What about Morphine?
Long acting opioid medications are also called sustained release (SR), controlled release (CR) or extended release (ER). These can come in oral or transdermal formulations.
Breakthrough Dose (BTD) is an additional dose used to control breakthrough pain (a transitory flare of pain that occurs on a background of relatively well controlled baseline pain). It does not replace or delay the next routine dose. BTD is also known as a rescue dose.
Opioid titration has traditionally been referred to as adjusting the dosage of an opioid.) It requires regular assessment of the patient’s pain, when and why it occurs as well as the amount of medication used in the previous 24 to 72 hour period.
Opioid rotation is switching one opioid for another. It is required for patients with inadequate pain relief and / or intolerable opioid related toxicities or adverse effects.
Opioid naïve patient refers to an individual who has either never had an opioid or who has not received repeated opioid dosing for a 2 to 3 week period.
Opioid tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effect over time. It is a known pharmacologic effect of opioids. Tolerance to the analgesic effects of opioids is relatively uncommon.
https://www.fraserhealth.ca/-/media/Project/FraserHealth/FraserHealth/Health-Professionals/Professionals-Resources/Hospice-palliative-care/Sections-PDFs-for-FH-Aug31/9524-25-FH---Sym_Guide-PrinciplesOfOpioidMgmt.pdf
PRESCRIBING OPIOIDS:
A Reference Guide
What are the essential medications in palliative care?
Ranking of ‘essential’ drug:
- 1 Morphine -- Pain
- 2 Haloperidol -- Delirium
- 3 Dexamethasone -- Anorexia/cachexia
- 4 Midazolam -- Terminal restlessness
- 5 Metoclopramide -- Nausea/vomiting
- 6 Clonazepam -- Terminal restlessness
- 7 Paracetamol -- Pain
- 8 Amitryptiline -- Neuropathic pain
- 9 Pamidronate -- Hypercalcaemia
- 10 Cyclizine -- Nausea/vomiting
- 11 Hyoscine hydrobromide -- Excess oropharyngeal secretions
- 12 Diazepam -- Anxiety
- 13 Lorazepam -- Anxiety
- 14 Omeprazole -- Dyspepsia
- 15 Chlorpromazine -- Delirium
- 16 Fentanyla -- Pain
- 17 Spironolactone -- Ascites
- 18 Ranitidine -- Dyspepsia
- 19 Promethazine -- Nausea/itch
- 20 Frusemide -- Ascites
Principles of a good death
- To know when death is coming, and to understand what can be expected
- To be able to retain control of what happens
- To be afforded dignity and privacy
- To have control over pain relief and other symptom control
- To have choice and control over where death occurs (at home or elsewhere)
- To have access to information and expertise of whatever kind is necessary
- To have access to any spiritual or emotional support required
- To have access to hospice care in any location, not only in hospital
- To have control over who is present and who shares the end
- To be able to issue advance directives which ensure wishes are respected
- To have time to say goodbye, and control over other aspects of timing
- To be able to leave when it is time to go, and not to have life prolonged pointlessly
Palliative Care and Pain Management at the End of Life
Palliative sedation may
be considered when an imminently dying patient is experiencing
suffering (physical, psychologic, and/or spiritual) that is refractory
to the best palliative care efforts. Terminal restlessness and dyspnea have been the most common indications for palliative sedation, and thiopental and midazolam are
the typical sedatives used.
For patients who have advanced kidney
disease, midazolam is recommended, but the dose should be reduced
because more unbound drug becomes available.
Before
beginning palliative sedation, the clinician should consult with a
psychiatrist and pastoral services (if appropriate) and talk to the
patient, family members, and other members of the healthcare team about
the medical, emotional, and ethical issues surrounding the decision. Formal informed consent should be obtained from the patient or from the healthcare proxy.
https://bit.ly/3bAIGdU
- ☛ Talking about dying won't kill you
- ☛ It is important to talk about dying with those closest to you, before the event
- ☛ Consumers with chronic illness talk about end of life wishes with loved ones and GP
- ☛ The majority of carers provided very positive feedback
- ☛ Not for all (pre-evaluation of carers preparedness)
- It is therefore, not only legally protected to treat pain, but actually out of the scope of good practice if one fails to practice adequate pain management, especially for those suffering from chronic or terminal illness.
- A key aspect of palliative medicine lies in the idea that the goals of analgesic therapy for pain, especially in the context of advanced illness, may change dramatically, but with open and honest communication between patient and physician, patients can be assured of comfortable chronic care, as well as end-of-life care. One must always appreciate the contribution of pain specifically to suffering and aim to alleviate discomfort—be it physical or emotional—as the primary goal of treatment.
Overall, what is the patient’s level of consciousness:
- alert (normal)
- vigilant (hyperalert)
- lethargic (drowsy but easily roused)
- stuporous (difficult to rouse)
- comatose (unrousable)
https://ipalapp.com/assess/symptoms/Talk tip: ask the family, “How were his/her final moments?” “How are you feeling?” “Do you have any questions?”
https://ipalapp.com/manage/last-days-and-hours-death-and-afterwards/
https://www.scielo.br/
Clinical Practice Guidelines for Quality Palliative Care, 4th edition
Palliative
care principles and practices can be integrated into any health care
setting, delivered by all clinicians and supported by palliative care
specialists who are part of an interdisciplinary team (IDT) with the
professional qualifications, education, training, and support needed to
deliver optimal patient- and family-centered care. Palliative care
begins with a comprehensive assessment and emphasizes patient and family
engagement, communication, care coordination, and continuity of care
across health care settings.
Serious illness is defined as “a health condition that carries a high risk of mortality and either negatively impacts a person’s daily function or quality of life or excessively strains their caregiver” (Kelley and Bollens- Lund, 2018).
Ever since the days of Hippocrates, medications have been administered through the rectum.
Since most oral symptom medications used in palliative care can be given rectally (e.g. most opioids, benzodiazepines, glucocorticoids, anti-emetics), a rapidly declining patient at home who can no longer take anything by mouth can often be managed with rectal medications instead of transporting the patient or ordering new drugs.
https://www.mypcnow.org/fast-fact/palliative-care-per-rectum/
Assessing pain
Always try to diagnose the cause of any pain prior to treatment, by making a detailed assessment including:
https://www.pharmaceutical-journal.com//research/review-article/treatments-for-neuropathic-pain/20203641.fullarticle?firstPass=false
First-line treatment with strong opioids considering:
If your client is on an opioid:
The palliative care team
GP
Serious illness is defined as “a health condition that carries a high risk of mortality and either negatively impacts a person’s daily function or quality of life or excessively strains their caregiver” (Kelley and Bollens- Lund, 2018).
Ever since the days of Hippocrates, medications have been administered through the rectum.
Since most oral symptom medications used in palliative care can be given rectally (e.g. most opioids, benzodiazepines, glucocorticoids, anti-emetics), a rapidly declining patient at home who can no longer take anything by mouth can often be managed with rectal medications instead of transporting the patient or ordering new drugs.
https://www.mypcnow.org/fast-fact/palliative-care-per-rectum/
FATIGUE IN PALLIATIVE CARE
https://pharmacopallcare.blogspot.com/2020/09/fatigue-in-palliative-care-ika-syamsul.html
Assessing pain
Always try to diagnose the cause of any pain prior to treatment, by making a detailed assessment including:
- Physical effects or manifestations.
- Functional impact of pain.
- Psychosocial factors.
- Spiritual aspects.
Neuropathic pain (NP) is caused by damage or injury to the nerves that transfer information between the brain and spinal cord from the skin, muscles and other parts of the body. NP can negatively impact a patient’s quality of life.
Possible side effects of opioid medicines include:
https://palliativecare.org.au/
- constipation — can be relieved by regularly taking laxatives
- nausea and vomiting — is often only temporary or can be alleviated with medicines
- drowsiness or confusion — may occur for only a short time after starting treatment or increasing the dose
- dry mouth — may improve with time
- itchy skin — may improve with time
First-line treatment with strong opioids considering:
titration schedule
formulation
routes of administration
breakthrough pain.
https://www.nice.org.uk/guidance/cg140/evidence/opioids-in-palliative-care-appendix-d-how-this-guideline-was-developed-pdf-186485294formulation
routes of administration
breakthrough pain.
If your client is on an opioid:
- Do they have a Breakthrough?
- Do they have something for Barfing?
- Do they have something for their Bowels?
Regular monitoring (at least daily) with visual analogue, numerical or verbal rating scales allows
treatment to be modified promptly where pain is inadequately
controlled. Self-assessment should be used wherever possible, including
in patients with cognitive impairment, only substituting with
observational pain rating scales when a patient cannot complete
self-assessment.
https://patient.info/doctor/pain-control-in-palliative-carePALLIATIVE TREATMENT FOR PAIN AND OTHER SYMPTOMS
https://pharmacopallcare.blogspot.com/2020/09/palliative-treatment-for-pain-and-other.html
Physician Orders for Life-Sustaining Treatment (POLST) is
a form that gives seriously-ill patients more control over their
end-of-life care, including medical treatment, extraordinary measures
(such as a ventilator or feeding tube) and CPR. Printed on bright pink
paper, and signed by both a patient and physician, nurse practitioner or
physician assistant, POLST can prevent unwanted or ineffective
treatments, reduce patient and family suffering, and ensure that a
patient's wishes are honored.
https://capolst.org/ or Download the POLST form.The palliative care team
GP
- Continues to see you for day-to-day health care issues and may coordinate your palliative care
Specialist palliative care nurse
- may work in a community or hospital setting, can provide ongoing care and may coordinate your palliative care
Community nurse
- visits you at home to supervise medical care, assesses your needs for supportive care, and works with your gp
Palliative care specialist* (physician)
- treats pain and other symptoms to maximise wellbeing and improve quality of life; usually works in collaboration with your gp or palliative care nurse
Cancer specialists* (oncologists and surgeons)
- may refer you to the specialist palliative care team and continue to provide cancer treatment to help manage your symptoms
Counsellor, psychologist
- help you manage your emotional response to diagnosis and treatment
Psychiatrist* (*specialist doctor)
- specialises in the diagnosis and treatment of mental illness, can prescribe medicine and uses evidencebased strategies to manage emotional conditions
Spiritual care practitioner (pastoral carer)
- discusses any spiritual matters and helps you reflect on your life and search for meaning; if appropriate, may arrange prayer services and other religious rituals
Pharmacist
- dispenses medicines and gives you advice about dosage and side effects
Occupational therapist
- assists in adapting your living and working environment; can suggest equipment, such as a hospital bed, wheelchair and bedside commode (toilet chair)
Physiotherapist
- helps with restoring movement and mobility, and preventing further injury
Diversional therapist
- offers recreational activities to improve your wellbeing
Dietitian
- recommends an eating plan and tries to use diet to assist with digestive issues, such as nausea or constipation
Speech pathologist
- helps with communication and swallowing problems
Social worker
- links you to support services and helps you with emotional, practical and financial issues; may also be called a welfare officer
Volunteers
- can help with home or personal care and transport, and also offer companionship
Palliative care should utilize
an integrated interdisciplinary approach,
based on:
- Respect for the dignity of patients and families,
Access to competent and compassionate palliative care,
Support for caregivers,
Improved professional and social support for families in need of palliative care, and
Continued improvement of pediatric palliative care through research and education.
https://web.archive.org/web/20210131000637/https://txpeds.org/palliative-care-toolkit
To
assist physicians in navigating the various topics associated with
providing palliative care, the TPS Palliative Care and End-of-Life
Web-Based Toolkit has been divided into the following sections:
MODIFIED EDMONTON SYMPTOM ASSESSMENT SCALE
1a. Please rate your pain now.
1b. Please rate your pain during the last 3 days.
1c. Is your pain control acceptable to you?
2. How would you describe your activity level during the last 3 days?
3. How would you describe your amount of nausea during the last 3 days?
4. How would you describe your level of constipation in the last 3 days?
4a. When was your last bowel movement?
5. How would you describe your feelings of depression during the last 3 days?
6. How would you describe your feelings of anxiety during the last 3 days?
7. How would you describe your level of fatigue during the last 3 days?
8. How has your appetite been during the last 3 days?
9. How would you describe your sense of well-being during the last 3 days?
10. How short of breath have you been during the last 3 days?
11. How has your physical discomfort been during the last 3 days?
https://web.archive.org/web/20210130222054/https://www.quia.com/files/quia/users/illinoisjim/Articles/Curriculum/cancer_palliative_care.pdf
1a. Please rate your pain now.
1 No pain
2. Mild pain
3. Moderate pain
4. Severe pain
2. Mild pain
3. Moderate pain
4. Severe pain
1b. Please rate your pain during the last 3 days.
1. No pain
2. Mild pain
3. Moderate pain
4. Severe pain
2. Mild pain
3. Moderate pain
4. Severe pain
1c. Is your pain control acceptable to you?
1. Very acceptable
2. Acceptable
3. Not acceptable
2. Acceptable
3. Not acceptable
2. How would you describe your activity level during the last 3 days?
1. Very active
2. Somewhat active
3. Minimally active
4. Not active
2. Somewhat active
3. Minimally active
4. Not active
3. How would you describe your amount of nausea during the last 3 days?
1. Not nauseated
2. Mildly nauseated
3. Moderately nauseated
4. Very nauseated
2. Mildly nauseated
3. Moderately nauseated
4. Very nauseated
4. How would you describe your level of constipation in the last 3 days?
1. No constipation
2. Mild constipation
3. Moderate constipation
4. Severe constipation
2. Mild constipation
3. Moderate constipation
4. Severe constipation
4a. When was your last bowel movement?
1. Today
2. Yesterday
3. 2–3 days ago
4. More than 4 days ago
2. Yesterday
3. 2–3 days ago
4. More than 4 days ago
5. How would you describe your feelings of depression during the last 3 days?
1. Not depressed
2. Mildly depressed
3. Moderately depressed
4. Very depressed
2. Mildly depressed
3. Moderately depressed
4. Very depressed
6. How would you describe your feelings of anxiety during the last 3 days?
1. Not anxious
2. Mildly anxious
3. Moderately anxious
4. Very anxious
2. Mildly anxious
3. Moderately anxious
4. Very anxious
7. How would you describe your level of fatigue during the last 3 days?
1. Not fatigued
2. Mildly fatigued
3. Moderately fatigued
4. Very fatigued
2. Mildly fatigued
3. Moderately fatigued
4. Very fatigued
8. How has your appetite been during the last 3 days?
1. Very good appetite
2. Moderate appetite
3. Poor appetite
4. No appetite
2. Moderate appetite
3. Poor appetite
4. No appetite
9. How would you describe your sense of well-being during the last 3 days?
1. Very good sense of well-being
2. Moderately good sense of well-being
3. Not very good sense of well-being
4. Poor sensation of well-being
2. Moderately good sense of well-being
3. Not very good sense of well-being
4. Poor sensation of well-being
10. How short of breath have you been during the last 3 days?
1. No shortness of breath
2. Mild shortness of breath
3. Moderate shortness of breath
4. Very short of breath
2. Mild shortness of breath
3. Moderate shortness of breath
4. Very short of breath
11. How has your physical discomfort been during the last 3 days?
1. No physical discomfort
2. Mild physical discomfort
3. Moderate physical discomfort
4. Severe physical discomfort
2. Mild physical discomfort
3. Moderate physical discomfort
4. Severe physical discomfort
https://web.archive.org/web/20210130222054/https://www.quia.com/files/quia/users/illinoisjim/Articles/Curriculum/cancer_palliative_care.pdf
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