Symptom Management Guidelines
These guidelines are intended for inter-professional clinicians working with adults living with advanced life-limiting illness. Though these guidelines were created for adults, the symptoms may also be experienced by children with advanced illness.
https://bc-cpc.ca/cpc/wp-content/uploads/2019/10/SMG-Interactive-Oct-16-2019.pdf
A Systematic Review of the Prevalence of Signs of Impending Death and Symptoms in the Last 2 Weeks of Life
https://bit.ly/2Lzf3ih
The classes of medication most commonly used in palliative care are:
- 1. analgesics (to treat pain)
- 2. antiemetics (to treat and also to prevent nausea and vomiting)
- 3. laxatives / aperients (to prevent and treat constipation)
- 4. adjuvant medications (medications that work with analgesics to improve pain or symptom control)
- 5. steroids (that may reduce a range of symptoms related to inflammation), and
- 6. antidepressants (to treat depression, or sometimes pain) and other neuroleptic medications (to treat depression, anxiety, or pain delirium) and sedatives.
Suggested medication for inclusion in a Just In Case Box is:
Morphine or diamorphine 10mg x 5 amps for pain
Levomepromazine 25mg x 5 amps for nausea and vomiting
Midazolam 5mg/ml 2ml amps (10mg) x 5 amps for agitation
Hyoscine butylbromide (Buscopan) 20mg x 5 amps to reduce respiratory secretions
Water for injection as appropriate for dilution of diamorphine
https://www.somersetccg.nhs.uk/EasysiteWeb/
Non-Pharmacological Care in the Last Hours or Days of Life
General considerations
- Discontinue unnecessary prescriptions, monitoring activities, and procedures. Consider stopping anything that doesn’t focus on comfort and alleviating symptoms/distress unless there is a good reason to continue it. Common areas that require review include:
- I/V fluids, antibiotics, s/c heparin, insulin, enteral nutrition and TPN.
- O2 masks and nasal prongs unless clear symptom benefit.
- Stop blood and radiological tests.
- Stop monitoring vital signs including oxygen saturation, fluid balance etc.
- Deactivate ICDs and remove cardiac monitors.
- Ensure DNACPR order signed / EWS stopped.
- Opioids are the foundation of pain management in advanced diseases because they are available in a number of formulations and, when dosed appropriately, they are effective and safe.
- Due to differences in levels of expressed subtypes of opioid receptors, a given patient might be more sensitive to the analgesic effect or side effects of a specific medication. Therefore, if dose escalation of one opioid is inadequate to control pain and further increases in dose are limited by intolerable side effects, rotation to another opioid is recommended.
- Certain treatments are indicated for specific pain syndromes. Bony metastases respond to NSAIDs, bisphosphonates, and radiation therapy in addition to opioid medications. As focal back pain is the first symptom of spinal cord compression, clinicians should have a high index of suspicion for compression in any patient with malignancy and new back pain. Steroids and radiation therapy are considered emergent treatments for pain control and to prevent paralysis in this circumstance.
Rapid Transfer Home in the Last Days of Life
Management
Follow five steps below to:
- facilitate a peaceful death in the patient’s preferred place
- facilitate seamless transfer from hospital or hospice to home within normal working hours. Prevent re-admission where possible. https://www.palliativecareguidelines.scot.nhs.uk/media/71315/2019-rapid-transfer.pdf
Rapid Discharge Guidance
Needs Assessment Guidance
This document provides guidance to health and social care professionals who provide or co-ordinate the care of people with life-limiting conditions. It helps professionals to assess the palliative care needs of patients with life-limiting conditions and to decide when it is appropriate to refer to a specialist palliative care service.https://bit.ly/3dHsGrY
No consensus
exists on the definition
of fatigue
or a standardized method of assessment.
“Fatigue is a subjective
feeling of tiredness, weakness
or lack of energy”.
In the context
of palliative and advanced disease,
fatigue can be viewed
as an inevitable characteristic
of the last phase of life.
https://web.archive.org/web/20210130094648/https://cjon.ons.org/sites/default/files/X540P15L51228244_first.pdf
Role Delineation Framework
The outcomes will be:
https://www.st-gemma.co.uk/
- Pain and other symptoms should be controlled effectively
- The individual, carers and family should feel well supported and appropriately involved in their care planning
- The individual, carers and family should feel confident in the skills and knowledge of their health and social care professionals
- The individual, carers and family should know who to contact in an emergency and
- The individual should be able to die in their place of choice
Full manual including references and evidence
Clinical Decision Support Tool
for the interpretation of and response to
Palliative care Outcome Scale (POS) scores:
APPM Master Formulary 2020 (5th edition)
https://bit.ly/35VeFUF
Naloxone
In palliative care patients receiving opioids for pain relief, naloxone should not be used for drowsiness or delirium which is non-life threatening, because of the dangers of reversing the analgesia and precipitating hyperalgesia and acute physical withdrawal, which, in some cases, may be fatal. The aim is to increase the respiratory rate, not the conscious level.
The doses of naloxone advised in the BNF for treatment of acute opioid toxicity may NOT be appropriate for the management of opioid-induced respiratory depression and sedation in those receiving palliative care and in chronic opioid/opiate use.
(Patient Safety Alert November 2014)
If respiratory rate ≥8/min, patient easily rousable and not cyanosed:
☛ Reduce opioid dose; may require omission of next dose
If respiratory rate <8/min and the patient is unconscious:
☛ Stop opioid eg remove patch, stop syringe driver
☛ Dilute naloxone 400mcg/ml (1ml ampoule), to 10ml using 0.9% saline for injection
☛ Give 0.5ml (20mcg) IV every 2 mins until respiratory rate >8/min
☛ Further boluses may be required as the half-life of naloxone is shorter than many opioids
☛ With very long acting opioids eg fentanyl or buprenorphine patch, it may be necessary to set up a 24 hour IV infusion of naloxone based on the bolus requirements. Seek specialist advice.
https://web.archive.org/web/20200808210928/https://www.harrogateandruraldistrictccg.nhs.uk/data/uploads/commissioning/guidelines-for-prescribing-opioids-in-palliative-care-11.10.18.pdf
The rectal route is a good alternative for hospice patients when the oral route fails. The walls of the rectum are highly vascularized and quickly and effectively absorb many of the medications used for EOL symptom control. Medications delivered to the distal one-third of the rectum partially avoid the first pass effect through the liver, allowing greater bioavailability for some medications compared with the oral route.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708715/
The Palliative Care Handbook - NINTH EDITION
Palliative care has come a long way from the beginnings of the modern hospice movement in the 1960s and is now widely understood as an essential part of care for the whole person during life-limiting illness and at end-of-life. As the authors of The Palliative Care Handbook (ninth edition) point out, too often people with dementia miss out on palliative care referrals and treatments that could make such a difference for them in their final days.
https://drive.google.com/
↓↓↓↓↓
LAST DAYS OF LIFE DAYS
- Medical review
- All reversible causes of deterioration explored
- Multidisciplinary Team agree patient is in the last days of life
- Clear, sensitive communication with patient and those identified as important to them
- Dying person and agreed others are involved in decisions about treatment and care as they want
- Agree on-going monitoring and support to avert crisis
- Advance Care Planning discussion offered or reviewed
- On-going District Nurse support
- ICD discussion and deactivation if not previously initiated
- Decisions made are regularly reviewed and revised accordingly
- Individual plan of care for the dying person including holistic assessment, review of hydration and nutrition, symptom control etc. is agreed, coordinated and delivered with compassion
- Anticipatory medication prescribed and available to prevent a crisis
- Needs of those identified as important are explored, respected and met as far as possible
- OOH/NWAS updated
- Update EPaCCS Record as and when necessary
- Review package of care if necessary
- Referral to other services e.g. Specialist Palliative Care
How does the Palliative Medicine team interact with my primary doctors?
The Palliative Medicine team works
alongside the doctors on your treatment team
to provide you with the best care.
If you are an oncology patient,
your oncologist will be responsible
for your oncology treatment plan,
including any chemotherapy,
radiation,
and other medical treatments related to your diagnosis.
If you are a primary care patient,
your primary care provider will be responsible
for your treatment plan.
Palliative Medicine providers will
manage any medications prescribed by team.
If you have any questions regarding
who is responsible for managing a particular medication,
please do not hesitate to ask.
EMERGENCIES IN PALLIATIVE CARE
Edmonton Symptom Assessment Scale (ESAS)
ESAS assesses nine common symptoms
with option of adding a tenth symptom;
each symptom is rated on an 11 point (0–10)
numerical rating scale.
ESAS-r retains the core elements of the ESAS,
with revisions focusing on symptom assessment time frame,
terminology, item order, and format.
ESAS-r-CS contains further modification
to include constipation and sleep disturbance,
and addition of a spiritual well-being domain
to the ESAS-r-CS elements is
termed ESAS-r-CSS.
https://www.onlinelibrary.wiley.com/doi/10.1002/cam4.1125
Opioid equianalgesic dose conversions: Quick check table
50 Ways to Take a Break
5 SIGNS
YOUR LOVED ONE
MAY BE READY FOR PALLIATIVE CARE
Here are signs that a patient may be ready for palliative care:
1. Advanced, life-limiting illness or condition — such as dementia, central nervous system disease, cancer, renal disease, COPD, heart failure, liver disease, septic shock or major trauma
2. Frequent hospitalizations or ER visits — two or more in last 6 months
3. Uncontrolled symptoms — pain, dyspnea, depression, fatigue, etc. – despite optimal medical management
4. Functional decline — unexplained weight loss, loss of mobility, frequent falls, skin breakdown, etc.
5. A permanent feeding tube is being considered
Okay kan, Bro!
IKA SYAMSUL HUDA MZ
