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October 2012
Palliative Care Practice Guidelines
Thomas Palliative Care Services
VCU Massey Cancer Center
VCU Health System
Development and Verification
• The practice guidelines were developed by an interdisciplinary group of palliative care clinicians based on the best available research for each symptom addressed. If two medications seemed equally beneficial, medications were then selected based on cost, side effect profile, nursing time, and availability on our formulary.
• The practice guidelines are reviewed annually by our group of fellows, attending physicians, pharmacists, and nurses to determine if changes need to occur. The impact on symptoms are evaluated annually to determine if we have improved symptom burden within our population of patients. These practice guidelines have been reviewed by outside experts in the past.
• Nurses and fellows are educated on the use of the practice guidelines which also help instruct residents who are doing their palliative training on consistent research-based symptom management practice.
• We believe this has improved symptom management throughout the institution for those patients who do not receive or require a palliative care consult.
October 2012
October 2012 3
Table of ContentsAgitation 3
Alternative Route for Opioid Administration 4
Anorexia 5
Anuria 6
Bladder Spasms Treatment 7
Bowel treatment – stepped care program 8
Candidiasis – Oral 9
Candidiasis – Perineal 10
Dyspnea 11
Fever 12
Hiccough 13
Mucositis 14
Pruritus 15
Secretions 16
Seizures – Acute Management 17
Sleep Disturbance 18
Wound Odor 19
Name DateMedical Director, Thomas Palliative Care Unit
Name DateDirector, Nursing
October 2012 4
Agitation
Haloperidol 0.5 mg PO/IV/SC every 4 hours as needed
Continue same dose Haloperidol every 12 hrs scheduled
Evaluate to continue, taper or dc
Titrate up by 1 mg every 1 hour until desired effect achieved (1mg, 2 mg, 3 mg, etc); MDD 20 mg
Lorazepam 0.5mg PO or IVevery 1-2 hours as needed
MDD* 12 mg
Continue LorazepamEvaluate regularly to taper or
discontinue
Consider Palliative Service consultation
relief no relief
relief
no relief after MDD Haldol
no relief after 24 hours
Excessive physical or mental restlessness. Increased activity that is generally not purposeful and associated with anxiety.
Depending on appropriateness, evaluate for reversible causes, including delirium and treat the underlying etiology if possible.Symptom control may begin concurrently with diagnostic work-up.
Nonpharmacological interventions: reorientation, maintaining sleep wake scheduleAvoid restraints, minimize immobilizing treatments, maintain communication, med reconciliation
Consider Palliative Service consultation
atypical antipsychotic meds starting doses for deliriumOlanzapine 2.5mg q12hrsRisperidone 0.25mg q12hrsQuetiapine 12.5mg q12hrs
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
* MDD = Maximum Daily Dose
Benzodiazepines may increase agitation and delirium; consider chlorpromazine 25 mg IV every 8 hrs
October 2012 5
Alternative Route for Opioid Administration
If patient is unable to take PO analgesicAND
IV access is not available
Example: 360 mg of PO MSO4 every day divided by 3 = 120
divided by 24 hrs = basal rate of 5 mg/hr IV MsO4
PCA dose would be 2.5 mg q 6 minBolus = 3 times basal dose = 15 mg
q 1hr
Convert 24-hour opioid requirement of continuous
infusion of Basal Opioid via PCA pump. May add PCA dose of
atleast 50% of basal rate every 6 min w/ bolus 3 times basal rate
of every1 hr
Convert to Fentanyl patch using equianalgesic coversion card,
continue to give Fentanyl sublingual at dose of 25 mcg
every ½ hour prn(Note: no benefit from patch for
8-14 hours)
Convert to subcutaneous infusion of PCA using 27 gauge needle (PCA dose remains the same, change lock out to every 15 min). Infusion volume not to
exceed 2 ml/hr so may need higher concentration.
Remember can call pharmacy for assistance in how to order
SQ PCA.
Convert to rectal, vaginal or stoma route for long acting opioid (same dose) using
Fentanyl injection sublingual 25 mcg every 30 min prn.
Can give Roxanol(morphine 20mg/ml) sublingual and it can be given to patients that aren’t
awake. Document patient ability to
maintain internally.
OPTIONS
May also place subcutaneous needle for use if only intermittent opioids required, convert PO dose to parenteral dose using equianalgesic
conversion card. Continue prn schedule.
** Physicians NOTE: Please consider incomplete cross tolerance in your conversions.
If IV access is no longer availableAND
Patient is able to take PO medications, select appropriate long and short acting opioids and
convert dosage requirements using equianalgesic conversion card
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
October 2012 6
Anorexia
Appetite SuppressionIF BOTHERSOME TO PATIENT
Continue megestrol at current dose
Trial of megestrol acetate (Megace)400 mg liquid PO daily
Reassess at 1 week for efficacy
Prednisone 20mg daily (considered most useful if estimatedprognosis less than 6 weeks)
relief no relief
A loss of appetite with noted weight loss which is bothersome to the patient.
Supportive counseling for patient and family:anorexia as a natural symptom of disease, validation of normalcy, dietary and nutritionalchanges and counseling
HIV Patients: Dronabinol starting dose 2.5mg bid MDD 20mg daily(NOTE: Dronabinol is non-formulary)
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
Recommend increase dose of megestrol to 800 mg liquid PO
dailyReassess at 1 week for efficacy
(consider risk for DVT)
Continue megestrol at current dose
relief no relief
October 2012 7
Anuria
Catheterize for residual urine or perform bedside bladder scan if available
Less than 250 mlsOver 250 mls
Leave catheter in place Evaluate volume status
Re-asses catheter need periodicallyIf catheter becomes plugged irrigate with
normal saline prn
Minimal to no urine output.
Review medications: Anticholinergic, antidepressants, antihistamines, opioids ascause
Management for BPH
Anuria can be part of dying process, enact algorithm if unexpected or patient symptomatic, eg pain, agitation.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
October 2012 8
Bladder Spasms Treatment
Obtain urinalysis and culture of clean catch
urine
If indwelling catheter is present would do this
first
Negative urinalysis
Positive urinalysisContact MD
Anticipate TMP/SMX
Assess catheter function; irrigate gently with NS
Consider replacing if catheter present
greater than 5 days
Oxybutynin 5 mg PO TID x 48 hours-
MDD 20 mg. If PO difficult, available in
patch 3.9mg/day twice a week (patch not in
formulary)
Start TMP/SMX DS PO twice/day; if sulfa
allergic, ceftriaxone 1g IV daily
No further intervention is
needed
Oxybutynin 5 mg TID x 48 hours
MDD 20 mgOR
Scopolamine 0.4mg IV or sub
cutaneously every 4 hours prn
Continue Oxybutynin
MD/RN/Rx consult Scopolamine patch
every 72 hoursOR
scopolamine 0.4mg IV every 4 hours prn
Promote increased fluid intake as appropriate
Oxybutynin 5 mg PO TID x 48 hours
MDD 20 mg
An intermittent cramping sensation of the bladder resulting in discomfort and/or pain.
Treat pain with prn analgesic while analysing cause
Alternative to oxybutynins:Tolterodine
Newer agents: solifenacin,Trospium, darifenacinNewer agents are non-formulary
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
October 2012 9
Bowel treatment – stepped care program
Stool softener and/or gentle laxativeDocusate 100 mg twice/day (taking no
opioids)Senokot 1 tab twice/day (taking opioids)
If no bowel movement for 48 hour period add one of these:
Milk of magnesia concentrate 10 ml po every day
ORBisacodyl 10 mg PO/PR every day if po
not tolerated or refused
If no bowel movement in next 12 hours, perform rectal exam
to rule out impaction
If not impacted, Magnesium citrate 8 oz
ORFleets enema
Soften with glycerin suppository then manually disimpact
Increase the prophylactic regimen to 2 tab Senokot
twice/dayConsider Palliative Service consultation
If impacted, Fleets enema
Increase the prophylactic regimen to 2 tab Senokot
twice/dayConsider Palliative Service consultation
Treatment to alleviate hard stools and/or constipation associated with opioid administration.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
For opioid induced constipation, consider methylnaltrexone SQ injection
(<62kg=8mg, >62kg=12mg SQ every other day until BM)
Follow up with tap water enema until clear
October 2012 10
Candidiasis – Oral
Nystatin susp 400,000-600,000 swish and swallow four times/day; hold in
mouth 2-5 minutesOR
Clotrimazole troche 10 mg five times a day
Improved after 48 hours
Continue 7 days
Not improved and patient using appropriately, or not able
to swallow
Mucocutaneous candidiasis: Fluconazole 200 mg Loading Dose then 100 mg every day x 14 days.
Whitish patches on the inner oral cavity, tongue or throat, which may or may not cause discomfort.
Remember someone who is immunocompromised may need to get fluconazole from the beginning.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
Esophageal candidiasis: Fluconazole 400 mg Loading Dose then 200 mg every day x 14 days.
October 2012 11
Candidiasis – Perineal
Clotrimazole cream 1% applied twice/day or nystatin powder tid & area
kept dry
Improved after 48 hours
Continue clotrimazole or nystatin
powder 7-14 days
No improvement after 48 hours
Fluconazole 150 mg one time dose.
Reddened areas between skin folds in the genital area, which may or may not cause discomfort.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
October 2012 12
DyspneaComplete respiratory assessment
If oxygen sats <90% give oxygen 2L/min.Check hemoglobin and transfuse if
consistent with care goals established on signout.
Complains of dyspnea Bronchospasm with audible wheeze
If mild CHF(crackles on exam), with respiratory
distress
Furosemide 40 mg PO/IV for one dose
Monitor for improvement. Consider MD consult
For end stage, consider fentanyl nebulizer 25 mcg every 2 hours
prn with 2.5 ml of NS
Trial of oxygen 2 liters/min
Reassess every 2 hours
If no relief, Consider Morphine 10 mg PO every 2 hours prn or 3
mg subcutaneous or IV hourly prn; monitor respirations
Fentanyl nebulizer 25 mcg in 2.5 ml of NS every 2
hours prn
If no relief, lorazepam 0.5 mg PO or IV every
4 hours prn.Monitor respirations
If relief, continue lorazepam prn
MDD 10 mg/day
Albuterol 2 inhalations every 4 hours prn or 3ml nebulized every
2 hours prn
If no relief, add oxygen 2 liters/min and ipratropium 1-2 inhalations every 4-6 hours prn or 2.5 ml nebulized every 4 hours prn
If relief, continue
If improvement, continue
If no relief, add fentanyl nebulizer 25 mcg in 2.5 ml NS every 2 hours prn.
Consider adding oxygen 2 liters/min
The sensation of air hunger. May be exhibited by gasping, accessory muscle involvement in breathing, tachypnea,
discomfort.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
Consider non-pharmacologic options (e.g. fans, relaxation, CPAP or BiPAP, physical comfort measures, relaxation)
October 2012 13
Fever
Symptomatic Fever or RigorsRefer to signout to see goals of care.
Workup needed?
Source of infection is suspected by history or exam
Treat symptomatically, especially end stage disease
Consider workup and possible antibiotic therapy
Acetaminophen 650 mg PO/PR every 4 hours scheduled x 24 hours (avoid other tylenol containing products) if
symptomatic or temp > 101 POReassess after 24 hours
If no relief, try Ibuprofen 400 mg PO or aspirin 650 mg PO or aspirin
suppository 600 mg every 6 hours or ketorolac IV (15 mg)every 6 hrs x 24 hrs
If no relief, consider Palliative Service consultation
yes no
A temperature of over 101.4 (orally), 100.4 (axillary), or 100.4 (for patients with known neutropenia.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
October 2012 14
Hiccough
Baclofen 5mg po every 6 hours prn,
can increase to 10mg every 6hrs if
CrCl >30
Can continue baclofen. Haloperidol 2 mg PO/Subcutaneous/IV
Maintenance 2 mg PO three times/day
Continue as neededConsider scheduling
Metoclopramide 10 mg PO/IV every 6 hours prn
Maintenance 10-20 mg po 4 times/day
Continue as needed
If no relief, consider anesthesia consult for block
Continue as needed
No effect
EffectIf no effect or unable to take PO
Effect
A spasmodic intermittent closure of the glottis following lowering of the diaphragm causing a short, sharp, inspiratory cough.
Non-pharmacological treatment:Holding breath, mild irritation of nasopharynxValsalva, sipping liquids slowly, 5th vertebrae rubbing
If GERD: maalox 30ml PO every 4 hours prn, canStart PPI on formularyEg: esomeprazole 40mg daily
Consider Gabapentin 300mg PO 3 times/day
ORChlorpromazine 25 mg
PO 3 times/day
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
October 2012 15
Mucositis(without obvious infection)
Sodium bicarbonate rinsesOR
1:1 Isotonic saline/sodium bicarbonate rinses every 2 hours while awake
If relief, continue rinses as needed. Reassess in 7 days.
If no relief, start trivalent mouth wash (Benadryl, maalox, lidocaine mixture)5 ml
swish/spit every hourOR
swish/swallow every 4 hours
Consider other analgesic interventions such as PCA, viscous lidocaine, topical cocaine. Consider Palliative Service consultation
No relief after 24 hours
Inflammation of the mucus membranes. Generally causes pain in the oral cavity and throat and exhibited by excessive drooling, spitting and mucus production.
Evaluate for and treat thrush if present (see oral candidiasis algorithm); consider evaluating for oral HSV
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
Consider non-pharmacologic measures (e.g. removal of dentures; avoiding salty, acidic or dry foods; change PO to IV formulation as appropriate/able)
October 2012 16
Pruritus
Establish probable cause:
Consider medications, high bilirubin, skin irritants
Hydroxyzine 10 mg every 6 hours PO prn
If obstructive jaundice-cholestyramine 4gm PO every day
before breakfast.
Hydrocortisone/Pramoxine foam 4 times/day prn
ORDiphenhydramine 25 mg PO/IV
every 6 hours
Improved after 24 hours, continue prn
No improvement after 48 hours
Increase cholestyramine to 4gm PO ac breakfast & dinner
-Consider PO Rifampicin 150 mg daily & possible titration with monitoring of liver function & CYP450 drug interactions
- If not on SSRI or SNRI anti-depressant, consider PO Sertraline 50 mg daily & titrate up to 100 mg after a week
Consider Palliative Service consultation
Severe itching.
If opioid induced, trial another opioid – hydromorphone if
currently on morphine or fentanyl if currently on hydromorphone
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible..
Contact physician, consider narcan infusion (2.5 mg in 250 ml, start @ 4ml/hr & titrate to max. rate of 12
ml/hr) or opioid rotation
October 2012 17
Secretions
Assess saliva
Diminished saliva (xerostomia)
Increased secretions without trach(Note: with trach evaluate risk of excessively drying up secretions)
Thick secretions
Guaifenesin 200 mg PO every 4 hours prn
Increase fluid intakeEncourage oral fluid intake and good oral care
Use artificial saliva
Suck on sugarless candy, chew
sugarless gum
If history of radiation to head/neck Pilocarpine 5 mg PO tid, up to 10 mg tid if necessary
If disturbing to pt/family, consider a trial of scopolamine patch every 72
hours and scopolamine 0.4 mg subcutaneous/IV now and every 4
hours prn
No reliefIf relief, continue treatment
Add a second scopolamine patch every 72 hoursOR
Increase scopolamine to 0.6mg subcutaneous/IV every 4 hours prn
ORGlycopyrrolate 0.2-0.4 mg IV/SQ q4-6h prn
Consider Palliative service consultation
Oral or airway lubrication. May be noted by excessive, noisy respirations
If patient unconscious, consider suction
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
October 2012 18
Seizures – Acute Management
Seizure
Lorazepam 2 mg IV/Sublingual/Subcutaneous statNotify physician
May repeat in 15 min prnMAXIMUM 8 mg
(Consider 2 mg IV midazolam or 5mg IV diazepam if lorazepam not available)
Is it appropriate to escalate care for this patient?
Notify family, consider chronic suppression with lorazepam
Further work-up, monitoring and medication load for chronic suppression therapy
Yes No
Sudden, non-purposeful, rhythmic movement of any part of the body or facial muscles lasting from less to a minute to more that several minutes.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
October 2012 19
Sleep Disturbance(consider etiology and r/o delirium, treat cause)
Consider cause including pain, anxiety, agitation, caffeine, medications
Zolpidem 5 mg PO at bedtime, may repeat in one hour if no delirium
If sleep loss related to depression, consider treatment options accordingly
If relief, continue as needed
If no relief after 2 nights, notify physicianConsider a trial of temazepam 15 mg PO qhs
Use with caution in > 60 yr old & consider trazodone 25-50 mg PO qhs instead
If relief, continue as needed
An inability to fall asleep and or stay asleep causing discomfort or fatigue.
Control environmental factors: minimize nighttime interruptions, lights, television, late meals, caffeine encourage daytime OOB, and lights
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
Is this daytime sedation?Considerations include:
Caffeine 100 mg PO every 6 hours until 4 PM
ORMethylphenidate 2.5-5 mg 2 times
per day (2nd dose no later than noon, max. 10 mg bid)
ORModafinil 100 mg every morning
October 2012 20
Wound Odor
Use room deodorizer
Apply absorptive dressing with wound cover using:•Calcium alginate•Gauze packing•4x4s or kerlix roll gauze with NS•Foam dressing, or•Baby diapers for heavy drainage
Apply non-adherent (oil emulsion) gauze as first layer on wounds that are dry, when dressings stick,
or bleeding is a factor
Cleanse with normal saline or wound cleanser
Consider topical 0.75% metronidazole gel (in a heavily draining wound this may increase drainage and not help
odor)
Consult Wound Care TeamContinue
Lightly spray outer dressing with Enzymatic Rain with each change
A strong, noticeable, offensive smell emanating from a wound.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible..
Algorithm Evidence-Based References
• Agitation– Jackson, KC, Lipman, AG. Drug therapy for delirium in terminally ill patients. In: The Cochrane Library, Issue 2, Chichester, UK: John Wiley
Sons, 2004.– Breitbart W, Marotta R, Platt MM, Weisman H, Derevenco M, Grau C, Corbera K, Raymond S, Lund S, Jacobson P. A double-blind trial of
haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J.Psych1996 ;153:231-7.– Stahl, S. Essential Psychopharmacology: Neuroscientific Basis and Practical Applications 2nd ed. Cambridge University Press 2000.– Pasacreta, J., Minarik, P., & Nield-Anderson, L. (2006). Anxiety and depression. In B. R. Ferrell, & N. Coyle. (Eds.), Textbook of palliative
nursing (2nd ed., pp. 375-400). New York, NY: Oxford University Press. • Alternative Route for Opioid Administration
– Bruera E, Brenneis C, Michaud M, et al. Use of the subcutaneous route for the administration of narcotics in patients with cancer pain. Cancer 1988; 62: 407-411.
– Principles of analgesic use in the treatment of acute pain and cancer pain. American Pain Society, 5 th Edition, 2003 www.ampainsoc.org– Pereira J et al. Equianalgesic dose rations for opioids: a critical review and proposals for long-term dosing. J Pain Sym Manage 2001;22:672-
687.– Gourlay GK. Treatment of cancer pain with transdermal fentanyl. The Lancet Oncology 2001; 2:165-172.
• Anorexia– Jatoi A, Windschitl HE, et al. Dronabinol Versus Megestrol Acetate Versus Combination Therapy for Cancer-Associated Anorexia: A North
Central Cancer Treatment Group Study. Journal of Clinical Oncology, Volume 20, Number 2, 2002; 567-573.– Inui, A., Cancer Anorexia-Cachexia Syndrome: Current issues in research and management, CA Cancer J Clin 2002; 52: 72-91.– Jatoi, A. On appetite and its loss, Classic Papers, Supplement to JCO, Vol 21, No 9 (May 1), 2003: pp 79s-81s.– Bistrian, B. (1999). Clinical trials for the treatment of secondary wasting and cachexia. Journal of Nutrition, 129(1S Suppl), 290 S-294 S– Fainsinger, R. L., & Periera, J. (2004). Clinical assessment and decision-making in cachexia and anorexia. In D. Doyle, G.W.C. Hanks, N.
Cherney, & K. Calman. Oxford textbook of palliative medicine (3rd ed., pp. 533-560). Oxford, UK: Oxford University Press• Anuria
– Cravens (2000) Am Fam Physician 61(2): 369-76– Walsh (1998) Campbell's Urology, Saunders, p. 159-62
• Bladder Spasms Treatment– Herbison, P, Hay-Smith, J, Ellis, G, Moore, K. Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive
bladder: systematic review. BMJ 2003; 326:841.– Nicolle, LE, Bradley, S, Colgan, R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic
bacteriuria in adults. Clin Infect Dis 2005; 40:643.– Howe, RA, Spencer, RC. Cotrimoxazole. Rationale for re-examining its indications for use. Drug Saf 1996; 14:213.
• Bowel Treatment – stepped care program– Klaschik E, Nauck F, Ostgathe C. Constipation--modern laxative therapy. Support Care Cancer. 2003;11(11):679-685. Epub 2003 Sep 2020.– Mancini I, Bruera E. Constipation in advanced cancer patients. Support Care Cancer. 1998; 6(4):356-364.– Locke, GR III, Pemberton, JH, Phillips, SF. AGA technical review on constipation. Gastroenterology 2000; 119:1766.
October 2012 21
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
Algorithm Evidence-Based References
• Candidiasis – Oral
– Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004; 38:161-89.– Sweeney MP, Bagg J. The mouth and palliative care. Am J Hosp & Pall Care 2000; 17(2):118-124.
• Candidiasis – Perineal
– Sobel JD, Brooker D, Stein GE, Thomason JL, Wermeling DP, Bradley B, Weinstein L. Single oral dose fluconazole compared with conventional clotrimazole topical therapy of Candida vaginitis. Fluconazole Vaginitis Study Group. Am J Obstet Gynecol. 1995 Apr;172(4 Pt 1):1263-8.
– National guideline for the management of vulvovaginal candidiasis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999; 75 Suppl 1:S19.
– Rex, JH, Walsh, TJ, Sobel, JD, et al. Practice guidelines for treatment of candidiasis. Clin Infect Dis 2000; 30:662. • Dyspnea
– Bruera E, Sweeny C and Ripamonti C. Dyspnea in patients with advanced cancer. In: Principles and Practice of Palliative Care and Supportive Oncology. 2 nd Ed Berger A, Portenoy R and Weissman DE (eds). Lippincott-Raven, 2002.
– Chan KS et al. Palliative Medicine in malignant respiratory diseases. In Oxford Textbook of Palliative Medicine 3 rd Ed. Doyle D, Hanks G, Cherney N and Calman N. Oxford, 2005
– Fohr SA. The double effect of pain medication: separating myth from reality. J Pall Med 1998; 1:315-328.– Coyne, P. J., Lyne, M.E., & Watson, A. C. (2002). Symptom management in people with AIDS. American Journal of Nursing,
102(9), 48-56. – Coyne, P., J., Viswanathan, R., and Smith, T., "Nebulized Fentanyl Citrate Improves Patients Perception of Breathing,
Respiratory Rate, and Oxygen Saturation in Dyspnea." Journal of Pain and Symptom Management. February, 23 (2), 2002, pp. 157-160.
– NCCN Clinical Practice Guidelines in Oncology: Palliative Care. V.2.2012. Available at NCCN.org Jensen Jensen D, Alsuhail A, Viola R, Dudgeon DJ, Webb KA, O'Donnell DE J Pain Symptom Manage. Inhaled fentanyl citrate improves exercise endurance during high-intensity constant work rate cycle exercise in chronic obstructive pulmonary disease.
– 2012 Apr;43(4):706-19. Epub 2011 Dec 14.
– .• Fever
– Zell JA, Chang JC. Neoplastic fever: a neglected paraneoplastic syndrome. Support Care Cancer. 2005 Nov;13(11):863-4. – Oh DY, Kim JH, Kim DW, Im SA, Kim TY, Heo DS, Bang YJ, Kim NK Antibiotic use during the last days of life in cancer
patients. Eur J Cancer Care (Engl). 2006 Mar;15(1):74-9.– Boulant JA: Thermoregulation. In: Machowiak PA, ed.: Fever: Basic Mechanisms and Management. New York, NY: Raven
Press, 1991, pp 1-22– Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: Toxicity And Response
Criteria The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982.– Young LS: Fever and septicemia. In: Rubin RH, Young LS, eds.: Clinical Approach to Infection in the Compromised Host. 2nd
ed. New York, NY: Plenum Medical, 1988, pp 75-114– Zhukovsky DS: Fever and sweats in the patient with advanced cancer. Hematol Oncol Clin North Am 16 (3): 579-88, viii, 2002.
October 2012 22
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
Algorithm Evidence-Based References
• Hiccough– Kolodzik PW, Eilers, MA: Hiccups (singultus): Review and approach to management. Ann Emerg Med 1991; 20:565-573.– Rousseau, P. Hiccups. Southern Med J 1995; 2: 175-181. – Lewis J. Hiccups: Causes and cures. J Clin Gastro 1985; 7:539-552.
• Mucositis– Dodd MJ, et al. Radiation-induced mucositis: a randomized clinical trial of micronized sucralfate versus salt & soda mouthwashes. Cancer Invest.
2003;21(1):21-33. – Shih A, Miaskowski C, Dodd MJ, Stotts NA, MacPhail L. A research review of the current treatments for radiation-induced oral mucositis in patients
with head and neck cancer. Oncol Nurs Forum. 2002 Aug;29(7):1063-80. Links– Berger AM and Kilroy TJ. Oral Complications. in DeVita V et al (eds) Cancer: Principles and Practices of Oncology. 6 th edition. Lippincott Williams
& Wilkins. 2001.– Rubenstein, EB, Peterson, DE, Schubert, M, et al. Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and
gastrointestinal mucositis. Cancer 2004; 100: 2026.– Epstein, JB, Schubert, MM. Oropharyngeal mucositis in cancer therapy. Review of pathogenesis, diagnosis, and management. Oncology (Huntingt)
2003; 17:1767.• Pruritus
– Beuers U, Boberg KM, Chapman RW, et al. EASL clinical practice guidelines: management of cholestatic liver diseases. J Hepatol 2009;51:237-67.– Alan B. Fleisher, Jr and Jason R. Michaels. Pruritus. In: Principles & Practice of supportive Oncology. Eds: Ann Berger, Russell K. Portenoy, David
E. Weissman. Lippincott-Raven Publishers Philadelphia 1998; 245-250.– Krajnik M and Zylicz. Understanding pruritis in systemic disease. J Pain Symp Manage 2001; 21:151-168.– Mayo MJ, Handem I, Saldana S, et al. Sertraline as first line treatment for cholestatic pruritis. Hepatology 2007;45:666-74.– NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. V.2.2012. Available at NCCN.org.
• Secretions– Wilders H, Menten J. Death rattle: prevalence, prevention and treatment. J Pain Symptom Manage 2002; 23:310-317.– Cooke, C, Ahmedzai, S, Mayberry, J. Xerostomia--a review. Palliat Med 1996; 10:284.– Richardson, PS, Phipps, RJ. The anatomy, physiology, pharmacology and pathology of tracheobronchial mucus secretion and the use of
expectorant drugs in human disease. Pharmacol Ther [B] 1978; 3:441.– LeVeque FG, Montogomery M, Potter D, et al. A multicenter, randomized, double‐blind, placebo‐controlled, dose‐titration study of oral pilocarpine for
treatment of radiation‐induced xerostomia in head and neck cancer patients. J Clin Oncol 1993;11:1124‐31.– Johnson JT, Ferretti GA, Nethery WJ, et al. Oral pilocarpine for post‐irradiation xerostomia in patients with head and neck cancer. N Engl J Med
1993;329:390‐5.– NCCN Clinical Practice Guidelines in Oncology: Palliative Care. V.2.2012. Available at: NCCN.org.
• Seizures – Acute Management– DroneyJ, Hall E, Status Epilepticus in a Hospice Inpatient Setting. Journal of Pain and Symptom Management Vol36 No 1 July 2008– Cereghino, J. Rectal Diazepam for threayment of Acute Repetitive Seizures in Adults. Archives of Neurology Vol 159 Decemver 2002– Treiman, DM. Pharmacokinetics and clinical use of benzodiazepines in the management of status epilepticus. Epilepsia 1989; 30(suppl 2):s4.– Chapman, MG, Smith, M, Hirsch, NP. Status epilepticus. Anaesthesia 2001; 56:648.
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Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.
Algorithm Evidence-Based References
• Sleep Disturbance– Carlos H. Schenck, Mark W. Mahowald, and Robert L. Sack.Assessment and Management of Insomnia JAMA 2003 289: 2475-2479.– NCCN Clinical Practice Guidelines in Oncology: Palliative Care. V.2.2012. Available at: NCCN.org.
• Wound Odor– Paul Walker. The pathophysiology and management of pressure ulcers. In: Topics in Palliative Care, Volume 3. Eds. Russell K. Portenoy and
Eduardo Bruera. Oxford University Press 1998. Pp 253-270.– Grocott P. The palliative management of fungating malignant wounds. J Wound Care. 2000; 9 (1):4-9. – Newman V, Allwood M, Oakes RA. The use of metronidazole gel to control the smell of malodorous lesions. Palliat Med. 1989; 3: 303-305.– Bates-Jensen, B.M. (2006). Skin disorders: Pressure ulcers – assessment and management. In B.R. Ferrell, & N. Coyle (Eds.), Textbook of
palliative nursing (2nd ed., pp. 301-328.). New York, NY: Oxford University Press. – Bates-Jensen B.M., Seaman, S. & Early, L. (2006). Skin disorders: Tumor necrosis, fistules, and stoma. In B.R. Ferrell, & N. Coyle (Eds.),
Textbook of palliative nursing (2nd ed., pp. 329-344.). New York, NY: Oxford University Press– Grocott, P., & Dealey, C. (2004). Symptom management: Nursing aspects. In D. Doyle, G. Hanks, N. Cherney, & K. Calman (Eds.) Oxford
textbook of palliative medicine (3rd ed., pp. 628-640). Oxford, UK: Oxford University Press. – Mamedio C, Anduciolo C, Nobre MRC. A systematic review of topical treatments to control odor of malignant fungating wounds. J Pain
Symptom Manage 2010; 39: 1065-76.
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Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.