hour increments depending on the patch type in use. Remember to include the breakthrough doses used. It will take 12-24 hours for the new dose to take effect so give breakthrough analgesia at the correct dose, as required.
Changing fentanyl patches to another opioid
Fentanyl accumulates in the skin under the patch. It can persist for up to 24 hours after patch
removal. Patients should be monitored carefully for signs of opioid toxicity for 24-48 hours if
fentanyl is changed to another opioid.
1. Remove the fentanyl patch; prescribe an immediate release opioid, 1-2 hourly, as required, for
the first 24 hours. 2. Calculate the opioid dose by converting from fentanyl to immediate release oral morphine using the conversion chart. Reduce the dose by 1/3rd.
3. To convert to any other immediate release opioid, refer to Choosing & changing opioids. Seek advice if in doubt. Example of an initial dose calculation when discontinuing a fentanyl patch Fentanyl patch dose Oral morphine dose Subcutaneous morphine dose 50 micrograms/ hr x 72 hrs 20 mg, 1-2 hourly Remember that all opioid conversions are approximate; monitor the patient.
4. After 24 hours, review the doses used and prescribe a regular, 4 hourly dose of immediate release opioid in addition to the correct as required dose. 5. Titrate the patient's opioid requirements for at least 48 hours before converting to a modified release (long acting) opioid or a subcutaneous opioid infusion. Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Fentanyl patches Fentanyl patches in the last days of life
1. If a patient is semi-conscious or close to death, continue the fentanyl patch, changing it every
2. If a new, opioid responsive pain develops, use subcutaneous morphine as required for breakthrough pain. Use the conversion chart to calculate the dose of morphine. 3. After 24 hours, the breakthrough doses of morphine given in that period can be totalled and this dose of morphine administered as a SC infusion in a syringe driver or pump over the next 24 hours in addition to the fentanyl patch.
Dose Conversions
• All opioid dose conversions are approximate.
• Round the dose down if the patient is pain free or frail; round up if the patient has pain and is
less unwell or younger.
• Reduce the dose by up to 30% when changing opioid if the patient is opioid toxic, frail or elderly and re-titrate.
• Reduce the dose by up to 30% when converting from fentanyl back to morphine or another opioid and re-titrate.
• Patients should be monitored closely so that the dose can be adjusted if necessary.
• Manufacturers of the various formulations of fentanyl have issued different recommendations for dose conversion, as have drug regulatory bodies.
• Fentanyl is approximately 100-150 times more potent than oral morphine; this table provides a guide to dose conversions, but if in doubt seek advice.
Immediate release oral Fentanyl patch dose 24 hour oral morphine dose 1 Assuming use of about 1/6th of the 24hour oral morphine dose. • Converting from fentanyl given by IV infusion or via a PCA device. • Calculate the hourly dose of fentanyl (micrograms/ hour)• Prescribe the patch strength closest to this dose (micrograms/ hour)• Continue the IV fentanyl for the first 12 hours after the patch is applied.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Fentanyl patches Fentanyl patch care
• Apply to intact, non-hairy skin on the upper trunk or upper arm; avoid areas treated with
radiotherapy, scar tissue or oedematous areas.
• Apply each new patch to a different skin site; clean the skin with water only as soap products can alter absorption. Make sure skin is dry.
• Fentanyl patches should not be cut.
• Record the date, time and site if the patch is changed by different people.
• Change the patch every 72 hours at about the same time of day.
• Check the patch daily to ensure it is still in place.
• If patch adherence is poor, use an adhesive dressing or tape; fentanyl is unsuitable for patients with marked sweating.
• Used patches still contain active drug. Fold the patch over so it sticks together. Dispose of it safely (sharps bin for inpatients, domestic waste in the community). Wash your hands after patch changes.
Heat / pyrexia increases the absorption of fentanyl and can cause toxicity.
• Avoid direct contact with heat (eg. hot water bottle, heat pad).
• Showering is possible as the patches are waterproof, but avoid soaking in a hot bath, saunas or sunbathing.
• If the patient has a persistent temperature of 39°, the patch dose may need reviewed.
Practice points
• Fentanyl patches are used for moderate to severe, stable pain.
• Do not change formulation/ brand.
• Do not change fentanyl patches to another opioid in a dying patient, continue the fentanyl
patch and use an additional opioid as required.
Resources
Professional
Palliative Care Drug Information online: http://www.palliativedrugs.com/
Patient
Patient leaflet on website:
Discharge planning/ community use
• The same patch formulation should be prescribed and dispensed consistently for each patient.
• Ensure patients understand the safe use, storage and disposal of the patch, and the
importance of not heating the skin under the patch.
Key references
1. Donner B. Long term treatment of cancer pain with transdermal fentanyl. J Pain Symptom Management 1998;
2. Ahmedzai S. Transdermal fentanyl versus sustained release oral morphine in cancer pain: preference, efficacy and quality of life. J Pain Symptom Management 1997; 13:254-261.
3. Fine PG. Fentanyl in the treatment of cancer pain. Seminars in Oncology 1997; 24(5): 20-27.
4. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Management 2004:25(5): 497-504.
5. Twycross R, Wilcock A. Eds. Palliative Care Formulary (3rd Edition) 2007, Palliativedrugs.com Ltd., Nottingham.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Patient information leaflet Other names:
Durogesic D-trans®, Matrifen®, Durogesic®, Tilofyl® You should stay on the same brand of fentanyl unless your doctor changes it. Check the name of the medicine on the box.
Q. What is fentanyl used for?
A. Fentanyl is used for moderate to severe pain that has not been well controlled on other regular pain killers. Fentanyl is used to control on-going pain. It is not used for pain that only lasts for a short time. You will be given a different, quick acting pain killer for breakthrough pain if you need it.
Q. How do I take fentanyl?
A. The fentanyl is inside a patch with a sticky back that is stuck on to the skin. The medicine passes from the patch through the skin into the body. Each patch is used once. The patches are waterproof so you can have a shower or go swimming. Check that the patch is still in place each day. Q. How long does a fentanyl patch last?
A. Each patch lasts for three days. Change your patch (or all your patches) every third day, at about the same time of day. Use a calendar to record the day when you need to change your patch. You should not stop using fentanyl suddenly.
Q. How do I change my patch?
A. (1) Wash your hands before and after changing your patch. Used patches still contain some of the medicine so need to be disposed of carefully. Take the old patch off, fold it in half so that it sticks together firmly and put it back in its original packet. The used patch can then be put in the bin with your household rubbish. Return any unused patches to your pharmacy.
(2) Choose a place on the upper body or upper arm. The skin should not have any cuts, scars or spots and should not be too hairy. Clean the skin with water only – not soap. Make sure it is cool and completely dry.
(3) Tear the packet with the new patch open. Peel off the plastic backing. Stick the patch on to the clean area of skin. Press it on firmly. Do not stick the patch on the same place twice in a row.
(4) Keep patches, like all medicines, in a safe place and away from children.
Q. What do I do if a patch falls off or I forget to change it?
A. Stick a new one on as soon as you can. If you are very late changing your patch, you may need to take another pain killer until the fentanyl starts working again.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Patient information leaflet Q. What should I do if I still get pain while using fentanyl?
A. When you first start fentanyl or the dose is increased it takes time to work. Your doctor will give you extra pain killers to take if you need them until your patch is working. Some people find that doing certain things like having a bath or going for a walk brings on pain. Your doctor or nurse may suggest you take a quick acting pain killer before you start doing something that brings on pain.
If your pain is not well controlled and you need to take more than 2-3 doses of extra pain killer a day, tell your doctor or nurse.
Q. How will I know if fentanyl is not going to work for some of my pain?
A. Although fentanyl is a very good pain killer, it does not help all types of pain. You may still have pain despite using bigger doses of fentanyl and may feel unwell if the dose is too high. The answer below tells you what signs to look for.
Tell your doctor or nurse if this happens. Your doctor may need to reduce your dose of fentanyl and suggest other treatments to help the pain.
Q. Are there any side effects from using fentanyl?
A. Fentanyl is a safe and effective pain killer but can have side effects. It is important to know when the dose might be too high.
• Too high a dose of fentanyl:
Contact your doctor or nurse if you:• are more sleepy than usual• become muddled or confused• have more difficulty walking or talking than usual Contact a doctor urgently if the patient has:• shallow breathing• marked sleepiness• a slow pulse or cold clammy skin • Heat effects:
Heat speeds up the way the fentanyl is released from the patch. • Avoid direct heat on the patch like a hot water bottle, electric blanket, heat pad, or • Do not soak in a hot bath or sunbathe while using fentanyl patches• If you develop a fever, try to keep your temperature down and contact your doctor if your temperature is 39° or higher.
• Changing from another pain killer:
A few people who change from another pain killer to fentanyl feel unwell in the first 24-
48 hours with sickness, shivering, stomach pains or diarrhoea. Contact your doctor if this happens.
• Constipation:
Fentanyl tends to cause less constipation than some other strong pain killers but you
may still need to take a laxative regularly.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Patient information leaflet • Skin/rash irritation:
If you develop itching or redness under the patch, tell your doctor or nurse.
• Patch falls off frequently:
Sweating or applying the patch to hairy skin may prevent it sticking well. Your nurse
can give you some sticky tape or a dressing to keep the patch on. Clipping or shaving excess hair may be needed in some people – do not use shaving foam, gel or soap as they affect the way the medicine goes into the skin.
Q. Can I drive?
A. You may be able to drive but you must discuss this with your doctor. (Patient information leaflet: Strong pain killers and driving).
Q. Can I drink alcohol?
A. A small glass of wine, beer, sherry or whisky may help you feel better and improve your appetite. It is best to avoid taking more than this as you may become too drowsy.
(Discuss this leaflet with your doctor or nurse who will answer any questions you may have) Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Group Members Palliative Care Guidelines Group Members
Dr Kirsty Boyd (Chair) Consultant in Palliative MedicineRoyal Infirmary of Edinburgh, NHS Lothian Consultant in Palliative MedicineWestern General Hospital, NHS Lothian Senior Pharmacist Palliative Care, NHS Lothian Medical Director and Consultant in Palliative MedicineSt Columba's Hospice, Edinburgh Clinical Nurse Specialist/LecturerPalliative Care, St John's Hospital, NHS Lothian Clinical Nurse Specialist Pain ManagementRoyal Hospital for Sick Children, NHS Lothian General PractitionerNHS Lothian Dr Gordon Canning Consultant in Palliative Medicine, St Andrews Hospice, NHS Lanarkshire MacMillan Lead GPNHS Borders District NurseNHS Lothian MacMillan Area Lead PharmacistPalliative Care, NHS Lanarkshire Community Clinical Nurse SpecialistMarie Curie Hospice, Edinburgh Principal Palliative Care PharmacistNHS Lothian Lead GP for Cancer and Palliative CareNHS Lothian District NurseNHS Lothian Formulary PharmacistNHS Lothian Designed by: Graphics Lab, The University of Edinburgh Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Hiccup Hiccup in Palliative Care
Introduction
Hiccups lasting more than 48 hours are not uncommon in patients with advanced cancer and can
be very distressing.
Assessment
• Causes in patients with advanced cancer include:
o Gastric stasis and distension (most common cause)o Gastro-oesophageal refluxo Metabolic disturbances (eg. uraemia, hypercalcaemia)o Infectiono Irritation of diaphragm or phrenic nerveo Hepatic disease/ hepatomegalyo Cerebral causes (e.g. tumour, metastases) Management
• Treat reversible factors.
• Hiccups often stop spontaneously. Treatment is only required if hiccups are persistent.
• Try simple physical manoeuvres initially and those that worked previously.
Medication
• Prokinetic: domperidone or metoclopramide oral 10-20mg, 8hourly.
• Treat any gastro-oesophageal reflux with a proton pump inhibitor.
• Dexamethasone oral 4-8mg in the morning may reduce compression/ irritation if the patient
has a hepatic or cerebral tumour. Stop if no benefit after a week.
• Other options for intractable hiccups supported by limited evidence include: • haloperidol oral 0.5-1mg at bedtime for under 2 weeks to avoid side effects.
• baclofen oral 5-20mg, 8 hourly (avoid abrupt withdrawal).
• levomepromazine oral 3-6mg at bedtime (now used as an alternative to chlorpromazine; avoid if hypotensive).
• nifedipine oral 5-20mg, 8 hourly (avoid if hypotensive).
• If other treatments are unsuccessful and the patient is very distressed, try midazolam SC 10-30mg / 24hours as an infusion via a syringe driver or pump, reducing the dose as the patient improves. Non-drug
• Simple measures or ‘home remedies' can be effective.
o Sipping iced water or swallowing crushed ice.
o Breathing into a paper bag particularly if the patient is hyperventilating.
o Interrupting normal breathing e.g. holding breath.
o Rubbing the soft palate with a swab to stimulate the nasopharynx.
• Acupuncture may be effective.
Key references
1. Regnard C. Hiccup. In Oxford Textbook of Palliative Medicine. 3rd Edition 2004, p477-9
2. Back I. Palliative Medicine Handbook http://www.pallcare.info/
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Emergencies in Palliative Care Hypercalcaemia in Palliative Care
Introduction
• Hypercalcaemia is the commonest life-threatening metabolic disorder in cancer patients.
• Occurs most frequently in myeloma, and in breast, renal, lung and thyroid cancer.
• 20% of patients with hypercalcaemia do not have bone metastases.
• Common symptoms: malaise, thirst, nausea, constipation, polyuria, delirium.
• Treatment may not be appropriate in a dying patient at the end of life – seek advice.
• To reduce risk of renal toxicity from bisphosphonate treatment, consider withholding
medication that affects renal function (eg. NSAIDs, diuretics, ACE inhibitors).
Patient presents with symptoms suggestive of hypercalcaemia.
Check calcium + urea & electrolytes, eGFR, albumin Corrected calcium ∗ Corrected calcium ∗ Corrected calcium Severe hypercalcaemia can cause seizures Rehydrate with 1-3litres 0.9% NaCl IV Monitor calcium if or arrhythmias - seek -check calcium, U & E next morning patient at risk of consultant advice Calcium is still raised – treat with pamidronate IV (reduce dose in renal impairment)♦ Corrected calcium (mmol/L) Diluent & maximum infusion rate 500mls NaCl 0.9% over > 60 minutes 500mls NaCl 0.9% over > 60 minutes 500mls NaCl 0.9% over > 90 minutes 500mls NaCl 0.9% over > 90 minutes If calcium >3.0mmol/l, some units routinely give pamidronate 90mg as a higher dose may increase response and delay relapse.
Review treatment of Continue IV fluids until patient able underlying cancer. to maintain oral hydration.
Monitor renal function. pre-treatment level after rehydration Recheck calcium after 5 days.
and pamidronate. Maintain good hydration; recheck calcium after 2-3 Seek advice; review Calcium has decreased from days. Do not repeat pre-treatment level but is pamidronate until 7 days after first dose to avoid ♦ Pamidronate in renal impairment: seek advice
• GFR >20ml/min: give pamidronate over at least 90 minutes. ∗ Corrected calcium = • GFR <20ml/min: consider risks & benefits of pamidronate. measured calcium + Maximum infusion rate 20mg/hr; consider dose reduction. (40 - serum albumin) X 0.02 Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Itch Itch in Palliative Care
Introduction
Itch may be localised or due to systemic disease. It can cause discomfort, frustration, poor sleep,
anxiety and depression. Persistent scratching leads to skin damage – excoriation and thickening.
Patients with itch usually have dry skin.
Assessment
• Examine the skin; look for local and systemic causes. May be multifactorial.
• Primary skin disease (eg. atopic dermatitis, contact dermatitis, psoriasis).
• Infection – candidiasis, lice, scabies, fungal infection.
• Medication – opioids (particularly morphine, diamorphine).
• Systemic diseases that can cause itch include:
Cholestatic jaundice Chronic kidney disease Iron deficiency +/- anaemia Primary biliary cirrhosis Paraneoplastic syndrome Mycosis fungoides Management
• Treat underlying cause(s). Review medication to exclude a drug reaction.
• Use an emollient or aqueous cream frequently as a moisturiser.
• Add an emollient to bath water and use aqueous cream as a soap substitute.
Topical Agents
• Emollients
• Aqueous cream (1% menthol can be added).
• Crotamiton 10% cream (Eurax) or capsaicin (0.025%) cream for localised itch.
• Topical corticosteroid (mild/moderate potency) once daily for 2-3 days if the area is inflamed
but not infected.
Medication
• Antihistamine (stop if no benefit after a few days).
• Sedating antihistamine if poor sleep is a problem (eg. chlorphenamine, hydroxyzine).
• Some non-sedating antihistamines can have an antipruritic effect (eg loratadine, cetirizine).
• An antidepressant can help if the patient has associated anxiety or depression.
• Cimetidine 400mg twice daily for itch in lymphoma or polycythaemia.
(Check BNF for drug interactions).
• Biliary stenting: may relieve the symptoms of cholestatic jaundice.
Practice points
• Avoid topical antihistamines as they can cause allergic contact dermatitis.
• Systemic treatment is often unnecessary if skin care is improved.
Patient advice points
• Keep nails short and clean. Wear loose clothing, preferably cotton. Keep cool.
• Dry skin by gently patting rather than rubbing; then apply moisturisers.
• Avoid lanolin and perfumed products; try a little baking soda in the bath water.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Last days of life Last days of life
Introduction
When al reversible causes for the patient's deterioration have been considered, the
multi-disciplinary team agrees the patient is dying and changes the goals of care.
Reversible causes to consider include
• opioid toxicity • renal impairment • hypercalcaemia Clinical signs of dying may include:
Patient is bedbound Increasingly drowsy or semicomatose Only able to take sips of fluid Difficulty swallowing tablets Management of a dying patient and their family
Plan and document care; consider using a care pathway or checklist.
Team
• Discuss prognosis (patient is dying), goals of care (maintaining comfort) and preferred place of
death with the patient and/or family.
• If discharge home is possible, prompt and careful planning are needed. Contact GP, community nurse and occupational therapist urgently.
Medical staff
• Clarify resuscitation status; check DNAR form has been completed. (See: local policy)
o Reassure the patient and family that full supportive care will continue.
• Discontinue inappropriate interventions (blood tests, IV fluids and medication, vital signs monitoring, frequent blood sugar tests).
• Medication – review at least once daily.
o Stop any treatment not needed for symptom control.
o Choose an appropriate route. If able to swallow, consider liquid formulations otherwise change to the subcutaneous or rectal route.
o Consider need for a SC infusion of medication via a syringe driver/pump.
o Anticipatory prescribing of as required medication in advance for common symptoms.
o Discontinue tube feeding/ fluids if respiratory secretions are present, if there is risk of aspiration due to reduced conscious level, or at the patient's request.
o Over-hydration contributes to distressing respiratory secretions. Artificial fluids are usually not appropriate, but if indicated can be given subcutaneously Nursing staff
• Comfort nursing care (pressure relieving mattress, reposition for comfort only), eye care, mouth
care (sips of fluid, oral gel), bladder and bowel care. • Explain to the family why the nursing and medical care has been altered and what changes to • Ward team; record arrangements for contacting the family when the patient deteriorates or dies.
Community team; ensure the family/ carers know who to contact when the patient dies.
• Consider emotional, spiritual/ religious, legal and family needs including those of children. • Identify those at increased risk in bereavement and seek additional support. o Previous multiple losses or recent bereavemento Ambivalent or dependent relationshipo Living alone and lacking a support networko Mental illness, drug or alcohol dependencyo Dependent children (See: Bereavement on website) Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Last days of life Symptom Control in the last days of life
Anticipatory prescribing
All patients should have as required medication for symptom control available.
Opioid analgesic SC, hourly; dose depends on patient, clinical problem and previous opioid.
• 1/6th of 24 hour dose of any regular opioid.
• If not on a regular opioid, morphine SC 2-5mg or diamorphine SC 2.5-5mg.
• Anxiolytic sedative: midazolam SC 2.5-5mg, hourly.
• Anti-secretory medication: hyoscine butylbromide (Buscopan) SC 20mg, hourly.
• Anti-emetic: cyclizine SC 25-50mg, 8 hourly or levomepromazine SC 2.5-5mg, 8-12 hourly.
Pain
• Paracetamol or diclofenac (as liquid/ dispersible or rectally).
NSAID benefits may outweigh risks in a dying patient; can help bone, joint, pressure sore,
inflammatory pain.
Convert any regular oral morphine or oxycodone to a 24 hour, SC infusioneg. oral morphine 30mg = SC morphine 15mg = SC diamorphine 10mg eg. oral oxycodone 15mg = SC morphine 15mg = SC oxycodone 7-8 mg • Breakthrough analgesia, should be prescribed hourly as required: • 1/6th of 24 hour dose of any regular opioid orally and subcutaneously.
• If not on any regular opioid, prescribe morphine SC 2-5mg or diamorphine SC 2.5-5mg.
Agitation / delirium
Anxiety/ distress midazolam SC 2.5-5mg, hourly, as required Confusion/ delirium haloperidol SC 2.5mg, once or twice daily Established terminal delirium/ distress midazolam SC 20-30mg over 24 midazolam SC 40-80mg over hours in a driver/pump 24 hours in a syringe driver/pump + midazolam SC 5mg hourly, + levomepromazine SC as required OR regular rectal 12.5-25mg, 6-12 hourly, as required.
diazepam 5-10mg, 6-8 hourly.
Stop any haloperidol.
Nausea/ vomiting • If already controlled with an oral anti-emetic, use the same drug as a SC infusion.
• Treat new nausea/ vomiting with a long acting anti-emetic given by SC injection or give a suitable antiemetic as a SC infusion in a syringe driver/ pump.
Long acting anti-emetic: haloperidol SC 1mg twice daily or 2.5mg once daily. levomepromazine SC 2.5mg twice daily or 5mg once daily.
• Persistent vomiting: an NG tube, if tolerated, may be better than medication.
Other guidelines
Subcutaneous medication (prescribing advice and drug compatibility tables)

End-of-life care in non-cancer illnesses: Renal disease, Liver disease, Heart disease - see website Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Last days of life Breathlessness
• Oxygen is only useful if hypoxic; nasal prongs are better tolerated than a mask.
• A fan or position change can help.
midazolam SC 2.5-5mg hourly, as required &/ or lorazepam breathlessness/ distress sublingual 0.5mg, 4-6 hourly, as required.
opioid (2 hourly as required) • regular opioid → 25% of the 4 hourly breakthrough analgesia dose of opioid.
• no opioid → morphine SC 2mg or diamorphine SC 2.5mg.
midazolam SC 5-20mg + morphine SC 5-10mg or breathlessness/ distress diamorphine SC 5-10mg (if no opioid for pain) in syringe driver/ pump.
Respiratory tract secretions
• Avoid fluid overload; assess fluid balance, stop IV/SC fluids and tube feeding.
Changing the patient's position may help.
• Intermittent SC injections often work well or medication can be given as a SC infusion.
1st line: hyoscine butylbromide SC 20mg, hourly as required (up to 120mg/ 24hours).
2nd line: glycopyrronium bromide SC 200micrograms, 6-8 hourly as required. 3rd line: hyoscine hydrobromide SC 400micrograms, 2 hourly as required.
Acute terminal events Dying patients occasionally develop acute distress; can be due to:
• Bleeding: haemorrhage from GI or respiratory tract, or external tumour.
• Acute pain: bleeding into a solid tumour, fracture, ruptured organ.
• Acute respiratory distress: pulmonary embolism, retained secretions.
Management
• Prescribe sedation in advance if patient at risk; document and discuss anticipatory care plan
with family and key professionals.
• Give midazolam IM 5-10mg into deltoid muscle or diazepam rectal solution 10mg PR (can be given via stoma) or sedate using IV midazolam if IV access available.
• If patient is in pain or has continued respiratory distress despite midazolam, give additional morphine SC or diamorphine SC as required.
Practice points
• Opioid analgesics should not be used to sedate dying patients.
• Sudden increase in pain or agitation; exclude urinary retention, constipation, fracture.
• Subcutaneous infusions provide maintenance treatment only. Additional doses of medication
by SC injection will be needed if the patient's symptoms are not controlled.
• Midazolam is titrated in 5-10 mg steps. Up to 5mg can be given in a single SC injection (1ml). Single SC doses can last 2-4 hours. Useful as an anticonvulsant.
• Rectal diazepam solution; longer acting alternative to midazolam given PR or via a stoma.
• Terminal secretions can be controlled in about 60% of cases; fluid overload, aspiration and respiratory infection increase incidence.
• Consider a nicotine replacement patch for heavy smokers.
Resources
Professional
NHS End of life care Programme http://www.endoflifecare.nhs.uk/eolc
Liverpool Integrated Care Pathway http://www.mcpcil.org.uk/liverpool_care_pathway
Patient
Patient leaflet on website: What happens when someone is dying.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Levomepromazine Levomepromazine in Palliative Care
Description
A phenothiazine used widely in palliative care to treat intractable nausea or vomiting, and for
severe delirium/ agitation in the last days of life.
6mg scored tablet Named patient preparation. Allow time for pharmacist to order. Disperses well in water.
25mg scored tablet Listed in BNF but rarely used in palliative care as too high a dose for most patients.
Injection 25mg/ml Used by subcutaneous injection or continuous subcutaneous Indications
• Second line, broad spectrum antiemetic for intractable nausea/ vomiting.
• Potent sedative used to manage severe delirium/ agitation in a dying patient.
Cautions
• Lowers blood pressure and can cause significant postural hypotension in ambulant patients.
Check blood pressure before starting treatment and then daily until dose stable.
Additive hypotensive effect if combined with other antihypertensives.
• Additive sedative effect if combined with other sedating drugs.
• Liver impairment: dose reduction and careful titration. Inhibits cytochrome P450 metabolism – check BNF for drug interactions.
• Rarely causes prolonged QT interval in cardiac disease or hypokalaemia.
• Parkinsonism, epilepsy (lowers seizure threshold).
Side effects
• Skin irritation at infusion site; add more diluent when preparing syringes.
• Cover syringe containing the infusion as degrades in sunlight (purple colouration).
• Drowsiness, dry mouth, dystonia, neuroleptic malignant syndrome (rarely).
Dose & Administration
• Low doses for nausea/ vomiting and higher doses for delirium/ agitation.
• SC dose is half the oral dose.
• Each dose can last 12-24 hours; once or twice daily SC injection is an alternative to a
continuous subcutaneous infusion.
Antiemetic
• Oral starting dose: 3mg once or twice daily.
• SC starting dose: 2.5-5mg (0.1-0.2ml) once or twice daily, or as a continuous SC infusion.
• Usual dose range: 3-25mg / 24 hours.
Sedative:
• Second line added to a benzodiazepine (midazolam SC 30mg/ 24hours or diazepam PR
5mg, 8hourly) if the patient is dying and agitated. Exclude other causes of terminal delirium • Injections will be needed to gain control of agitation while a SC infusion takes effect and may be needed if agitation worsens; use 12.5-25mg SC, 6-12 hourly.
• Subcutaneous infusion dose: 25-100mg over 24 hours.
Further information
Pal iative Care Drug Information online: http://www.pal iativedrugs.com
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: McKinley T34 syringe pump drug compatibility & stability charts Compatibility and stability charts for a subcutaneous
infusion in a McKinley T34 Syringe Pump
Table 1: Subcutaneous Morphine Infusion
Diluent: Water for injections
These are not clinical doses to prescribe. Most patients do not need such high doses.
Read the relevant guidelines.
• Use this table to check for concentrations that are stable.
• Refer to the relevant guidelines to obtain the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response.
Concentrations of two drug combinations that are
physically stable

17ml in 20ml syringe
22ml in 30ml syringe
Morphine Sulphate Morphine Sulphate Glycopyrronium bromide Morphine Sulphate Morphine Sulphate Hyoscine butylbromide Morphine Sulphate Hyoscine hydrobromide Morphine Sulphate Morphine Sulphate Morphine Sulphate Morphine Sulphate Concentrations of three drug combinations that are
physically stable

17ml in 20ml syringe
22ml in 30ml syringe
Morphine Sulphate Morphine Sulphate Morphine Sulphate Hyoscine butylbromide Morphine Sulphate Morphine Sulphate NHS Lanarkshire Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: McKinley T34 syringe pump drug compatibility & stability charts Table 2: Subcutaneous Diamorphine infusion in a McKinley T34 Syringe Pump
Diluent: Water for injections

These are not clinical doses to prescribe. Most patients do not need such high doses.
Read the relevant guidelines.
• Use this table to check for concentrations that are stable.
• Refer to the relevant guideline to obtain the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response.
Concentrations of two drug combinations that are
physically stable

17ml in 20ml syringe
22ml in 30ml syringe
Glycopyrronium bromide Hyoscine butylbromide Hyoscine hydrobromide Concentrations of three drug combinations that are
physically stable

17ml in 20ml syringe
22ml in 30ml syringe
Hyoscine butylbromide Issue date: January 2009 Review date: March 2012 NHS Lanarkshire Palliative Care Guidelines: McKinley T34 syringe pump drug compatibility & stability charts Table 3: Subcutaneous Oxycodone infusion in a McKinley T34 Syringe Pump
Diluent: Water for injections

These are not clinical doses to prescribe. Most patients do not need such high doses.
Read the relevant guidelines.
• Use this table to check for concentrations that are stable.
• Refer to the relevant guideline to obtain the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response.
• The concentration of oxycodone injection is 10mg/ml. If the 24hour dose of oxycodone exceeds 60mg, an alternative opioid may be needed for breakthough pain.
Concentrations of two drug combinations that are
physically stable

17ml in 20ml syringe
22ml in 30ml syringe
Do not mix - Incompatible Do not mix - Incompatible Hyoscine butylbromide Hyoscine hydrobromide Concentrations of three drug combinations that are
physically stable

17ml in 20ml syringe
22ml in 30ml syringe
Hyoscine butylbromide Hyoscine hydrobromide Hyoscine butylbromide NHS Lanarkshire Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: McKinley T34 syringe pump drug compatibility & stability charts Table 4: Subcutaneous Alfentanil infusion in a McKinley T34 Syringe Pump
Diluent: Water for injections

These are not clinical doses to prescribe. Most patients do not need such high doses.
Read the relevant guidelines.
• Use this table to check for concentrations that are stable.
• Refer to the relevant guideline to obtain the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response.
Concentrations of two drug combinations that are physically stable
17ml in 20ml syringe
22ml in 30ml syringe
Glycopyrronium bromide Hyoscine butylbromide Hyoscine hydrobromide Concentrations of three drug combinations that are physically stable
17ml in 20ml syringe
22ml in 30ml syringe
Hyoscine butylbromide Key references
1. Dickman A: The syringe driver: continuous subcutaneous infusions in palliative care. 2nd Edition, 2004. OUP.
2. Palliative care drug information online http://www.palliativedrugs.com/
Further reading: http://www.palliativecareguidelines.scot.nhs.uk
Issue date: January 2009 Review date: March 2012 NHS Lanarkshire Palliative Care Guidelines: Mouth Care Mouth Care in Palliative Care
Introduction
Mouth care is a frequently neglected but crucial aspect of palliative care. It maintains self-esteem,
and the person's ability to communicate and enjoy food and drinks.
Assessment
• Identify patients at risk of oral problems and plan regular mouthcare:
e.g. receiving chemotherapy/radiotherapy, elderly, terminally ill, immunocompromised,
nasogastric or PEG tube fed, O therapy, dysphagia, oro-pharyngeal disease. • Drug history: Anticholinergics (e.g. cyclizine, hyoscine, tricyclics) – increase dry mouth.
Bisphosphonates – risk of osteonecrosis of the jaw particularly if teeth/gums are in poor condition. • Examine thoroughly using a torch and tongue depressor. Remove dentures and ensure privacy. Avoid pain by lubricating cracked lips. Look for signs of dryness, coating, ulceration, infection or tooth decay. Assess for pain.
• Document findings accurately and assess daily or at each visit.
Healthy mouth
• Keep mouth and lips clean, moist and intact; remove plaque and debris.
• Prevent oral infection, tooth decay and halitosis.
• Maintain fluid intake with frequent, small drinks.
• Oral care using a soft, small-headed toothbrush, fluoride toothpaste and water after each meal
and at bedtime.
• Gauze on a gloved finger, soaked in water or chlorhexidine 0.2% may be used if the patient is unconscious or unable to tolerate a toothbrush.
• Apply oral gel to dry lips after oral care.
• Dentures should be cleaned and soaked overnight in a cleanser.
Mouthcare if receiving chemotherapy/radiotherapy – key differences:
• Chlorhexidine is not effective and may be harmful.
• Use bicarbonate mouthwash (5ml spoonful dissolved in 1 pint of warm water) 4-6 times daily to
keep the mouth clean.
• Avoid antipyretic analgesics (paracetamol, aspirin) if the patient is at risk of neutropenia; can mask fever due to sepsis.
Painful mouth
• Assess cause and treat accordingly.
• Treat painful mucositis with benzydamine hydrochloride 0.15% (Difflam) 15ml, 2-3 hourly for up
to 7 days. Dilute 1:1 with water if it stings too much.
• Consider sucralfate suspension.
• Analgesia: soluble paracetamol and/or aspirin gargle. Co-codamol (30/500) or morphine – if • Look for herpes simplex infection and treat appropriately.
Dry/ coated mouth
• Frequent oral care, maintain hydration, review medication.
• Use a moistened soft toothbrush to remove coating.
• Chlorhexidine gluconate 0.2% mouthwash, 10ml used twice daily. Dilute 1:1 with water if it
stings. Inhibits plaque formation.
• Cold, unsweetened drinks taken frequently through the day.
• Saliva substitutes or oral gel if other measures insufficient.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Mouth Care Candidiasis
• Chlorhexidine gluconate 0.2%, 10ml twice daily.
• Nystatin suspension 1ml, as a mouthwash then swallowed, 4 times daily for 7-14 days. Give
nystatin with any dentures out and at least 30 minutes after chlorhexidine or it becomes inactive.
• Fluconazole (capsules or suspension) 50mg daily for 7-14 days. Check BNF for drug • Angular cheilitis can be treated with nystatin suspension. Miconazole gel (topically 4 times daily) can be used to treat cheilitis and oral candidiasis.
• Dentures should be cleaned thoroughly.
Ulcerated mouth
• Identify the cause if possible; exclude infection, dental problems.
• If ulcers are painful, try benzydamine hydrochloride 0.15% (Difflam) 15ml, 2-3 hourly; or a
topical steroid (eg. hydrocortisone lozenge or triamcinolone in orabase).
• Use chlorhexidine gluconate 0.2% mouthwash twice daily to prevent and treat infection.
• If persistent mucositis, consider sending swab for culture.
• Treat herpetic ulcers on the lips with topical aciclovir; use oral aciclovir for herpes infection in • Treat anaerobic (foul smelling) lesions or gingivitis with oral metronidazole. Practice point
• Refer to a dentist if pain or ulceration is related to teeth or dentures.
Patient / carer advice points
• Regular toothbrushing and dental hygiene are essential. Visit a dentist regularly.
• Avoid sugary drinks. Try sugar free chewing gum.
Resources
Patient
Patient leaflet on website: Managing a dry or sore mouth.
Key references
1. Davies A, Finlay I. Oral Care in Advanced Disease: OUP 2005, Oxford
2. De Conno. Mouth care. In Oxford Textbook of Palliative Medicine. 3rd Edition 2004, p673-687
3. Gillam JL, Gillam DG. The assessment and implementation of mouth care in palliative care: a review.
The Journal Royal Society Promotion of Health 2006; 126(1): 33-37 Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Naloxone Naloxone in Palliative Care
Description
Antagonist for use in severe opioid induced respiratory depression.
Preparation
• 400 micrograms/ml injection (1ml ampoule).
Indications
• Reversal of life-threatening respiratory depression due to opioid analgesics, indicated by:
• A low respiratory rate < 8 respirations/minute.
• Oxygen saturation <85%, patient cyanosed.
If less severe opioid toxicity • Omit next regular dose of opioid; review analgesia.
• Monitor the patient closely; maintain hydration, oxygenation.
Cautions
• Naloxone is not indicated for opioid induced drowsiness and/or delirium that are not life
• Naloxone is not indicated for patients on opioids who are dying.
• Patients on regular opioids for pain and symptom control are physically dependent; naloxone given in too large a dose or too quickly can cause an acute withdrawal reaction and an abrupt return of pain that is difficult to control.
• Patients with pre-existing cardiovascular disease are at more risk of side effects. Side effects
Opioid withdrawal syndrome: anxiety, irritability, muscle aches; nausea and vomiting; can include
life-threatening tachycardia and hypertension.
Dose & Administration
Small doses of naloxone by slow IV injection improve respiratory status without completely
blocking the opioid analgesia.
• Stop the opioid.
• High flow oxygen, if hypoxic.
• Dilute 400 micrograms naloxone (1 ampoule) to 10ml with sodium chloride 0.9% injection in a
10 ml syringe.
• Administer a small dose of 80 micrograms (2ml of diluted naloxone) as a slow IV bolus. Flush the cannula with sodium chloride 0.9%.
• Give 80 microgram (2ml) doses at 2 minute intervals until the respiratory rate is above 8. Flush the cannula between the naloxone doses. • Patients usually respond after 2-4ml of diluted naloxone with deeper breathing and an improved conscious level.
• A few patients need 1-2mg of naloxone. If there is little or no response, consider other causes (e.g. other sedatives, an intracranial event, acute sepsis, acute renal failure causing opioid accumulation).
• Closely monitor respiratory rate and oxygen saturation. Further doses may be needed. The duration of action of many opioids exceeds that of naloxone (15-90 minutes) and impaired liver or renal function will slow clearance of the opioid.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Naloxone Dose & Administration
Prolonged or recurrent, opioid induced respiratory depression
:
• If repeated naloxone doses are required, start a continuous intravenous infusion of naloxone
via an adjustable infusion pump.
• Add 1mg of naloxone (= 2.5ml of 400 micrograms/ml naloxone injection) to 100ml of sodium chloride 0.9% to give a concentration of 10 micrograms/ml. • Calculate the dose requirement per hour by totalling the naloxone bolus doses and dividing by the time period over which all the doses have been given.
• Start the IV infusion of naloxone at half this calculated hourly rate.
• Adjust the naloxone infusion rate to keep the respiratory rate above 8 (do not titrate to
the level of consciousness). • Continue to monitor the patient closely.
• Continue the infusion until the patient's condition has stabilised. • Additional IV boluses may need to be given using naloxone diluted in sodium chloride 0.9% as If in doubt, seek advice
• Seek and treat the precipitating cause(s) of the opioid toxicity.
• Review the regular analgesic prescriptions. Good Practice Point
• Naloxone should be available in all clinical areas where opioids are used.
(National Patient Safety Agency)
• Naloxone is also available in disposable, pre-filled syringes. These doses may be too high for
patients on regular opioid analgesics. Resources
Professional
Palliative Care Drug Information online http://www.palliativedrugs.com/
Community use
• Naloxone may be administered IM when IV access is not immediately available
• 100 micrograms (0.25ml) naloxone IM should be given and repeated after five minutes if there
is no improvement with the first dose.
• An IV line should be sited as soon as possible.
Key references
1. Twycross R, Wilcock A. Palliative Care Formulary (3rd Edition) 2007, Palliativedrugs.com Ltd., Nottingham
2. National Patient Safety Agency. Safer practice notice 2006/12
3. Adult Emergencies Handbook. NHS Lothian: University Hospitals Division.
4. Electronic Medicines Compendium. www.medicines.org.uk/naloxone http://emc.medicines.org.uk/emc/
5. Lothian Joint Formulary. Section 15.1.7. www.ljf.scot.nhs.uk Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Nausea / Vomiting Nausea / Vomiting in Palliative Care
Introduction
Common, distressing symptoms that can be controlled with careful assessment of underlying
causes, and selection of appropriate medication and route of administration.
Assessment
Seek and treat any reversible causes including:
• gastric irritation • hypercalcaemia • gastroenteritis Management
Choice of drug is based on likely cause(s), side effect profile and route of administration of
antiemetics, and patient's condition/ prognosis. Drug doses and prescribing advice - see chart.
Impaired gastric emptying:
Prokinetic antiemetic: • Intermittent vomiting that • Locally advanced cancer • metoclopramide relieves nausea.
(stomach, pancreas, liver • Early satiety.
metastases, gross ascites) • Audible splash, and • Morphine, anticholinergics • dexamethasone frequent small vomits if • Gastroenterostomy (extrinsic compression/ fluid retained in flaccid • Autonomic neuropathy obstruction from tumour, (diabetes, alcoholism, chronic diffuse gastric tumour) • Other autonomic features kidney disease, coeliac plexus • proton pump inhibitor (eg syncopal episodes, infiltration, paraneoplastic (gastric irritation, reflux) postural hypotension).
syndrome, Parkinson's disease)
Regurgitation:
• Dysphagia, pain, • Obstruction/ compression of • dilatation, stent, laser regurgitation, coughing.
• dexamethasone (opioids, antibiotics, SSRI • metoclopramide • Persistent nausea, little antidepressants, digoxin) • levomepromazine relief from vomiting.
• Extensive cancer • Sepsis• Renal or liver impairment• ↑ calcium, ↓ magnesium, ↓ sodium • Intermittent vomits that Medical management if may relieve nausea.
• Mechanical obstruction surgery not appropriate.
• Colic in mechanical • Peristaltic failure obstruction.
(autonomic neuropathy or • Constipation.
• Worse in the morning.
• Compression/ irritation by tumour • Headache.
• Raised intracranial pressure • add dexamethasone • Neck stiffness.
• Anxiety
Vestibular system:
• prochlorperazine • Worse on movement.
• Motion sickness • Vertigo, deafness if ear • Base of skull, brainstem disease • hyoscine hydrobromide • levomepromazine • Seek specialist advice Unknown or multiple causes:
• metoclopramide • Review possible causes/ • Broad spectrum treatment using and/or levomepromazine previous treatment.
single or multiple drugs. • or cyclizine + haloperidol• add dexamethasone Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Nausea / Vomiting Practice points
• Even if the patient is not vomiting, ask about nausea (often not reported).
• Mechanisms of nausea/ vomiting are complex and multiple pathways are affected; a pragmatic
approach selecting the antiemetic most likely to be effective and then a second drug or drugs is often effective. • Avoid combining drugs with a similar mode of action or side effect profile; and do not combine prokinetics with anticholinergics.
• If patient is vomiting or if oral absorption is in doubt, use the subcutaneous route or rectal • Prescribe the antiemetic regularly and as required starting with the lowest dose.
• Review the treatment and response every 24 hours until symptoms are controlled.
• Continue to review antiemetic use regularly. Stop if underlying cause has resolved.
• Nausea can usually be fully controlled; vomiting about once a day may be acceptable in bowel • Many antiemetics are used outside their marketing authorisation in palliative care, including by the subcutaneous route; this is supported by extensive clinical experience. Palliative medicine specialists occasionally recommend other regimens. This should be clearly documented in the patient's notes. (see: Medication outside marketing authorisation on website).
Patient/ carer advice points
• Make sure the patient knows if the antiemetic is to be taken regularly or as needed; explain the
treatment and plan review.
• Offer dietary advice; small, frequent meals may be better.
• Avoid strong smells, and any nausea triggers.
• Acupuncture/ acupressure has been used for nausea in chemotherapy or surgery.
Resources
Professional
Palliative Care Drug Information online: http://www.palliativedrugs.com/
Patient
Patient leaflet on website: Managing sickness & vomiting
Key References
1. Wood GJ. Management of intractable nausea and vomiting in patients at the end of life. JAMA 2007;
2. Stephenson J. An assessment of aetiology based guidelines for the management of nausea and vomiting in patients with advanced cancer. Support Care Cancer 2006; 14:348-353 3. Glare P. Systematic review of the efficacy of antiemetics in the treatment of nausea in patients with far- advanced cancer. Support Care Cancer 2004; 12: 432-440 4. Kennett A. An open study of methotrimeprazine (levomepromazine) in the management of nausea and vomiting in patients with advanced cancer. Support Care Cancer 2004; 13: 715-721 5. Mannix K. Palliation of nausea and vomiting. CME Cancer Medicine 2002;(1):18-226. Bentley A. Management of nausea and vomiting using clinical pictures. Palliative Medicine 2001; 5:247-253 Issue date: January 2009 Review date: March 2012 Antiemetic information chart
Oral dose range
As required
24 hour SC
dose range
• Anticholinergic antihistamine.
Slows peristalsis in GI tract; acts directly on vomiting centre.
Side effects: dry mouth, urinary retention, blurred vision; also hypotension, extrapyramidal effects, confusion.
• Prokinetic action in GI tract; blocked by anticholinergics.
Lower risk of extrapyramidal side effects than metoclopramide.
Available as 30mg suppository; dose 30-60mg PR twice daily.
• Central and peripheral actions.
Prokinetic action in GI tract; blocked by anticholinergics.
Extrapyramidal side effects (caution in those < 20 years). Injection is 5mg/ml so give larger as needed doses IM not SC.
Issue date: January 2009 • Main action is dopamine blockade; avoid in Parkinson's disease.
Can cause extrapyramidal side effects (eg apathy, withdrawal) especially at higher doses for over 1-2 weeks.
Once daily SC dose can be used as alternative to SC infusion.
• Phenothiazine with a broad spectrum of action.
Use low doses to avoid sedation and hypotension.
Palliative Care Guidelines: Nausea / Vomiting 6mg scored tablet is available on named patient basis; tablet disperses well in water. (see: Levomepromazine on website) SC dose is half the oral dose; a dose can last 12-24 hours.
Slows perstalsis and reduces secretions in GI tract.
Less central side effects than hyoscine hydrobromide.
Review date: March 2012 • Anticholinergic Slows peristalsis and reduces secretions in GI tract.
Side effects: dry mouth, drowsiness, confusion.
Available as topical patch (1mg/ 72 hours) • Used for motion sickness, post-operative vomiting.
Buccal tablet 3mg once or twice daily is available.
• Adjuvant antiemetic; oral dose the same as SC/IM dose Best given in the morning to maintain diurnal rhythm. Monitor for side effects. Review and reduce to lowest effective dose or stop.
See BNF/ Formulary for drugs and doses • Constipating; proven value in oncology Palliative Care Guidelines: Patient information leaflet Other names:
Oramorph® liquid (immediate release or quick acting morphine) Sevredol® tablets (immediate release or quick acting morphine) Modified release morphine:

MST Continus® tablets or granules (12 hourly, long acting morphine) Zomorph® capsules (12 hourly, long acting morphine) Morphgesic® SR tablets (12 hourly, long acting morphine) MXL® capsules (24 hourly, long acting morphine) There are different forms of morphine and different brands – check the name of the
medicine on the box.

Q. What is morphine used for?
A. Morphine is used for moderate to severe pain, and to help breathlessness. Quick acting morphine starts to work after about 30 minutes and usually lasts for about 4 hours. It is used to control breakthrough pain as it works quickly. It may be given in regular doses when your doctor is working out how much morphine is needed to control your pain.
Long acting morphine is used to control on-going pain and is taken regularly.
Q. Isn't morphine only used for patients who are at the end of life?
A. NO. Morphine is given for different sorts of severe pain. This may be as a result of cancer, heart disease or other illnesses. Treatment with morphine may be needed to allow you to continue having as comfortable a life as possible. You will be able to go on taking morphine for as long as you need to. The effects do not wear off with time and the dose can be increased if needed.
Q. When do I take it?
A. Quick acting morphine is sometimes taken regularly every 4 hours. An extra dose can be taken if the pain comes back between the regular doses or if you are taking long acting morphine to control your pain. Wait about 30-60 minutes after taking the extra dose of quick acting morphine. If you still have pain take a second dose. If you need more than 2-3 extra doses of quick acting morphine in a day, tell your doctor or nurse. Long acting morphine is taken every 12 hours to control pain. When you are at home, take your morning dose when you wake up and then the evening dose about 12 hours later. There is one type of long acting morphine (MXL®) that is taken once every 24 hours.
Do not stop taking morphine suddenly.
Q. What do I do if I forget to take a dose?
A. Take a dose as soon as you remember. Do not take a double dose to make up for the missed one. If you are sick and bring up the medicine, repeat the dose as soon as you feel better.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Patient information leaflet Q. Are there any side effects from taking morphine?
A. Sleepiness This is most common when you first take morphine or when the dose is increased. It should improve after a few days.
Constipation This is a very common side effect. It is important to drink plenty of fluids and always take a laxative regularly as prescribed by your doctor. The dose of laxative can be increased or reduced to make sure you pass a soft motion regularly.
Sickness If you feel sick when you first start to take morphine, try taking it with food. Your doctor may need to give you some anti-sickness medicine for a few days until the sickness goes away.
Q. Will I become addicted to morphine and unable to stop taking it?
A. NO. If you no longer need to take morphine, your doctor wil reduce the dose gradual y.
Q. Will morphine always relieve my pain completely?
A. Although morphine is a very good pain killer, it is not helpful for all types of pain. Other treatments may be needed and suggested by your doctor or nurse.
Q. What do I do if I get pain between the regular doses of morphine?
A. If the pain is mild, paracetamol may help. (Do not take more than 8 paracetamol tablets in 24 hours). If it is more severe you should take a dose of quick acting morphine (see above). If you need more than 2-3 extra doses in a day, tel your doctor or nurse.
Some people find that doing certain things like having a bath or going for a walk brings on the pain. Your doctor or nurse may suggest you try taking a dose of quick acting morphine before your start doing something that brings on the pain.
Q. How will I know if the morphine is not going to work for some of my pain?
A. You may still have pain despite taking bigger doses of morphine and may feel unwell in one or more of these ways:• more sleepy than usual• feeling sick more of the time• restlessness or jumpiness• bad dreams Do not worry if this happens. Tell your doctor or nurse. Your doctor may reduce your dose of morphine and suggest other treatments to help the pain.
Q. Can I drive?
A. You may be able to drive but you must discuss this with your doctor. (Patient information leaflet: Strong pain killers and Driving).
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Patient information leaflet Q. Can I drink alcohol?
A. A small glass of wine, beer, sherry or whisky may help you feel better and improve your appetite. It is best to avoid taking more than this as you may become too drowsy.
(Discuss this leaflet with your doctor or nurse who will answer any questions you may have) Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Patient information leaflet Other names:
Oxynorm® capsules (immediate release or quick acting oxycodone) Oxynorm® liquid (immediate release or quick acting oxycodone) Oxycontin® tablets (modified release or 12 hourly, long acting oxycodone) There are different forms of oxycodone – check the name of the medicine on the box.
Q. What is oxycodone used for?
A. Oxycodone is used for moderate to severe pain. Quick acting oxycodone starts to work after about 30 minutes and usually lasts for about 4 hours. It is used to control breakthrough pain as it works quickly. It may be given in regular doses when your doctor is working out how much oxycodone is needed to control your pain.
Long acting oxycodone is used to control on-going pain and is taken regularly.
Q. Isn't a pain killer like oxycodone only used for patients who are at the end of life?
A. NO. Oxycodone is given for different sorts of severe pain. This may be as a result of cancer, heart disease or other illnesses. Treatment with oxycodone may be needed to allow you to continue having as comfortable a life as possible. You will be able to go on taking oxycodone for as long as you need to. The effects do not wear off with time and the dose can be increased if needed.
Q. When do I take it?
A. Quick acting oxycodone is sometimes taken regularly every 4-6 hours. An extra dose can be taken if the pain comes back between the regular doses or if you are taking long acting oxycodone to control your pain. Wait about 30-60 minutes after taking the extra dose of quick acting oxycodone. If you still have pain take a second dose. If you need more than 2-3 extra doses of quick acting oxycodone in a day, tell your doctor or nurse.
Long acting oxycodone is taken every 12 hours to control pain. When you are at home, take your morning dose when you wake up and then the evening dose about 12 hours later.
Do not stop taking oxycodone suddenly.
Q. What do I do if I forget to take a dose?
A. Take a dose as soon as you remember. Do not take a double dose to make up for the missed one. If you are sick and bring up the medicine, repeat the dose as soon as you feel better.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Patient information leaflet Q. Are there any side effects from using oxycodone?
A. Sleepiness
This is most common when you first take oxycodone or when the dose is increased. It
should improve after a few days.
Constipation
This is a very common side effect. It is important to drink plenty of fluids and always
take a laxative regularly as prescribed by your doctor. The dose of laxative can be increased or reduced to make sure you pass a soft motion regularly.
Sickness
If you feel sick when you first start to take oxycodone, try taking it with food. Your
doctor may need to give you some anti-sickness medicine for a few days until the sickness goes away.
Q. Will I become addicted to oxycodone and unable to stop taking it?
A. NO. If you no longer need to take oxycodone, your doctor will reduce the dose gradually so that you stop taking it without problems.
Q. Will oxycodone always relieve my pain completely?
A. Although oxycodone is a very good pain killer it is not helpful for all types of pain. Other treatments may be needed and suggested by your doctor or nurse.
Q. What do I do if I get pain between the regular doses of oxycodone?
A. If the pain is mild, paracetamol may help. (Do not take more than 8 paracetamol tablets in 24 hours). If it is more severe you should take a dose of quick acting oxycodone (see above). If you need more than 2-3 extra doses in a day, tell your doctor or nurse.
Some people find that doing certain things like having a bath or going for a walk brings on the pain. Your doctor or nurse may suggest you try taking a dose of quick acting oxycodone before your start doing something that brings on the pain.
Q. How will I know if the oxycodone is not going to work for some of my pain?
A. You may still have pain despite taking bigger doses of oxycodone and may feel unwell in one or more of these ways: • more sleepy than usual• feeling sick more of the time• restlessness or jumpiness• bad dreams Do not worry if this happens. Tell your doctor or nurse. Your doctor may reduce your dose of oxycodone and suggest other treatments to help the pain.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Patient information leaflet Q. Can I drive?
A. You may be able to drive but you must discuss this with your doctor. (Patient information leaflet: Strong Pain Killers and Driving).
Q. Can I drink alcohol?
A. A small glass of wine, beer, sherry or whisky may help you feel better and improve your appetite. It is best to avoid taking more than this as you may become too drowsy.
(Discuss this leaflet with your doctor or nurse who will answer any questions you may have) Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Oxycodone Oxycodone in Palliative Care
Description
Potent, synthetic opioid analgesic; used second line.
Immediate release oxycodone
OxyNorm ® capsules
OxyNorm ® liquid
Modified release (long acting) oxycodone 5mg, 10mg, 20mg, Oxycodone injection 10mg/ml, 20mg/2ml Indications
Second line oral and injectable analgesic for moderate to severe opioid responsive pain in
patients unable to tolerate oral morphine, subcutaneous morphine or diamorphine due to persistent side effects (eg sedation, confusion, hallucinations, itch).
Cautions
• Immediate release, modified release and injection preparations have similar names. Take care
when prescribing, dispensing or administering oxycodone.
• Frail or elderly patients need smaller doses less frequently and slower titration.
• Liver impairment: reduced clearance.
Avoid in patients with moderate to severe liver impairment.
• Renal impairment: reduced excretion.
Titrate slowly and monitor carefully in mild to moderate renal impairment.
Avoid in chronic kidney disease stages 4-5 (eGFR <30ml/min).
Drug interactions
No clinically significant interactions.
Side effects
• Opioid side effects similar to morphine - monitor for opioid toxicity.
• Prescribe a laxative and an antiemetic as needed (eg metoclopramide).
Dose & Administration
• Immediate release oral oxycodone:
Prescribe 4-6 hourly regularly and use the same dose as required for breakthrough pain.
• Modified release (long acting) oral oxycodone:
o Prescribe 12 hourly, with 1/6th of the 24 hour dose as immediate release oral oxycodone for breakthrough pain.
o Biphasic action; a rapid release is followed by a controlled release phase. If the patient has pain when the dose of modified release (long acting) oxycodone is given, wait an hour before giving a breakthrough dose of immediate release oxycodone. Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Oxycodone Dose & Administration
• Oxycodone injection:
o Continuous subcutaneous infusion in a syringe driver or pump over 24 hours.
o In addition, prescribe 1/6th of the 24hour infusion dose subcutaneously, 1-2 hourly as required for breakthrough pain. o If the infusion dose is greater than 60mg / 24 hours, use another opioid for breakthrough injections (low concentration of oxycodone preparation limits dose for SC injection to 10mg in 1ml).
o Diluent: water for injection.
o Dose conversions are given below.
Dose Conversions
• Oxycodone is approximately twice as potent as morphine.
Oral morphine 60mg ≈ oral oxycodone 30mg ≈ subcutaneous oxycodone 15mg Subcutaneous morphine 30mg ≈ subcutaneous oxycodone 15mg Subcutaneous diamorphine 20mg ≈ subcutaneous oxycodone 15mg • As with all opioid conversions, these are approximate doses.
• Dose conversions should be conservative and doses rounded down.
• Monitor the patient carefully so that the dose can be adjusted if necessary. • If the patient has opioid toxicity, reduce the dose by 1/3rd when changing opioid.
Discharge planning / Community use
• The unscheduled care service should be informed that the patient is receiving this second line
opioid in a syringe driver or pump. • The Community Pharmacy Palliative Care Network stocks a limited supply of oral and injection preparations of oxycodone for emergency use.
Key references
1. Shah S, Hardy J. Oxycodone: a review of the literature. European J Palliative Care 2001; 8: 93-96
2. Smith M et al. Oxycodone has a distinctly different pharmacology from morphine. European J Pain 2001; 15
(Suppl A): 135–136. 3. Mucci-LoRusso P et al. Controlled release oxycodone compared with controlled release morphine in the treatment of cancer pain: a randomised, double blind parallel group study. European J Pain 1998; 2: 239-249 Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Pain Assessment Pain Assessment for People with Cognitive
Impairment / Communication Difficulties
Aims

Exclude other problems
• fear, anxiety or disorientation/ isolation
• Involve the patient as much • other physical symptoms – eg constipation as possible in the assessment • delirium or chronic confusion and management of their • stress related behaviours • Use a team approach; involve the family, staff and carers Immediate treatment may be required before
who know the patient well.
further assessment
• Assess each pain separately Adjust the dose of analgesia to take account of recent and identify the likely Seek advice
• Assess the impact of the pain Enhance verbal and non-verbal communication
on the patient and family.
• Allow plenty of time.
• Make a diagnosis and explain • Use sensory aids where needed- hearing aid, glasses, this to the patient and family.
signing, visual tools.
• Agree a pain management • Minimise distractions – noise, bright lights, activity.
• Use the person's preferred name at the start of each question to hold their attention and focus. 1. Is pain the main • Use simple language; short sentences.
cause of the patient's • Repeat questions; check understanding.
• Consider using pictures – body maps, photographs, 2. Is the pain severe and Find out
• How the patient usually behaves when comfortable.
3. Can the patient • How the patient usually expresses themselves when participate in the • If the patient has had previous pain problems due to a long term condition (e.g. arthritis).
4. Is there a carer, friend • About any non-drug treatments used for pain relief or staff member who and medications currently or previously used, knows the patient including their effectiveness and any side effects.
and can help with assessment? Actions
• Record your assessment; consider using a behavioural tool
Pain is often poorly assessed (eg. Abbey, Doloplus 2, DisDAT) and inadequately managed in • Different pains may require different interventions. The people with dementia, learning management of distress related behaviour is important. disabilities or a stroke.
Seek advice
• Decide if the Adults with Incapacity Act is needed to cover treatment. (See guideline on website) • Discuss management with patient / carers. A trial of analgesics and / or non-drug treatments may be appropriate. If opioids are required, discuss any concerns regarding their use.
• Agree goals for pain relief and a monitoring plan.
See website for references and online resources including behavioural pain assessment tools.
http://www.palliativeguidelines.scot.nhs.uk Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Pain Assessment Pain Assessment – Five Key Questions
Aims

Immediate treatment may be required
before further assessment.
• Obtain the patient's own Adjust the dose according to current analgesic use.
description and assessment Seek advice
of their pain. Most patients have more than one pain.
Ask about
• Assess each pain separately • Site / radiation - body diagrams can help
and identify the likely • Character - a list of descriptive words may help
Intensity / severity - a rating scale can help
• Assess the impact of the pain • Timing
on the patient and family.
Exacerbating factors
• Make a diagnosis and explain • Relieving factors (including medication)
this to the patient and family.
Effect on function / sleep
• Agree a pain management Use a structured pain assessment tool to make a full assessment and record of the patient's pain.
Disease?
1. Is the pain severe and e.g. direct invasion by cancer; distension of an organ; pressure on surrounding structures.
2. What is the pain like? e.g. constipation with opioids; chemotherapy neuropathy; mucositis; late onset pain fol owing radiotherapy.
3. What is causing the e.g. pressure sores.
4. Is it a specific type of Other unrelated pathology?
e.g. arthritis; cervical spondylitis, osteoporosis, vascular disease, neuropathy.
5. Are other factors Bone Pain
Worse on pressure or stressing bone, or weight bearing.
Nerve Pain
Burning / shooting / tingling / jagging, altered
sensation / dermatomal distribution.
Liver Pain
• Record your pain score and Hepatomegaly, right upper quadrant tenderness.
assessment. Use a pain assessment tool.
Episodic/ incident pain
• Different pains may require Sudden onset pain occurring spontaneously or with different interventions to movement; can be severe but may be very short lived.
Raised intracranial pressure
(see: Pain management) Headache (and/or nausea) worse with lying down, • Discuss management with more often present in the morning.
patient / carers. If opioids are prescribed, discuss any concerns about their use Intermittent, cramping pain (e.g. addiction, side effects, Consider adjuvant therapies
tolerance, hastening death) • Agree goals for pain relief; • Anxiety / depression.
and a monitoring plan.
• Other psychological factors e.g. fear, ‘unfinished • Other physical symptoms e.g. nausea, breathlessness.
• Family / carer distress.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Pain Management STEP 3: Moderate to Severe Pain

+ PARACETAMOL
+/- OTHER
contraindicated) Stop any step 2 opioid
Seek advice:
Codeine or dihydrocodeine 60mg qds ≈ 30mg oral morphine / 24hours ♦ Severe pain.
If titrating with immediate release If starting with modified release
oral morphine prescribe
oral morphine prescribe
5mg, 4 hourly and as required for 10-15mg, 12 hourly and ♦ Dose of opioid has breakthrough pain. immediate release morphine 5mg increased rapidly as required for breakthrough pain.
but patient is still in pain.
Use lower doses and increase dose more slowly if patient is frail, ♦ Episodes of acute elderly or has renal impairment. severe pain.
♦ Pain worse on for second/ third line opioids.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Renal Palliative Care - Last Days of Life Renal Palliative Care – Last Days of Life
Introduction
• Guideline for patients with stage 4-5 chronic kidney disease (eGFR <30ml/min).
• Other relevant guidelines: Last days of life, Subcutaneous medication, Alfentanil, Fentanyl.
• Survival after renal dialysis withdrawal is usually about 7-10 days, but some patients with
residual renal function may live much longer and need continuing care.
• If a patient is likely to stop dialysis soon, plan end-of-life care in advance.
Assessment
Diagnosis of the terminal phase can be difficult. Reversible causes of deterioration include
hypercalcaemia, infection, and opioid toxicity. Clinical signs include:
• bed-bound and drowsy or semicomatose.
• only able to take sips of fluid/ difficulty swallowing tablets.
• poor tolerance of renal replacement therapy.
Management
Plan and document care of the patient and family; consider using a care pathway or checklist.
• Discuss prognosis (patient is dying), goals of care (maintaining comfort), and preferred place of
death with patient and/or family.
• Clarify resuscitation status; check DNAR form has been completed. (See: local policy) • Reassure the patient and family that full supportive care will continue.
• Stop unnecessary investigations and monitoring (BP, pulse, temperature).
• Discontinue medication not needed for symptom control, and review daily.
Some patients may still benefit from oral diuretics, adjuvant analgesics, bicarbonate.
• If able to swallow, consider liquid formulations. Otherwise use the SC or rectal route.
• Offer oral fluids, maintaining any fluid restriction; stop IV/IM/SC fluids.
• Comfort nursing care (pressure relieving mattress, reposition for comfort only), eye care,
mouth care (sips of fluid, oral gel), bladder and bowel care.
Anticipatory prescribing
All patients should have as required medication for symptom control available:
• Opioid analgesic: alfentanil SC hourly (100-250micrograms, if not on a regular opioid).
• Anxiolytic sedative: midazolam SC 2.5-5mg, hourly.
• Anti-secretory medication: hyoscine butylbromide (Buscopan) SC 20mg, hourly.
• Anti-emetic: haloperidol SC 0.5-1mg, 12 hourly or levomepromazine SC 2.5-5mg, 8-12 hourly.
Pain (see dose conversion chart below)
• Paracetamol or an NSAID (benefits may outweigh risks in a dying patient) can help bone, joint,
pressure sore, inflammatory pain.
o Morphine / diamorphine are renally excreted as is oxycodone to a lesser extent; these opioids accumulate and can cause significant toxicity with repeated doses. o A single dose can be given if the patient is not opioid toxic while a supply of alfentanil or fentanyl is obtained. • No regular opioid: alfentanil SC 100-250micrograms hourly, as required.
• Fentanyl patch: continue patch, use correct SC alfentanil dose for breakthrough pain. • Other opioids should be converted to a subcutaneous infusion of alfentanil in a syringe driver/ pump with the correct SC alfentanil dose, hourly as required (see chart).
Myoclonus or muscle stiffness/ spasm: midazolam SC infusion, 5-20mg over 24 hours.
Anxiety/distress: midazolam SC 2.5-5mg, hourly, as required.

Try to address psychological and family concerns causing patient anxiety.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Renal Palliative Care - Last Days of Life Breathlessness
• May be due to pulmonary oedema, acidosis, anxiety or lung disease.
• Oral diuretic if able to swallow. Avoid fluid overload; consider ultrafiltration.
midazolam SC 2.5mg hourly, as required &/ or lorazepam breathlessness/ distress sublingual 0.5mg 8 hourly, as required.
alfentanil SC hourly, as required.
- fentanyl patch or alfentanil infusion: see chart for dose.
- no regular opioid: alfentanil SC 100-250micrograms. midazolam SC 5-20mg + alfentanil SC 500 micrograms (if no breathlessness/ distress opioid for pain) via a syringe driver or pump.
Respiratory tract secretions
1st line: hyoscine butylbromide SC 20mg, hourly as required (up to 120mg/ 24hours).
2nd line: glycopyrronium bromide SC 100micrograms, 6-8 hourly as required.
Nausea / vomiting• Nausea is common due to uraemia and co-morbidity.
• If already controlled with an oral anti-emetic, continue it as a subcutaneous infusion or use a
long acting anti-emetic: haloperidol SC 0.5-1mg twice daily or 1-2.5mg once daily. levomepromazine SC 2.5mg twice daily or 5mg once daily.
• Treat persistent nausea with levomepromazine SC 5-12.5mg once or twice daily or use 5-25mg over 24 hours in a syringe driver/ pump.
Delirium
• Common and may worsen as uraemia increases; needs active management
Mild delirium/ hallucinations Haloperidol SC 2.5mg, once daily Established terminal delirium/ distress midazolam SC 20-30mg over midazolam SC 40-80mg over 24 hours in a driver/pump 24 hours in a syringe driver/ pump + midazolam SC 5mg hourly, + levomepromazine SC as required OR regular rectal 12.5-25mg, 6-12 hourly, as diazepam 5-10mg, 6-8 hourly.
required, stop any haloperidol.
Practice points
• Opioid analgesics should not be used to sedate dying patients.
• Avoid renally excreted opioids (codeine, dihydrocodeine, morphine, diamorphine, oxycodone).
• Subcutaneous infusions provide maintenance treatment only; additional SC doses of medication
will be needed if the patient's symptoms are not controlled.
• Midazolam is titrated in 5-10 mg steps. Up to 5mg can be given in a single SC injection (1ml). Single SC doses can last 2-4 hours. Useful as an anticonvulsant.
• A marked increase in pain in the dying patient is unusual; reassess and seek advice.
• As uraemia worsens, the patient may become more agitated and need an increased dose of midazolam, and in some cases additional levomepromazine.
Resources
Professional
NHS End of life care Programme http://www.endoflifecare.nhs.uk/eolc
Liverpool Integrated Care Pathway http://www.mcpcil.org.uk/liverpool_care_pathway
Patient

Key references
1. Bunn R, Ashley C. The renal drug handbook Oxford, Radcliffe Medical Press 2004
2. Chambers J. Supportive care for the renal patient Oxford, OUP 2004
3. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Management 2004; 28(5): 497-504
Further reading: http://www.pal iativecareguidelines.scot.nhs.uk
Issue date: January 2009 Review date: March 2012 A guide to opioid doses for dying patients with acute renal impairment or stage 4-5 chronic kidney disease (GFR < 30ml/min)
• Use this chart as a guide. The doses are approximate and not exact equivalent doses.
• Always prescribe an appropriate opioid drug and dose for breakthrough pain.
• Avoid renally excreted opioids (codeine, dihydrocodeine, morphine, diamorphine, oxycodone) • • Reduce the dose by up to 30% when changing opioid if the patient is opioid toxic, frail or elderly and re-titrate.
• Particular care is needed when changing between opioids at higher doses or when the dose of the first opioid has been rapidly increased as these patients are at greater risk of adverse effects. Monitor the patient carefully; if in doubt – seek advice
Change to alfentanil or fentanyl Opioids of choice in moderate to severe renal impairment 4 hourly 24 hour 24 hour 4 hourly 24 hour 4 hourly 24 hour 24 hour SC as required total oral total SC total oral total SC dose, hourly, driver/ pump dose Palliative Care Guidelines: Renal Palliative Care - Last Days of Life Issue date: January 2009 1mg (1000 micrograms) 1 If it is not possible to obtain alfentanil, a single 4 hourly dose of morphine SC, diamorphine SC or oxycodone SC may be given as an interim measure but should not be repeated. A continuous subcutaneous infusion should not be used.
Review date: March 2012 Alfentanil clearance is reduced in liver impairment; reduce dose and titrate.
Alfentanil is supplied as 500micrograms/ ml. If higher SC breakthrough doses or a SC infusion dose over 6mg are needed – seek advice.
4 Fentanyl is approximately four times more potent than alfentanil and longer acting. Fentanyl clearance may be reduced in severe liver impairment, and it can accumulate in chronic kidney disease. Fentanyl SC injections can be used for breakthrough symptom control if alfentanil is ineffective due to its short duration of action. The low concentration of the fentanyl preparation limits the SC injection dose to a maximum of 50 micrograms (1ml). Fentanyl SC 50 micrograms is approximately equivalent to alfentanil SC 200-250 micrograms. Seek advice.
Palliative Care Guidelines: Renal Palliative Care - Last Days of Life Compatibility Table: Subcutaneous Alfentanil Infusion in a Syringe Driver
Diluent: Water for injections

These are not clinical doses to prescribe. Most patients do not need high such doses.
Refer to the prescribing guide above.
• Use this table to check for concentrations that are stable.
• Read the guideline: Subcutaneous infusion of medication in Palliative Care. • Use the minimum effective dose and titrate according to response.
Maximum concentrations of two drug combinations that
are physically stable

14ml in 20ml syringe
17ml in 30ml syringe
Glycopyrronium bromide Hyoscine butylbromide Hyoscine hydrobromide Maximum concentrations of three drug combinations
that are physically stable

14ml in 20ml syringe
17ml in 30ml syringe
Hyoscine butylbromide Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Renal Palliative Care Symptom control in patients with chronic kidney
disease/ renal impairment
Introduction
• This guideline covers modifications to standard symptom control that are recommended in
patients with chronic kidney disease or acute renal impairment.
• Renal impairment is common in patients with diabetes, cardiovascular disease or cancer (from disease or treatment eg. chemotherapy, obstructive uropathy, myeloma).
• Symptom control is complicated by delayed drug clearance, dialysis effects and renal toxicity associated with commonly used medication (eg. NSAIDs).
• 50% of dialysis patients have pain. Depression and other symptoms are common.
Chronic kidney disease (CKD)
CKD stage 1
Normal renal function CKD stage 2
Mild impairment (eGFR 60-89 ml/min) CKD stage 3a
Moderate impairment (eGFR 45-59 ml/min) CKD stage 3b
Moderate impairment (eGFR 30-44 ml/min) Anaemia, fatigue, muscle cramps CKD stage 4
Severe impairment (eGFR 15-29 ml/min) In addition: anorexia, nausea, insomnia, neuropathy, gout CKD stage 5
End stage renal disease In addition: itch, headache, (eGFR < 15 ml/min) cognitive impairment; death • Pain is common and associated with many of the complications of advanced CKD.
• Look for multiple types of pain and/or other symptoms due to: o renal disease (polycystic kidneys, liver cysts, amyloid).
o co-morbidity (diabetes, vascular disease, angina).
o dialysis (abdominal pain in peritoneal dialysis, headache, fistula problems).
o other pathology (cancer, osteoarthritis).
• Pain in patients with chronic kidney disease: o Musculoskeletal pain.
• Muscle spasm, cramps, restless leg syndrome.
• Osteoporosis.
• Renal osteodystrophy.
• Osteomyelitis, disc infection.
• Carpal tunnel syndrome.
o Neuropathic pain – renal or diabetic peripheral neuropathy.
o Ischaemic pain – peripheral vascular disease, vasculitis.
o Calciphylaxis – complex pain caused by tissue ischaemia due to calcification of small vessels/ subcutaneous tissue.
• Identify chronic pain (needs regular analgesia) and any intermittent/ episodic pain as this often needs managed separately with short acting analgesics/ non-drug measures.
• Some drugs will be cleared by dialysis; an extra dose during or after dialysis may be needed.
• Patients are often on multiple drugs with a high risk of interactions/side effects.
Management
• Much of the advice in the palliative care guidelines is applicable to patients with renal disease.
See table for renal prescribing advice.
• • Choice and dose of opioids depends on the degree of renal impairment. • Mild renal impairment; use lower starting doses of renally excreted opioids (codeine, dihydrocodeine, morphine, diamorphine, oxycodone) and slower titration.
• Stages 3-5 chronic kidney disease; use a modified WHO analgesic ladder (see page 2).
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Renal Palliative Care Pain management in renal disease
STEP 1: Mild Pain
Assess pain fully before treatment. Ask the patient regularly about their pain.
Paracetamol +/- adjuvant analgesic
Record a pain score. STEP 2: Mild to moderate pain
Paracetamol
+ low dose opioid or nefopam +/- adjuvant analgesic
• Nefopam is a moderately potent, non-opioid – reduce dose if GFR < 60ml/min.
• Low dose oxycodone or tramadol can be used if GFR > 30ml/min – reduce dose and
frequency, monitor closely for side effects (drowsiness, hallucinations, confusion).
STEP 3: Moderate to severe pain
Paracetamol
+ selected opioid +/- adjuvant analgesic
• Fentanyl patch – opioid of choice for stable pain; well tolerated, not renally excreted or
removed by dialysis. Can accumulate with longer term use; monitor and adjust dose.
Nefopam is used for breakthrough pain or an oral opioid as in step 2. • Alfentanil injection– used as a SC injection, sublingually, or as a subcutaneous infusion.
• Methadone – titration complex so only use on specialist advice.
Adjuvant analgesics (for prescribing advice see table below)
Seek advice:
♦ Severe pain.
Antidepressant or anticonvulsant: for nerve pain
♦ Pain not responding to Start at a low dose; titrate slowly. No clear difference in efficacy.
• amitriptyline (side effects: confusion, hypotension, dry mouth) ♦ Dose of opioid has increased rapidly but • gabapentin (side effects: sedation, tremor); adjust dose for renal function patient is still in pain.
• sodium valproate • carbamazepine ♦ Episodes of acute severe pain.
Ketamine: complex neuropathic pain including calciphylaxis
♦ Pain worse on (see: Ketamine on website) Symptom control in renal disease (see prescribing advice tables)
• Depression – common and underdiagnosed. (see: )
• SSRI antidepressant (eg sertraline) is often used.
• Dialysis associated symptoms (hypotension, nausea, cramps, fatigue) – review dialysis prescription.
• Hiccups – (see: • Treat any other underlying cause eg gastro-oesophageal reflux.
• Prokinetic antiemetic (metoclopramide or domperidone).
• Baclofen – adjust dose for renal function.
• Itch – common and distressing. (see: • Good skin care with regular use of emol ients +/- antihistamine.
• Ondansetron has been used for intractable uraemic itch; 4-8mg twice daily.
• Nausea/ vomiting – assess likely cause (see:).
• Gastric stasis is common – treat with metoclopramide (short term) or domperidone• Levomepromazine is a useful broad spectrum antiemetic; use low doses and monitor for hypotension.
• Cyclizine worsens dry mouth in patients on fluid restriction.
• Restless leg syndrome – affects 20-40% of uraemic patients.
• Clonazepam oral y starting at 0.5mg nocte.
• Gabapentin 100-300mg nocte (adjust dose for renal function).
• Other common symptoms include and – see relevant pal iative care Issue date: January 2009 Review date: March 2012 Prescribing advice for palliative care patients with chronic kidney disease/renal impairment – Part 1
For further information see: other Palliative Care Guidelines & Last days of life (renal) guideline
Moderate:
GFR 60-89 ml/min
GFR 30-59 ml/min
Normal starting dose 6-8 hourly dosing 50-75% normal dose Nephrotoxic, ↑ risk of GI bleed (platelet dysfunction). Only used when patient is Normal starting dose AVOID or use small Metabolites accumulate. Reports of severe (monitor closely) dose and titrate slowly Dihydrocodeine: v toxicity in CKD stage 4/5.
small dose, slowly Normal starting dose 50 -100mg, 12 hourly Use 50mg, 12 hourly for dialysis patients. (Max 200 mg / 24 hrs) Risk of confusion/ delirium.
30-60mg, 8 hourly Can accumulate if on dialysis. Full dose ≈ fentanyl 12 microgram patch.
Morphine/ diamorphine AVOID or use very CNS depot clears slowly in HD. Metabolites Issue date: January 2009 accumulate in PD. Single dose post HD can be used. Monitor closely.
dialysis dosing.
Normal starting dose AVOID or use very ↑ half life, and ↓ excretion of metabolites. dose, reduce dose low dose & monitor Avoid modified release preparation. frequency to 8 hourly Palliative Care Guidelines: Renal Palliative Care Normal starting dose Can accumulate after longer term use; monitor and adjust dose.
Normal starting dose Normal starting dose Normal or reduced Normal starting dose Normal starting dose Seek specialist advice re dose and titration. 75% dose, 8 hourly 50% dose, 8 hourly Reduced clearance; more risk of (10mg, 8 hourly) extrapyramidal side effects.
Normal starting dose Normal starting dose Review date: March 2012 (10mg, 6-8 hourly) Normal starting dose Normal starting dose Dry mouth. More CNS side effects. (25mg, 8 hourly) Hypotension, tachyarrhythmias reported.
Normal starting dose Lowers seizure threshold, ↑risk cardiac arrhythmias, may accumulate.
Start low & titrate Start low & titrate Sedation at higher doses. Causes hypotension. Lowers seizure threshold.
Normal starting dose Normal starting dose Normal starting dose May help itch, constipating.
Issue date: January 2009 Palliative Care Guidelines: Renal Palliative Care Prescribing advice for palliative care patients with chronic kidney disease/ renal impairment – Part 2
For further information see: other Palliative Care Guidelines & Last days of life (renal) guideline
Moderate:
GFR 30-59 ml/min
GFR 15-29 ml/min
Normal starting dose Start lower & titrate Used for insomnia, anxiety and muscle spasm/ myoclonus.
0.5mg, 6 hourly or nocte Start lower & titrate Start lower and titrate dose for 2.5mg, 1-2 hourly Start lower & titrate all benzodiazepines. Metabolites excreted renally and protein Normal starting dose binding is reduced.
Review date: March 2012 Start low dose & titrate Lower dose & titrate 300mg alternate days.
Parent drug accumulates. If on dialysis, only after it.
Withdraw gradually, over a week.
Normal starting dose Normal starting dose Well tolerated, avoid if liver 100-200mg, 12 hourly disease. Titrate slowly .
Normal starting dose Normal starting dose Drug interactions.
100-200mg, 12 hourly Normal starting dose Normal starting dose Drug interactions, side effects, and contraindications can limit use.
Titrate slowly.
Normal starting dose Normal starting dose Check BNF for drug interactions Normal starting dose Normal starting dose Normal starting dose (eg. with tramadol). Start at lowest e n dose and titrate carefully in CKD Normal starting dose Normal starting dose Start at low dose and monitor closely.
Withdraw gradually.
Ketamine oral or SC Starting dose orally Normal starting dose May be tolerated in Little information available. Less (see guideline on standard doses but start than 2-3% of ketamine is excreted at low dose and monitor unchanged. Can accumulate.
Seek specialist advice.
Normal starting dose Normal starting dose Normal starting dose Normal starting dose 20mg SC, 1-2 hourly Normal starting dose Normal starting dose Use for respiratory secretions, bowel colic, bladder spasms.
SIGN 103 recommends that creatinine clearance estimated by the Cockcroft-Gault formula be used for drug dosing as published recommendations are
based on this prediction equation for GFR. The tables are a guide to dose adjustments. Each patient should be assessed and monitored individually.

Palliative Care Guidelines: Renal Palliative Care Measuring renal function
• Prediction equations are more accurate than serum creatinine or 24-hour urine creatinine
• The equations are affected by age, sex and weight so are less reliable in older people and those with cachexia, obesity or oedema.
• eGFR is reported in routine laboratory results but is less accurate at values of > 60ml/ min.
• Cockcroft-Gault formula is recommended in drug manufacturer's information. GFR (ml/min) = (140- Age) X IBW (kg) X 1.23 if male (1.04 if female) serum creatinine (micromoles/l) Ideal Body Weight (IBW) is recommended for the calculation particularly if the patient is oedematous or obese.
= male 50 + 2.3kg per inch over 5 feet = female 45.5 + 2.3kg per inch over 5 feet Key references
1. Scottish Intercollegiate Guidelines Network. Diagnosis and management of chronic kidney disease. SIGN 103,
Edinburgh 2008.
2. Douglas C. Symptom management for the adult patient dying with advanced chronic kidney disease: a review of the literature and development of evidence based guidelines by a United Kingdom Expert Consensus Group. Palliative Medicine 2009; 23:103-110.
3. Murtagh FE. Symptoms in advanced renal disease: a cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis. J Palliative Medicine 2007;10:1266-1276.
4. Ashley C. The Renal Drug Handbook 2004: Radcliffe Medical Press, Oxford5. Chambers J. Supportive Care for the renal patient. 2004: Oxford University Press.
6. Broadbent A. Palliation and Chronic Renal Failure: Opioid and other palliative medications – dosage guidelines. Progress in Palliative Care: 2003; 11(4): 183-190.
7. Broadbent A. Palliation and Renal Failure: Common non-opioid medication dosage guidelines. Progress in Palliative Care: 2003; 11(2): 59-65.
8. Dean M. Opioids in renal failure and dialysis patients. Journal Pain & Symptom Management: 2004; 28(5):497- 9. Aronoff G. The Renal Drug Book 2002 10. Cohen C M. Renal Palliative Care in Non-malignant disease. 2001 Oxford University Press.
11. Farrell A. Analgesic use in patients with renal failure. European Journal Palliative Care, 2000: 7(6), 201-205.
12. Polizzotto M N. Symptomatic Management of Calciphylaxis: A Case Series and Review of the Literature. Journal Pain & Symptom Management 2006; 32(2): 186-190.
13. Cohen M. Renal Palliative Care. Journal of Palliative Medicine 2006; 9(4):977-991.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Subcutaneous medication Subcutaneous infusion of medication in Palliative Care
Introduction
• Portable devices are frequently used in palliative care to deliver a continuous subcutaneous
infusion of medication over 24 hours. Check which device is used in your area.
Indications
Patient is unable to take medication orally due to:
• Persistent nausea and/ or vomiting.
• Dysphagia.
• Bowel obstruction or malabsorption.
• Reduced level of consciousness, such as in the last days of life.
General information
• Use your local protocol for setting up a syringe driver or syringe pump.
• The table below contains information about preparations, dose ranges and indications for
single drugs that can be given by subcutaneous infusion for symptom control in palliative care. Compatibility tables
• The tables contain information about the stability and compatibilities of drug combinations that
are given in a subcutaneous infusion in palliative care. • The compatibility charts should not be used to guide prescribing. They do not contain
clinical dose information. Read the relevant sections of the palliative care guidelines for the
symptom(s) being treated when choosing the correct dose to prescribe.
• Use the correct compatibility tables for the infusion device in use in your area. Compatibility tables are available for a syringe driver and for the McKinley T34 syringe pump for: • Morphine and one or two other drugs• Diamorphine and one or two other drugs• Oxycodone and one or two other drugs• Alfentanil and one or two other drugs • Drugs, doses or combinations other than those listed in the compatibility charts are used occasionally on the recommendation of a palliative care specialist. Any recommendation given by the palliative care specialist should be documented clearly in the patient's notes.
Practice Points
• A continuous subcutaneous infusion of medication aims to maintain symptom control. If the
patient has uncontrolled symptoms before the infusion is started or during the infusion period, give breakthrough doses of medication as required.
• Prescribe the medication for subcutaneous infusion and the diluent (usually water for injection). The infusion is usually given over 24 hours.
• Prescribe the correct breakthrough dose, as required, for each medication in the infusion but avoid a volume over 1ml for subcutaneous bolus injection.
• Prepare a new syringe every 24 hours.
• Protect the syringe from direct light.
• Check the syringe regularly as per local protocol for precipitation, cloudiness, particles, colour change; make sure it is running to time. Check the line, connection and cannula regularly.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Subcutaneous medication Single drugs used in a subcutaneous infusion in Palliative Care
Diluent: water for injections

Single agent
Indications and dose range
Indications: opioid responsive pain, • 1st line opioid analgesic. 10mg, 30mg in 1ml Dose: See Choosing & Changing opioids
Indications: opioid responsive pain, • Can be diluted in a small volume. 10mg, 30mg, 100mg, • Preferred for high opioid doses.
Dose: See Choosing & Changing opioids
Indications: opioid responsive pain, • 2nd line opioid analgesic if morphine/ diamorphine not tolerated.
Dose: See Choosing & Changing opioids
Indications: opioid responsive pain, • 3rd line opioid; seek specialist advice.
1mg (1000micrograms) • 1st line in stages 4 /5 chronic kidney in 2ml, 5mg in 10ml Dose: See Choosing & Changing opioids
Indications: nausea and vomiting (bowel • Anticholinergic; reduces peristalsis.
obstruction or intracranial disease). • Can cause redness, irritation at site.
Dose: 50-150mg / 24 hours
• Do not mix with oxycodone or hyoscine.
Indications: nausea and vomiting (gastric stasis/outlet obstruction, opioid) • Avoid if complete bowel obstruction or Dose: 20-120mg / 24 hours
Indications: opioid or metabolic induced • Long half life: can also be given as a nausea, delirium.
once daily SC injection.
Dose: 2.5-5mg / 24 hours
Indications: complex nausea, terminal • Lowers blood pressure.
delirium/ agitation. • Long half life: can be given as a once or Dose: 5-25mg / 24 hours - antiemetic.
twice daily SC injection.
Dose: 25-100mg / 24 hours - terminal
• See: Levomepromazine.
Anticholinergics for chest secretions or bowel colic
HYOSCINE
Indications: chest secretions, bowel • 1st line; non-sedative.
obstruction (colic, vomiting). Dose: 40-120mg / 24 hours
20mg in 1mlGLYCOPYRRONIUM Indications: chest secretions or colic. • 2nd line; non-sedative. 200 micrograms in 1ml Dose: 600-1200 micrograms /24 hours
• Longer duration of action than hyoscine.
600 micrograms in 3mlHYOSCINE Indications: chest secretions. • 2nd line; sedative. Dose: 400-1200 micrograms / 24 hours
• Can precipitate delirium.
400 micrograms in 1ml600 micrograms in 1ml Indications: anxiety, muscle spasm/ • Anxiolytic (5-10mg/ 24 hours).
10mg in 2ml (preferred) myoclonus, seizures, terminal delirium/ • Muscle relaxant (5-20mg/ 24 hours).
• Anticonvulsant (20-30mg/ 24 hours).
Dose: titrate according to symptoms and
• 1st line sedative (20-80mg / 24 hours).
Other medication occasionally given by SC route in palliative care
DEXAMETHASONE
Indications: bowel obstruction, raised • Subcutaneous dose is the same as oral.
intracranial pressure or intractable nausea • Available as different dose formulations and vomiting.
so check preparation. Dose: 2-16mg / 24 hours
• Can be given as a daily SC injection (in the morning).
• Given as a single drug infusion, mixes poorly.
Indication: bone/ inflammatory pain if patient • Specialist supervision only.
in last days of life.
• Give an oral PPI if still able to swallow.
Dose: 10- 30mg / 24 hours
• Long half life particularly in frail patients; can be given as a twice daily SC injection.
Indications: intractable vomiting due to • Some formulations very expensive. bowel obstruction, fistula discharge.
• Potent antisecretory agent.
(5ml multi-dose vial) Dose: 300–900 micrograms / 24 hours
• Does not treat nausea.
• Limit fluid intake to 1-1.5 litre/ 24 hours.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Subcutaneous fluids Subcutaneous Fluids in Palliative Care
Introduction
Artificial hydration is occasionally indicated in palliative care. Before fluids are started, the goals of
this treatment must be clarified by the healthcare team, discussed with the patient and family, and
then reviewed regularly.
Sodium chloride 0.9% 500-1500ml can be given subcutaneously over Indications for artificial hydration
• Patient has persistent symptoms due to dehydration that are not responding to other
management options (eg. intractable nausea, marked postural hypotension).
• Dehydration is contributing to poor renal clearance of opioids (eg. morphine, diamorphine) that are causing symptoms of toxicity such as delirium. The opioid dose and general pain management should also be reviewed.
• The subcutaneous route (SC) can be used if it can meet the patient's fluid requirements in the short term when oral intake is inadequate and maintaining an intravenous line is difficult or inappropriate. Cautions / contraindications
• If a patient is imminently dying, hydration will not improve survival or symptom control and
increases the risk of distressing respiratory secretions. • Fluid overload, ascites, peripheral oedema due to hypoalbuminaemia.
• Patients on fluid restriction or at risk of fluid overload (heart failure, haemodialysis).
• Site problems due to tissue or skin disorders, thrombocytopenia or coagulopathy.
• Intravenous hydration is more effective in some situations (eg hypercalcaemia, hypovolaemia, acute renal failure).
Dose and administration: See local protocol.
• An overnight SC infusion of 500ml will often meet baseline fluid requirements.
• Choose a suitable site: abdominal wall, thigh or chest wall.
• Avoid areas with skin damage/ disease, oedema or lymphoedema, scarring or previous
radiotherapy, near a stoma or a mastectomy scar.
• Fluids are infused by gravity feed; 500ml can be given over 8-12 hours.
• Check site daily and rotate at least every 48 hours to minimise tissue damage. • Re-site the infusion if there is fluid leakage from the site or significant local pooling of fluid consistent with poor absorption.
Practice points
• Artificial hydration will not improve a dry mouth or associated thirst and is never a substitute for
• In the last days of life, artificial fluids and feeding that have been started previously should be • Maintaining hydration can be an emotive issue for families and their concerns need to be addressed sensitively when decisions are being made about artificial hydration and nutrition. Campbell C. Artificial nutrition and hydration. National Council for Palliative Care /Association for Palliative Medicine. 2007 London. National Council for Hospice & Palliative Care Services.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Emergencies in Palliative Care Seizures in Palliative Care
Introduction
• Seizures (generalised or partial) occur in 10-15% of palliative care patients most often due
to primary or secondary brain tumours, cerebrovascular disease, epilepsy, or biochemical abnormalities (eg. low sodium, hypercalcaemia, uraemia).
• An advance care plan is needed if the patient wishes to avoid hospital admission.
Assessment
• Exclude other causes of loss of consciousness or abnormal limb/ facial movement. (eg
vasovagal episode (faint), postural hypotension, arrhythmia, hypoglycaemia, extrapyramidal side effects from dopamine antagonists, alcohol).
• Find out if the patient has had previous seizures or is at risk - history of epilepsy, previous secondary seizure, known cerebral disease.
• Is there a problem with usual antiepileptic drug therapy – unable to take oral medication, drug interactions – check BNF (eg.corticosteroids reduce the effect of carbamazepine, phenytoin).
Management
Acute seizure management
• Put the patient in the recovery position; move any objects that might cause injury.
• If seizure does not resolve quickly, anticonvulsant medication is needed.
Treatment options
• In hospital, diazepam (emulsion) IV in 2mg bolus doses up to 10mg or lorazepam 4mg by slow
IV injection are used. • Diazepam rectal solution 10-30mg given PR or via a stoma.
• Midazolam SC 5mg, repeated after 5 minutes.
• Buccal midazolam 10mg can be given using the parenteral preparation or the buccal liquid (special order product).
Persistent seizures
• IV phenytoin is used in hospital settings.
• Phenobarbital can be given as 100mg IM bolus dose followed, if needed, by a subcutaneous
infusion of phenobarbital 200-400mg diluted in water for injection over 24 hrs. Seek advice from a palliative care specialist.
Chronic seizure control
• Most patients with a structural cause for seizures benefit from treatment.
• Follow SIGN guideline recommendations. Check BNF for drug interactions.
o Partial or secondary generalised seizures - sodium valproate, carbamazepine or lamotrigine.
o Primary generalised seizures – sodium valproate or lamotrigine. • Dying patient unable to take oral medication - antiepileptics have a long half life so additional anticonvulsant treatment may not be needed. o Midazolam SC 5mg or diazepam rectal solution PR 10mg, if required.
o Midazolam SC 20-30mg infusion over 24 hrs can be used as maintenance therapy.
Practice points
• Phenytoin is no longer a first line drug for chronic seizure control. It interacts with many drugs,
and is prone to cause side effects including sedation in palliative care patients.
Professional resource
SIGN Guideline 70 (Epilepsy in Adults): http://www.sign.ac.uk/
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Emergencies in Palliative Care Spinal Cord Compression
Definition
Malignant spinal cord compression occurs when the dural sac and its contents are compressed at
the level of the cord or cauda equina.
• It affects about 5% of patients with cancer. Lung, breast, and prostate cancer are the
commonest causes but it occurs in other cancers.
• Cord compression can be the initial presentation of cancer.
• Late diagnosis is common causing permanent loss of function and significant morbidity. Assessment
• Consider cord compression in any patient with cancer.
• Thoracic cord compression is commonest but any part of the spine and multiple sites can be
• Sites of pain and level of compression do not always correlate; X-rays and bone scans can be • Key signs and symptoms
• New, progressively severe back pain (particularly thoracic). • New spinal nerve root pain (burning, shooting, numbness) – may radiate down anterior or posterior thigh (like sciatica), or like a band around the chest or abdomen.
• Coughing, straining or lying flat may aggravate pain.
• New difficulty walking or climbing stairs; reduced power (motor weakness), sensory impairment or altered sensation in limbs. • Bowel or bladder disturbance - loss of sphincter control is a late sign with a poor prognosis.
• A full neurological examination should be done but may be normal initially.
• MRI is the correct investigation - images the whole spine.
Cauda equina syndrome
Compression of lumbosacral nerve roots below the level of the cord itself results in a different
clinical picture.
• New, severe root pain affecting low back, buttocks, perineum, thighs, legs.
• Loss of sensation often with tingling or numbness in the saddle area.
• Leg weakness, often asymmetrical.
• Bladder, bowel and sexual dysfunction – occur earlier than in cord compression. Loss of anal
Management
Emergency referral is essential – see local protocol for your NHS Board.
• High dose dexamethasone, unless contraindicated, should be started as soon as a diagnosis
of cord compression is suspected: 16mg orally and then daily in the morning. Withdraw gradually after radiotherapy treatment.
• If clinical suspicion of spinal instability, transport as a spinal injury.
• • If there is complete paraplegia and loss of sphincter control, radiotherapy may improve pain control but is unlikely to restore function. • Patients with residual disability need a full multidisciplinary assessment and continuing supportive care including physiotherapy, occupational therapy, pressure area care, bladder and bowel care; social care, psychological and family support.
Issue date: January 2009 Review date: March 2012 Palliative Care Guidelines: Sweating Sweating in Palliative Care
Introduction
Excessive sweating occurs in about 16% of patients with advanced cancer, occurs more at night
and may need a change of clothes and/ or bedding.
Assessment
There are multiple causes including:
• Infection (check patient is not at risk of neutropenic sepsis)
• Lymphoma
• Disseminated cancer (particularly with liver metastases)
• Medication
• SSRI (selective serotonin reuptake inhibitor) antidepressants• hormone therapies (tamoxifen, aromatase inhibitors, gonadorelin analogues) • oestrogen deficiency (natural or treatment related menopause)• androgen deficiency (surgical or hormone treatment)• hypoglycaemia• hyperthyroidism • Alcohol withdrawal• Autonomic neuropathy Management
• Treat any underlying cause, including infection (if appropriate).
• Reduce room temperature, remove excess bedding, increase ventilation, use a fan.
• Wear loose cotton clothing, cool with tepid sponging.
• Maintain fluid intake to avoid dehydration.
• Review medication and prescribe an alternative if possible.
Medication
Sweating with pyrexia:
• Paracetamol 1g, 6 hourly.
• Non-steroidal anti-inflammatory drug.
Sweating without pyrexia (associated with tumour): • Non-steroidal anti-inflammatory drug or dexamethasone 1-2mg daily.
• Antimuscarinic (amitriptyline 10-50mg nocte, levomepromazine 3-6mg nocte) • Cimetidine 400-800mg once daily. (Check BNF for drug interactions).
Sweating with hormone insufficiency: • Seek advice from an oncologist about hormone replacement therapy. Key references
1. Watson M et al. Oxford Handbook of Palliative Care Oxford University Press. 2005; 291-293.
2. Pittelkow M. Sweating. In Oxford Textbook of Palliative Medicine. 3rd Edition 2004, p581-585.
3. Twycross R, Wilcock A. Symptom Management in Advanced Cancer. Third Edition. Radcliffe Medical Press.
2001; 312-315.
Issue date: January 2009 Review date: March 2012

Source: http://www.eldercaregivers.com.my/uploads/3/1/4/5/31451139/nhs_lanarkshire_palliative_care_guidelines.pdf

Aquaculture information pack

AQUACULTURE INFORMATION PACK FEBRUARY In this document The Sustainable Inshore SIFT is a Scottish charity (Registered Scottish Charity Number SC042334) founded in 2011 with the aim of achieving the sustainable management of Scotland's inshore waters so that they provide the maximum long term benefits to all coastal communities.

Pone.0021881 1.8

Altered Negative Unconscious Processing in MajorDepressive Disorder: An Exploratory NeuropsychologicalStudy Zhi Yang1, Jinping Zhao2, Yi Jiang3*, Chunbo Li4*, Jijun Wang4, Xuchu Weng3,5, Georg Northoff5,6 1 Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing, China, 2 School of Life Science and Technology, University of