Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017) Key References NHS Lanarkshire Palliative Care Guidelines 3 rd Edition NICE CG140. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. May 2012 The British Pain Society. Opioids for persistent pain:Good practice January 2010 Page 1 of 12 Palliative Care for Adults - Guidance for Primary Care These principles are intended for guidance and do not cover all aspects of an individual patients care. They reflect commonly accepted practice in palliative medicine. The use of some medicines may be off-label – this may relate to dose, route or indication. Contents Pain Control p 1-5 McKinley T34 Syringe Pump p 10 Management of Toxicity to Opioids p 6 Symptom Control in the last days of life Shortness of Breath Bronchial Secretions Agitation p 11 Nausea and Vomiting p 7 Constipation p 8 Use of A Syringe Driver p 9 Useful Contacts p 12 Effective Communication Is Imperative For Effective Symptom Control PRINCIPLES OF PAIN CONTROL Assess: Prior to treatment an accurate assessment should be made to determine the cause (consider if reversible), type and severity of the pain and its affect on the patient. Assess All Pains and treat accordingly. Patients with cancer still develop other pains, which could be related to the treatment, debility or unrelated causes. Consider Total Pain: The physical, emotional, social, and spiritual dimensions of distress all affect a patient’s perception of pain. Consider any Factors That Lower Or Raise Pain Tolerance (see page 2). Discuss and Explain symptoms and treatments (pharmacological and non-pharmacological) to patient and carer. With Continuous Pain Prescribe Continous Analgesia, never just PRN. Use the WHO Pain Ladder in choosing appropriate analgesia. If Strong Opioids are required discuss and resolve any concerns about strong opioids, including concerns about addiction and overdose. All patients/carers should be provided with a patient information leaflet. Start with immediate release oral morphine every 4 hours. If higher frequency use is anticipated in an individual case, contact specialist palliative care for advice. The patient does not need to be specifically woken to take a dose during the night. In some cases, it may be appropriate to start with a 12 hour release oral morphine preparation. This should be started at low dose and titrated accordingly. Use low doses and titrate the dose slowly if the patient is frail, elderly or has renal impairment. Breakthrough Pain: If only prescribed immediate release morphine, give additional PRN doses for breakthrough pain at the same dose as the regular 4-hourly dose. If on sustained release opioids prescribe additional immediate release opioid for episodes of breakthrough pain. This is given 4-hourly PRN at a dose of one sixth of the total daily dose of opioid (ask the patient to keep a record of usage). Use this record of all morphine administered to calculate dose increases in the sustained release opioid. Constipation occurs with all opioids. Laxatives are usually needed (see page 9) Nausea should be treated with an appropriate anti-emetic (see page 10). Review frequently to optimise analgesia as soon as possible. Pain can be managed in the majority of patients. If pain is not controlled, review assessment. Specialist Advice should be sought ASAP especially if pain has not responded to treatment, dose of opioid has increased rapidly but patient is still in pain, there are episodes of severe acute pain or pain is worse on movement. Consider renal and hepatic function. Dose adjustment or alternative medicine choices may be required. Seek specialist advice if required. IF UNCERTAIN PLEASE CONTACT A SPECIALIST TEAM FOR ADVICE. see useful contact numbers on page 12
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Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Key References NHS Lanarkshire Palliative Care Guidelines 3
rd Edition
NICE CG140. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. May 2012 The British Pain Society. Opioids for persistent pain:Good practice January 2010 Page 1 of 12
Palliative Care for Adults - Guidance for Primary Care
These principles are intended for guidance and do not cover all aspects of an individual patients care. They reflect commonly accepted practice in palliative medicine. The use of some medicines may be off-label –
this may relate to dose, route or indication.
Contents
Pain Control p 1-5 McKinley T34 Syringe Pump p 10 Management of Toxicity to Opioids p 6 Symptom Control in the last days of life
Shortness of Breath
Bronchial Secretions
Agitation
p 11 Nausea and Vomiting p 7
Constipation p 8 Use of A Syringe Driver p 9
Useful Contacts p 12
Effective Communication Is Imperative For Effective Symptom Control
PRINCIPLES OF PAIN CONTROL Assess: Prior to treatment an accurate assessment should be made to determine the cause
(consider if reversible), type and severity of the pain and its affect on the patient.
Assess All Pains and treat accordingly. Patients with cancer still develop other pains, which could be related to the treatment, debility or unrelated causes.
Consider Total Pain: The physical, emotional, social, and spiritual dimensions of distress all affect a patient’s perception of pain.
Consider any Factors That Lower Or Raise Pain Tolerance (see page 2).
Discuss and Explain symptoms and treatments (pharmacological and non-pharmacological) to patient and carer.
With Continuous Pain Prescribe Continous Analgesia, never just PRN.
Use the WHO Pain Ladder in choosing appropriate analgesia.
If Strong Opioids are required discuss and resolve any concerns about strong opioids, including concerns about addiction and overdose. All patients/carers should be provided with a patient information leaflet.
Start with immediate release oral morphine every 4 hours. If higher frequency use is anticipated in an individual case, contact specialist palliative care for advice.
The patient does not need to be specifically woken to take a dose during the night.
In some cases, it may be appropriate to start with a 12 hour release oral morphine preparation. This should be started at low dose and titrated accordingly.
Use low doses and titrate the dose slowly if the patient is frail, elderly or has renal impairment.
Breakthrough Pain: If only prescribed immediate release morphine, give additional PRN doses for breakthrough pain at the same dose as the regular 4-hourly dose.
If on sustained release opioids prescribe additional immediate release opioid for episodes of breakthrough pain. This is given 4-hourly PRN at a dose of one sixth of the total daily dose of opioid (ask the patient to keep a record of usage). Use this record of all morphine administered to calculate dose increases in the sustained release opioid.
Constipation occurs with all opioids. Laxatives are usually needed (see page 9)
Nausea should be treated with an appropriate anti-emetic (see page 10).
Review frequently to optimise analgesia as soon as possible. Pain can be managed in the majority of patients. If pain is not controlled, review assessment.
Specialist Advice should be sought ASAP especially if pain has not responded to treatment, dose of opioid has increased rapidly but patient is still in pain, there are episodes of severe acute pain or pain is worse on movement.
Consider renal and hepatic function. Dose adjustment or alternative medicine choices may be required. Seek specialist advice if required.
IF UNCERTAIN PLEASE CONTACT A SPECIALIST TEAM FOR ADVICE. see useful contact numbers on page 12
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Key References SIGN Guideline 106: Control of pain in patients with Cancer 2008 Turk DC and Okifuji A. Assessment of patients’ reporting of pain: an integrated perspective Lancet 1999;353:17848 Gold Standards Frameork for Palliative care. http://www.goldstandardsframework.org.uk/ Page 2 of 12
MEASUREMENT AND ASSESSMENT AND OF PAIN Factors affecting pain tolerance*
* SIGN Guideline 106: Control of pain in patients with Cancer 2008
Measuring pain The patient should be the prime assessor of his or her pain. Measuring using the scales below* creates some objectivity between one review and the next.
* Turk DC and Okifuji A. Lancet 1999;353:17848
In addition to, or as a minimum, grade pain as per the Gold Standards Framework PACA tool (Patient and Carer assessment tool SCR3):
GSF PACA score Pain level
0 Pain absent
1 Pain present, not affecting daily life.
2 Pain present, moderate effect on daily life
3 Pain present, daily life dominated by symptom
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Key References NHS Lanarkshire Palliative Care Guidelines 3
rd Edition
NICE CG140. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. May 2012 The British Pain Society. Opioids for persistent pain:Good practiceJanuary 2010 Page 3 of 12
TREATMENT GUIDANCE FOR PAIN
NON-OPIOIDS Paracetamol or NSAIDs (e.g.
ibuprofen or naproxen)
WEAK OPIOIDS e.g.Codeine
Max dose in 24h – 60mg qds Ensure dose is titrated and optimised
before considering strong opioid
STRONG OPIOIDS (Immediate release Morphine)
e.g. Morphine sulphate oral solution 10mg/5ml 5-10mg 4 hourly.
Increase dose by 30-50% each day if necessary to achieve pain control.
Use a record of all immediate release morphine used to inform increases.
If pain remains uncontrolled consult with specialist. Lower doses should be used in elderly/renally
impaired.
ANTICIPATE CONSTIPATION a stimulant and faecal softener
laxative is recommended (see
table on page 8)
1st LINE SLOW RELEASE MORPHINE Use 12 hour release preparation ONLY
Calculate 12 hourly dose by adding up total amount of immediate release morphine taken over the last 24
hours and divide by 2. New breakthrough dose (4 hourly immediate release dose) will be 1/6
th of the dose of the total daily dose.
For all patients on regular strong opioids, always prescribe an opioid for breakthrough pain – to be used when required. A maximum total daily dose of 120mg morphine (or equivalent) should not be exceeded without specialist advice.
The dose of opioid for breakthrough pain is equivalent to one sixth of the 24 hour dose (i.e 4 hourly dose).
Ask the patient to keep a record of how much breakthrough medication they have needed.
All patients on opioids should be prescribed a regular laxative and a prn anti-emetic.
Refer to page 5 for approximate equivalent doses when converting between opioids
For management of opioid toxicity see guidance on page 6.
Pain controlled on regular dose. Convert to equivalent dose of slow release
opioid if not already prescribed.
Start with slow release morphine preparation (12 hour release) instead of immediate release if appropriate
Continue laxative
Consider anti-emetic PRN (may only be necessary for the first 4-5 days)
Ensure patient/carer is counselled on regular and breakthrough medication to avoid confusion
If pain remains uncontrolled refer to specialist
Refer to page 5 for approximate conversion doses between opioids
Co-prescribing of weak and strong opioids is NOT recommended – stop any weak opioid
before initiating a strong opioid
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significant renal impairment, then use of 2nd
line opioid may need to be considered.
Second line choices - Fentanyl patches or oral oxycodone HCl – refer to guidance overleaf re choice.
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Key References NHS Quality and Productivitybulletin. Appropriate prescribing of fentanyl patches December 2011 and Appropriate prescribing of oxycodone December 2011 NHS Lanarkshire Palliative Care Guidelines 3
rd Edition
British National Formulary Ed66 September 2013-March2014 Page 4 of 12
COMMON TYPES OF PAIN
VISCERAL / SOFT TISSUE
Constant dull pain poorly localised.
Usually opioid responsive
BONE PAIN
Usually well localised worse on movement
local tenderness.
Partly opioid responsive Generally NSAID and paracetamol
responsive Radiotherapy may help if metastases are
present at the site of pain
NEUROPATHIC PAIN
Often described as burning, stabbing, shooting or ‘pins and needles’
May be partially opioid responsive Likely to require an adjunctive analgesic e.g. tricyclic
antidepressant or anticonvulsant e.g. gabapentin
USE OF SECOND LINE STRONG OPIOIDS Oral morphine is the first line choice where a strong opioid is required. A second line choice should be used for moderate to severe opioid responsive pain where oral morphine is not suitable. Specialist advice should be sought before changing treatment and to discuss alternatives. The table below outlines the place in treatment for oral oxycodone and fentanyl patches:
ORAL OXYCODONE FENTANYL PATCHES Consider if
Analgesia is inadequate with morphine despite dose optimisation (this may include circumstances in which opioid rotation is being considered); or
Dose optimisation of morphine is limited by persistent adverse effects.
Consider if:
There is an established swallowing difficulty, persistent nausea and vomiting, GI blockage or severe renal impairment where dose adjustment with morphine is not feasible.
There are unacceptable side effects from morphine
The patient is not tolerating oral medication. Not suitable for patients with unstable or rapidly changing pain.
Can be prescribed generically. Should be prescribed by brand name to ensure patients remain on the same preparation.
Oxycodone is available as both modified release formulation (12 hour) preparation and immediate release preparation.
Patches are changed every 72 hours (3 days). If more than one patch is needed apply them at the same time to avoid confusion.
Patients should be counselled appropriately on the differences between the preparations to avoid confusion regarding which is for regular dosing and which for breakthrough pain.
Patients should be counselled to use a new area of (hairless) skin and remove old patches. Heat/pyrexia increases the rate of fentanyl absorption and can cause toxicity – ensure pyrexic patients are monitored for adverse events and counsel all patients to avoid exposing the application site to external heat e.g radiators, hot water bottles.
There should be a clear reason for changing to oxycodone and for ongoing prescribing. If, after an adequate trial of oxycodone, no benefit has been achieved, consider changing back to morphine or alternative analgesia.
If dose needs to be increased, increase patch dose by 12 – 25 micrograms/hr (unless dose >100-150 micrograms/hr, in which case increase by 50 micrograms/hr). Frail or elderly patients may need lower doses and slower titration. Improved analgesic effect may take up to 12 hours. Leave a minimum interval of 48 hours between dose increases.
Reduced clearance in mild to moderate renal impairment so titrate slowly and monitor. Consider dose reduction and increased dosage and time between doses if required. Avoid in stage 4-5 chronic kidney disease Avoid in moderate to severe liver impairment as clearance is reduced.
No initial dose reduction is needed in renal impairment but monitor for signs of accumulation. Dose reduction may be needed in severe liver impairment.
Immediate release oxycodone can be used for breakthrough pain. Ensure the patient/carer is aware of when and at what dose to use the immediate release and modified release preparations.
Ensure immediate release morphine i.e. morphine sulphate oral solution 10mg/5ml is available for breakthrough pain at an appropriate dose The 12mcg/hr strength patch is licensed for dose titration but may be used for patients requiring a lower starting dose (unlicensed) It can take 22 hours or longer for the plasma fentanyl concentration to decrease by 50%. Therefore if replacing fentanyl with another strong opioid seek specialist advice.
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Page 5 of 12
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Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Page 6 of 12
MANAGEMENT OF TOXICITY TO OPIOIDS There is a wide variation in the dose of opioid that causes symptoms of toxicity. Be aware this can also occur if the level of pain has reduced significantly e.g. after radiotherapy used to manage bone metastases as opioid requirements may decrease post treatment. Common warning signs of opioid toxicity or overdose
Increasing/persistent drowsiness (exclude other causes)
New onset or worsening confusion
Muscle twitching/myoclonus/jerking
Vivid dreams/hallucinations
Agitation
Respiratory depression (overdose/severe toxicity)
Coma (overdose/severe toxicity) Management of toxicity Mild toxicity:
Consider decreasing the opioid dose by a third and closely monitor the patient.
Ensure patient is well hydrated
Contact specialist palliative care team for advice regarding ongoing management
Consider advance care plan and admitting patient
Change syringe driver medications/dose on specialist advice Moderate to severe toxicitiy:
Seek specialist advice immediately
Call an ambulance if medical emergency
Be careful not to confuse a dying patient with someone who is experiencing opioid toxicity, be clear
on the diagnosis. If in doubt, seek specialist advice.
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Key References British National Formulary Ed 66 September2013-March 2014 NHS Lanarkshire Palliative Care Guidelines 3
rd Edition
NHS Wales Adult Palliative Care General Guidelines. October 2011 Palliative Care Formulary 4, September 2012 Page 7 of 12
NAUSEA AND VOMITING 1.GENERAL MEASURES Consider potentially reversible factors and treat these if possible and appropriate (correction may not be indicated for some of these if the patient is imminently dying). Causes include:
2. MANAGEMENT Choice of medication is based on likely cause, side effect profile and route of administration as well as patients condition/prognosis.
Cause First Line Second Line
For gastritis or gastric stasis use a prokinetic anti-emetic (provided the patient is not in bowel obstruction).
Metoclopramide 10mg orally
tds (caution in those at risk of extrapyramidal side effects e.g. Parkinson’s disease) or
Domperidone 10mg orally or rectally
tds
(note MHRA advice re cardiac risk). Extrapyramidal side-effects rare with domperidone
Levomepromazine
6.25-12.5mg orally ON (avoid when at risk of seizure e.g. brain metastases, epilepsy).
For most chemical causes of vomiting (e.g. opioids, hypercalaemia, uraemia) use a centrally acting anti-emetic
Haloperidol 1.5-3mg orally once daily or 2.5-5mg continuous subcutaneous infusion (both unlicensed) / 24hrs
Levomepromazine 6.25-12.5mg (i.e. ¼ - ½ 25mg tablet) orally nocte
or 6.25-25mg continuous subcutaneous infusion /24hrs (avoid when at risk of seizure).
Raised intra-cranial pressure, motion sickness
Cyclizine 50mg orally tds or
50-150mg continuous subcutaneous infusion / 24hrs
OTHER CONSIDERATIONS
Syringe driver for continuous subcutaneous infusion or IM Injections
Also consider use of an antacid or proton pump inhibitor
Use metoclopramide with caution in those at risk of/from extrapyramidal side-effects e.g. Parkinson’s
disease. Extrapyramidal side-effects are rare with domperidone.
Review efficacy of anti-emetic medication every 24 hours until control achieved
If underlying cause is resolved, review and discontinue antiemetic medication
Avoid combining medications with similar mode of action or side-effect profile
Do not combine prokinetics with anticholinergics
If nausea and vomiting are not controlled with oral antiemetics, review the patient’s regular oral medications and consider conversion to alternative route in order to maintain absorption e.g to fentanyl patches or syringe driver
Advise patient/carer on good mouth care and on avoiding any nausea triggers e.g. strong smells
Refer to local specialist palliative care team if causes such as bowel obstruction or raised intracranial pressure are suspected.
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Key References British National Formulary Ed 66 September2013-March 2014 NHS Lanarkshire Palliative Care Guidelines 3
rd Edition
NHS Wales Adult Palliative Care General Guidelines. October 2011 Palliative Care Formulary 4, September 2012 Page 8 of 12
CONSTIPATION
Regularly enquire about constipation.
Clarify the cause before starting treatment.
Beware, chronic constipation can mislead and be misdiagnosed . Signs include:
abdominal pain
anorexia
malaise
colic
tenesmus
spurious diarrhoea
urinary retention
intestinal obstruction
mental confusion
Patients should be advised to maintain an adequate fluid intake
A stepwise approach to laxative therapy should be adopted – prescribe regular laxative treatment and optimise before adding or changing treatment.
Daily laxatives are necessary for almost all patients on strong opioids (unless already liable to diarrhoea).
Most patients will need a softener and a stimulant.
Increase doses as necessary every 1-2 days. Rectal measures may still be required e.g. glycerol suppositiories or sodium citrate enema
Stimulant laxatives act within 6-12 hours
Osmotic laxatives may take 1-3 days to have an effect
Stool softeners take 24-36 hours to act
For patients experiencing abdominal pain, do not titrate opioid dose to treat this – investigate and treat cause.
ROUTINE LAXATIVES
Softener
Docusate sodium
100mg capsules
Initially 100mg BD Max 200mg TDS
Softener at lower doses and mild stimulant at higher doses. Mostly a faecal softener.
Osmotic laxative
Lactulose 10-20mls OD-BD Can be unpalitable, and can cause wind and distension, but some patients may prefer.
Macrogol oral powder
Initially 1-3 sachets a day. Max 8 sachets daily for 1-3 days for faceal impaction
1 sachet administered with 125ml water is isotonic. It is important to ensure sachet is administered in the correct volume of liquid. For use in faecal impaction refer to current edition of the BNF Large volume of liquid may be difficult to take for some patients e.g. frail.
Stimulant – avoid in intestinal obstruction
Senna tablets or liquid
1-2 tabs OD-BD or 7.5mg/5ml syrup 10–20mls ON
Can cause abdominal cramps.
Bisacodyl 5mg tablets or 10mg suppositories
5-10mg ON (oral) 10mg ON (PR)
Mostly acts on large bowel.
Docusate sodium
100mg capsules Initially 100mg BD Max 200mg TDS
Softener at lower doses & mild stimulant at higher doses. Mostly a softener.
Co-danthramer and co-danthrusate are options for severe constipation in palliaitive care patients ONLY. Seek advice from a specialist before initiating and refer to full prescribing information for dosage information.
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Key References British National Formulary Ed 66 September2013-March 2014 NHS Lanarkshire Palliative Care Guidelines 3
rd Edition Page 9 of 12
USE OF A SYRINGE DRIVER
A syringe driver is an alternative administration route where other routes of administration are not viable or continuous infusion is needed.
Medication is delivered by continuous subcutaneous infusion (CSCI).
Indications for its use include: persistant nausea and vomiting, dysphagia, intestinal obstruction, coma, or too weak to take oral medications.
Take advice from the local specialist palliative care team regarding the need for a syringe driver, medications, doses etc. If there is no specialist palliative care support available a GP could initiate and write a prescription for treatment including completing a syringe driver prescription sheet.
Try to anticipate the need for a syringe driver and prescribe in advance so that drugs and paperwork are all correct and present when the drugs are needed and can be sourced within working hours. Most pharmacies can obtain palliative care drugs within 24 hours and should be able to inform you if there is any likely delay.
Engage district nurse service to set up and monitor syringe driver
A syringe driver prescription/authorisation sheet will need to be completed and given to the DN or left with the patient for the DN to action.
A maximum of three medications can be administered via a syringe driver. On rare occasions four drugs can be given – ONLY on specialist palliative care team advice.
Water for injection is the usual diluent
The use of most opioids for continuous subcutaneous infusion is unlicensed.
Before setting up a syringe driver, it is important to explain its use to the patient and their family. It is important that the syringe driver is not seen just as the last resort but as an effective method of relieving certain symptoms by injection.
Ensure compatibilities of medications in the syringe driver have been checked prior to prescribing – check with the specialist palliative care team if required.
Refer to table on page 5 for approximate dose conversions between opioids
Note: Morphine injection is available in different strengths (e.g. 10mg/ml, 30mg/ml). Care needs to be taken when prescribing, preparing and administering, to ensure patient receives the correct dose. Seek specialist advice
SYMPTOM DRUGS GUIDELINES TO DOSAGE
Pain Morphine sulphate
If opioid naïve start at 10-15mg/24hrs.
For both medications:No ceiling limit. Titrate cautiously. Do not titrate above 120mg morphine daily (or equivalent) without specialist advice
Diamorphine hydrochloride If opioid naïve start at 5- 10mg/24hrs.
Colic Hyoscine butylbromide 20-160mg in 24 hours
Bronchial secretions Hyoscine Hydrobromide
Glycopyrronium bromide
1200-2400 micrograms in 24 hours. Confusion limits use. 200-400 micrograms, 6-8 hourly as required
Nausea and vomiting Metoclopramide 30-100mg in 24 hours
Cyclizine (do not dilute with
sodium chloride 0.9%) 50-150mg in 24 hours
Nausea and vomiting/ restlessness
Levomepromazine
(avoid if risk of fitting.) 6.25-25mg in 24 hours (for anti-emetic) 12.5-150mg in 24 hours (for restlessness/sedation) Higher doses for sedation only
Nausea and vomiting Haloperidol 2.5-5mg in 24 hours Doses >8mg/day risk extrapyramidal effects Above 2mg/ml can precipitate in diamorphine
Terminal agitation, anti-convulsant
Midazolam 10-60mg in 24 hours (ensure flumazenil available)
LESS COMMONLY USED DRUGS – SPECIALIST INITIATED
Dexamethasone (If possible, should be administered as sole drug in syringe driver. Seek specialist advice if site
irritation occurs)
Ketorolac (Bone pain)
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Key References British National Formulary Ed 66 September2013-March 2014 NHS Lanarkshire Palliative Care Guidelines 3
rd Edition
NHS Cumbria and Lancashire North Palliative Care guidance 2008 Page 10 of 12
McKinley T34 Syringe Pump
There is only one type of syringe driver in use across North Central London – this is the McKinley T34
The volume in the syringe will infuse over 24 hours
Refer to local guidance (community nursing policy) or consult with specialist palliative care team or district nurses for advice on equipment, setting up and administration of syringe pump.
The infusion line should be checked each visit/regularly for signs of redness, induration, crystallisation of the infusing solution, leakage.
For advice on managing injection site reactions, seek advice from the palliative care team.
A Syringe driver prescription/authorisation chart should be completed for medicines to be administered via the pump. This can be accessed via community nurses or palliative care team or local GP website.
Compatibility of medications to be mixed in a syringe driver should be checked. Seek advice from the palliative care team.
Syringe driver drug compatibility chart
Hyo
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Cycliz
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Dexam
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With acknowledgement to (and adpated from) NHS Cumbria and Lancashire North Palliative Care guidance
Key
Compatible
Sometimes incompatible
Incompatible
No data available
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
Key References British National Formulary Ed 66 September2013-March 2014 NHS Lanarkshire Palliative Care Guidelines 3
rd Edition Page 11 of 12
SYMPTOM CONTROL IN LAST DAYS OF LIFE
SHORTNESS OF BREATH KEY POINTS
Very frightening for patient– empathy important.
Is it appropriate to treat underlying cause? e.g. CCF - Seek specialist advice if in doubt
Are there reversible causes that can be treated? e.g. pulmonary embolism, infection, pleural effusion etc.
Check oxygen saturation
SYMPTOM CONTROL
Visualised reminder charts can be used to remind patient in crisis
Physical measures e.g. open windows, fan, keep face cool
Refer to physio for relaxation techniques
Where appropriate - bronchodilators (via spacer/nebuliser), antibiotics, steroids, diuretics, oxygen (only if hypoxic). Oxygen must be specialist intiated.
Consider low dose oral morphine to help manage e.g. 1- 2.5mg oral morphine liquid regularly 4 hourly or PRN. Patient will require an oral syringe to measure small volumes/doses of morphine liquid
BRONCHIAL SECRETIONS IN LAST 48 HOURS KEY POINTS
Consider if these are due to treatable underlying cause e.g. heart failure
General management measures include repositioning to lateral position, avoiding over hydration, addressing family distress
SYMPTOM CONTROL Conscious Patient
hyoscine butylbromide 20mg sc/orally stat or 60 – 120mg over 24 hrs in syringe driver OR
glycopyrronium bromide 200-400mcg SC, 6-8 hourly as required Unconscious Patient or where sedation may be of benefit
hyoscine hydrobromide 400-600 micrograms sc stat PRN or 1200-2400 micrograms over 24 hrs in syringe driver
For other measures available – consult local specialist palliative care team.
May still be appropriate to use sedation even if reversible causes are present.
SYMPTOM CONTROL
Subcutaneous stat administration or CSCI (continuous subcutaneous infusion) via a syringe driver over 24hrs may be needed.
1
st line
LORAZEPAM (if patient conscious) 500microgram to 1mg orally or sublingually 4-6 hourly PRN (max 4mg daily)
MIDAZOLAM - useful in patients who are at risk of seizure
Use 2.5-5mg SC hourly PRN or 10-60mg over 24 hours in syringe driver
2nd
line LEVOMEPROMAZINE - avoid if risk of seizure.
Is both sedative and anti-emetic.
Use 6.25-25mg SC OD-BD (antiemetic) or 25-100mg (restlessness) over 24 hours in syringe driver
Higher doses should only be used for restlessness A combination of both sedatives may be needed, but ONLY on specialist advice.
Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)
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USEFUL CONTACTS - LOCAL SPECIALIST PALLIATIVE CARE TEAMS If you wish to discuss how you manage the palliative care needs of a patient with a specialist palliative care service the following are the options. This may enable the patient to be managed in their own home and avoid a hospital admission.
Sainsburys Pharmacy, 17-21 Camden Road, London NW1 9LJ. Tel 020 7482 3828 Haringey Pharmacies providing on demand medicines for end of life care and other specialist medicines
Boots the Chemist Unit A2, Tottenham Hale Retail Park, N15 4QD. Tel: 0208 801 7243 Monday – Saturday 09:00 – 19:00, Sunday 11:00 – 17:00
Hornsey Central Pharmacy 151 Park Rd, Crouch End N8 8JD Tel: 020 3074 2700 Monday – Saturday 07:00 – 22:00, Sunday 09:00 – 19:00
This guideline is an update of the 2010 guideline and was reviewed with input from CCG representatives and local specialists from Camden, Islington and Haringey teams – March 2014 Adapted from the original The Pocket Guide for Palliative Care 2004. For clinical queries relating to this guideline please contact the local CCG borough medicines management team or local specialist team