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Palliative Care Symptom Guide Table of Contents

General Principles of Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Pain Scale for patients who cannot communicate (Abbey Pain Scale) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Select Opiate Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Equianalgesic dosing (Opioid conversion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Patient Controlled Analgesia (PCA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Transdermal Fentanyl Conversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Guidelines for Naloxone Administration and Patient Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9Constipation and Bowel Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10-11Delirium: Diagnosis and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12-14Dementia: Course and Prognostication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-16Depression: Screening tools and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17-19End Stage Liver Disease: Prognostication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20-21End of life care: Symptom Management Common Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Oral Secretions at the End of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Palliative Care and Pain Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

July 2010

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Pain Scale

No Pain Worst Pain ImaginableNone = 0; Mild = 2 .5; Moderate = 5; Severe = 7 .5; Excruciating = 10

General Principles of Pain Management1. Assess pain using a standardized pain scale.Painisasubjectivefeeling:askthepatientusingtheabove0-10scale.If the patient is cognitively impaired, use the Abbey

pain scale.(Seepage2.)Frequencyofassessment:atthetimeoftheinitialinterview,everyeighthours,andPRN(atleasteverytwohourswhenpainissevere).2. Inopiatenaivepatients,startwithshort-acting opioids(morphine,hydromor-

phone,andoxycodone)tocontrolacute,moderatetoseverepain.Never use long-acting opioids to control acute pain.

3. Whentitratingorchangingopiatedose,startbycalculatingthepreviousday’sOralMorphineEquivalent(OME).a. Since all potent opioids produce analgesia by the same mechanism, they

will produce the same degree of analgesia if provided in equianalgesic doses(seeequanalgesictable).

b. Rectal=oralc. SQ=IM=IV

4. Determineifthedoseisadequateforthepainanddoseadjust. a. Titrateatleastevery24hourswhenthepainismoderateandasoftenasevery

fourhourswhenusingIVopioidsandthepainissevere. b. Increasedose25-50%formoderatepainand50-100%forseverepain.5. Determine the opiatethatwillbeusedanddoseadjustforincomplete

crosstolerance. a.Theonlyreasontochangefromoneopiatetoanotherissideeffectsor

renalfailure. b.Whenrotatingopiate,decreasethedose25-50%tocorrectforincompletecross

tolerance.

6. Determine the route theopiatewillbegiven. a.IMshouldneverbegiven.7. Determine the dosing schedule. a.Fornon-opiatenaivepatients,uselong-actingpainmedicineforongoingpain,not

prn;foropiatenaivepatientsuseonlyprnuntilyouhaveasenseofhowmuchmedicinethepatientneeds.

b.Give66-75%ofpatient’sstabledailyOMEaslongacting. c.Considerapcaifthepainrequirementsarerapidlyincreasingorunknown.8. Determinebreak through dose(foracutepaininpatientwithotherwise

controlledpain). a.Usethesameopiateforshort-andlong-actingpainwhenpossible. b.5-15%oftotaldailylongactingopiatedoseevery3hrprn.9. Manageopiate side effects.Constipationmustbetreatedprophylactically

(seepage6).10.Determinewhetherco-analgesicswouldhelp.

1 2 3 4 5 6 7 8 9 100

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Abbey Pain ScaleAbbey Pain Scale for the assessment of pain in patients who cannot communicate .

Rating ScaleAbsent = 0 Mild = 1 Moderate = 2 Severe = 3

Domain Scale

Vocalization0-3

Facial expressions 0-3

Change in body language 0-3

Behavioral change (confusion, refuse to eat, alteration in usual patterns)

0-3

Physiological changes 0-3

Physical changes (skin tear, pressure area contractions, etc .)

0-3

Total Score No Pain = 0-2 Mild = 3-7 Moderate = 8-13 Severe = 14+Reference: Abbey J., Piller N., DeBalis A., Esterman D. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. International Journal of Palliative Nursing, 2004, Vol. 10, No 1, 6-13.

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PHARMACISTS WILL NOT MAKE SUBSTITUTIONS OR CORRECTIONS FOR OPIATES. IF SCRIPTS ARE NOT WRITTEN EXACTLY (e.g., CORRECT DRUG, DOSE, AND SCHEDULE), THEY WILL NOT BE FILLED.SELECT NON-INJECTABLE OPIOID PRODUCTS

Drug Formulation/Strength (mg/mg) (8)Anexsia (hydrocodone/acetaminophen) (4,6) Tabs 5/325 (scored), 5/500 (scored), 7 .5/325, 7 .5/650 (scored), 10/660 (scored)Empirin with Codeine (codeine/aspirin) (4,6) Tabs 30/325 (#3), 60/325 (#4)Lorcet (hydrocodone/acetaminophen) (3,4) Tabs 7 .5/650 (scored), 10/650 (scored) Caps 5/500Lortab (hydrocodone/acetaminophen) (3,4) Tabs 2 .5/500, 5/500 (scored), 7 .5/500 (scored), 10/500 Elixir 7 .5/500 per 15 mLNorco (Hydrocodone/acetaminophen) (3,4) Tabs 5/325, 7 .5/325, 10/325Percocet (oxycodone/acetaminophen) (3,4) Tabs 2 .5/325, 5/325, 7 .5/325, 7 .5/500, 10/325, 10/650 Percodan (oxycodone/aspirin) (4) Tabs 5/325 Roxicet (oxycodone/acetaminophen) (4) Tabs 5/325 Caps 5/500 Oral Solution 5/325 per 5 mLTylenol with Codeine (codeine/acetaminophen) (3) Tabs 15/300 (#2), 30/300 (#3), 60/300 (#4) Oral Solution 12/120 per 5 mLVicodin (hydrocodone/acetaminophen) (3,4) Tabs 5/500, 7 .5/750 (ES), 10/660 (HP)Vicoprofen (hydrocodone/ibuprofen) (6) Tabs 7 .5/200Zydone (hydrocodone/acetaminophen) (4,6) Tabs 5/400, 10/400

Drug Short Acting (mg) Long Acting (mg)Morphine Tabs (15, 30 mg) Caps (15, 30 mg) MS Contin Tabs (q12hr) (15, 30, 60, 100, 200 mg) MSIR Oral Solution (10 mg/5 mL, 20 mg/5 mL) Oramorph SR Tabs (q12hr) (15, 30, 60, 100 mg) MSIR, Roxanol Oral Concentrate (100 mg/5mL) (1) Kadian Caps (q12hr or q24hr) (10, 20, 30, 50, 60, 80, 100, 200mg) (2, 6, 7) Supp (5, 10, 20, 30 mg) Avinza Caps (q24hr) (30, 60, 90, 120 mg) (2, 5)Oxycodone Roxicodone Tabs (5, 15, 30 mg) OxyIR Caps (5 mg) OxyContin Tabs (q12hr) (10, 15, 20, 30, 40, 60, 80 mg) Roxicodone Oral Solution (5 mg/5 mL) OxyFAST, Oxydose, Roxicodone Intensol Oral Concentrate (20 mg/mL) (1,6) Hydromorphone Dilaudid Tabs (2, 4, 8 mg) (8 mg brand-name scored) (Dilaudid) Dilaudid Oral Solution (5 mg/5 mL) Supp (3 mg) Codeine Tabs (15, 30, 60 mg) Solution or Elixir (15 mg/5 mL) Fentanyl Actiq Lozenge (200, 400, 600, 800, 1200, 1600 mcg) (5) Duragesic Transdermal Patch (12 .5, 25, 50, 75, 100 mcg/hr)Oxymorphone Opana (5, 10 mg) Opana ER (5, 7 .5, 10, 15, 20, 30, 40 mg)

SELECT COMBINATION OPIOID PRODUCTS

(1) Orders for concentrated oral opioid solutions must include drug name and strength (e.g. 100 mg/5mL) to avoid confusion with other oral solutions. (2) Data supporting safe use with enteral feeding tubes (must use size 16 French or larger) . See Kadian prescribing information and UPMC PUH SHY online formulary (Avinza) for product-specific instructions . (3) Maximum daily dose of acetaminophen is 4 grams in patients with normal liver function. (4) Many other brand name products contain similar combinations of opioids. (5) Formulary restricted. (6) Non-formulary. (7) Please note 200 mg not to be confused with 20 mg. (8) As of Fall 2008, all combination opiates with more than 325 mg of acetaminophen will be non-formulary.

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Oral and Parenteral Opioid Analgesic Equivalencies and Relative Potency of Opioids as Compared with Morphine*When converting from one opioid to another, you should use 50–75% of the equivalent dose . Allow for incomplete cross-tolerance between dif-ferent opioids (may need to titrate up rapidly and use PRN dose to ensure effective analgesia for the first 24 hours) . Avoid IM injections because of inconsistent absorption and patient discomfort .

*These are rough approximations; individual patients may vary . ** Equivalency for a one time dose of IV Fentanyl only . For Fentanyl patch conversion, see page 6 .1) Meperidine is not a first-line opioid . Avoid in patients with renal dysfunction . Contraindicated with MAOIs . Please see UPMC Meperidine

Guidelines before prescribing .2) Parenteral opioid: onset of action, 5 minutes; peak, 15 min .3) Oral opioid: onset of action, 15–30 minutes; peak, 45–60 min .4) Equivalency if acute; when long-term, potency is 100 mcg=4 mg IV morphine .Please refer to APS Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (2003); American Pain Society (APS) Guideline for the Management of Cancer Pain in Adults and Children (2005).

Opioid Agonists Parenteral mg (2) Oral mg (3) Duration of Effect Morphine 10 30 3–4 hours Oxycodone 20–30 3–4 hours Hydromorphone 1 .5 7 .5 3–4 hours Meperidine (1) (not recommended) 75 300 3 hours Fentanyl (4) 0 .1** 1–2 hours Codeine 130 200 3–4 hours Hydrocodone 25–30 Oxymorphone 1 10 3–6 hours

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Patient Controlled Analgesia (PCA)The following are suggestions for the PCA order for adults . Like all opioid orders, doses must be individualized .

Use the preprinted PCA order form for all new PCA orders and dose changes. EDUCATE FAMILIES NOT TO PRESS THE PCA BUTTON!

*Opioidtolerantandchronic/cancerpainpatientsmayrequirehigherdosesandcontinuousinfusions.

1.PCAaloneisamaintenancetechnique.Patientsshouldreceiveloadingdoses(deliveredthroughtheinfuser)thataretitratedtoachieveanadequatelevelofanalgesia(painscorelessthanorequalto4/10).

2.Quantitydeliveredwhenbuttonispressed.Reducedosesby30-50%inelderlyandpatientswithliverdisease.Donotincreasedosebasedonincreasedbodyweight;thisisespeciallyimportantinpatientswithObstructiveSleepApnea.Dosingdependsonthepatient—youngvs.elderly/opioidnaivevs.tolerant.

3.Howfrequentlydemanddosecanbeactivated.Patientmustbeableto

pressthebuttonandbeabletocomprehendinstructionsonwhentopressthebutton.Intheelderly,consideralongerlockoutinterval.

4.The hour limit should not be less than the available total hourly patient administered dose.Bolusdosesandthecontinuousinfusionareincludedintheone-hourdoselimitcount.

5.Notrecommendedforpatientswhoareopioidnaive,theelderly,patientswithalteredmentation,orwithObstructiveSleepApnea,COPD,orasthma.

6.Morphineisgenerallytheopioidofchoice.Hydromorphoneispreferredinpatientswithimpairedrenalfunction.

If pain unrelieved following administration of loading dose(s), increase loading dose by 50% and titrate to pain score less than or equal to 4/10.

Loading Starting Patient Lockout One-hour Dose Continuous infusion dose(s) (1) Administered Dose* (2) Interval (3) Limit (optional) (4) rate in mg/hr (5) Morphine (6) Opioid naive: 1 mg 8 –20 min . 7–10 mg 2-4 mg q 15 min Elderly (>70 yrs .) 0 .5 mg 8 –20 min . 4– 6 mg 2mg q 20 min . titrated to pain relief Hydromorphone Opioid naive: 0 .2 mg 8 –20 min . 0 .7–1 .4 mg (Dilaudid) 0 .2–0 .3 mg q 15 min Elderly (>70 yrs .) Elderly: 0 .1 mg 8 –20 min . 0 .4–0 .6 mg 0 .2mg q 20 min titrated to pain relief

When indicated, calculate based on

intermittent PCA use or previous opioid

requirement .

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TO CONvERT TO TRANSDERMAL FENTANYL—NOT USED FOR ACUTE PAIN OR INITIAL OPIOID THERAPY. USE FOR PATIENTS WHO ARE UNABLE TO TAKE PO OR HAvE CHRONIC CANCER PAIN. Determine the 24-hr parenteral morphine equivalent . Dose patch at 50–75% of the previous 24-hr opioid use . Prescribe a short-acting opioid for breakthrough pain

(5-15% of total daily long acting opiate dose every 3 hr prn) . Patch duration = 72hrs . Increase the patch dose based on the average amount of additional short-acting opioid required in the previous 72 hrs . Allow patch at least 48hrs before adjusting the dose . For dosages of transdermal fentanyl over 100 mcg/hr multiple patches can be used .

Parenteral Morphine Transdermal Fentanyl Equivalent (mg/24 hours) Equivalent (mcg/hr) 8 to 22 25 23–37 50 38–52 75 53–67 100 68–82 125 83–97 150

TWENTY-FOUR HOUR ORAL MORPHINE EQUIvALENT DIvIDED BY 2 IS EQUAL TO FENTANYL PATCH DOSE IN MCG/HR.

Iv FENTANYL DOSE/HR=TRANSDERMAL FENTANYL DOSE

NOTE: PATCH TAKES 12–24 HRS TO ACHIEvE FULL EFFECT. WHEN REMOvING A PATCH, REMEMBER THE ANALGESIC EFFECT CAN STILL LAST 24 HRS.

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Guidelines for Naloxone Administration and Patient Monitoring1. Nurses may administer naloxone without a physician’s order

when patients who have received an opioid meet the following criteria: (a) Sedation Scale = 3 (Somnolent; Difficult to arouse), (b) RR < 8 OR Oxygen Saturation < 92% and RR < 12

2. If the criteria listed above are met, stop the administration of the opioid (including fentanyl patches) and benzodiazepines .

3. Provide oxygen via face mask STAT.

4. Method for naloxone administration: Naloxone 0.04 mg IV q 1 minute until a change in alertness is observed. Dilute 0 .4mg naloxone (one ampule) with NSS to a total volume of 10ml (1 ml = 0 .04 mg) in a 10 ml syringe .

5. Notify the primary physician and/or house staff of the need to immediately evaluate the patient. If the house staff does not arrive within five minutes or if the nurse assesses the need, a “Condition C” should be called .

6 Titrate the prescribed naloxone until the patient is responsive. The half-life of naloxone (ONE HOUR) is shorter than the half-life of opioid agonists . Naloxone administration should not cause pain to return or precipitate opioid withdrawal. If a response is not obtained after one ampule of naloxone (10 cc of diluted solu-tion) is administered, examine the patient for alternate causes of sedation and respiratory depression. For assistance with further naloxone dosing, please contact the Toxicology Treatment Program (412-647-7000) .

7. Re-evaluate the events leading to the need for naloxone administration. In cases where the prescribed opioid dosing was too high, reassess the therapeutic plan for pain management . Consider decreasing the opioid dose by 50%. Resume opioid administration when the patient is easily aroused, is beginning to experience pain, and after the RR increases to > 9 .

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Nausea and Vomiting: TreatmentMechanism-based therapy involves the following steps:1. Acompletehistoryandphysicalincludingoropha-

ryngeal,abdominal,rectalandneurologicalexams2. Considerlabs:BUN/Cr,Na,LFT’s,amylase/lipase,

Ca,druglevels3. Considerimaging:flatplateoftheabdomento

assessforconstipation,AbdominalCTtoevaluateforobstruction,HeadCT/MRI

4. Determinewhichreceptorsaremediatingthesymptoms(seebelow)

5. Chooseanantiemetictoblocktheimplicatedrecep-tors(seenextpage)

Pathophysiology of nausea and vomiting Nausea and vomiting are triggered by activation of one of four main pathways:1 . ChemoreceptorTriggerZone(CTZ):Mainreceptors:

D2,5HT3,NK12. Cortex:Mainreceptorsareinthevomitingcenter.3. Vestibularapparatus:Mainreceptors:Ach,H14. Peripheralpathways:Mediatesnauseafromtrigger-

ingofGI/visceralchemoreceptors(localtoxins)andmechanoreceptors(stretch).Enterochromaffincellsrelease5HT3whendamaged(iebychemotherapyorradiation)whichactivateslocal5HT3receptors.

Thesefourpathwayssendsignalstothevomitingcenter

(mainreceptors:H1,Ach,5HT2)whichtriggersnauseaandvomitingwhenthresholdsarereached.If nausea is persistent, severe or refractory:• Scheduleantiemeticsaroundtheclock,notPRN• Choosesecondandthirdantiemeticswhichworkon

differentreceptors.• ConsiderPalliativeCareconsultforsecondandthird

linetherapiesINADDITIONTOUSINGANTIEMETICS,ALWAYSTREATANYREVERSIBLECAUSES(medications,anxiety,constipation,hypercalcemia,thrush,increasedICP,GERD,pain)ALWAYSEVALUATEFORCONSTIPATIONANDPERFORMARECTALEXAMAvoiduseofpromethazinebecauseofadverseeffectsincludingsedationandrespiratorydepressionAvoidbenzodiazepinesunlessthenauseaisfromanxietybecausetheycansedatethepatientandincreaseriskofaspirationFornauseaassociatedwithvomiting,giveantiemeticsviatheIVrouteuntilsymptomsarecontrolledEvaluateforclinicalsignsofbowelobstruction(persis-tentnauseabrieflyrelievedbyvomiting,abdominalpain,distendedabdomen,obstipation)Ifbowelobstruction,considersurgeryand/orGIconsultsforpossiblesurgicalrepairorventingPEGtube

Considerpalliativecareconsultformedicalmanagementofbowelobstruction.References:WoodGJ,ShegaJW,LynchB,VonRoennJH.Managementofintractablenauseaandvomitinginpatientsattheendoflife“Iwasfeelingnauseousallofthetime…nothingwasworking.”JAMA.2007;298(10):1196-1207.

Receptors:D2:Dopaminetype2receptor,5HT3:5-hydroxytrypta-minetype3receptor,5HT2:5-hydroxytryptaminetype2receptor,Achm:muscarinicacetylcholinereceptor,H1:histaminetype1receptor,NK1:Neurokinintype1receptor

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Drug(GenericName)

Receptoractivity

CommonClinicalIndications Dosage/Route Cost Comments/

SideEffects

Haloperidol D2 OpioidInducedN/V 0.5-4mgPOorSQorIVQ6h $ IVhaslessEPScomparedtoPO

Metoclopramide PeripheralD2 ImpairedGImotilityOpioidInducedN/V

5-20mgPOorSQorIVACandHS $ EPS,esophagealspasm,andcolicinGItractobstruction

Prochlorperazine D2 OpioidInducedN/VN/Vofunknownetiology

5-10mgPOorIVevery6hor25mgPRQ6h

$ EPSandsedation

Scopolamine Ach,H1 MotioninducedN/V 1.5mgTransdermalpatchevery3d $ Drymouth,blurredvision,ileus,urinaryretention,andconfusion

Ondansetron 5HT3 ChemotherapyorradiationinducedN/V

4-8mgPOasapillordissolvabletabletorIVevery4-8h

$$ Headache,fatigue,andconstipation

Dexamethasone DecreaseICP N/VrelatedtoIncreasedICP

4-8mgQAMorBID,PO(aspillorliquid)andIV

$ Agitation,Insomnia,Hyperglycemia

N/V:Nausea/Vomiting

Nausea and Vomiting: Treatment

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Medication Onset of action Usual starting dosage Site and Mechanism of ActionOsmoticlaxatives

Lactulose 24-48h 15-30mlq12-24h Colon;osmoticeffect

PolyethyleneGlycol 48-96h 17g(1tbsp)powderin8ozwaterq24h GItract;osmoticeffect

Sorbitol 24-48h 15-30mlq12-24h,max150ml/d Colon;deliversosmoticallyactivemoleculestothecolon

SalineLaxatives*

Magnesiumcitrate 30min-3h 120-240mlx1;10ozq24h Smallandlargebowel;attractsandretainswaterinthebowellumen

Magnesiumhydroxide(MOM) 30min-3h 30mlq12-24h Colon;osmoticeffect&increasedperistalsis

Stimulantlaxatives

Bisacodyl 6-10h 5-15mgx1 Colon;stimulatesperistalsis

Bisacodyl(PR) 15min-1h 10mgx1 Colon;stimulatesperistalsis

Senna 6-10h 2tabsqhs Colon;stimulatemyentericplexus,alterswaterandelectrolytesecretion

Surfacelaxatives

Docusate 24-72h 100mgq12-24h Smallandlargebowel;detergentactivity;softensfeces

Constipation and Bowel Protocol

Bulklaxativesalonearenotusefulinthetreatmentofopiateinducedconstipation*AvoiduseofMOMandrelatedproducts(includingsodiumphosphateenemaproducts)inpatientswithrenaldysfunctionbecauseofriskofhyperphosphatemiaReference:ReubenDB,HerrKA,PacalaJT,etal.GeriatricsatYourFingertips2009,11thedition.NewYork:TheAmericanGeriatricsSociety;2009BOWELREGIMEN:Withfewexceptions,all patients on opioid therapy need an individualized bowel regimen.Whenandeffectiveregimenisfounditmust be continued for the duration of the opioid therapy.Ifapatienthasnotbeenonabowelregimen,thestep1regimenshouldbestarted.Ifthereisnoresponsein24hours,movetothenextstep.Atanygiventime,iftherehasbeennobowelmovementinfourormoredays,asodiumphosphateormineraloilenemashouldbeadministered.Ifthisisnoteffec-tive,ahighcolonictapwaterenemashouldbeadministered.Beawareofthepossibilityofbowelobstructionorfecalimpaction.AdigitalrectalexamshouldbeperformedpriortostartingabowelregimenandifnoBMfor4days.

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Constipation and Bowel Protocol

Step 1—Begin with a laxative . The following are some suggestions: a . MOM 30cc po qd b . Senna 1 tab po qdStep 2—Senna 2 tabs bidStep 3—Senna 3 tabs bidStep 4—Senna 4 tabs bid + Lactulose 15cc po bidStep 5—Senna 4 tabs bid+ Lactulose 30 cc po bidStep 6—Senna 4 tabs bid + Lactulose 30 cc po qid

Otherdrugsthatcanexacerbateconstipation:anticholinergics(tricyclicantidepressants,scopolamine,oxybutinin,promethazine,diphenhydr-amine),lithium,verapamil,bismuth,iron,aluminium,calciumsaltsOpiodAntagoniststotreatrefractoryconstipation:Methylnaltrexone(MNTX)isaquaternaryaminewhichdoesnotcrossthebloodbrainbarriertocausereversalofopioidanalgesiaorwithdrawal.Useoforalnaloxoneforconstipationhasbeenassociatedwiththeseeffects.MNTXisapprovedforuseinpatientswhohavebeenonasteadyopioidregimenfor2weeksandlaxativeregimenfor3days.Greaterthan50%ofpatientswillhaveabowelmovementwithin4hoursofbeinggiventhedosebysubcutaneousinjection.Ingeneral,itisrecommendedthatoralandrectallaxativeregimensshouldhavebeentried,priortoutilizingMNTX.PtswithfecalostomybagsandPDcatheterswereexcludedfromthestudies.ThereisadosingordersetintheEMR.

BOWEL REGIMEN: With few exceptions, all patients on opioid therapy need an individualized bowel regimen. Start with the step 1 regimen . When an effective regimen is found it must be continued for the duration of the opioid therapy .

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Delirium: Diagnosis DSM-IV criteria for delirium include four components: A . Acute onset, over hours to days .B . Behavioral disturbance, marked by a reduced clarity in the patient’s

awareness of the environment, with impaired ability to focus, sustain, or shift attention . The patient may be agitated, irritable, and emotionally labile, OR drowsy, quiet, and withdrawn .

C . Consciousness level fluctuates over the course of the day . D . Different from dementia, delirium cannot be accounted for by a patient’s

preexisting, established, or evolving dementia . Delirium is conceptualized as a reversible illness, except in the last 24–48 hours of life .

1 . Delirium occurs in at least 25–50% of hospitalized cancer patients, and in a higher percentage of patients who are terminally ill . Delirium increases the risk of in-hospital and six-month mortality .

2 . Differential diagnosis: D: Drugs (opioids, anticholinergics, sedatives, benzodiazepines, steroids, chemo- and immunotherapies, some antibiot-ics); E: Eyes and Ears (poor vision and hearing, isolation); L: Low flow states (hypoxia, MI, CHF, COPD, shock); I: Infections; R: Retention (urine/stool), Restraints; I: Intracranial (CNS metastases, seizures, subdural, CVA, hypertensive encephalopathy); U: Under-hydration, Under-nutrition, Under-sleep; M: Metabolic disorders (sodium, glucose, thyroid, hepatic, deficiencies of vitamin B12, folate, niacin, and thiamine) and Toxic (lead, manganese, mercury, alcohol) .

3 . Routinely screen for delirium, and monitor delirious patients frequently .

AssessmentAsk family or friends of patient

Patient is easily distracted . Abnormal Digit Span: Inability to repeat a series of five digits (start with reading aloud a string of two random digits, then increase) and vigilance A: At least two errors (read aloud in neutral normal tone a list of 10 letters with four A’s . Patient taps when A is read) . Rambling or irrelevant conversation, unclear or illogical flow of ideas, or topic switching, or ask patient’s family . Ask: 1) Can a rock float? 2) Are there fish in the sea? 3) Is one pound more than two pounds? 4) Do you use a hammer to pound a nail? 5) Command say to patient, “Hold up this many fingers .” (Examiner holds two fingers in front of patient .) Next, do the same thing with the other hand (not repeating holding up the number of fingers) .

Hyper-alert, drowsy, stuporous, or unarousable

Feature1 . Acute onset and fluctuating course

AND 2 . Inattention

PLUS3 . Disorganized thinking >2 errors

OR4 . Altered level of consciousness

Confusion Assessment Method (CAM) ICU for the Diagnosis of DeliriumDiagnosis positive with 1 and 2, plus 3 or 4

See www.icudelirium.org for more information and http://elderlife.med.yale.edu for more information on the CAM and delirium in the hospital.

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Delirium: Treatment Rule out other medical causes of delirium . Review medications, and discontinue or decrease anticholinergic and/or benzodiazepine doses . Check for drug-drug interactions . Rotate opioids, reduce doses by 25% if possible, and avoid meperidine .

Benzodiazepines are NOT effective in treating delirium, may worsen delirium, and should be used cautiously only as adjunct therapy with neuroleptics when relief of agitation is required .

Neuroleptics are used for treatment of delirium . Haloperidol is the standard neuroleptic for treatment of delirium . Risperidone, olanzapine, and quetiapine are atypical neuroleptics, generally with fewer side effects . All neuroleptics can cause QT prolongation .

Supportive care to prevent and reduce delirium includes frequent orientation (well-lit rooms, caregivers, calendars, clocks, communication), therapeutic activities (patient mobilization 3x/day when possible), non-pharmacologic sleep aids (see page 12), treatment of hearing and vision problems, treatment of incontinence, and volume repletion . Confusion increases the risk of falls . Pay attention to patient safety . Constant supervision (sitter) may be more beneficial than restraints or sedation .

Table 2: Drugs used for treatment of delirium in the hospital setting

Generic name(Common brandname)

Starting dose

Dosing interval

Max q24hdose

Formulations EPS Anti-cholinergic

Sedation Comments**

Haloperidol(Haldol®)

0 .5-1mg(2mg in ICU*)

0 .5-1hour forurgentsymptoms .Otherwise Q6Hor Q8H

20mg 0 .5, 1, 2, 5, 10 mgtablets . Available asoral solution and asan injectableproduct .

+++ + ++ IV has less EPScompared to PO .***

(continued)

14

Abbreviations: EPS: extrapyramidal symptoms; IM: intramuscular; IV: intravenous; ODT: oral disintegrating tablet; SQ: subcutaneous .Definition: †Sundowning: Onset of confusion in the elderly that typically begins in the evening*Refer to the UPMC Presbyterian Shadyside “Acute Agitation Management” order set .** The FDA has determined that the use of antipsychotic medications in the treatment of behavioral disorders in elderly patients with dementia is associated with increased mortality . This risk appears to be highest during the first two weeks of use .*** Use IV haloperidol with caution in patients with prolonged QT interval . Increased risk of arrhythmia and sudden death exists with high IV doses .

Generic name(Common brandname)

Starting dose

Dosing interval

Max q24hdose

Formulations EPS Anti-cholinergic

Sedation Comments**

Risperidone(Risperdal®)

0 .25-1mg BID or up to Q6HPRN

6mg 0 .25, 0 .5, 1, 2, 3,4mg tablets .Available as ODT

++ + + Caution withrenal failure .

Olanzapine(Zyprexa®)

2 .5-10mg

Debilitatedor elderly:2 .5 mg .

DAILY

IM: Q2H(Maximum: 3doses daily)

20mg 2 .5, 5, 7 .5, 10, 15,20 mg tablets .Available as ODTand IM injection

+ ++ ++ Patients with hypoactivedelirium, >70yearsCNS malignancymay not respond well .

Quetiapine(Seroquel®)

12 .5- 50mg

BID 800mg 25, 50, 100, 200,300, 400 mg tablets

+ ++ +++ Start DAILY at 4pm forsundowning† and then time subsequent, additional dosesbased on symptoms .

Aripiprazole(Abilify®)

5-15mg Q AM 30mg 2, 5, 10 . 15, 20,30mg . Available asIM and oral solution

++ + ++ Useful for hyperactivedelirium . Can cause insomnia if given at night

Delirium: Treatment

15

EstimatedfrequenciesofCausesofDementiaAlzheimersDisease(AD):60-70%Otherprogressivedisorders:15-30%(eg,vascular,Lewybody,frontotemporal)Completelyreversibledementia(eg,drugtoxicity,metabolicchanges,thyroiddiseases,subduralhematoma,normalpressurehydrocephalus:2-5%

Dementia: Course

Progression of AD Common clinical features Usual MMSE; CDR* scores

MildCognitiveimpairment(preclinical)

ReportbypatientorcaregiverofmemorylossNofunctionalimpairmentObjectivesignsofmemoryimpairment6-15%annualconversionratetodementiasyndrome

26-30;0.5

Early,mildimpairmentYr1-3fromonsetofsymptoms

Disorientedtodate;namingdifficulties;recentrecallproblemsDecreasedinsight;socialwithdrawal;irritability,moodchanges

21-25;1

Middle,moderateimpairmentYr2-8fromonsetofsymptoms

Disorientedtodate,place;comprehensiondifficulties;impairednewlearning;gettinglostinfamiliarareasDelusions,agitation,aggression;restless,anxious,depressionNotcooking,shopping,bankingProblemswithdressing,grooming

11-20;2

Late,severeimpairmentYr6-12fromonsetofsymptoms

Nearlyunintelligibleverbaloutput;remotememorygoneNolongergroomingordressing;incontinentMotororverbalagitation

0-10;3

*MMSE:MiniMentalStatusExam,CDR:ClinicalDementiaRatingScaleReference:ReubenDB,HerrKA,PacalaJT,etal.GeriatricsatYourFingertips2009,11thedition.NewYork:TheAmericanGeriatricsSociety;2009

16

Dementia: PrognosticationFunctional Assessment Staging (FAST) Mortality Risk Index Score (Mitchell)

Stages Points Risk Factor

1 . No difficulties2 . Subjective forgetfulness3 . Decreased job functioning and organizational capacity4 . Difficulty with complex tasks, instrumental ADLs5 . Requires supervision with ADLs6 . Impaired ADLs, with incontinence7 . A . Ability to speak limited to six words B . Ability to speak limited to single word C . Loss of ambulation D . Inability to sit E . Inability to smile F . Inability to hold head up

1 .9 Complete dependence with ADLs1 .9 Male gender1 .7 Cancer1 .6 Congestive heart failure1 .6 O2 therapy needed w/in 14 days1 .5 Shortness of breath1 .5 <25% of food eaten at most meals1 .5 Unstable medical condition1 .5 Bowel incontinence1 .5 Bedfast1 .4 Age > 83 y1 .4 Not awake most of the day

National Hospice and Palliative Care Organization- FAST Stage 7A- hospice appropriate7C or worse, median survival- 3.2 months

Risk estimate of death within 6 months Score Risk %

Compared to FAST Stage 7C, the MRI had greater predictive value of six-month prognosis .

Mortality Risk Index has been validated only in newly admitted nursing home residents .

0 8 .9 1-2 10 .8 3-5 23 .26-8 40 .49-11 57 .0≥12 70 .0

Tsai S, Arnold RA. Fast Fact and Concept #150. Prognostication in Dementia. February 2006. End-of-Life/Palliative Education Resource Center (www.eperc.mcw.edu).

17

Depression: Screening Tools and TreatmentA shorter screening test for depression is to ask:

1 . Are you feeling either depressed or hopeless most of the time over the last 2 weeks?

2 . Have you found little brings you pleasure or joy over the last 2 weeks?

From: R Arnold . Fast Fact and Concept #146: Screening for Depression in Palliative Care . End-of-Life/Palliative Education Resource Center (www .eperc .mcw .edu) . 2005

Spiritual Distress Screen—A Quick Screen

1 . Ask “Are you at peace”?

2 . If the answer is no, ask the patient if he/she would like to see a chaplain .

Source: Archives of Internal Med 2006:166:101-5 .

Some select antidepressants are listed in the table next page:

18

Category Generic(Common Brand Name)

Starting PO dose(depression)*

Dosinginterval

Therapeuticdose/day range*

Generic(Y/N)

Formulations (mg)

SSRIs Citalopram(Celexa®)

10-20mg DAILY 10-60mg Y 10, 20, 40 (tablets)10mg/5mL (solution)

Escitalopram(Lexapro®)

5-10mg DAILY 10-20mg N 5,10, 20 (tablets)5mg/5mL (solution)

Sertraline(Zoloft®)

25-50mg DAILY 50-200mg Y 25, 50, 100 (tablets)100mg/5mL (solution)

SNRIs Venlafaxine(Effexor®)

75mg/day divided BID-TID 150-375mg Y 25, 37 .5, 50, 75, 100 (tablets)

Venlafaxine XR(Effexor XR®)

37 .5-75mg DAILY 75-225mg N 37 .5, 75, 150 (capsules)

Duloxetine(Cymbalta®)

20mg BID 30-60mg N 20, 30, 60 (delayed-released capsules)

Stimulants Methylphenidate(Ritalin®)

2 .5-5mg BID 8a,12p 5-40mg (fordepression)

Y 5, 10, 20(tablets)

Commonly used antidepressants: dosing, formulations

Abbreviations: CR, SR, XL, XR: sustained-release products SSRIs: Serotonic Specific Reuptake Inhibitors, SNRIs: Serotonin Norepinephrine Reuptake InhibitorsOthers: Use the following w/caution in renally impaired patients: all SNRIs, all formulations of buproprion and mirtazapineUse the following w/caution in hepatically impaired patients: All SSRIs, methylphenidate, all SNRIs and bupropion*The therapeutic dose/day range varies from the minimum efficacious dose up to the maximum tolerated or daily recommended amounts . Maximum daily doses are dependent upon indication for use and should only be used as a guide . Initial doses should be low in elderly patients and increased gradually . Doses of up to 300 mg of venlafaxine XR have been used in practice, but are not FDA-approved . The doses for methylphenidate can be higher than 20mg but are generally not recommended .

19

Drug (Commonbrand name)

Cost perday*

Anticholinergic Insomnia Arrhythmia GI Distress Comments**

Citalopram(Celexa®)

$ + + + ++ Mild to moderately activating, few drug interac-tions .

Escitalopram(Lexapro®)

$ + +++ +++ ++ Long t1/2, helpful for non compliance, also activating .

Sertraline(Zoloft®)

<$ -- + + +++ Moderately activating .

Venlafaxine(Effexor®)

$ $ + +++ ++ +++ Dual serotonin/norepinephrine action at doses of 150-225mg which is effective in neuropathic pain and is mildly activating . On switching from thevenlafaxine XR to venlafaxine, the shorter half life of venlafaxine requires frequent dosing to reach the same dose of venlafaxine XR .Use with caution in patients with hypertension .

Venlafaxine XR(Effexor® XR)

$ $ $ $ + +++ ++ ++

Duloxetine(Cymbalta®)

$ $ $ $ ++ ++ + ++ FDA-approved for diabetic neuropathy and off-label use for urinary incontinence . Do not use in patients with liver dysfunction . Use caution in patients with seizure disorder .

Methylphenidate(Ritalin®)***

<$ -- ++ +++ + Energizing, may increase appetite .

Commonly used antidepressants: costs, side effects, comments

Abbreviations: ODT: oral disintegrating tablet; t1/2: half-life .*Cost per day of a typical daily dose was calculated based on generic products when available . Cost data was extrapolated from www .drugstore .com .**Activating antidepressants tend to cause insomnia .***Not FDA-approved for treatment of depression .

20

End-Stage Liver DiseaseDefine as cirrhosis + 2 of (alb<3, bili>3, ascites require Tx; encaph with Glasgow <10; cachexia or UGIB require > 2 units)

Child C- roughly 90% die if admit to ICU; if Cr >1.3 and ventilator closer to 95+%

Child 1 2 3

Ascites none slight moderate

Bilirubin (mg/dL) <2 2-3 >3

Albumin (mg/L) >3 .5 28 .-3 .5 <2 .8

PT < 1 .7 1 .8-2 .3 >2 .3

Encephalopathy none Gr I-II Gr II-III

Child Score 1-year mortality 2-year

A 5-6 <5% 15%

B 7-9 20% 40%

C >10 55% 65%

21

End-Stage Liver Disease (continued)SUPPORT data for prognosis in cirrhosis:

MELD=.957 x logc(cr in mg/dl)+ .378 xlogc(bili) +1.120 logc(INR)

Cr 1-2 1 pt Age >65 1 pt

Cr > 2 2 pt PT>16 1 pt

Glasgow 10-14 1 pt Vent or pO2<60 1 pt

Glasgow<10 2 pt

Total 1-month 6-month mortality

0-1 12% 25%

2-3 40% 50%

>4 75% 90%

Total popl 30% 50%

Score 3-month mortality

0-9 0-5%

10-19 13-29%

20-29 50%

30-39 60-80%

40+ 95+%

Calculator- http://www .mayoclinic .org/meld/mayomodel6 .html

22

Opioids in Actively Dying Patients 1 . The following guidelines are for “comfort measures” patients

ONLY . See Print On Demand and/0r CPOE CMO order sets .

• “Titrate to comfort” medication orders are not acceptable . Parameters for drug dosing and titration must be included on all written and electronic care sets .

2 . Opioid naive patient (all doses are for morphine):

• Loading dose: 2–5 mg IV push .

• If distress not relieved in 15 minutes after initial loading dose, give bolus equal the loading dose increased by 50 percent . If severe distress persists repeat the dose every 15 minutes until comfortable .

• For increased pain/distress give extra bolus dose/s equal to the last given bolus dose every 30 min . as needed .

• If using more than 2 bolus doses over 6-hour period, consider starting a continuous infusion . To calculate the continuous infusion rate divide the total dose over last 6 hours by 6 .

3 . Non-naive patients:

• For patients who have been taking opioid pain medications within last 24 hours calculate the equianalgesic parenteral dose of morphine for the last 24 hrs (see page 4 for opioid equivalencies) .

• Divide the total 24 hour IV morphine dose by 24 to determine initial hourly infusion rate (mg/hour, IV) . Start continuous infusion at this rate .

• If patient in pain/distress use loading dose = hourly infusion rate .

• If distress not relieved in 15 min after initial loading dose or the patient in increased pain/distress, administer the loading dose increased by 50 percent and repeat every 15 minutes until comfortable .

• If using more than two bolus doses over 6-hour period, deter-mine new continuous infusion rate by recalculating total dose given over last 6 hours and dividing it by 6 .

23

Oral Secretions at the End of Life As the level of consciousness decreases in the dying process, patients lose their ability to swallow and clear oral secretions . As air moves over the secretions, the resulting turbulence produces noisy ventilation with each breath, described as gurgling or rattling noises . Death rattle is a good predictor of near death; one study indicated the median time from the onset of death rattle to death was 16 hours .

Non-pharmacological treatments: Position the patient on their side or in a semi-prone position to facilitate postural drainage . Reassure family about noise; can compare to snoring .

While there are no evidence-based guidelines, the standard of care is to use muscarinic receptor blockers (anti-cholinergic drugs) .

*Use atropine ophthalmic drops .Tertiary amines which cross the blood-brain barrier (all but glycopyrrolate) cause CNS toxicity (sedation, delirium) . Source: K Bickel; R Arnold . Fast Fact and Concept #109: Death Rattle and Oral Secretions, 2nd Edition . End-of-Life/Palliative Education Resource Center (www .eperc .mcw .edu) 2003 .

Drug (Trade Name) Route Starting Dose Onset

hyoscyamine hydrochloride Scopolamine Transdermal 1 (~1 mg/3 days) 12 hrs .

hyoscyamine sulfate Levsin Drops, Tabs (oral) 0 .125 mg 30 min .

glycopyrrolate Robinul Pills (oral) 1 mg 30 min .

glycopyrrolate Robinul Injection (SC, IV) 0 .2 mg 1 min .

atropine Atropine Injection 0 .1 mg 1 min .

atropine multiple Sublingual* 1 gtt (1%) 30 min

24

UPMC Pain and Palliative Care Resources (area code 412) PUH/MUH Palliative Care Service/Cancer Pain 647-7243, pager: 8511

PUH/MUH Chronic Pain Service 647-4991

PUH/MUH Medical Ethics 647-7243, pager: 2881

PUH/MUH Acute Interventional Perioperative Pain Service (AIPPS) 647-7243, pager: 7246 (PAIN)

Shadyside Acute Interventional Perioperative Pain Service (AIPPS) 692-2333

Shadyside Dept . of Medical Ethics 263-8347, pager

Shadyside Dept . of Palliative Care 647-7243, pager: 8513

Shadyside Chronic Pain Service 665-8030, after hours call 665-8031

Magee-Womens Hospital of UPMC Palliative Care (malignant pain) 647-7243, pager: 8510

Magee-Womens Hospital of UPMC Pain Medicine (nonmalignant/outpatient) 641-7600

Magee-Womens Hospital of UPMC Pain Medicine (chronic pain / inpatient) 901-2891

Childrens Hospital of Pittsburgh Supportive Care Program 692-3234

Magee-Womens Hospital UPMC Womens Cancer Center Palliative Care Clinic (E . Weinstein) 641-4530

VA Palliative Care Program inpatient and oncology 688-6000 Ext . 816178; or pager 645-2345 Geriatric palliative care—pager 958-0215

UPMC Hillman Cancer Pain, Rehabilitation and Supportive Care (outpatient) 692-4724

UPMC Cardiopulmonary Disease Palliative Care Clinic (W . Teuteberg) 647-6000

UPMC PUH Pain Medicine (outpatient) 692-2234

Centre Commons Pain Medicine (outpatient) 665-8030

St . Margaret—Pain Medicine (outpatient) and Chronic Pain Service (outpatient) 784-5119 (outpatient) or 784-4000 (UPMC St . Margaret Operator)

Family Hospice and Palliative Care 572-8800

25

Questionsorcommentsregardingthisinformation,contactRobertArnold,MD(rabob@pitt.edu),692-4834,pager2322.ThisinformationprovidedbythePalliativeCareProgramismerelyintheformofrecommendationsanddoesnotreplacetheserviceofaphysician.Author:MamtaBhatnagar,MDwithfeedbackfromColleenDunwoody,RN;JustinEngleka,NP;PaulHan,MD;SusanHunt,MD;LindaKing,MD;RayParonish,NP;RowanaSchwatz,PharmD;SusanSkledar,RPh,MPH;PegVerrico,RPh;ElizabethWeinstein,MD;GordonWood,MDandRobertArnold,MD.ThispaincardwasmadepossiblewithgeneroussupportoftheThe Center for Quality Improvement and Innovation.ProducedincooperationwiththeUniversityofPittsburgh.TheUniversityofPittsburghisanaffirmativeaction,equalopportunityinstitution.UMC72974-0410

•Psychological or spiritual counseling for patients and their families•Discharge planning and interface with local hospices•Bereavement services in the event of death•Outpatient palliative care follow-up

Indications for Palliative Care Referral:•Pain in patients with life-limiting illness•Management of other symptoms such as nausea, vomiting, shortness of breath, delirium •Negotiating goals of treatment or end-of-life decision making•Family support for a patient with a life-limiting illness

VERSION 9 .0 PAIN CARD

Institute to Enhance Palliative Care