Managing Symptoms at the End of Life When the Oral route Fails

• 1. What is an RMAD?• 2. Indications for the Use of the RMAD• 3. Benefits of RMAD Placement• 4. Making an RMAD• 5. Placing an RMAD• 6. Administering Medications via the RMAD• 7. Documentation

A RMAD is a device which allows for easy and comfortable administration of fluids or medications that are in solution or suspension into the rectum.

A tube to carry the medication into the rectum

Small holes at the end of the tube to disperse the medication onto the rectal mucosa

A medication port

A balloon inflation port which inflatesa 10ml balloon inside the rectum

RMAD placement showing easy access to ports.

Placement of the RMAD in the distal 1/3 of the rectum.

Indications•The patient is in the last days to week of life, no longer able to swallow, and:

•Oral doses of liquid pain medications > 1.5ml•Symptoms spiraling out of control•Family is overwhelmed•Patient is severely Agitated•Multiple oral medications for comfort•Copious oral secretions or vomiting •Bowel obstruction•Seizures

 

Benefits of RMAD placement

1. Quick control of severe symptoms• (Pain, Agitation, SOB, Seizures < 1HR)

2. The patient no longer has to be repositioned for medications

3. Medication administration is painless

4. All current comfort medications can be continued

Benefits of RMAD placement

4. Highly cost effective

5. More reliable/quicker acting than transdermal gels

6. Families can give all medications easily by one route

7. Decreased chance of aspiration of medications

The RMAD Kit1 Large Zip-lock bag1 RMAD1 Package water soluble lubricant 1 Mortar and Pestle2 -10ml syringes1-3ml syringe1-specimen container1- Catheter securing device2-Clean barrier pads1 pair- non-sterile gloves2- Medication and Instruction Sheets1- RMAD Quick Reference Sheet

Making an RMAD Step 1: Open one 14fr and one 16fr-5cc Foley catheter,

but do not remove the 16fr catheter from its package.

Making an RMAD Step 2: Cut the valve off of the 14fr catheter

Making an RMAD Step 3: Place the cut valve (green) onto the drainage end of the16fr catheter.

Making an RMADStep 4: Place tape (cloth-paper tape works well) around the drainage end and valve.

Making an RMAD Step 5: Leave the finished RMAD in the package.

Assessment Guidelines Prior to Placement

•Assess rectal opening for wounds, abscesses, or drainage

•Assess for diarrhea or hard stool

•Assess for allergy to latex, if present, use non-latex catheters to make RMAD.

Six general guidelines for administering medications via the RMAD.

1.Use cool tap water (not refrigerated).2.Suspend solid medications as follows:

For a small sized tablet (e.g., Valium) add 1ml water For a medium sized tablet (e.g., Phenobarbital) add 1.5ml water For a large sized tablet (e.g., Vicodin) add 2 ml water

3.Total amount should not exceed 13ml (including flush).4.Instill over 5 to 10 seconds. 5.Tip syringe back and forth.6.Always flush the RMAD with 3ml water after every dose.

Medications that can be given via RMAD•Liquid Morphine•Benzodiazepines (Ativan, Diazepam, etc.)

•Barbiturates (Nembutal, Phenobarbital)

•NSAID’s (excluding salicylates)

•Oral steroids

•Most anti-seizure Medications (not Dilantin)

•Anti-nausea Medications

•Resperidal and Haloperidol

Medications that cannot be given via RMAD.

•Dilantin

•Any “Do not Crush” Medications*•Switch to short acting given ATC

•ASA and related Medication (Salicilates)•Switch to Indocin

Sample Orders for RMAD Placement and Medications.

Placement:

“RN to place Rectal Medication Administration Device 3 inches into rectum. Inflate balloon to 10ml.”

Medications:

PhenobarbitalGive Phenobarbital 400mg every 12 hours rectally

via RMAD.

Morphine (Scheduled) Give Liquid morphine (20mg/ml) -4ml every 4 hours rectally around the clock via RMAD.