palliative care guide v2 - 2014 - Amazon Web Services · Web viewPalliative Care for Adult s –...

Palliative Care for Adults – Guidance for Primary CareThis guidance contains suggested advice for the management and treatment of adult

palliative care patients. It applies to Camden primary care practitioners (GPs and practice nurses). It will also be relevant to practice-based and community pharmacists

in assisting with patient education and suitable treatments

Comments on this document should be sent to the Medicines Management Team, by email to [email protected]

This document is for use by Camden Prescribers only – the information contained in it is not suitable to be shared with patients / public or non NHS Organisations.

Not to be used or reproduced for commercial or marketing purposes.

This document is produced to inform and review local decision making using the best available evidence at the time of publication. The information in this document may be superseded in due course. Every care has been taken in the

compilation and publication of this document, however, neither the Medicines Management Team nor Camden CCG will be held responsible for any loss, damage, or inconvenience caused as a result of any inaccuracy or error within these

pages. Camden CCG is not responsible for the content or availability of any external sites to which it may include links. Please be aware that this information is correct at the time of the search and Camden CCG is under no obligation to

inform you if the situation changes in the future. The information provided is the property of Camden CCG and is subject to Intellectual Property and Database Rights.

The information contained in this guideline is issued on the understanding that it is accurate based on the resources at the time of issue. For further information please refer to the Summary of Product Characteristics

or contact a member the MMT.

The information in this document is a broad guideline only; it does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in

consultation with the patient and/or guardian or carer. Treatment of an individual patient should always be modified according to need & circumstances, and may involve a multidisciplinary approach.

Camden CCG does not restrict assessment, treatment, therapy, or care on the basis of age, disability, race, religion or belief, gender, sexual orientation, gender reassignment, pregnancy and maternity or marriage and

civil partnership or any other irrelevant consideration.

BEFORE USING THIS GUIDANCE ALWAYS ENSURE YOU ARE USING THE MOST UP TO DATE VERSION

1 SUMMARY This guidance contains suggested advice for the management and treatment of adult palliative care patients being managed in primary care. It applies to Camden CCG primary care practitioners (GPs and practice nurses). It will also be relevant to practice-based and community pharmacists in assisting with patient education and suitable treatments

2 RESPONSIBLE PERSON: Head of Medicines Management

3 ACCOUNTABLE DIRECTOR: Director of Quality and Clinical Effectiveness

4 APPLIES TO: NHS Camden Clinical Commissioning Group (CCG) primary care practitioners and prescribers

5 GROUPS/ INDIVIDUALS WHO HAVE OVERSEEN THE DEVELOPMENT OF THIS GUIDANCE:

Camden Medicines Management TeamCamden, Islington and Haringey Palliative Care Working group including community palliative care teams, consultants, specialist nurses, GPs and prescribing advisersCamden and Islington GP Clinical Lead for Palliative and End of Life Care

6 GROUPS WHICH WERE CONSULTED AND HAVE GIVEN APPROVAL:

Camden Medicines Management Committee (CMMC)

7 EQUALITY IMPACT ANALYSIS COMPLETED:

Guidance Screened

Date Template completed

Date

8 RATIFYING COMMITTEE(S) & DATE OF FINAL APPROVAL:

Camden Medicines Management Committee2008, 2014, 2018

9 VERSION: 3

10 AVAILABLE ON: Intranet Website

11 RELATED DOCUMENTS: Camden Prescribing Recommendations (CPR)

12 DISSEMINATED TO: To be placed on Camden GPs Website and distributed via Prescribing Matters newsletter to Camden Prescribers and clinicians.

13 DATE OF IMPLEMENTATION: 2008, updated 2014, updated 2018

14 DATE OF NEXT FORMAL REVIEW: January 2021

DOCUMENT CONTROL

Date Version Action Amendments2008 1 Guidance first

implemented

Agreed by CMMC

N/A

2014 2 Guidance reviewed and updated

Agreed by CMMC December2018

3 Guidance reviewed and updated.

This guideline is an update of the 2014 guideline and was reviewed with input from CCG representatives and local specialists from Camden, Islington and Haringey teams – December 2018

This information is a broad guideline only. Treatment of an individual patient should always be modified according to need & circumstances, and may involve a multidisciplinary approach

Palliative Care for Adults – Guidance for Primary Care v3 of 21


Adapted from the original The Pocket Guide for Palliative Care 2004. For clinical queries relating to this guideline please contact the local CCG medicines management team or local specialist team




Palliative Care for Adults - Guidance for Primary Care These principles are intended for guidance and do not cover all aspects of an individual patient’s care. They

reflect commonly accepted practice in palliative medicine. Further advice should be sought from the specialist palliative care team where required. The use of some medicines may be off-label – this may relate

to dose, route or indication.

Contents

General PrinciplesPain Control

p 4p 5

Symptom Control in the Last Days of Life p 13 Useful Contacts p 15

Management of Toxicity to Opioids p 10 Appendices p 17Appendix I – Use of a Syringe Driver Appendix II - Hydration and Nutritional Support

Nausea and Vomiting p 10Constipation p 12

GENERAL PRINCIPLES The purpose of this document is to provide guidance to primary care clinicians in managing and

treating adult palliative care patients within primary care. It is aimed at non-specialists and covers the most common issues presenting in palliative care patients. This guidance is intended for use in addition to seeking patient specific advice from the specialist palliative care team as needed.

Healthcare professionals caring for adults at the end of life need to take into consideration the person's current mental capacity to communicate and actively participate in their end of life care, including giving consent. Where possible involve patients AND their carers in prescribing decisions. The principles outlined in NICE guidance (NG31) for communication and shared decision making should be followed .

Where appropriate, anticipate what medicines may be needed for end of life symptom control so that if required, these can be given without unnecessary delay and prevent inappropriate admission to hospital. The decision to prescribe medication for use in the future should always be based on a risk/benefit analysis. Reasons for not providing anticipatory medicines include risk of drug diversion or misuse.

The use of medicines off-label, or use of unlicensed medicines, may be more common in palliative care than other specialities. The use of a licensed medicine should be considered first. If it is deemed necessary to prescribe off-label, the available evidence and cost-effective product choice should be considered. Unlicensed medicines should only be used where the clinician is satisfied there is not an alternative, suitably licensed medicine that would meet the patient’s needs and that there is sufficient evidence base and/or experience of using the medicine. Specialist palliative care advice can be sought.

Where relevant, prescribing guidance and medicines choices approved via the North Central London Joint Formulary Committee should be followed: https://www.ncl-mon.nhs.uk/

Specialist palliative care teams can be contacted for additional advice and guidance at any stage. This includes telephone advice. Recommendations may be outside those included in this guidance. In this scenario, prescribing and treatment recommendations will be discussed with the primary care prescriber and agreement sought before transfer of clinical and prescribing responsibility occurs.

Specialist palliative care guidance such as the Palliative Adult Network Guidance (PANG) is available. This may provide additional information. The information contained overleaf should be referred to in the first instance.



http://book.pallcare.info/index.php

https://www.ncl-mon.nhs.uk/

https://www.nice.org.uk/guidance/ng31/chapter/Recommendations#communication


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 effect on the patient.

Assess All Pains and treat accordingly. Patients with cancer may develop other pains, which could be related to treatment, debility or other unrelated causes.

Consider Total Pain: The physical, emotional, social, and spiritual dimensions of distress all affect a patient’s perception of pain.

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 team 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 1-4-hourly PRN at one sixth of the total daily dose of opioid (ask the patient/carer to keep a record of usage). Use this record of all morphine administered in 24 hours to calculate dose increases in the sustained release opioid.

Patients should be appropriately counselled on how to take breakthrough opioids. If three or more doses have been taken within three hours and pain is still not controlled, the patient should be advised to contact a healthcare professional (GP, district nurse or community palliative care team)

Constipation occurs with all opioids. Laxatives are usually needed (see page 13). 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 promptly 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 17




ASSESSMENT AND MEASUREMENT OF PAIN

COMMON TYPES OF PAIN

VISCERAL / SOFT TISSUE Constant dull pain poorly localised.

Usually opioid responsive

BONE PAIN Usually well localisedworse 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

MEASURING PAINThe 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 level0 Pain absent1 Pain present, not affecting daily life.2 Pain present, moderate effect on daily life3 Pain present, daily life dominated by symptom



http://www.goldstandardsframework.org.uk/library-tools-amp-resources


TREATMENT GUIDANCE FOR PAIN


NON-OPIOIDSParacetamol or NSAIDs (e.g.

ibuprofen or naproxen)

WEAK OPIOIDSe.g. codeine

Max dose in 24h – 60mg qdsEnsure dose is titrated and optimised

before considering strong opioid

STRONG OPIOIDS(1st line - immediate release morphine)

e.g. morphine sulphate oral solution 10mg/5ml Dose coversion

10mg oral codeine ≡1mg oral morphineLower initial doses are recommended in opioid naïve patients e.g.

2.5mg oral morphine 4 hourlyIncrease dose by 30-50% each day if necessary to achieve pain

control. Use a record of the total amount of immediate release morphine

taken in 24 hours to inform dose increases. If pain remains uncontrolled consult with specialist.

Lower doses and increased dosing intervals should be used in elderly/renal impairment (seek specialist advice). Seek pecialist

advice in moderate to severe liver impairment

ANTICIPATE CONSTIPATIONa stimulant and faecal softener

laxative is recommended (see

table on page 12)

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 1/6th of the total daily dose.

For all patients on regular strong opioids, always prescribe an immediate release opioid to be used when required for breakthrough pain. A maximum total daily dose of 120mg morphine (or equivalent) should not be exceeded without specialist advice.

Ask the patient to keep a record of how much breakthrough medication they have needed.If more than 2 doses of breakthrough analgesia are required in a 24 hour period, seek specialist advice and review pain management.

Fentanyl patches and oral oxycodone should be prescribed by brand name. Pain crisis – sudden change in pain that is severe, uncontrolled and causing distress despite regular analgesia is a medical

emergency – seek specialist advice All patients on opioids should be prescribed a regular laxative and an anti-emetic. Refer to page 9 for approximate equivalent doses when converting between opioids For management of opioid toxicity see guidance on page 10. If considering changing from an opioid to alternative analgesia or vice versa, discuss with specialist palliative care team.

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 Ensure

patient/carer is counselled on regular and breakthrough medication to avoid confusion

If pain remains uncontrolled refer to specialist

Refer to page 9 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

AD

JUVA

NT A

NA

LGESIC

SN

SA

IDs or other adjuvant drugs e.g. tricyclics, anticonvulsants m

ay be added at any stage.A

ssess and continue if of benefit

2nd LINE STRONG OPIOIDSIf there are unacceptable side effects from morphine

(e.g. excessive drowsiness, constipation or itching) or significant renal impairment, then use of 2nd line opioid

may be considered.

Refer to guidance on page 8 and SEEK SPECIALIST ADVICE

WHO Step 1Mild painNon-opioid

analgesics +/- adjuvant

WHO Step 2Moderate

painWeak opioid + non-opioid +/-

adjuvant

WHO Step 3

Moderate to severe pain

Strong opioid + non-opioid+/- adjuvant

Steps on the WHO Pain

Ladder

http://www.who.int/cancer/palliative/painladder/en/

http://www.who.int/cancer/palliative/painladder/en/


USE OF SECOND LINE STRONG OPIOIDS

The table below outlines the place in treatment for oral oxycodone and fentanyl patches:

FENTANYL PATCHES ORAL OXYCODONEConsider 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. Opioid naïve patients should be commenced on oral or parenteral opioids and the dose titrated until pain is controlled before converting to 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.

Fentanyl patches are available as matrix and reservoir patches. The two patch formulations have different medication release characteristics and are not interchangeable.

Fentanyl patches should be prescribed by brand name to ensure patients remain on the same preparation and a cost-effective preparation is supplied e.g. Matrifen®

Prescribe by brand name (e.g. Longtec®) to ensure patient receives cost-effective product and same product each time.

Patches are changed every 72 hours (3 days). If more than one patch is needed apply them at the same time to avoid confusion.

Oxycodone is available as modified release (12 hourly) and immediate release preparations.

Patients should be counselled to remove old patches and use a new area of clean, dry, hairless skin for each patch change.

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.

Patients should be counselled appropriately on the differences between the preparations to avoid confusion regarding which is for regular dosing and which is for breakthrough pain.

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). Do NOT increase dose by more than 50% at each dose increment. Also consider the use of PRN/breakthrough analgesia. Frail or elderly patients may need lower doses and slower titration. Improved analgesic effect may take up to 12-24 hours. Leave a minimum interval of 48 hours between dose increases. Significant blood levels of fentanyl will persist for up to 24 hours after removal of the patch.

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.

Renal impairment: No initial dose reduction is needed in renal impairment but monitor for signs of accumulation.

Liver impairment: Dose reduction may be needed in severe liver impairment.

Renal impairment: Reduced clearance in mild to moderate renal impairment so initiate at low dose, titrate slowly and monitor. Consider dose reduction and increased time between doses if required. Ideally avoid modified release preparations and restrict to prn use only.

Avoid if eGFR less than 20 mL/minute/1.73 m 2 (seek specialist advice)

Liver impairment: Avoid in moderate to severe liver impairment as clearance is reduced (seek specialist advice).

Ensure immediate release morphine e.g. morphine sulphate oral solution 10mg/5ml is available for breakthrough pain at an appropriate dose The 12 microgram/hr strength patch is only licensed for dose titration but may be used for patients requiring a lower starting dose (unlicensed)

If considering changing to an alternative opioid seek specialist advice first.

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. Prescribe by brand name e.g. Longtec®



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.Pain crisis – sudden change in pain that is severe, uncontrolled and causing distress despite regular analgesia, is a medical emergency – seek specialist advice..


Medicine Route of Administration

Dose equivalent to 10mg oral morphine

Dose conversion ratio TO oral morphine

Morphine oral 10mg N/AMorphine IM, IV, SC 5mg 1:2Codeine oral 100mg 10:1Dihydrocodeine oral 100mg 10:1Oxycodone oral 5mg 1:2 (some evidence for ratio of 1:1.5)

Oxycodone SC 2.5mg (approx) 1:4 (some evidence for ratio of 1:3) Diamorphine SC 3mg 1:3Tramadol oral 100mg 10:1

Dose conversions for fentanyl patches (British National Formulary)

72-hour Fentanyl patches are approximately equivalent to the following 24-hour doses of oral morphine

24-hour dose of oral morphine Equivalent strength of 72-hour fentanyl patch30mg daily Fentanyl ‘12’ patch60mg daily Fentanyl ‘25’ patch120mg daily Fentanyl ‘50’ patch180mg daily Fentanyl ‘75’ patch240mg daily Fentanyl ‘100’ patchFentanyl equivalences in this table are for patients on well-tolerated opioid therapy for long periods; for patients who are opioid naive or who have been stable on oral morphine or other immediate release opioid for only several weeks, seek specialist advice. Conversion ratios vary and these figures are a guide only, specialist palliative care teams may use alternative conversion ratios. Morphine equivalences for transdermal opioid preparations have been approximated to allow comparison with available preparations of oral morphine. Patients who are taking a daily dose of morphine that falls between fentanyl patch strengths may need to be changed to a patch which is either slightly less or slightly more potent than the morphine dose, seek specialist advice.

Transdermal preparations of fentanyl are not suitable for acute pain or in patients whose analgesic requirements are changing rapidly because the long time to steady state prevents rapid titration of the dose.

Prescribers should ensure that they are familiar with the correct use of transdermal preparations (inappropriate use has caused fatalities). Immediate-release oral morphine can be given for breakthrough pain.

It is important for prescribers to be aware that conversion ratios are an approximate guide only and specialist palliative care teams may use alternative conversion ratios. Following patch initiation or dose change, patients should be reassessed frequently for efficacy and adverse effects.

The 24-hour oral doses of morphine listed above are considered to be approximately equivalent to the fentanyl patches shown, however when switching due to possible opioid-induced hyperalgesia, reduce the calculated equivalent dose of the new opioid by 25 to 50%.



Converting to or from oral morphine to alternative opioids – dose conversions

The doses listed in the table

above are

approximate

equivalent

doses only.

Where no

direct dose

conversion

information is

available dose equival

ents have been

estimated via

indirect conversion.

Patients

should be

carefully

monitored

after any

change in

medication and

dose


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). Respiratory rate of <12bpm is a medical

emergency. Stop opioid and seek urgent medical attention. 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

NAUSEA AND VOMITING1.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:

Medicines Cough Severe painUraemia Anxiety InfectionHypercalcaemia Bowel obstruction Raised intracranial pressureConstipation Ascites

In palliative care patients, especially those with advanced cancer, nausea and vomiting is often multifactorial and all causes should be investigated. Drugs should be given as a stat dose and then regularly, NOT as required, and by an appropriate route. If absorption may be compromised give antiemetics by continuous subcutaneous infusion (CSCI) in a syringe driver. If appropriate, consider non-drug measures e.g. psychological measures for anxiety, and dietary advice. Evidence for alternative therapies such as acupuncture, acupressure, ginger is limited.



Be careful not to confuse a patient who is dying with someone who is experiencing opioid toxicity, be clear on the diagnosis. If in doubt, seek specialist advice.


2. MANAGEMENTChoice 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 10-20mg orally tds (caution in those at risk of extrapyramidal side effects e.g. Parkinson’s disease) or

Domperidone 10mg orally tds (note MHRA advice re cardiac risk, max 30mg daily). Extrapyramidal side-effects rare with domperidone

Also consider use of an antacid or proton pump inhibitor (PPI)

Levomepromazine 6.25-12.5mg (i.e. ¼ - ½ of 25mg tablet) orally nocte (avoid when at risk of seizure e.g. brain metastases, epilepsy).

Doses greater than 12.5mg/24 hours may be sedating.

For most chemical causes of vomiting (e.g. opioids, hypercalaemia, uraemia) use a centrally acting anti-emetic

Haloperidol 0.5-1mg orally nocte/bd or0.5-1mg continuous subcutaneous infusion/ 24hrs (both unlicensed).

(Dose may be titrated up as needed to a maximum of 10mg in 24 hours - seek specialist advice)

Levomepromazine 6.25-12.5mg (i.e. ¼ - ½ of 25mg tablet) orally nocte

or 3.125-6.25mg continuous subcutaneous infusion /24hrs. Max. 25mg/24 hours (avoid when at risk of seizure).

Drowsiness with doses greater than 12.5mg/24hrs may limit titration

NB levomepromazine 6.25mg PO equivalent to 3.125mg SC

Raised intra-cranial pressure, motion sickness

Cyclizine 50mg orally tds or 50-150mg continuous subcutaneous infusion / 24hrs

Levomepromazine 6.25mg (i.e. ¼ of 25mg tablet) orally nocte

Cause not clear Cyclizine 50mg orally tds or Metoclopramide10mg orally

tds or Haloperidol 0.5-1mg orally

nocte/bd (Dose may be titrated up as needed to a maximum of 10mg in 24 hours – seek specialist advice)

Levomepromazine 6.25mg (i.e. ¼ of 25mg tablet) orally nocte

For resistant nausea and vomiting due to chemotherapy and/or radiotherapy

Consult oncology team

Use metoclopramide, levomepromazine and haloperidol with caution in those at risk of extrapyramidal side-effects. These individually may enhance the extrapyramidal effects of other drugs such as SSRIs and tricyclic antidepressants. Domperidone is the antiemetic of choice in Parkinson’s disease. Extrapyramidal side-effects are rare with domperidone.

The overall safety profile of domperidone, and in particular its cardiac risk and potential interactions with other medications, should be taken into account if there is a clinical need to use it at doses or durations greater than those authorised. This should not be done without specialist advice.

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 e.g. oxybutynin, tolterodine 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.



http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON418518


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.

CONSTIPATION Regularly enquire about constipation. Consider potentially reversible causes of constipation e.g. poor oral intake, opioids, dehydration,

abdominal masses/ ascites etc. Most patients will need a softener and a stimulant. Patients should be advised to maintain an adequate fluid intake A stepwise approach to laxative therapy should be adopted – prescribe regular laxative treatment,

titrate treatment and optimise before adding or changing treatment. Daily laxatives are necessary for almost all patients on strong opioids (unless already liable to

diarrhoea). Regularly review and optimise treatment. Check adherence to treatment before increasing dose or changing treatment Increase doses as necessary every 1-2 days. Rectal measures may still be required e.g. glycerol

suppositiories.

For patients experiencing abdominal pain, do not titrate opioid dose to treat this – investigate and treat cause.

ROUTINE LAXATIVESSoftener – takes 24-36 hours to actDocusate sodium 100mg capsules

Initially 100mg BD orallyMax 200mg TDS

Softener at lower doses and mild stimulant at higher doses. Mostly a faecal softener.

Osmotic laxative – may take 1-3 days to have an effectMacrogol oral powder

Initially 1-3 sachets a day orally 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.A large volume of liquid may be difficult to take for some patients e.g. frail.

Stimulant – avoid in intestinal obstruction. Takes 6-12 hours to act (suppositories act within 10-30 minutes)Glycerol suppositories

4g suppository PR PRN Moisten with water before use

Bisacodyl 5mg tablets or 10mg suppositories

5-10mg nocte (oral)10mg nocte(PR)

Mostly acts on large bowel. Can cause abdominal cramps

Senna tablets or liquid

1-4 tabs(7.5mg - 30mg) nocte orallyor 7.5mg/5ml syrup 5–20mls nocte

Can cause abdominal cramps.

Docusate sodium 100mg capsules

Initially 100mg BD orallyMax 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 palliative care patients ONLY. Seek advice from a specialist before initiating and refer to full prescribing information for dosage information.

SYMPTOM CONTROL IN LAST DAYS OF LIFE




Several resources are available to support care in the last days of life. For example, UCLH Excellent Care in the Last Days of Life guidance documents and the ‘One Chance to Get it Right’ document by the Leadership Alliance for the Care of Dying People, June 2014.

Recognising when a person may be in the last days of lifeThe possibility that a person may die within the next few hours/days must be recognised and communicated clearly, having ensured that reversible causes have been excluded. An appropriate clinician caring for the patient at home, in conjunction with support from other multidisciplinary team members, should offer the patient dedicated time to have a compassionate and sensitive discussion, answering any questions that they may have, to the extent that the patient wishes to talk about such matters. If possible, the patient should be consulted regarding who they wish to have in attendance for this conversation. If the patient is unconscious or lacks capacity for these decisions, communication with those known to be closest to the patient is crucial.

Care in the last days of life Document the details of the conversation had with the patient/carer regarding the last days

of life Consider the person’s mental capacity to communicate and actively participate in their end

of life care and shared decision making Provide individualised care Ensure hydration is maintained and route of hydration is offered appropriately according to

individual needs and desires. Consider non-pharmacological methods of symptom management where appropriate e.g.

repositioning to manage pain or the use of fans to minimise the impact of breathlessness. Review current medications and stop those which are not providing symptomatic benefit or

that may cause harm. This should be done in discussion and in agreement with the patient and/or carer. Seek specialist advice if required.

Use an individualised approach to prescribing anticipatory medicines for people who are likely to need symptom control in the last days of life. Indications, route of administration and dose should be specified. Document an individualised care plan.

Consider the following medications for use in the dying person. Oral or transdermal medication (where applicable) should be considered in patients who

remain able to take these medications safely and effectively, and it remains their wish to do so.

For those patients who require pharmacotherapy for symptom control, and the injectable route is appropriate and desired , the document: Improving the Quality of Care in the Last Days of Life: A practical guide to getting medications right published by NHS London Clinical Networks may be consulted for additional information on medications which may be considered for use in the dying person. Please use in conjunction with the rest of the information in this guideline.



http://www.londonscn.nhs.uk/publication/improving-the-quality-of-care-in-the-last-days-of-life/


https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/323188/One_chance_to_get_it_right.pdf




SHORTNESS OF BREATHKEY POINTS

Very frightening for patient Is it appropriate to treat underlying cause? e.g. congestive cardiac failure (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 Physcial measures e.g. open windows, fan, keep face cool Refer to physio for relaxation techniques Where appropriate – bronchodilators (via spacer), antibiotics, steroids, diuretics, oxygen (ONLY if

hypoxic). Oxygen must be specialist initiated and clinically appropriate. Consider low dose immediate release oral morphine e.g. 1- 2.5mg oral morphine liquid 4 hourly

and/or PRN. If the patient is already on morphine for pain control, use the existing immediate-release breakthrough analgesic dose for the relief of breathlessness.

Benzodiazepines may help in the relief of anxiety associated with breathlessness (no evidence that benzodiazepines directly relieve breathlessness). Consider lorazepam 0.5 – 1mg sublingual prn (maximum 4mg/24 hours; maximum 2mg/24 hours if frail/elderly)

BRONCHIAL SECRETIONS KEY POINTS

Consider if these are due to a treatable underlying cause e.g. heart failure General management measures include repositioning to lateral position, avoid over hydration,

addressing family distress.

SYMPTOM CONTROL Hyoscine butylbromide, hyoscine hydrobromide or glycopyrronium bromide injections can be given.

Give stat dose and review response after 60 mins, if effective, PRN or regular doses via syringe driver can be given.Consult specialist palliative care team. Also see syringe driver section (Appendix 1)

AGITATIONKEY POINTS

Ensure calm and comfortable environment Treat reversible causes

o Paino Urinary retentiono Constipation

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 24 hours may be needed.1st line Lorazepam (if patient conscious) 500 microgram to 1mg orally or sublingually 4-6hourly PRN (max

4mg daily) or Midazolam. Use 2.5-5mg SC hourly PRN or 10-60mg over 24 hours in syringe driver (Discuss with

specialist palliative care team if requiring >40mg /24 hours)

2nd line Levomepromazine – avoid if risk of seizure Sedative and antiemetic Use 25-100mg for restlessness over 24 hours in syringe driver Lower doses are used for antiemetic purposes


USEFUL CONTACTS - LOCAL SPECIALIST PALLIATIVE CARE TEAMS If you wish to discuss how to manage the palliative care needs of a patient with a specialist palliative care service, contact details of the local specialist palliative care teams are given below.

Local community specialist palliative care teams

Area Team base Office hours Out of hours

Islington ELiPse team, Well House, Benwell Road

Mon-Fri: 09:00 - 17:00Tel: 020 3317 5777

Email: [email protected]

Tel: 020 3456 7890 (UCLH Trust Switchboard) and ask to air-call the palliative care team.Provides telephone advice and visiting where needed.

South Camden

UCLH Mon-Fri: 08:30 - 17:00Tel: 020 3447 7140Email: [email protected]

North Camden

Royal Free Hospital Mon-Fri: 09:00 - 17:00Tel: 020 7830 2905

Sat-Sun: 9.00 - 5.00Tel: 020 7794 0500 ext 23304 and ask to air-call the palliative care team

Haringey North London Hospice Mon-Fri: 09:00 - 17:00Tel: 020 8343 8841

Available on: 07957 588273

City and Hackney

St Joseph’s Hospice Mon-Fri: 09:00 - 17:00 Tel: 020 8525 6060First Contact Team Tel: 0300 303 0400

Mon-Sun: 18:00 - 08:00Tel: 020 8525 6000

DISTRICT NURSES

24hr District Nurse (DN) Message Service Telephone No.Camden (DN Available 24h - 7 days a week)

Tel: 020 3317 5916OOH referrals: Tel: 0207 391 6360 (from 17:00–08:30)

Islington (Whittington Health) (DN Available 08:30-24:00 - 7 days a week)

Tel: 020 3316 1111OOH referrals: Tel: 020 7527 4250

City and Hackney (DN available 08:30-23:30 - 7 days a week)

Tel: 020 7683 4144

Haringey 24hr District Nurse (DN) Message Service(DN available 24 hours 7 days a week)

Monday–Friday 09:30–16:00Phone: 020 7288 3555District Nursing message-taking service for out of hours referrals: Phone: 020 7288 3555

Local Hospices contact detailsMarie Curie Hospice HampsteadSt John’s Hospice St Joseph’s HospiceNorth London Hospice

Tel: 020 7853 3400 email: [email protected]: 020 7806 4040 email: [email protected]: 020 8525 6000Tel: 020 8343 8841 (Out of hours for advice: 07957 588273) email: [email protected]

Pharmacy servicesIslington Pharmacies (Palliative care medicines scheme) for Islington patients only:

Clan Pharmacy. 150 Upper Street. N1 1RA Tel:020 7359 7595 Dev’s Chemist (Atchem Ltd). 110 Seven Sisters Road. N7 6AE Tel:020 7607 3081

Camden 100 hour pharmacies Boots the Chemists, Unit 19, St Pancras Station, N1C 4QL. Tel: 020 7833 0216 Boots the Chemists, Western Ticket Hall, Kings Cross Station. N1C 4AP Tel: 020 7278 5861 Baban Pharmacy, 42 Chalton St, NW1 1JB. Tel: 020 7388 9989 IPSA Pharmacy, 7 Harben Parade, Finchley Road. NW3 6JP. Tel: 020 7449 9490 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 Philips Chemist 193 Lordship Lane, Tottenham, London, N17 6XF Tel: 020 8808 4040

Monday – Friday 09:00 – 18:30, Saturday 09:00 – 17:30 Pharmacy Express 214 High Road, London, N22 8HH. Tel: 020 8888 1669 Monday – Friday 09:00 – 18:30, Saturday 09:00 – 13:00

ReferencesThis information is a broad guideline only. Treatment of an individual patient should always be modified according to need & circumstances, and may involve

a multidisciplinary approachPalliative Care for Adults – Guidance for Primary Care v3 of 21

Odejide, Oluwaseun - Prescribing Advisor, 11/12/18,

To check if this OOH for NLH is up to date

Odejide, Oluwaseun - Prescribing Advisor, 11/12/18,

Information to be updated

tel:0207

tel:020

mailto:[email protected]

mailto:[email protected]


1. National Institute for Health and Care Excellence (NICE). Care of dying adults in the last days of life. NICE guideline [NG31] Published date: December 2015. Available via https://www.nice.org.uk/guidance/ng31 (Last accessed December 2018)

2. National Institute for Health and Care Excellence (NICE). Palliative care for adults: strong opioids for pain relief. Clinical guideline [CG140] Published date: May 2012. Last updated: August 2016. Available via https://www.nice.org.uk/guidance/cg140 (Last accessed December 2018)

3. Palliative Care Adult Network Guidelines (PANG) 2018. http://book.pallcare.info/ (Last accessed December 2018)4. NHS Scotland. Scottish Palliative Care Guidelines. https://www.palliativecareguidelines.scot.nhs.uk/ (Last accessed December 2018)5. Palliative Care Formulary (PCF) online. Available via https://www.palliativedrugs.com/palliative-care-formulary.html (Last accessed

December 2018)6. Leadership Alliance for Care of Dying People. One chance to get it right. June 2014. Available via

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/323188/One_chance_to_get_it_right.pdf (Last accessed December 2018)

7. NHS London Clinical Networks. Improving the quality of care in the last days of life. Available via http://www.londonscn.nhs.uk/publication/improving-the-quality-of-care-in-the-last-days-of-life/ (Last accessed December 2018)

8. British National Formulary (BNF) online. Last updated: 6 November 2018. Accessed via https://bnf.nice.org.uk/ 9. UCLH Palliative Care Quick Reference Guide. July 2018. (Authored by Dr Sarah Yardley and Dr Julia Bichard)

APPENDICES



https://bnf.nice.org.uk/


https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/323188/One_chance_to_get_it_right.pdf

https://www.palliativedrugs.com/palliative-care-formulary.html

https://www.palliativecareguidelines.scot.nhs.uk/

http://book.pallcare.info/

https://www.nice.org.uk/guidance/cg140

https://www.nice.org.uk/guidance/ng31


APPENDIX I: USE OF A SYRINGE DRIVER A syringe driver is an alternative route of administration where other routes are not viable.

Medication is delivered by continuous subcutaneous infusion (CSCI). Indications include: persistent nausea and vomiting, dysphagia, intestinal obstruction or poor intestinal

absorption, coma, or too weak to take oral medications. Obtain 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 (DN) 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, however compatibility should be checked as some drugs are

less compatible with water for injections in comparison to sodium chloride 0.9% e.g. ondansetron. 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 9 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 VIA SYRINGE DRIVERPain Morphine sulphate If opioid naïve start at

10mg/24hrs. For all 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.

Oxycodone Do not use in opioid naive patients. Calculate 24 hour dose from patients previous opioid dose

Colic Hyoscine butylbromide 20 - 120mg in 24 hours (For higher doses, seek specialist advice)Bronchial secretions Hyoscine hydrobromide 1200 - 2400 micrograms in 24 hours. Confusion limits use.

Hyoscine butylbromide 20 -120mg/24 hours

Glycopyrronium bromide 600 – 1200 micrograms /24 hoursNausea 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.)3.125 - 25mg in 24 hours (for anti-emetic) 12.5 -100mg in 24 hours (for restlessness/sedation) – For doses above 100mg/24 hours seek specialist adviceHigher doses for sedation only

Nausea and vomiting Haloperidol(caution in epilepsy, may lower seizure threshold)

0.5mg - 10mg in 24 hoursDoses >8mg/day risk extrapyramidal effectsAbove 2mg/ml can precipitate in diamorphine

Terminal anxiety and 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)




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 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 compatibility

Drug combinations may be compatible only at certain concentrations, therefore the concentration of each drug in the syringe should be compared with compatibility data, not the dose. Seek specialist advice.

Check the solution in the syringe regularly for precipitation and/ or discoloration and discard the contents if this happens.

Some drugs are irritant if administered by the SC route and therefore should not be used in a syringe pump. These include diazepam, chlorpromazine, prochlorperazine

Care should be taken when mixing more than two drugs in a syringe and in ensuring that the diluent is compatible with each of the drugs.

The following points are useful to consider when mixing drugs in a syringe pump, especially if compatibility data is lacking: Drugs with a similar pH are more likely to be compatible Most of the drugs commonly used in syringe pumps are acidic in solution, therefore more alkaline

medications e.g. dexamethasone, furosemide, ketorolac could cause compatibility problems if added. A second syringe pump should be considered to administer these drugs

Exposure of the syringe mixture to extremes of temperature and light can affect stability and should be avoided where possible.

In general, drugs tend to be more stable in lower concentrations in solution. Therefore, a larger syringe with more diluent may be required where possible. If this is not possible the drugs may need to be separated and administered using more than one syringe. Seek specialist advice.

Drugs with long durations of action can alternatively be given equally well as a bolus SC or intravenous injection once or twice daily, for example dexamethasone and levomepromazine. This avoids the need to add to a syringe mixture that may affect stability

Skin irritation around the needle site, poor symptom control or an unexpected loss of symptom control may be the result of drugs becoming unstable when mixed together. Frequent checks of the syringe pump contents for precipitation or discoloration as well as the patient’s condition is essential.




APPENDIX II

Hydration and Oral Nutritional Support in Palliative Care Patients

Maintaining hydrationEnsure hydration is maintained in palliative care patients and the route of hydration is offered appropriately according to individual needs and desires. For patients considered to be in the last days of life, principles and approach to hydration should be considered and offered in line with NICE Clinical guideline 31 – Care of dying adults in the last days of life.

The use of subcutaneous fluids for hydration in the last days of life should always be discussed with the specialist palliative care team prior to initiation.

Palliative care and Oral Nutritional Supplements(ONS) Loss of appetite is a complex phenomenon that affects both patients and carers. Be aware of the potential tensions that may arise between patients and carers concerning a patient’s loss of appetite. This is likely to become more significant through the palliative stages and patients and carers may require support with adjusting and coping.

Principles of care: The patient should always remain the focus of care. Carers should be supported in consideration of the

environment, social setting, food portion size, smell and presentation and their impact on appetite. Use of ONS in palliative care should be assessed on an individual basis. Appropriateness of ONS will be

dependent upon the patient’s health and their treatment plan. Emphasis should always be on the enjoyment of nourishing food and drinks and maximising quality of life.

Management of palliative patients can be divided into three stages: early palliative care, late palliative care, and the last days of life. Care aims will change through these stages.

If ONS is required consider seeking specialist advice and refer to local guidelines for preferred product choice.

Treatment with ONS should be regularly reviewed.

Nutritional management in early palliative care In early palliative care, patients may have months or years to live and may be undergoing palliative

treatment to improve quality of life. Screening and assessment for nutritional needs should be undertaken, using local nutrition support

pathways and guidance, as early intervention could improve the patient’s response to treatment and potentially reduce complications.

When prescribing nutrition supplements consider whether a patient is likely to consistently manage two servings of ONS per day as, if not, they are unlikely to derive any significant benefit to well-being or nutritional status from the prescription.

Nutritional management in late palliative care In late palliative care, the patient may be experiencing increased symptoms such as pain, nausea and

reduced appetite. The nutritional content of the meal is no longer of prime importance and patients should be encouraged

to eat and drink the foods they enjoy. The main aim is to maximize quality of life including comfort, symptom relief and enjoyment of food. Aggressive feeding is unlikely to be appropriate especially as this can cause discomfort, as well as distress and anxiety to the patient, family and carers.

The goal of nutritional management should not be weight gain or reversal of malnutrition, but quality of life.

Nutrition screening, weighing and initiating prescribing of ONS at this stage is not recommended. Prescribing ONS for the sake of ‘doing something’ when other dietary advice has failed would not generally be recommended.

Nutritional management in the last days of life In the last days of life, the patient is likely to be bed-bound, very weak and drowsy with little desire for

food or fluid. The aim of nutritional support should be to provide comfort for the patient and offer mouth care and sips

of fluid or mouthfuls of food as desired.

Adapted from the Macmillan Durham Cachexia Pack 2007



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