Palliative Care Pocket Guidelines

36 Pages·4.191 MB·English

by  Boyd K.

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Palliative Care Pocket Guidelines 2010
Palliative care aims to improve the quality of life of patients and their families Contents
facing the problems associated with any life limiting illness.
These Guidelines reflect a consensus of opinion about good practice in the
Specialist palliative care services ...............................................................2-3
management of adults with a life limiting illness. There is a separate section
on the website covering paediatric palliative care.
Pain assessment .........................................................................................4-5
Every effort has been made to ensure the accuracy of the text and
that evidence informed information has been included. Adherence to guideline Pain management .......................................................................................6-7
recommendations will not ensure a successful outcome in every case. It is Choosing & changing opioids ...................................................................8-13
the responsibility of all professionals to exercise clinical judgement in the
Fentanyl ...................................................................................................14-20
management of individual patients. Palliative care specialists occasionally
use or recommend other drugs, doses or drug combinations than those given Oxycodone ..............................................................................................21-23
here.
Breathlessness ........................................................................................24-27
© NHS Lothian. Please acknowledge authorship if you copy or disseminate
these guidelines. The Guidelines Group members would like to thank all those Constipation ............................................................................................28-33
involved in preparation of these resources.
Delirium ...................................................................................................34-36
Emergencies ............................................................................................38-39
Palliative Care Guidelines: websites
Hypercalcaemia..................................................................................40-41
The printed Palliative Care Guidelines, additional guidelines, references, more
Cord compression ..............................................................................42-43
information about specialist services, information for patients and further
professional resources are available online. Last days of life .......................................................................................44-49
NHS Lothian intranet: Nausea/ vomiting ....................................................................................50-55
http://intranet.lothian.scot.nhs.uk/nhslothian/healthcare/a_z/p/palliative_care.aspx Subcutaneous infusions of medication ...................................................56-59
NHS Lothian website:
Compatibility charts ................................................................................60-65
http://www.nhslothian.scot.nhs.uk/ourservices/palliative/
SHOW website: http://www.palliativecareguidelines.scot.nhs.uk
Other resources
Correspondence and enquiries to:
• Palliative care drug information online http://www.palliativedrugs.com/
Dr Kirsty Boyd (Palliative Care Guidelines Group Chair)
Palliative Care Service • Dickman A: The syringe driver: continuous subcutaneous infusions in
Royal Infirmary of Edinburgh palliative care. 2nd Edition, 2005. OUP.
Little France Crescent,
• Palliative medicine handbook http://www.pallcare.info/
Edinburgh EH16 4SA
Tel: [phone]
e-mail: [email protected]
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Re-issue date: August 2010 Review date: August 2013 Palliative Care Pocket Guidelines 2010 (Third edition | Version 2)
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pecialist Palliative Care Services in NHS Lothian • Specialist palliative care services offer telephone advice, a single assessment visit or a period of specialist care according to need.• Specialist palliative care is available to patients in any care setting; home, hospital, or care home. Referral Can be made for a patient who has any life limiting illness, and is in or is entering the palliative phase of their illness, if they have; • complex end of life care needs.• uncontrolled pain or other symptoms.• complex physical, psychological, spiritual or family needs that cannot be met by the staff in that care setting. Community palliative care servicesHospice inpatient units Available Monday to Friday, 9am - 5pm.Marie Curie Hospice, EdinburghFrogston Road West, EH10 7DR Marie Curie Hospice community teamTel: 0131 470 2201 Tel: [phone] Fax: [phone] (team office with answerphone)http://hospiceedinburgh.mariecurie.org.uk/ 0131 470 2201 (hospice reception)St Columba’s Hospice, EdinburghFax: 0131 470 2200 15 Boswall Road, EH5 3RW St Columba’s Hospice community teamTel: 0131 551 1381 Tel: [phone] (hospice reception)Fax: [phone] Fax: [phone]http://www.stcolumbashospice.org.uk/ Hospital palliative care teamsWest Lothian community teamTel: 01506 523534 Available Monday to Friday, 9am - 5pm.Fax: [phone]Western General Hospital, EdinburghEast Lothian community teamRadiopage for all referrals/urgent queries: Tel: [phone] #6410 (07659 549 704) Fax: [phone]Tel (answerphone): 0131 537 2243 Royal Infirmary of Edinburgh Palliative care day servicesHospital pager for urgent referrals: Marie Curie Hospice day unit 5715 or via switchboard 0131 536 1000 Tel: [phone]Tel (answerphone): 0131 242 1993 Fax: [phone]Fax: [phone] (for non-urgent referrals) St Columba’s day hospiceSt John’s Hospital, LivingstonTel: 0131 551 1381Hospital pager for all referrals/urgent queries: Fax: [phone] or via switchboard 01506 523000 Tel (answerphone): 01506 522010The Macmillan Centre: West LothianTel: 01506 523531Palliative care pharmacistFax: 01506 522005 EdinburghTel: 0131 470 2201/2234 (Mon, Wed, Fri am)Palliative care out-of-hoursTel: 0131 551 1381/7712 (Tues, Thurs, Fri pm)• Contact one of the Lothian hospices. Radiopage: 07699 613 264• Palliative Care Community Pharmacy West Lothian (St John’s Hospital)Network stocks essential medication. Tel: [phone] (Mon-Thurs 9-3, Fri am)• A senior doctor and/or consultant is Hospital pager: 3918 available to give telephone advice on or via switchboard 01506 523 000.complex patients. Pocket Guidelines 2010 (Third edition | Version 2)
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THER ADJUVANT Seek advice: Severe pain.♦ Pain not ♦responding. Dose of opioid has ♦increased rapidly but patient is still in pain. Episodes of acute ♦severe pain. Pain worse on ♦movement.
+/- O hours ase 5mg pain.
Severe Pain or OLNSAID ep 2 opioidds 30mg oral morphine / 24≈ If starting with modified releprescribeoral morphine 10-15mg, 12 hourly and immediate release morphine as required for breakthrough more slowly if patient is frail, ersion 2)
STEP 3: Moderate to OPIOID + PARACETAM Stop any stCodeine or dihydrocodeine 60mg q If titrating with immediate release prescribeoral morphine 5mg, 4 hourly and as required for breakthrough pain. Use lower doses and increase dose elderly or has renal impairment. are Pocket Guidelines 2010 (Third edition | V
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hoosing and Changing Opioids in Palliative Care Introduction • Opioids are used for pain and breathlessness. • Most palliative care patients respond well to titrated oral morphine.• A small number of patients may need to be changed to another opioid: o Oral route is not available.o Pain is responding but patient has persistent, intolerable side effects. (Consider reducing the dose and titrating more slowly or adding an adjuvant analgesic before changing opioio Moderate to severe liver or renal impairment. o Poor compliance with oral medication.o Complex pain (consider adjuvant analgesics/ other pain treatments). Choosing an opioid for moderate to severe pain (see: Pain management)First line opioids: Morphine • Range of oral preparations; SC injection and in a syringe pump.• Renally excreted, active metabolites – titrate morphine slowly and monitor carefully in chronic kidney disease.• Consider other opioids in stage 4-5 chronic kidney disease, dialysis patients.• Low doses and slow titration in liver impairment. Diamorphine• Highly soluble opioid used for SC injection and in a syringe pump. • Use for high dose SC breakthrough injections (above 180mg SC morphine/ 24hrs). Powder preparation is diluted in a small volume of water for injections.• As with morphine, cautious use in renal and liver impairment. Second line opioids: Oxycodone • For moderate to severe pain if morphine/ diamorphine are not tolerated.• Immediate and modified release oral preparations; SC injection; syringe pump. • Lower concentration preparation limits dose for SC injection to 10mg (1ml).• Avoid in moderate to severe liver impairment, clearance is much reduced.• Mild to moderate renal impairment: reduced clearance so titrate slowly and monitor carefully. Avoid in stage 4-5 chronic kidney disease. Fentanyl • Topical patch lasting 72 hours; use if oral and SC routes unsuitable.• For stable pain if morphine is not tolerated; dose cannot be changed quickly.• No initial dose reduction in renal impairment but may accumulate over time. dose reduction may be needed in severe liver disease.• Liver impairment; (seek specialist advice)Third line opioid: Alfentanil • Short acting, injectable opioid for SC injection and in syringe pump. • In episodic/ incident pain can be given sublingually or subcutaneously.• Standard dose in renal disease including stage 4-5 chronic kidney disease.• Clearance may be reduced in liver impairment; reduce dose and titrate. (specialist use only)Fourth line opioid: Methadone • Oral methadone is used by specialists for complex pain; dosing is difficult due to the long half life; no renal excretion so standard dose in chronic kidney disease, half life prolonged in severe liver disease. Pocket Guidelines 2010 (Third edition | Version 2)
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hoosing & Changing Opioids Changing opioid • These doses / ratios are () and should be used as a .approximateguide≈• Dose conversions should be conservative and doses usually rounded down.• Monitor closely; extra care if frail, elderly patient; renal or hepatic impairment. • Always prescribe an appropriate drug and dose for breakthrough pain:th 1/6 of the 24 hour regular opioid dose. Equivalent doses of opioids recommended for use in palliative care Immediate release morphine Opioid doseOral morphine: opioid potency ratio Oral morphine 5 mg Oral codeine 60mg or1:10 ≈oral dihydrocodeine 60mg Oral morphine 10mg SC morphine 5mg2:1≈Oral morphine 10mg SC diamorphine 3mg3:1 ≈Oral morphine 10mg Oral oxycodone 5mg2:1≈Oral morphine 10mg SC oxycodone 2-3mg4:1≈Oral morphine 60-90mg in Fentanyl patch See: Fentanyl≈24hrs 25 micrograms/ hour Oral morphine 30mg SC alfentanil 1mg 30:1≈ (1000 micrograms)See: Alfentanil Immediate release oxycodone Oxycodone potency ratio Oral oxycodone 5mg SC oxycodone 2-3mg2:1≈See: Oxycodone Equivalent doses of opioids not generally recommended for palliative c Opioid dose Immediate release morphineMorphine: opioipotency ratio Oral tramadol 50mg Oral morphine 5-10mg1:5 to 1:10≈Oral nefopam 30mg Oral morphine 10mg1:3≈Buprenorphine patches 10 micrograms/ hour Oral morphine 10mg/ 24 hrs≈ 35 micrograms/ hour Oral morphine 30-60mg/ 24 hrs≈52.5 micrograms/ hour Oral morphine 60-90mg/ 24 hrs≈70 micrograms/ hour Oral morphine 90-120mg/ 24 hrs≈Oral hydromorphone 1.3mg Oral morphine 5-10mg5:1 to 7.5:1 ≈ Opioid toxicity • Wide variation in the dose of opioid that causes symptoms of toxicity.• Prompt recognition and treatment are needed. Symptoms include:o Persistent sedation (exclude other causes)o Vivid dreams/ hallucinations; shadows at the edge of visual fieldo Deliriumo Muscle twitching/ myoclonus/ jerkingo Abnormal skin sensitivity to touch• Reduce the opioid by a third. Ensure the patient is well hydrated. Seek advice.• Consider adjuvant analgesics and/or alternative opioids if still in pain.• Naloxone (in small titrated doses) is only needed for life-threatening respiratory depression. (see: Naloxone) ocket Guidelines 2010 (Third edition | Version 2)
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•••• RpRlCoPhiniraaeehg etlreddhitiv eciuueoceknrccpur t deeltii aohmi osrtteis hhdp c oeiee aanbsp irfrdd aioemooooc rriimess ksdwn ee anttht otoe.bbieo exyymnndi cuu toeah,ppd rbef p rtto wahooduihi oltn33 e soie00nner%% d a coein hvflww ddiatdhe hhnurergeeeal iynn-filn t r dgaiccstr nrthoub adoanget pnvsetrweig e.oifr-eii ntdtteiihgn tnher g oaa o ptspfpera iiboo.otiemieidden s nati f a h rstatah epseci d roelnyn da l opioid analgesics used for m Oral oxycodone 4-hr 12-hr 24-hr doseMR dosetotal dose 1 or 2mg-7 or 8mg 2 or 3mg5mg15mg 5mg15mg30mg 7 or 8mg20mg45mg 10mg30mg60mg 15mg45mg90mg 20mg60mg120mg 25mg75mg150mg 30mg90mg180mg of 30mg/ml. Oxycodone inje atient needs a dose that is i
increased as these patients are at greater risk of adverse effects. ond line aneous rphine 24-hr total dose 5mg 10mg 20mg 30mg 40mg 60mg 80mg 100mg 120mg ntration pain if p
M•• oMdFawCn eohhroinaseetretnpcona gkh inrine ti ynf ct ewlfehr:on e oderatmu aone lnpesddayenac lbo t htcsgxei o.uepy snDciandavotetefcedec lhric iosnmt aonideorae o.ncel s sdopfe noulf.ar vsloTcleeymhers tes c tomaoarr aniefnle binmnmeotoaI utmfr nmr pyeiehn lcad ii onssodume sso reahmeu rodoeebw f na utondc sr –ceaiun udlas r.mtlealhyteoi esgkrl pyit vaa heibnidnnl ev1 ea.m i sc ge Choosing & Changing Opioids A guide to dose conversions FROM morphine TO sec Subcutaneous SubcutOral morphinemorphinediamo 4-hr 4-hr 24-hr 4-hr 12-hr 24-hr dosedosetotal doseMR dosetotal dosedose 2 or 3mg5mg15mg1mg7 or 8mg1mg 5mg15mg30mg2 or 3mg15mg2mg 10mg30mg60mg5mg30mg3mg 15mg45mg90mg7 or 8mg45mg5mg 20mg60mg120mg10mg60mg7mg 30mg90mg180mg15mg90mg10mg 40mg120mg240mg20mg120mg10mg 50mg150mg300mg25mg150mg15mg 60mg180mg360mg30mg180mg20mg∗ MR = modified release (long acting) Morphine injection is available in a maximum conce∗10mg/ml.Another SC opioid will be needed for breakthrough Seek advice Palliative Care Pocket Guidelines 2010 (Third edition | Version 2)
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entanyl Patches in Palliative Care Description Potent opioid analgesic in a topical patch lasting 72 hours. Preparations ® ®Matrix patch12, 25, 50, 75,100 Durogesic D-TransMatrifenmicrograms/hour ®®Reservoir patch25, 50, 75,100 Durogesic Tilofylmicrograms/hourPatients should stay on the same preparation and not switch formulation/ brand. Indications • opioid for moderate to severe opioid responsive pain that is .Second linestable• Oral and subcutaneous routes are not suitable.• Patient unable to tolerate morphine/ diamorphine due to persistent side effects. • Poor compliance, but supervised patch application possible. Side effects • Similar to morphine but less constipation, nausea.• If signs of opioid toxicity (eg sedation, delirium), remove the patch and seek advice. Fentanyl will be released from the site for up to 24 hours. Monitor the patient for 24-48 hours.• Titrated naloxone is only needed for life-threatening, opioid induced respiratory depression.o A low respiratory rate < 8 respirations/minute.o Oxygen saturation <85%, patient cyanosed.• An allergic reaction to the patch adhesive can occur – change opioid. Cautions • Fentanyl is a potent opioid analgesic; check the dose carefully. 25 microgram fentanyl patch is equivalent to about 60-90mg of oral morphine in 24 hours.• Frail or elderly patients may need lower doses and slower titration. • Heat increases the rate of fentanyl absorption. This can occur if patient is febrile or the skin under the patch is heated. Avoid direct heat sources, use anti-pyretic measures. • dose reduction may be needed in severe liver disease. Liver impairment:• no initial dose reduction. May accumulate gradually over time. Monitor Renal impairment:patient and reduce dose. Fentanyl is not usually removed by dialysis. • If the patient has unstable pain or pain likely to change following treatment, do not start fentanyl. Seek advice and consider alternative opioids. Dose & Administration Starting a fentanyl patch 1. Choose a suitable patch - matrix patch allows titration in smaller increments.2. Calculate the dose of fentanyl from the conversion chart given here or seek advice. Patch strengths can be combined to provide an appropriate dose.3. The 12 microgram patch is licensed for dose titration, but may be used for patients needing a lower starting dose if recommended by a specialist. Pocket Guidelines 2010 (Third edition | Version 2)
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