Mississauga Halton Symptom Management kit€¦ · Mississauga Halton Symptom Management Kit 4 Mississauga Halton Adult Symptom Management Kit Accessing the SMK It is appropriate to

Mississauga Halton Adult Symptom Management Kit

Mississauga Halton Symptom Management Kit

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Information package

Table of Content Page Definition……………………………………………………………………….………2

Background……………………………………………………………………….…...2

Why Order a SMK……………………………………………………………….…….3

When should a SMK be ordered…………………………………………………….3

Accessing the SMK…………………………………………………….……………..4

Disposal of the SMKT including unused medications……………….…………….4

Contraindications for a SMK…………………………………………………………4

Process for ordering a SMK for a patient…………………………………………….5

Process for the administration of the medications from the SMK……….……….5

Content of the SMK ……………………………………………………….………….6

Cost of the SMK…………………………………………………………….…………7

Turnaround time to delivery or pick-up…………………………….………………..8

APPENDICES

1 – Palliative Performance Scale…………………………………………………….9

2 – MH Symptom Management Kit Prescription Form

3 – Expedited Access Individual Access Clinical Review Form &

4 - Memo re Expedited access Individual Access Clinical Review (ICR)

5 – Frequently Asked Questions (FAQ) Facilitated Access to Palliative Care Drugs Mechanism

6 – Medications – quick reference guide

7 - SMK Clinical Evaluation Form



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What is the Mississauga Halton (MH) Symptom Management Kit SMK? The MH Symptom Management Kit (SMK) is a standardized package of medications and related medical supplies provided to a patient who is approaching end-of-life for the purpose of relieving unanticipated or rapidly escalating symptoms. It can be accessed by a community nurse authorized by a Community Care Access Centre and/or a physician.

Background

SMKs have been available in several regions of Ontario as a system to support people in their choice to remain at home and out of hospital. In Halton, a Crisis Kit has been available for CCAC patients at end-of-life for several years now. It was recognized that there have been differences in the processes of how SMKs have been placed in the homes of patients across the Province and how they would be accessed once there. A Ministry of Health and Long Term Care Task Force was developed as an outworking of the Provincial End-of-Life Care Advisory Committee, to attempt to develop some consistency across the province and to support areas that do not have a SMK system.

The Task Force’s primary objective was to create a document that be could used as a guide to assist areas of the province not having a SMK system in their attempt to develop one. Initially, effort was made to develop a document that would not be prescriptive about how to develop a SMK system. However, as the Task Force continued its work, it was determined that effort should focus on finding one best practice approach to the processes that need to be employed in a SMK system. Within this approach would be flexibility to accommodate regional differences in various non-process based issues, such as but not limited to, physician prescribing practices, SMK contents etc.,

Although the draft guidelines produced by the Task Force were intended to be as clear as possible, they are only guidelines. Their purpose is to support communities as they work to develop their own local SMK system. These Task Force Guidelines have been used as the foundation for the Mississauga Halton Guidelines. The processes described in this document also take into consideration that each of the health care providers involved (i.e. Registered Nurses (RNs), Pharmacists and Medical Doctors (MDs)) must adhere to the Standards of Practice of their respective College.

Each of the College of Nurses of Ontario, the College of Physicians and Surgeons of Ontario and the Ontario College of Pharmacists has provided input to the Task Force document and by consensus has provided their support to it. However, that these organizations support this document does not necessarily mean that it will answer all professional practice questions that could arise. If a regulated health care provider has further professional practice questions that are not addressed in this document, he/ she is advised to contact his/ her respective college(s).


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Why order a SMK? While it is predictable that patients facing end-of-life are likely to experience increasing symptoms, sometimes the timing of those symptoms is not predictable. Having an SMK on hand ensures that the community nurse has a well thought out tool kit and instructions that make it possible for the nurse to respond quickly and appropriately to ease a patient’s unanticipated or rapidly escalating symptoms. At this time, the SMK is the only available option for emergency symptom management for in-home patients when the patient’s physician is not immediately available.

The SMK is not intended to replace the need for proper clinical assessment leading to well defined care plans that properly identify potential issues. Responsible care planning would include the service providers communicating during the course of the care to ensure that appropriate PRN medications are in place for the patient.

When should the SMK be ordered?

The decision regarding when the SMK should go into the home should be part of the development of the patient’s overall plan of care. The development of the plan should involve the patient, the patient’s family, the attending physician, the community nurse, and any other members of the patient’s care team.

Timing of placement of the SMK requires careful consideration. Placing the SMK in the home prematurely may result in the expiry of the medication. Placing the SMK in the home too late in the patient’s disease process could cause delay in the management of his/her symptoms and may result in Emergency Room or hospital admission.

Patients who are identified by CCAC as MIS Service Recipient Code 95 (End-of- Life Care category) should have a kit in place. Patients who are approaching the end-of-life phase of illness (Palliative Performance Scale (see Appendix 1 for PPS information), have a PPS of 40 or less or are deteriorating rapidly should have a kit in place.


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Accessing the SMK It is appropriate to use the SMK in emergency situations when:

• the patient has sudden symptoms that cannot be managed at home by

the medication already available for the patient or,

• it is not possible to access the patient’s physician and/or a pharmacy quickly enough to relieve the patient’s pain through additional prescriptions; or,

• the symptoms are of such intensity that, without the SMK, a visit to the emergency room/hospital would be required.

Disposal of the Kit & of Unused Medications

The SMK is for the use of the designated patient only. Contents may not be used by anyone else. Both Legislation (The Pharmacy Act) and the Standards of Practice for Pharmacists require that any medications and/or supplies remaining in the kit, that have been ordered for a patient as part of the SMK must be disposed of to be destroyed after the designated patient no longer needs it (i.e. after the patient has died). The nurse is to ensure that the family is aware of where to return the kit. If the kit was obtained from Calea, it must be disposed of by placing it in a biohazard waste container and requesting a pick-up from Calea. If from a community pharmacy, the kit should be returned there for disposal. Upon receiving the unused medications and/or supplies, the pharmacy must then destroy them, in accordance with the Standards of Practice.

The reason that remaining medications and supplies cannot be used for another patient is to protect the safety of the consumer. Because the SMK is not under the pharmacy control once it is in the home, neither the pharmacy nor the community nurse can guarantee that the kit has been maintained in perfect condition; e.g. it may have been stored at the wrong temperature, or in less than sterile conditions. Ensuring patient safety outweighs the relatively small financial loss incurred by discarding unused medications.

Contraindications to ordering a SMK

A SMK is contraindicated for patients at home when:

• the patient’s death is imminent, and specific medications should be

ordered for end-of-life care;

• the patient is a child whose weight is such that medications and/or dosages require special consideration;


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• the patient is incapable and there is no caregiver in the home who can be responsible for the SMK;

• there is evidence of substance use disorder by the patient and/or family and no effective plan can be implemented to prevent medication misuse;

• there is evidence that the medications in the SMK could be used in ways other than the intended purpose; and/or

• the security of the SMK cannot be guaranteed in the home.

Process for Ordering an SMK for the Home:

1. The CCAC case manager, community nurse and physician, in collaboration determine a patient’s need for an SMK, based on the patient PPS score and other indications that the patient is nearing the end-of-life stage of their illness or deteriorating rapidly.

2. The CCAC completes the top of the SMK prescription form (see

Appendix 2) with identifying information about the patient (patient name, address, date of birth, etc.).

3. The CCAC case manager faxes “SMK Prescription Form” to the

physician requesting a SMK. The Case Manager also sends a “Request for Palliative Care Medications” MOHLTC Form (see Appendix 3).

4. The physician completes the SMK form, which is actually the

prescription, and the Request for Palliative Care Medications MOHLTC Form faxes it to the pharmacy selected from the ones listed on the form. Physicians who are registered by the Ontario Medical Association to participate in the Facilitated Access to Palliative Care Drugs Mechanisms (see Appendix 4) do not need to complete the MOHLTC Form as long as their special privilege is noted on the prescription form.

5. The Case Manager orders the SMK supplies kit CMIS – XSMK95

(Oakville, Milton, Georgetown, Acton) and PMI – IVKIT95 (Mississauga, Etobicoke) for delivery with the SMK medications. If there is not a hazardous waste container in the patients’ home a medium size biohazard container is to be ordered.

6. The receiving pharmacist makes a copy of the completed SMK

prescription form, indicating “copy” on the form, and faxes it to the CCAC.

7. The pharmacist prepares the SMK and delivers it to the patient’s home,

preferably on the same day or call the family if the kit is to be picked up when it is ready.


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8. The SMK will be delivered in one bag, with a separate package for the supplies and one for the medications. The nurse will combine all of the elements into the box provided and instruct the family on where to store the kit and record the location of the kit in her notes.

Process for the administration of the medications from the SMK

• When the patient displays symptoms that require use of the medications contained in the SMK, the nurse in the home contacts the physician for discussion. The medication is administered as per the physician’s order and documented. As the SMK is not replenished, care planning to ensure on-going symptom management is essential as the medications in the kit will only provide coverage for 12-24 hours. The nurse must contact the physician to discuss adequate on-going prn medications.

• If the nurse is unable to contact the physician when access to the kit is required, the nurse administers the medications, based on the indication provided with the medication. She can refer to the quick reference medication information included in Appendix 6. The nurse informs the physician and case manager as soon as possible.

• The utilized medication is now part of the treatment plan for the patient, and is not returned into the SMK.

• When the kit is no longer needed in the home, the nurse instructs the

family on how to dispose of the kit and completes the SMK evaluation form (see Appendix 6) and returns the evaluation form to the CCAC Case Manager.

Content

There are four physical components to the SMK: Storage container Drugs and Medications Supplies and Other Kit Contents Documents (medication quick reference guide and SMK evaluation form)


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1) Storage Container

The SMK will be contained in a “Tupperware” like container. The Patient’s name and the date when the first medication in the kit will expire are posted on the outside of the container.

2) Drugs and Medications The SMK Prescription Form is a form listing a standardized set of pre-printed orders (medications, dosages, routes and frequency) that when completed and signed by the physician for a specific patient becomes a set of orders for that patient.

On the list is a choice of three opioid concentrations. The decision by the physician to order one or the other is made based on the patient’s previous opioid dosing or lack thereof, i.e. the opioid-naïve patient (has not been previously stabilized on an opioid). For unanticipated crisis pain management, the physician will select the opioid and opioid concentration and will specify the dose to be administered.

Each medication is stored in individual vials or zip lock bag with a prescription label for the patient appropriately attached.

3) Medication Quick Reference Guide

The Medication Quick Reference Guide included in this document (see Appendix 6) provides information the medications included in the kit, including indications for which each medication can be administered.

If a community nurse is concerned about his/her ability to assess a symptom and to evaluate the indication for a specific medication, he/she is recommended to not administer the medication and to contact a supervisor for advice. All nurses are accountable for their own decisions and actions and for maintaining competence in their practice (College of Nurses of Ontario guiding principles).

4) SMK Evaluation Form

The SMK Evaluation Form (See Appendix 7) is to be completed by the visiting nurse when the kit is no longer in use. The form is to be returned to the CCAC by fax with the CCAC discharge report.

Cost of the SMK

The cost of the SMK is $25.00, inclusive of medications, supplies forms and containers but not delivery cost.


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Turnaround time to delivery or pick-up

It is important to anticipate the needs of the patient and to place the SMK in the patient’s home in a timely manner. All completed paperwork and prescriptions must be received before the pharmacy can process a request for an SMK.

• There should not be a substantial delay between ordering the kit and providing the kit. Everywhere medications are available through the Expedite Section 8 Drug List because Pharmacists have agreed to cover the cost of Section 8 drugs initially and then obtain reimbursement from the Ontario Drug Benefit Plan.


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Appendix 1 – Palliative Performance Scale (reproduced from Victoria Hospice, 2003)

10 Mississauga Halton Symptom Management Kit

Appendix 2 - Mississauga Halton Symptom Management Kit

Prescription Form

Patient Name: _________________________________ HC#: ___________________

Address: _____________________________________ Tel:_____________________

Date of Birth (year/month/day)__________________________________

Opioid Analgesic (choose one opioid option only and initial) MD initial Medication Directions Mitte Coverage

Morphine 15 mg/ml injectable

1 ml vial

3

ODB

Hydromorphone 2 mg/ml

injectable

1 ml vial

3

ODB

Hydromorphone 10 mg/ml

injectable

1 ml vial

3

ODB

Medication Directions

Mitte Coverage

Haloperidol 5 mg/ml

Injectable

1 ml vial

For nausea and vomiting:

0.5 – 1 mg. sc q8h prn

For Delirium/agitation:

1 - 2 mg. sc q1h prn until controlled then

2 mg. q 6 h sc prn

3

ODB

Prochlorperazine 10 mg

Suppository

For nausea and vomiting:

1 supp pr q4h prn

2 ODB

Lorazepam 1 mg

Tablet

For sedation:

1 – 2 mg. SL q2h prn (crush tablet and

mix with small amount of water)

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ODB

Midazolam 5mg/ml

Injectable

1 ml vial

For sedation:

2 mg. sc q1h prn

2 PCFA

*

Expedited Sect 8**

Scopolamine 0.4 mg/ml

Injectable

1 ml vial

For excess respiratory secretions:

0.4 mg. sc q4h prn

6 PCFA

*

Expedited Sect 8**

Acetaminophen 650 mg

Suppository 650 mg. pr q4h for temp > 38.5o

2

ODB

Physician Name PRINT: ________________________________ CPSO #:___________

Physician Signature: _____________________________ Date:___________________

Phone#: (Daytime): ______________________ After hours/On-Call:______________

* PCFA (Palliative Care Facilitated Access) – Palliative Care physicians with provincial designation for this coverage

** Expedited Sect 8 – For Physicians without PCFA designation; “Request for palliative care medications - individual Clinical Review (Section 8) form to be completed and sent to the pharmacy.

tel:___________________


Appendix 3 - ODB Form for Expedited End-of-Life Care Request for Palliative Care Medications

Section 1 – Physician Information Section 2 – Patient Information First Name Initial Last Name First Name Initial Last Name

Street it Street Name Ontario Health Insurance Number

City Postal Code Gender: Male Female

Fax Telephone Date of Birth (YYYY/MM/DD)

Section 3 – Patient Diagnosis Primary Diagnosis:

This patient has a terminal illness and has chosen outpatient palliative treatment. Life expectancy is less than six months. The medications checked below are requested for symptom control for a maximum period of six months.

Section 4 – Requested Medication(s)

Diazepam injection or Lorazepam injection – for seizure control, anxiety when other dosage forms cannot be

used

[DIN 00399728 (5mg/mL)] [DIN 02243278 (4mg/mL)] Dimenhydrinate injection – for nausea when other dosage forms cannot be used [DIN 00392537 (50mg/mL)] Furosemide injection for diuresis when oral route cannot be used

[DIN 00527033 (10mg/mL)] Gabapentin - for neuropathic pain after failure of tricylic antidepressants and oploids if appropriate [DINs 02243446 (100mg); 02243447 (300mg); 02243448 (400mg); plus all interchangeable DINs Glycopyrrolate injection - for secretion control in the very terminal stage of care

[DIN 02039508 (0.2mg/mL)]

Hyoscine injection or Hyoscine oral (Buscopan®) - for abdominal spasm, pain

[DIN 00363839 (2Omg/mL)] [DIN 00363812 (10mg)] Methadone - if other opioids fail to control pain or lead to side effects [DINs 02247698(1mg); 02247699 (5mg); 02247700 (10mg); 02247701 (25mg); 02247694(1mg/mL);

02241377(10mg/mL)]

Metoclopramide injection for nausea when oral route cannot be used DIN 021 85431 (5mg/mL)] Midazolam injection• for use in respiratory distress, anxiety

[DIN 02240286 (5mg/mL)]

Octreotide injection (Sandostatin®

) - for bowel obstruction in palliative care [DINs 00839205 (100mcg/mL); 02049392 (200mcg/mL, 5mL); 00839213 (500mcg/mL)]

Oxycodone (Supeudol ®

) - for use when combination oxycodone & acetaminophen cannot be used [DINs 00789739 (5mg); 00443948 (10mg); 02262983 (20mg)] Phenytoin injection for use in seizure control, when oral dosage forms cannot be used [DIN 00780626 (50mg/mL)] Scopolamine injection• for secretion control in the very terminal stage of care [DINs 00541869 (0.4mg/mL); 00541877 (0.6mg/mL)]

Other (drug name, dose, dosage regimen and reason for use):

Requests for ICR coverage of other medications may be considered on a case-by-case basis. Please attach a separate written request, including the drug name, dosage regimen, rationale for use, and details of previous medications tried, by following the procedures as outlined in Part VIII of the current 0DB Formulary. Requests submitted this way may undergo a longer review process.

Physician Signature (Mandatory) CPSO Number: Date (YYYY/MM/DD):



Appendix 4 – Information about the Request for Palliative Care Medications Individual Clinical Access Review Expedited Access Process

MEMO FROM THE MOHLTC DRUG PROGRAMS BRANCH_



Appendix 5 - Frequently Asked Questions (FAQ) Facilitated Access to Palliative Care Drugs Mechanism

1. When does the Facilitated Access to Palliative Care Drugs mechanism become

effective?

• This funding mechanism becomes effective on March 23, 2007. 2. How will pharmacies know when to bill via this mechanism.

• Physicians are requested to indicate either “palliative” or “PCFA” directly on the prescription to signify to the pharmacist that the patient meets the eligibility requirements for reimbursement under this mechanism: “The patient has a terminal illness and has chosen outpatient palliative treatment. Life expectancy is less than six months and the medications are being requested for symptom control for a maximum period of six months.”

• Patients should also be ODB-eligible:

o Ontario residents aged 65 and over, o Ontario residents receiving social assistance, o Ontario residents receiving professional services under the

Home Care Program, o residents of long-term care facilities, and o people who have become eligible under the Trillium Drug

Program 3. Can the pharmacy bill using the drug product DIN?

• Reimbursement of the Facilitated Access to Palliative Care drug products under this mechanism is only allowed if the assigned PIN is used for billing. Claims that are billed with the DIN may be rejected for payment.

• A list of the PINs that are reimbursed under this mechanism was included in a BBS bulletin (#7012) sent to pharmacies on March 5, 2007.

4. Are any of the Facilitated Access to Palliative Care drug products interchangeable?

• The drug products are only interchangeable if they are so listed in Part III of the Comparative Drug Index (CDI) (e.g. various brands of gabapentin).

5. How can a pharmacy bill for the brand name Neurontin?

• The same mechanism to reimburse for brand name products where there are listed interchangeable products available is used {i.e. completion of an Adverse Drug Reaction (ADR) by the prescriber must be kept on file in the pharmacy}

6. Can any physician prescribe these medications for reimbursement? Only the physicians who are registered by the Ontario Medical Association (OMA) to participate in the Facilitated Access to Palliative Care Drugs mechanism will be able to prescribe these medications to allow for the pharmacy to claim for reimbursement under this FA mechanism. Physicians wishing to participate in this program are asked to note that the following criteria may be considered by OMA:



• Physicians who do more than 20 palliative care consults in a year;

• Physicians who do more than 50 palliative care visits in a year;

• Physicians who have been identified as a leader in palliative care by a regional director for Cancer Care Ontario (CCO);

• Physicians who have been identified as a leader in palliative care by the executive of the section of palliative medicine at the OMA;

• Physicians who have been identified as a leader in palliative care by an End of Life Network or Community Care Access Centre;

• Physicians who have become members of a Palliative Alternate Funding

Plan (AFP).

•

For further information regarding the list of physicians and/or criteria for physicians to be included on the list, please contact Dr. Howard Burke, c/o Ina Nesbitt, Ontario Medical Association at (416) 340-2234 or via email at [email protected].

Physicians who are not registered in this Facilitated Access to Palliative Care Drugs mechanism may still submit a written request to the ICR/EA Unit for consideration of coverage through the ICR/EA mechanism. The request should include details of the patient’s diagnosis, current clinical status, and life expectancy. These requests should also clearly specify that the requesting physician is not registered in the Facilitated Access to Palliative Care Drugs mechanism.

7. What is the total duration of approval allowed to be reimbursed?

• The total duration of approval will be granted for a period of six months from the initial billing/submission of a claim for a drug product under this mechanism.

• If the patient requires these medications beyond this six month period of time, further billing under this mechanism will not be allowed.

• Continuation of coverage will require the prescriber to submit a written request via the ICR/EA mechanism. Renewal requests should clearly specify that the patient requires continuing coverage.

• Inappropriate billing with the DIN may be subject to recovery of funds by the Ministry.

8. How can a physician request for coverage of drug products which are not included on this list?

• Requests for reimbursement of drugs not listed in this notice should be submitted in writing to the ICR/EA Unit as usual. These requests should provide details of the patient’s diagnosis, current clinical status, life expectancy, previous therapies tried, and the rationale for selection of the selected therapy.

9. What if there are other questions regarding this funding mechanism?

• Physicians inquiring about participating in this mechanism should contact Dr. Howard Burke, c/o Ina Nesbitt, Ontario Medical Association at (416) 340-2234 or via email at [email protected].

o On March 12, 2007, the initial list of participating physicians had been forwarded to OPA, OMA, and pharmacies (BBS bulletin #7014).

• Pharmacists should contact the ODB Help Desk in Kingston toll free at 1(800) 668-6641.

mailto:[email protected]

mailto:[email protected]



APPENDIX 6 – Medication Quick Reference Guide

MEDICATION

INDICATION

INFORMATION

SIDE EFFECTS AND CONTRA- INDICATION

Morphine (s.c)

To manage pain &/or dyspnea when the oral route is no longer possible

For the opioid-naïve patient – morphine 2.5 mg. q4h and 2.5 mg q1h prn; For patients already on opioids – dosing depends on the current opioid dose. Single dose is generally 5 – 10% of the total daily dose; the parenteral dose is 50%of the oral dose.

Nausea and vomiting Constipation Sedation Delirium/agitation Respiratory depression (unusual) Opioid toxicity (delirium, myoclonus, and increasing pain) At end of life patients often will not clear opioids normally and prn dosing may suffice in the opioid-naïve patient

Hydromorphone

(s.c.) (Dilaudid®)

To manage pain &/or dyspnea when the oral route is no longer possible

For the opioid-naïve patient – hydromorphone 0.5 mg. q4h and 0.5 mg. q4h prn

For patients already on opioids – dosing depends on the current opioid dose. Single dose is generally 5 – 10% of the total daily dose; the parenteral dose is 50%of the oral dose.

Nausea and vomiting Constipation Sedation Delirium/agitation Respiratory depression (unusual) Opioid toxicity (delirium, myoclonus, and increasing pain)

At end of life patients often will not clear opioids normally and prn dosing may suffice in the opioid-naïve patient

Haloperidol

(Haldol®)

Nausea

Agitation/Delirium

The drug of first choice for nausea and vomiting

The drug of first choice for agitation/delirium. May need multiple doses before control achieved. For severe delirium at the end of life may need to add sedation with lorazepam or midazolam

Restlessness (akathesisia) Stiffness and abnormal movements (extrapyramidal effects/dystonic reactions)

Fever - Neuroleptic malignant syndrome (fever, rigidity and confusion) – unusual

These side effects are uncommon with the doses used in the palliative setting.

Prochlorperazine

(Stemetil®)

Nausea and vomiting

Alternative drug to haloperidol for rectal administration

Contraindication: Difficulty using the rectal route

Side effects – same as haloperidol

Lorazepam

(Ativan®)

Anxiety Sedation

May be useful for mild sedation in combination with Haloperidol

Sedation Agitation – some patients will have a paradoxical response that requires discontinuation



Midazolam

(Versed®)

Sedation for severe end-of-life symptom distress has not been manageable by other means – most often severe delirium or dyspnea

Midazolam should only be used if all other means to manage the symptoms have failed and the patient/family is accepting of sedation. It may produce deep sedation. This medication has a rapid onset of action but is short- acting (1-2 hours). If symptoms remain severe a continuous infusion may be required

Sedation - should not be used if patient/family strongly opposed to intentional sedation.

Scopolamine

(Hyoscine®)

Excess respiratory secretions at the end of life

Will reduce respiratory secretions in approximately 40 – 65% of patients. If not responsive within 2-3 doses, will likely not respond

May cause sedation or agitation in patients who are still conscious

Acetaminophen supp. (Tylenol

®)

Fever

Contraindication: difficulty using the rectal route

References:

1. Symptom Management Guidelines, KFL&A Palliative Care Integration Project, Queen’s Palliative Care Medicine Program, 2005

2. The Edmonton Palliative Care Program, www.palliative.org

3. Andree Neron et al. Pharmacy Specialty Group on Palliative Care.(2000) Care Beyond Cure. A Pharmacotherapeutic Guide to Palliative Care. APES, and CSHP. Canada.

4. Doyle, D. et al 1999.Oxford Textbook on Palliative Care 2nd

ed. Oxford University Press. Great Britain.

http://www.palliative.org/



Appendix 7 - SMK Evaluation Form

Name of Patient:

Address of Patient:

Optional: Name of person completing evaluation:

Phone Number:

(Circle One)

1. Did you use the SMK? Yes No

2. Did the kit arrive within 24 hours of the initial request? Yes No

4. Did you reference or use the medication guidelines? Yes No

5. Did the patient have a planned death at home? Yes No

6. Were you able to contact the physician: prior to the use of the kit or after the use of the kit?

Prior After

7. Did the use of this kit prevent/ delay/ avoid transfer of your patient to an emergency department or hospital admission?

Yes No Don’t

Know

8. What medications were used from the kit?

1. 3.

2. 4.

Strongly

Disagree Disagree Mildly

Disagree Neutral Mildly

Disagree Agree Strongly

Agree

Overall, even if the SMK was unused, it was helpful to the family to have it in the home.

If used, overall the SMK was effective at managing the patient’s symptoms.

1 2 3 4 5 6 7 1 2 3 4 5 6 7

Overall the SMK was easy to use. 1 2 3 4 5 6 7

Comments:

COMPLETED FORM TO BE FAXED TO CCAC WITH THE DISCHARGE REPORT