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Microsoft word - sc guideline pallcare nhsl dec 09.doc

Guidelines for the Use of Subcutaneous Medications in Acknowledgments

These guidelines have been adapted for local use with kind permission from NHS
Greater Glasgow and Clyde.
Drug compatibility data has been extracted from the revised (2009) version of the
Lanarkshire Palliative Care Guidelines.
Contents
Part 1 - Bolus Administration 1. Rationale and Indications Advantages and disadvantages of Subcutaneous (SC) route S/C cannula insertion sites Choice of cannula Preparation of patient for insertion of SC cannula Removal of cannula Information on drugs given SC in Palliative Care Drug Administration Table (drugs commonly given by SC bolus) Part 2 - Continuous Subcutaneous Infusion (CSCI) Rationale and Indications Choice of cannula and infusion set Potential problems with CSCI Frequently asked questions Compatibility and stability of drugs Commonly used drugs given SC in Palliative Care Single drugs for SC infusion Morphine: Drug combinations for SC infusion Diamorphine: Drug combinations for SC infusion 10. Oxycodone: Drug combinations for SC infusion 11. Drug conversions 12. Breakthrough analgesia Appendix 1 - Contact details for Palliative Care Teams Appendix 2 - Contributors Bolus Administration 1. Rationale and indications
When the oral route is unavailable to patients the subcutaneous (SC) route is the
preferred method of drug administration. Intravenous (IV) injections should be
avoided because they are invasive and no more effective than the subcutaneous
route. Intramuscular (IM) injections should be avoided, as they are painful,
particularly in patients who are cachectic.
The SC route should not only be reserved for use in a dying patient. Consider this route for the treatment of pain and/or other symptoms when other routes of administration are inappropriate. Listed below are possible reasons why the SC route could be used:  Unable to take by mouth  Nausea and vomiting  Poor absorption, e.g. ileostomy. The SC route will not give better analgesia than the oral route unless there is a problem with absorption or administration.
2. Advantages and disadvantages of SC route
Advantages:

 Can be used when patients can no longer tolerate oral therapy due to nausea, vomiting or dysphagia  Increased patient comfort, avoiding the need for repeated injections  Suitable for patients who are very drowsy, comatose or semi-comatose  Avoids the administration of an excessive number of tablets  Cannula can be left in for 72 hours or longer if no redness/inflammation, therefore less demanding on nursing resources.
Disadvantages:
 Possible inflammation or irritation at infusion site  Possible leakage of SC site  Possible allergic reaction (rare occurrence)


3. SC cannula insertion sites

Acceptable SC cannual insertion sites (see diagram):
 Anterior aspect of the upper arms or anterior abdominal wall  Anterior aspect of the thigh  The scapula if the patient is distressed and/or agitated  Anterior chest wall
Sites not suitable for injection
 Skin folds and breast tissue  Directly over a tumour site  Lymphoedematous limb or oedema – absorption may be reduced  The abdominal wall if ascites present  Bony prominences – little SC tissue, absorption reduced  Previously irradiated skin – skin may be sclerosed, poor blood supply  Sites near a joint – uncomfortable, increased risk of displacement  Infected, broken or bruised skin
If a local reaction occurs, the cannula should be resited using a fresh cannula and
administration set. If this recurs, consider further diluting the drug(s). The site
need not be changed for up to 72 hours, or longer if the site is viable (sites
may last for 7 days or longer)
.


4. Choice of cannula
The BD Saf-T-Intima™ cannula, shown below, is the choice of cannula for SC medications. The rationale behind this preference is: Site reactions are less common Insertion is less traumatic Needle stick injury is reduced to patient and staff Less expensive than alternatives Can remain in situ longer than other devices. BD Saf-T-Intima™ 22 Gauge cannula (blue), code number FSP319.
Note
The BD Saf-T-Intima™ cannula has a dead space of 0.2ml. Drugs therefore require to be flushed through with at least 0.2ml of appropriate diluent. The diluent used will depend on the medication being given. For guidance please refer to Drug Administration Table, page 12. If a patient is started on a continuous SC infusion they may require a separate BD Saf-T-Intima™ cannula for bolus medications. It is highly recommended that a luer lock syringe is used for all bolus
injections and flushes to avoid possible leakage
.

5. Preparation of patient for insertion of SC cannula

BD Saf-T-Intima™ 22 Gauge cannula (blue), code number FSP319 Alcohol impregnated swab Occlusive dressing Non-sterile gloves Procedure
1. Wash hands as per hand hygiene policy. 2. Explain procedure to patient and gain consent. 3. Clean skin with an alcohol-impregnated swab. Allow to dry for a minimum of 4. Put on gloves. 5. Remove and dispose of clamp on the BD Saf-T-Intima™ to avoid accidental 6. Rotate white safety barrel to loosen needle. 7. Remove clear needle cover. 8. Grasp pebbled side wings, pinching firmly. 9. Pinch skin between thumb and forefinger to ensure SC tissue is identified. 10. Insert cannula at a 45-degree angle. 11. Cover the insertion site and wings with a transparent semi-permeable dressing 12. Hold wings of the cannula firmly and remove introducer (needle) by pulling back in a smooth single movement. This should leave injectable bung in-situ. 13. Dispose of needle in sharps container as per local policy. 14. Document date, time and place of cannula insertion in nursing notes. 15. Wash hands as per hand hygiene policy.  Check site 4 hourly (daily in community setting) for erythema, pain or swelling. Document findings of check on monitoring sheet.  If insertion is unsuccessful use another cannula. Do not reinsert  If blood appears in the cannula insert a new one in another site.  If the cannula is being used to deliver a subcutaneous infusion remove the bung and attach an anti-siphon extension set (e.g. McKinley 100-172S)  If the cannula is being used to deliver subcutaneous bolus injections remove the bung and cap Removal of cannula
The SC cannula can remain in situ for up to 72 hours or longer if there is no pain, swelling or erythema at the insertion site. • Document removal of cannula in nursing notes • Once the cannula is removed cover the site with a small elastoplast if any leakage appears. Note: Before discontinuing SC route and removing cannula, symptoms must be
well controlled and patient able to tolerate oral medications.
7. Information on drugs given SC in Palliative Care
It is common in palliative care to use licensed medicines for an unlicensed indication, route or dose. Such use can be supported by experience in clinical practice and accepted reference sources such as The Oxford Textbook of Palliative Medicine or the Palliative Care Formulary. The licensing process regulates the activities of pharmaceutical companies and not the prescribing practice of a qualified prescriber. The marketing authorisation for many of the injectable drugs used in palliative care does not specifically cover SC administration. This is indicated on the chart on page 12. In palliative care the SC route is preferred as it is less painful than IM and can also be utilised as a continuous infusion. Clinicians administering a drug that they have not previously used by the SC route, should be aware that: • Absorption may be slower than by IM route • Irritant drugs may cause a greater inflammatory reaction SC than IM • The total volume for a bolus injection is not too great (recommended • Absorption will be severely limited in patients who are ‘shocked' or
The commonly used drugs listed below must not be given by the SC route as
they may cause tissue necrosis:

• Antibiotics. • Diazepam. • Chlorpromazine. • Prochlorperazine (stemetil®). If you have any queries or concerns please see contact details documented in Appendix 1. 8. Drug Administration Table
All of the drugs below are commonly given by subcutaneous bolus or infusion in palliative care patients regardless of their licensed routes of administration Note: If administering cyclizine or haloperidol ensure line is flushed before
and after use with water for injection.

Licensed
Licensed
Licensed
Licensed
After injection FLUSH
for SC inj.
for IM inj.
for IV inj.
cannula/ line with:
Alfentanil
Sodium Chloride 0.9% Cyclizine
Water for injection Sodium Chloride 0.9% Organon brand
Sodium Chloride 0.9% Mayne brand
Diamorphine
Water for injection Sodium Chloride 0.9% Haloperidol
Water for injection Sodium Chloride 0.9% Hyoscine
Sodium Chloride 0.9% Hyoscine
Sodium Chloride 0.9% Ketamine
Sodium Chloride 0.9% Ketorolac
Sodium Chloride 0.9% Sodium Chloride 0.9% Sodium Chloride 0.9% Midazolam- Roche
Sodium Chloride 0.9% Midazolam- Phoenix
Sodium Chloride 0.9% Morphine sulphate
Sodium Chloride 0.9% Octreotide
Sodium Chloride 0.9% Oxycodone
Sodium Chloride 0.9% Use of Continuous Subcutaneous Infusions Rationale and Indications
Continuous subcutaneous infusions using a syringe pump are popular in palliative care as a method of delivering a wide range of medications when other methods of drug delivery are no longer available, or are unacceptable to the patient. Using the SC route avoids having to intravenously cannulate a terminally ill patient although the use of a CSCI should not be reserved for the dying patient. The medication is administered into the fatty tissue under the skin and is absorbed systemically. A CSCI infusion allows for a continuous infusion of drugs over a calculated period of time and can provide constant dosing for a range of commonly used agents including opioid analgesics (primarily morphine and diamorphine in the UK), antiemetics, anxiolytic sedatives, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs) and anticholinergic drugs. A significant advantage of subcutaneous infusion over other drug delivery methods is that plasma levels of a drug are much more stable, and appropriate symptom control can be achieved without the toxic effects of the peaks and troughs resulting from episodic drug administration. It can give relief of multiple symptoms including pain, nausea and vomiting, restlessness, confusion and excess respiratory secretions. Note: All drugs to be given by CSCI must be prescribed on the medicine
kardex and the SC infusion chart.


Indications for use of a CSCI

• Severe dysphagia /swallowing difficulties • Mouth, throat and oesophageal lesions • Intestinal obstruction • Profound weakness • Poor absorption of oral drugs • Unacceptable number of oral medications or volumes of syrups which make ingestion difficult • Unconscious patient • Intractable symptoms that are not well controlled by oral methods • Rectal route is inappropriate. Sites may last for up to 72 hours or longer if there are no local reactions. However, these should be checked and documented every four hours (daily in primary care settings) on the CSCI monitoring chart. The entire administration set should be replaced if a new mixture of drugs is used. 2. Choice of cannula and infusion set
The Saf-T-Intima™ is the cannula of choice for the administration of SC
medications. The rationale behind this preference is:
• Less likely to cause site reactions • Insertion is less traumatic • Needle stick injury is reduced • Less expensive • Can remain in situ longer than other devices.
Other considerations
Resite cannula if there are local reactions – use a new administration set each
time. If skin reactions are persistent the choice of drug(s) may have to be reviewed.
When in doubt contact a member of the specialist palliative care team.
Note: When delivering a CSCI an anti-syphon administration set (e.g. McKinley
100-172S) is strongly recommended, as there is a risk of ‘free flow'.
3. Potential problems with CSCI

Possible cause
Suggested action
Inappropriate or inadequate medication. Reassess patient's symptoms Medication being administered is Check that infusion is running Request medical or palliative care not controlling or managing – e.g. is there any symptoms. Patient comfort is not crystallization. Set up new infusion using a fresh Check that the syringe pump administration set and needle. Irritation of skin. Due to subcutaneous Check that drugs are reconstituted in correct diluent and in appropriate volume. Resite cannula. Adverse effects due to opioid Stop infusion. Contact medical staff Pin point pupils Agitation and restlessness Semi purposeful movements Incorrect rate set on pump dosage and choice of drug Visual and auditory hallucinations dosage and choice of other Malfunction of pump resulting Vivid dreams or nightmares in over infusion. The correct dose relieves pain Twitching or plucking at the air without adverse side effects. Ensure adequate hydration. Sedation may Seeing shadows at periphery of be present until symptoms resolve. Leakage at subcutaneous site. Inflammation at the site. Resite infusion changing the whole
Frequently asked questions

Which diluent should be used?
(Please consult page18 for the diluent table on single drug infusions) For cyclizine, higher doses of diamorphine, haloperidol and drug combinations, the diluent is usually water for injection. For drug combinations, it is important to check for stability information.
When should the CSCI be started?
If the patient is in pain and not currently on a modified or slow release opioid, e.g. MST or Oxycontin, the CSCI can be started immediately. If the patient is on a modified or slow release opioid preparation, start the CSCI when the next dose of oral modified or slow release opioid is due. If the patient is on a fentanyl patch, refer to the fentanyl patch algorithm, or consult the palliative care pharmacist or another member of the palliative care team for advice. If the patient has pain or other symptoms, e.g. nausea or distress, at the time of commencing the infusion, consider giving an initial breakthrough dose (by subcutaneous bolus route) as it may take several hours for the infusion to have an effect.
When should the CSCI be stopped if oral treatment is to be re-started?
The CSCI can be stopped as soon as the oral modified release dose of opioid is due to be given. The patient should have oral breakthrough medication prescribed as this may be required until the modified release dose reaches a therapeutic level.
What is the usual number of drugs that can be mixed together?
It is common to use two or three drugs mixed in a syringe. Before mixing drugs together it is important to check for stability information. This can be found on the attached charts or by consulting a pharmacist or palliative care specialist, or by contacting Medicines Information (contact numbers listed in Appendix 1). Information is also available from the following resources: • The Oxford Textbook of Palliative Medicine • Palliative Care Formulary • The Syringe Driver -continuous subcutaneous infusions in palliative care 5. Compatibility and stability of drugs
‘Instability' or ‘incompatibility' refers to chemical reactions that occur when diluting or mixing drugs, resulting in the formation of different chemicals that can be therapeutically inactive or possibly toxic to the patient. Sometimes there are visible signs of incompatibility such as cloudiness, change in colour or the appearance of crystals. However, some reactions will not be identified through changes in appearance. If in doubt, contact the palliative care pharmacist or another member of the palliative care team. Factors that affect stability include light, heat, pH, time and volume of diluent. Therefore, if a solution is to be given by CSCI, it is important to know that it will be stable in a suitable volume for 24 hours at room temperature.
6. Commonly used drugs given SC in Palliative Care
It is important to understand that the licensing process regulates the activities of pharmaceutical companies and not the prescribing practice of a qualified prescriber. If an untoward incident occurs with a licensed product in an approved clinical situation, depending on the circumstances, any liability arising subsequently may in part or whole be transferred to the license holder. Due to licensing restrictions, it is common in palliative care to use licensed medicines for an unlicensed indication, by an unlicensed route or in an unlicensed dose. This is ‘off-label' use of a medicine with a UK marketing authorization. In this case the manufacturer is unlikely to be found liable if the patient is harmed. The prescriber and the clinical pharmacist assume responsibility for ensuring appropriate use of medication and patient safety. Nursing staff who administer ‘off-label' medications also have a duty of care to the patient. ‘Off-label' use of medication can be supported by experience in clinical practice and accepted reference sources such as The Oxford Textbook of Palliative Medicine or the Palliative Care Formulary or local/national guidelines. (See table in Part 1, Section 8)
7. Single drugs for SC infusion
Note: The Palliative Care Team may recommend doses in excess of those
mentioned in this table.
Single agent
Indications and dose range
Comments
MORPHINE
Indications: Opioid responsive • 1st line opioid analgesic 10mg, 30mg in 1ml pain, breathlessness Dose: No max dose limit
DIAMORPHINE
Indications: Opioid responsive • Can be diluted in a small pain, breathlessness Dose: No max dose limit
• Preferred for high opioid OXYCODONE
Indications: Opioid responsive • 2nd line opioid analgesic if pain, breathlessness morphine/ diamorphine not Dose: No max dose limit
ALFENTANIL
Indications: Opioid responsive • 3rd line opioid; seek pain, breathlessness specialist advice (1000micrograms) Dose: No max dose limit
• 1st line in stages 4 /5 in 2ml, 5mg in 10ml chronic kidney disease Antiemetics
CYCLIZINE
Indications: nausea and vomiting • Anticholinergic; reduces (bowel obstruction or intracranial • Can cause redness, irritation Dose: 50-150mg / 24 hours
Indications: nausea and vomiting • Prokinetic (gastric stasis/outlet obstruction, • Avoid if complete bowel obstruction or colic Dose: 20-120mg / 24 hours
HALOPERIDOL
Indications: opioid or metabolic • Long half life: can be given induced nausea, delirium as a once daily SC injection Dose: 2.5-5mg / 24 hours
Antiemetic
Dose: up to 30mg
Agitation
Indications: Complex nausea, • Lowers blood pressure terminal delirium/ agitation • Reduces seizure threshold; Dose: 5-25mg / 24 hours -
benzodiazepine if risk of fits Dose: 25-100mg / 24 hours -
• Long half life: can be given terminal sedation as a once or twice daily SC injection Anticholinergics for chest secretions or bowel colic
HYOSCINE
Indications: chest secretions, • First line; non-sedative bowel obstruction (colic, Dose: 40-120mg / 24 hours
GLYCOPYRRONIUM
Indications: chest secretions • Second line; non-sedative 200microgram in 1ml • Longer duration of action 600microgram in 3ml Dose: 600-1200 micrograms
/24 hours
HYOSCINE
Indications: chest secretions • Second line; sedative Dose: 400-1200
400microgram in 1ml • Can precipitate delirium micrograms / 24 hours
600microgram in 1ml
Sedative
MIDAZOLAM

Indications: anxiety, muscle • Anxiolytic (5-10mg/ 24 spasm/ myoclonus, seizures, terminal delirium/ agitation • Muscle relaxant (5-20mg/ 24 Dose: titrate according to
• Anticonvulsant (20-30mg/ 24 symptoms and response • First line sedative (20-80mg Other medication occasionally given by SC route in palliative care
Indications: bowel obstruction, • SC dose is the same as oral raised intracranial pressure or • Available as different dose intractable nausea and formulations. Check Dose: 2-16mg / 24 hours
• Mixes poorly with other drug • Can be given as a daily SC injection (in the morning) KETAMINE
Indication: Complex pain • Specialist supervision only KETOROLAC
Indication: bone/ inflammatory • Specialist supervision only pain if patient in last days of • Give an oral PPI if still able Dose: 10- 30mg / 24 hours
• Long half life particularly in frail patients: given as a twice daily SC injection OCTREOTIDE
Indications: intractable • Some formulations very 200micrograms/ml vomiting due to bowel (5ml multi-dose vial) obstruction, fistula discharge • Potent antisecretory agent Dose: 300–900 micrograms
• Does not treat nausea / 24 hours
• Limit fluid intake to 1-1.5 Diluent
Single Drug

Water for Injection is the diluent of choice for most drugs. There are exceptions, however, and these drugs are listed below. Preferred Diluent
Sodium chloride 0.9% Ketamine (specialist advice only)
Sodium chloride 0.9% or Dextrose 5% Ketorolac (specialist advice only)
Sodium chloride 0.9% or Dextrose 5% Sodium chloride 0.9% Octreotide
Sodium chloride 0.9% Cyclizine is incompatible with sodium chloride 0.9%.
Two or more Drugs
When two or more drugs are mixed in a syringe the diluent is usually water for injection. If compatibility/stability data is available for an alternative diluent then that diluent should be used 8. Morphine: Drug combinations for subcutaneous infusion that are
stable for 24 hours
These are not clinical doses to prescribe. Most patients will not need
high doses. Read the relevant guidelines.
• Only use this table to check for concentrations that are stable • Refer to Table 1 for the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response • Monitor closely for visible signs of incompatibility such as the solution becoming cloudy, changing colour or the appearance of crystals
Drug Combination
Maximum 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
Drug Combination

Maximum 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 9. Diamorphine: Drug combinations for subcutaneous infusion
that are stable for 24 hours

These are not clinical doses to prescribe. Most patients will not need
high doses. Read the relevant guidelines.
• Only use this table to check for concentrations that are stable • Refer to Table 1 for the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response • Monitor closely for visible signs of incompatibility such as the solution becoming cloudy, changing colour or the appearance of crystals
Drug Combination
Maximum concentrations of two drug
combinations that are physically stable
17ml in 20ml syringe
22ml in 30ml syringe
Glycopyrronium bromide Hyoscine butylbromide Hyoscine hydrobromide
Drug Combination

Maximum concentrations of three drug
combinations that are physically stable
17ml in 20ml syringe
22ml in 30ml syringe
Hyoscine butylbromide The following combinations are not stable: • Diamorphine, dexamethasone and levomepromazine • Diamorphine, dexamethasone and midazolam • Diamorphine, cyclizine and metoclopramide • Octreotide and levomepromazine • Octreotide and cyclizine • Octreotide and dexamethasone 10. Oxycodone: Drug combinations for subcutaneous infusion
that are stable for 24 hours

These are not clinical doses to prescribe. Most patients will not need
high doses. Read the relevant guidelines.
• Only use this table to check for concentrations that are stable • Refer to Table 1 for the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response • Monitor closely for visible signs of incompatibility such as the solution becoming cloudy, changing colour or the appearance of crystals Drug Combination
Maximum concentrations of two drug
combinations that are physically stable
17ml in 20ml syringe
22ml in 30ml syringe
Hyoscine butylbromide Hyoscine hydrobromide Drug Combination
Maximum concentrations of three drug
combinations that are physically stable
17ml in 20ml syringe
22ml in 30ml syringe
Hyoscine butylbromide Hyoscine hydrobromide Hyoscine butylbromide 11. Drug Conversions
Converting to Diamorphine or Morphine

Diamorphine and Morphine are the opioids of choice for moderate to severe pain. Diamorphine is particularly suitable for use in a syringe pump because it is highly soluble in small volumes. 1g of diamorphine can be dissolved in 1.6 ml of water (21 ml of water are needed to dissolve 1g of morphine sulphate). However, when dose requirement is low morphine can be used equally well.For advice please contact Hospital Palliative Care Team or St Andrew's Hospice. (Refer to Appendix 1, for contact details). Subcutaneous diamorphine is 3 times the potency of oral morphine.
i.e. 30mg oral morphine = 10mg subcutaneous diamorphine.
To convert from oral morphine to subcutaneous diamorphine:
The total 24-hour dose of oral morphine should be divided by 3.
Subcutaneous morphine is 2 times the potency of oral morphine.
i.e. 30mg oral morphine = 15mg subcutaneous morphine.

To convert from oral morphine to subcutaneous morphine:
The total 24-hour dose of oral morphine should be divided by 2.
Example:
Patient is on MST 120mgs twice daily. Breakthrough dose is 1/6th of total 24hour dose i.e. 120 mg + 120 mg = 240 mg ÷ 6 = 40 mg. Patient has required 3 doses of breakthrough medication in preceding 24 hours. Total 24 hours oral morphine dose: 120 mg + 120 mg + 40 mg + 40 mg + 40mg = 360 mg. 360 mg divided by 3 = 120 mg of diamorphine subcutaneously over 24 hours. 360mg divided by 2 = 180 mg of morphine subcutaneously over 24 hours. Subcutaneous diamorphine is 1.5 x as potent as subcutaneous morphine.
i.e. 10mg subcutaneous diamorphine = 15mg subcutaneous morphine.
12. Breakthrough analgesia
Breakthrough analgesia should still be prescribed subcutaneously when a
continuous infusion is in use. The dose should normally be approximately 1/6th of
the current 24hr opioid. If the dose is difficult to calculate, round up or down to the
nearest easy dose to achieve. To avoid repeated injections a separate BD Saf-T-
Intima™ cannula can be left in situ at a SC site, secured with a dressing. Extra
doses can be administered via this SC route followed by a 0.2ml flush of sodium
chloride 0.9% or water for injection. Please refer to diluent table on page 10.
Caution: Breakthrough analgesia given for movement related pain or incident pain
in a patient whose background pain is satisfactorily controlled should not normally
be added into the regular 24hour dose as toxicity may ensue. Continue to give as
breakthrough in anticipation of incident related pain.
References

Back I (2001) Palliative Medicine Handbook BPM Books Cardiff.
British National Formulary (2009), March Dickman A., Scheider J., Varga J (2005) 2nd Ed. Syringe Driver Handbook Oxford UniversityPress Oxford Twycross R., Wilcock A., Thorp S. (2007) 3rd Ed. Palliative Care Formulary Radcliffe Oxon. Watson M., Lucas C., Hoy A., Back I (2005) Oxford Handbook of Palliative Care Oxford University Press Oxford. Scottish Intercollegiate Guidelines Network (2008). Control of pain in adults with cancer. Scottish Intercollegiate Guidelines Network, Edinburgh Lanarkshire Palliative Care Guidelines (2009) Appendix 1

Hospital Palliative Care Teams

Hairmyers Hospital
Clinical Nurse Specialist Medicines Information Palliative Care Pharmacist Monklands Hospital
Clinical Nurse Specialist Medicines Information Wishaw General Hospital
Clinical Nurse Specialist Medicines Information Primary Care
Community Macmillan Nursing Team St Andrew's Hospice
Macmillan Area Lead Pharmacist- Palliative Care
Strathcarron Hospice
24hour Cumbernauld area
Appendix 2
Contributors

Linda Johnstone, Macmillan Area Lead Pharmacist- Palliative Care, NHS Lanarkshire Gillian Muir, Macmillan Palliative Care Clinical Nurse Specialist, NHS Lanarkshire Adam Russell, Senior Clinical Pharmacist, NHS Lanarkshire

Source: http://www.nhslanarkshire.org.uk/Services/PalliativeCare/Documents/Guidelines%20for%20the%20use%20of%20Subcutaneous%20Medications%20in%20Palliative%20Care.pdf

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