✅ Quick Reference Guide for Symptom Management

Fatigue

• The most prevalent of symptoms reported in advanced disease
• Rule out possible causative factors and evaluate which might be treatable given goals of care: anemia, iron deficiency, electrolyte imbalances, hypothyroidism, hypoxia, nutrition deficiencies, medications, anxiety/depression, sleep abnormalities
• Exercise, physical therapy, occupational therapy
• Assistive devices, caregiving support (hygiene, cleaning, meals)
• Stimulants such as methylphenidate (Ritalin®) 2.5-5 mg PO QD or BID to start, then titrate prn
• Dexamethasone (Decadron®) 2-8 mg PO QD, do not give in the evening
• Mirtazapine (Remeron®) 15 mg PO QHS to enhance sleep, also improves appetite and mood

Insomnia/ Sleep Disorders

• Evaluate sleep patterns current and prior to diagnosis
• Suggest sleep hygiene measures: reduce caffeine in afternoon/evening, do not watch TV/computer/cellphone/tablets in bed, limit alcohol intake, cool room, warm bath before bed
• Relaxation therapy such as mindfulness exercises, meditation, guided imagery
• For some, pharmacologic therapies ineffective if used daily
• Zolpidem (Ambien®) 5-10 mg PO QHS; lower doses for women; safety concerns – sleep walking/eating
• Mirtazapine (Remeron®) 15 mg PO QHS to enhance sleep, also improves appetite and mood
• Buspirone (Buspar®) 5-20 mg PO TID
• Trazodone (Desyrel®) 25-50 mg PO QHS
• Avoid antihistamines (diphenhydramine) for sleeping aid, especially in elderly or frail

Constipation

• Assess frequency, volume, consistency and normal patterns of BMs
• Diarrhea may be due to impaction; rectal exam indicated
• Goal 3/week without straining, pain, tenesmus
• Identify potential causative factors that can be addressed: opioids, anticholinergics, antihistamines, phenothiazines, tricyclic antidepressants, diuretics, iron, chemotherapy, ondansetron, antacids, dehydration, inactivity, hypercalcemia, hypokalemia, partial bowel obstruction, spinal cord compression, autonomic neuropathy, depression, anorexia, hypothyroidism
• Encourage varied diet
• First evacuate bowel – magnesium hydroxide (Milk of Magnesia) 30 mL PO QD, magnesium citrate 150-300 mL per day, bisacodyl 2-3 tabs PO QD or 10 mg suppository or Fleet’s Enema (nothing per rectum if patient thrombocytopenic [< 50,000 platelets] or neutropenic [ANC < 500-1000]) – limit Fleet’s and other sodium phosphate agents in renal dysfunction; if these are ineffective, give:
• Methylnaltrexone (Relistor®) SQ [for opioid induced constipation only] – dosing is weight based; contraindicated in obstruction
• Naloxegol (Movantik®) 12.5 or 25 mg po q am (for opioid induced constipation only)

Constipation Ongoing Prevention

• All patients on opioids should have an order for a stimulant laxative and softener
• Add stimulant and softener combination (e.g., senna/docusate) and titrate to effect (max 8 tabs/day)
• Increase with upward titration of opioid dose
• If persistent, consider adding bisacodyl 2-3 tabs PO QD or 1 rectal suppository QD; lactulose 30-60 mL PO QD; metoclopramide (Reglan®) 10-20 mg PO QID; Magnesium hydroxide (Milk of Magnesia) 30 mL PO QD
• When constipation is related to opioids or in debilitated patient, changing the diet or adding fiber supplements is rarely helpful
• Educate patients/families; there is much stigma about discussing bowel function

Even when not eating, patients should have bowel movements every 1-2 days. Untreated constipation can lead to discomfort and increased pain, as well as agitation in the cognitively impaired patient.

Diarrhea

• Evaluate for potential causes of diarrhea common in palliative care and correct/treat when feasible: medications (overuse of laxatives, antibiotics, magnesium, chemotherapy), infection, diet, herbal products (e.g., milk thistle, cayenne, ginger) fecal impaction, malabsorption syndromes from surgery or tumor, radiotherapy that includes abdomen in treatment field, inflammatory bowel disease and other comorbid disorders
• Loperamide (Imodium®) 2 mg PO –start with 4 mg, followed by 2 mg after each BM, not to exceed 8 capsules/24 hours
• Diphenoxylate/atropine (Lomotil®) 1-2 tabs PO QID, maximum 8 per 24 hours
• Tincture of opium – 0.6 mL PO q 4-6 hours prn
• Methylcellulose (e.g. Metamucil®) or pectin can help provide bulk to liquid stools
• Octreotide (Sandostatin®) 50 mcg SQ/IV q 8 hours, maximum 1500 mcg/day
• Cholestyramine – 2-4 g PO/day before meals (especially for c. difficile diarrhea)
• Pancrelipase (Creon, Pancreaze®) 500 – 2500 lipase units/kg PO with meals

Dyspnea (Shortness of breath; Air hunger)

• Identify and treat reversible causes: airway obstruction (e.g., bronchodilators and/or corticosteroids), infection (e.g. antibiotics), CHF or fluid overload (e.g., diuretics), anxiety (e.g., anxiolytics)
• Opioids are first line therapy; start with morphine 2.5-5 mg PO every hour (any opioid can be used) - titrate upward aggressively
• Liquids may be easier to swallow or can be placed sublingually (although absorbed enterally): morphine liquid; oxycodone liquid
• Parenteral (IV or SQ) opioids - can be used if patient unable to swallow
• Add anxiolytics (benzodiazepines) only if anxiety is present (e.g., lorazepam every 4 hours as needed)
• Elevate head of bed (can use a fan for comfort)
• Consider oxygen only if patient is hypoxemic

Anorexia

• Educate and counsel patient/family regarding anorexia as a natural response to disease; interventions below only when loss of appetite bothersome to patient
• Environmental alterations: small, frequent meals, moist foods or those with sauce/gravy take less energy to eat, assistance with meal preparation to improve energy for eating
• Dexamethasone (Decadron®) 4 mg PO QD or prednisone 20 mg PO QD, especially when prognosis < 6 weeks
• Dronabinol (Marinol®) 2-10 mg PO every 4 hours, use with caution in the older adult
• Mirtazapine (Remeron®) 15 mg PO QHS to enhance sleep, also improves appetite

Nausea & Vomiting
Not intended to prevent or treat chemo -induced N&V

Rule out potentially reversible causes: constipation, central nervous system disease, pain, altered electrolytes, ICP, obstruction, antibiotics, chemotherapy, radiation therapy, opioids, digoxin

• If N & V due to activation of chemoreceptor trigger zone (CTZ) (e.g., medication-induced):
  • • • Prochlorperazine (Compazine®) 10 mg PO q 6 hours or 25 mg PR q 8 hours
      • Haloperidol (Haldol®) 0.5-4 mg PO or IV/SQ q 6 hours
      • Ondansetron (Zofran®) 4-8 mg PO or IV q 8 hours (best when used for chemo or RT induced N/V; less effective when treating opioid induced N&V)
      • Olanzapine (Zyprexa®) 2.5 – 10 mg PO QD - BID
      • Promethazine (Phenergan®) 12.5 –25 mg IV q 6 hours or 25 mg PO or PR q 6 hours

• If N & V due to gastric stasis causing early satiety, GI tract spasm:
  • • • Metoclopramide (Reglan®) 10-20 mg PO or IV TID AC & HS (not with bowel obstruction)
      • Hyoscyamine (Levsin®) 0.125-0.25 mg PO/SL q 4 hours prn

• If N & V due to vestibular effects (nausea exacerbated by movement):
  • • • Scopolamine transdermal patch 1.5 mg q 3 days (especially if underlying mechanism is vestibular - increased nausea or dizziness with ambulation)
      • Cyclizine (Meclizine®) 25-50 mg PO every 8 hours; best for motion sickness or increased intracranial pressure

• If mechanism of N & V is unclear, or unresponsive to other therapies:
  • • • Dexamethasone (Decadron®) 4-8 mg PO/IV daily
      • Dronabinol (Marinol®) 2-10 mg PO every 4 hours

Administer antiemetics around the clock (scheduled). If nausea is controlled, then try reducing after 2-3 days.

QUICK REFERENCE GUIDE FOR SYMPTOMS AT THE END OF LIFE

Pain in the Final Hours of Life

• Observe for escalating pain and increase medications accordingly
• May need to change route if swallowing is diminished; alternatives include transdermal, concentrated liquids taken orally in small volumes, parenteral
• Abruptly discontinuing opioids or benzodiazepines may precipitate withdrawal syndrome - reduce dose 25% daily if no sign of pain in comatose patient; return to previous dose if any sign of return of pain
• Myoclonus may occur; treat with Clonazepam (Klonopin®) 0.5 mg PO TID, MAX 20 mg/day or Lorazepam (Ativan®) 0.5-2.0 mg PO/IV q 4 hours if patient unable to swallow; may require Midazolam (Versed®); IV/SQ; rotate opioids

Delirium & Agitation

• Identify and treat reversible causes: full bladder, fecal impaction, pain, dyspnea (hypoxemia, secretions, pulmonary edema), severe anxiety, nausea, pruritus, medications (e.g., corticosteroids, neuroleptics, anticholinergics), dehydration, infection
• Haloperidol (Haldol®) 0.5-4 mg PO or IV/SQ q 6 hours (may repeat q 1 hour PRN in severe delirium)
• Lorazepam (Ativan®) 0.5-2 mg PO/SL/IV q 4 hours PRN, then schedule ATC once effective dose is determined (not recommended as SQ)
• Olanzapine (Zyprexa®) 2.5 – 20 mg PO QHS or Zyprexa (Zydis®) (orally disintegrating tablet) 5-20 mg PO QHS
• Risperidone (Risperdal®) 0.5 mg PO q PM, increase by 0.25-0.5 mg q 2-7 days
• Quetiapine (Seroquel®) 12.5 – 100 mg PO q 12-24 hours
• Chlorpromazine (Thorazine®) 12.5-25 mg PO/SQ q 4-12 hours, or 25 mg pr q 4-12 hours (IV can cause hypotension-avoid unless other agents ineffective and oral/rectal route unavailable)

Excessive Secretions
(“Death Rattle”)

• Atropine 0.4 mg SQ q 15 minutes PRN
• Scopolamine transdermal patch 1.5 mg TOP, start with 1 mg (about 4 hour onset), increase to 2 mg after 24 hrs. If insufficient, begin scopolamine 50 mcg/hr IV or SQ; double every hour to maximum of 200 mcg/hr
• Glycopyrrolate (Robinul®) 1-2 mg PO or 0.1 mg –0.2 mg IV/SQ q 4 hours PRN or 0.4-1.2 mg/day continuous IV/SQ infusion (this agent does not cross the blood brain barrier – less likely to cause confusion)
• Hyoscyamine (Levsin®) 0.125 – 0.25 mg PO q 4 hours (liquid can be placed sublingually)
• Change patient’s position
• D/C IV and/or enteral fluids as they may increase discomfort (e.g., cough, pulmonary congestion, sensations of choking/drowning, vomiting, edema, pleural effusions, ascites)
• If fluids not discontinued, IV or SQ rate ought not exceed 500 mL/24 hours
• Furosemide (Lasix®) PRN to control overhydration.
• Control thirst by moistening lips and mouth with substitute saliva (Oral Balance Moisture Gel® or Salivart®, at bedside apply as frequently as needed)

Patients may be too weak to expectorate. This is not painful, but distressing to family. Suctioning is traumatic, can cause bleeding and is painful. Do not suction beyond the oral cavity.

References (and for more details):

Ferrell, B., Coyle, N., & Paice, J. (Eds). (2015). Oxford textbook of palliative nursing, 4th Edition. New York,

NY: Oxford University Press.

Dahlin, C., Coyne, P., & Ferrell, B. (Eds). (2016). Advanced practice palliative nursing. New York, NY:

Oxford University Press.

Authors:

Patrick Coyne, MSN, ACHPN, ACNS-BC, FAAN, FPCN

Constance Dahlin, ANP-BC, ACHPN, FPCN, FAAN

Polly Mazanec, PhD, AOCN®, ACNP-BC, FPCN

Judith Paice, RN, PhD, FAAN

Published 2017 by:

City of Hope

Division of Nursing Research & Education (NRE)

1500 E Duarte Road, Duarte, CA 91010

Phone: 626.218.2346 Email: NRE@coh.org

www.cityofhope.org/nursing-research-and-education

Source:

https://prc.coh.org/

Guidelines for the Management at the End of Life

Mild-to-moderate pain

Acetaminophen

• 1000 mg orally or rectally 3–4 times a day
• Do not exceed 4 g per day. Use this agent with caution in the treatment of patients with liver disease.

Ibuprofen

• 800 mg orally 3–4 times a day

Codeine

• 30 mg (with or without 325 mg acetaminophen) orally every 3–4 hr as needed
• Do not exceed 360 mg per day.

Oxycodone

• 5 mg (with or without 325 mg acetaminophen) orally every 3–4 hr as needed
• If analgesia is inadequate with initial treatment, adjust the dosage to 10 mg orally every 3–4 hr as needed; for further management, see treatment for moderate-to-severe pain.

Moderate-to-severe pain in patients not currently receiving opioids

Morphine

• Oral: 5–15 mg every 30–60 min as needed
• Intravenous: 2–5 mg every 15–30 min as needed

Hydromorphone

• Oral: 2–4 mg every 30 min as needed
• Intravenous: 0.4–0.8 mg every 15–30 min as needed

For both morphine and hydromorphone:

If analgesia is inadequate with initial treatment, increase the bolus dose by 25–50% for moderate pain or by 50–100% for severe pain.

If the level of analgesia is acceptable, administer continuous infusion (equal to the total daily opioid dose) over 24 hr, with a breakthrough dose every hour equivalent to 10–20% of the total 24-hr opioid dose. If the current drug causes unacceptable side effects to the patient, administer an equianalgesic dose of a different opioid.

Moderate-to-severe pain in patients currently receiving opioids

• Bolus dose (up to 10–20% of total opioid taken in the previous 24 hr) every 15–60 min as needed

If previously satisfactory analgesia becomes inadequate, increase the basal and bolus dose by 25–50% for moderate pain or by 50–100% for severe pain.

For daily follow-up, calculate the total 24-hr dose received (basal plus breakthrough) and adjust the basal rate to equal this 24-hr opioid amount; adjust the bolus dose to 10–20% of this 24-hr total. If the current drug causes unacceptable side effects to the patient, administer an equianalgesic dose of a different opioid.

Neuropathic pain

Opioids

• Adjust dose until analgesia has been achieved (as described above for moderate-to-severe pain)

Glucocorticoids

• For example, 4–16 mg of dexamethasone intravenously daily
• Consider especially for acute neurologic injury, such as nerve or spinal cord compression from a tumor.

Transdermal lidocaine patches

• Consider especially when allodynia is present.

Short-acting antiepileptic drug (e.g., gabapentin or pregabalin) or tricyclic antidepressant

• If survival for more than a few days is anticipated, consider adding one of these agents immediately.

Dyspnea

Morphine

• Oral: 5–10 mg every 30 min as needed until patient is comfortable
• Intravenous: 2–4 mg every 30 min to 1 hr as needed until patient is comfortable

For patients already receiving opioids, increase the dose by 25–50%

For dose adjustments, follow the guidelines for treating moderate-to-severe pain.

Oxygen

• Adjust to achieve satisfactory oxygen saturation and subjective relief of dyspnea

Should be used only for patients with low oxygen saturation; oxygen delivered by a high-flow nasal cannula may be useful for patients with low oxygen saturation, as long as it does not cause discomfort for the patient.

Bilevel positive airway pressure

• Use if consistent with patient’s goals, as long as it does not cause discomfort for the patient, and if it is subjectively helpful.

Nonpharmacologic approaches

• Approaches include psychosocial support, relaxation and breathing training, facial cooling with a fan, keeping windows open for ventilation, keeping the ambient room temperature low, humidifying the air, and keeping the head of the bed elevated.

Cough

Codeine

• 30 mg orally every 4–6 hr as needed

Codeine is available in various liquid formulations, often with additional medications, or as a tablet.

Morphine

• Oral: 5–10 mg every 60 min as needed until patient is comfortable
• Intravenous: 2–4 mg every 30 min to 1 hr as needed

For dose adjustments, follow the guidelines for treating moderate-to-severe pain.

Xerostomia

Pilocarpine

• 5–10 mg orally 3 times daily (not to exceed 30 mg/day)

Evidence of pharmacologic effectiveness is minimal. This method requires that the patient be able to take medication by mouth.

Mouth care

• Approaches include the use of antimicrobial mouthwashes, saliva substitutes, oral hydration, mouth swabs, sugarless gum, lip balm, or a humidifier.

Excessive oral–pharyngeal secretions (“death rattle”)

Glycopyrrolate

• Intravenous or subcutaneous: 0.2 mg every 4 hr as needed, not to exceed 4 doses per day
• Oral: 0.5 mg 3 times per day

There is insufficient evidence to support the use of anticholinergic agents.

Family members and staff should be reassured about the low probability that the patient will have discomfort as a result of the secretions and should be counseled about the potential side effects of treatment.

Nausea and vomiting

Caused by bowel obstruction

If the patient has complete bowel obstruction, avoid prokinetic drugs.

Octreotide

• 100–200 μg subcutaneously 3 times per day (or 100–600 μg per day in an intravenous or subcutaneous infusion)

Although this treatment is commonly administered, studies have shown conflicting results regarding its usefulness.

Dexamethasone

• 4–8 mg orally or intravenously every day (up to 16 mg per day)

Caused by gastroparesis

Metoclopramide

• 10–20 mg orally or intravenously every 4–6 hr (up to 100 mg per day)

Caused by increased intracranial pressure

Dexamethasone

• 4–8 mg orally or intravenously once a day (up to 16 mg per day)

Caused by medications, uremia, toxins, or other unspecified or multiple factors

Metoclopramide

• 10–20 mg orally or intravenously every 4–6 hr (up to 100 mg total daily dose)

Haloperidol

• Oral: 1.5–5 mg 2–3 times per day
• Intravenous: 0.5–2 mg every 8 hr

Ondansetron

• 8 mg orally every 8 hr as needed

Dexamethasone

• 4–8 mg orally or intravenously once a day (up to 16 mg per day) Dexamethasone is usually combined with other antiemetics.

Constipation

Check for fecal impaction.

Senna

• 2–4 tablets (8.6 mg sennosides per tablet) or 1–2 tablets (15 mg sennosides per tablet) as a single daily dose or in two divided doses each day (not to exceed 100 mg per day)

Bisacodyl suppository

• 10-mg rectal suppository once daily as needed

Polyethylene glycol

• 17 g orally once daily as needed

Methylnaltrexone

• For patients weighing 38 to <62 kg: 8-mg dose subcutaneously every other day
• For patients weighing 62 to 114 kg: 12-mg dose subcutaneously every other day
• For patients weighing <38 kg or >114 kg: 0.15 mg/kg subcutaneously every other day

Anorexia

Dexamethasone

• 2–4 mg orally or intravenously once a day

Counsel the patient and family about the limited long-term value of treatment.

Fever

• Cooling blankets, ice packs, and sponging may be helpful; in some cases, however, the patient may find them troublesome.

Acetaminophen

• 650–1000 mg orally, rectally, or intravenously every 4–6 hr as needed (maximum dose, 4 g per day)

Naproxen

• 250–500 mg orally twice daily Naproxen may be of particular benefit in the treatment of neoplastic fevers.

Anxiety and insomnia

Lorazepam

• 0.25–2 mg orally, intravenously, or subcutaneously every 4–6 hr as needed; dose may be increased to 5 mg

Psychosocial interventions may be helpful. Sedation may increase the risk of falls.

Delirium

Haloperidol

• 0.5–1 mg orally or intravenously every hour as needed; when symptoms have been relieved, give the total daily requirement in 3 or 4 divided doses per day

If symptoms are refractory, consider a trial of another antipsychotic agent, instead of or in addition to haloperidol. If agitation is refractory to treatment, consider the addition of a benzodiazepine, with careful monitoring.

Source

https://www.nejm.org/doi/pdf/10.1056/NEJMra1411746?articleTools=true

Symptom Management in Palliative Patients

Restlessness
Midazolam 10 mg/2ml --- 2.5-5 mg PRN
Haloperidol 5 mg/ml --- 1.5-3 mg QDS
Levomepromazine 25 mg/ml --- 12.5-25 mg

Nausea and vomiting
Metoclopramide 10mg/2ml --- 10mg TDS
Cyclizine 50mg/ml --- 50mg TDS
Levomepromazine 25 mg/ml --- 12.5-25 mg
Haloperidol 5 mg/ml --- 1.5-3 mg QDS
Respiratory tract secretions
Hyoscine butylbromide 20 mg/ml --- 20 mg QDS
Hyoscine hydrobromide 400 --- mcg/ml 400 mcg
Glycopyrronium 200 mcg/ml --- 200-400 mcg

Pain
Diamorphine 5 mg --- 2.5-5 mg
Morphine 10 mg/ml --- 5-10 mg
Oxycodone 10 mg/ml --- 2.5-5 mg
Alfentanil 1 mg/2ml --- 300 mcg

https://www.yumpu.com/


QUICK REFERENCE GUIDE FOR SYMPTOM MANAGEMENT
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