palliative care practice guidelines thomas palliative care services vcu massey cancer center vcu...

Palliative Care Practice Guidelines

Thomas Palliative Care Services

VCU Massey Cancer Center

VCU Health System

Original May 2006

Revised 2008 2010 2012 2014

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.

November 2014

November 2014 3

Table of Contents

Alternative Route for Opioid Administration 5

Bladder Spasms Treatment 6

Bowel treatment – stepped care program 7

Dyspnea 8

Fever 9

Hiccough 10

Mucositis 11

Pruritus 12

Secretions 13

Wound Odor 14

Name DateMedical Director, Thomas Palliative Care Unit

Name DateDirector, Nursing

November 2014 4

Delirium

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

*consider QTc monitoring at higher doses

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

.

Delirium, or acute confusional state, is a syndrome that presents in two basic forms. In its hyperactive form, it is manifested as severe confusion and disorientation, developing with relatively rapid onset and fluctuating in intensity. In its hypoactive form, it is manifested by an equally sudden withdrawal from interaction with the outside world.

Nonpharmacological interventions: reorientation, maintaining sleep wake scheduleAvoid restraints, minimize immobilizing treatments, maintain communication, med reconciliation


atypical antipsychotic meds starting doses for deliriumOlanzapine 2.5mg q12hrsRisperidone 0.25mg q12hrsQuetiapine 12.5mg q12hrs*consider QTc monitoring at higher doses

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

November 2014 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.*methadone not to be used due

to risk of tissue necrosis

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


November 2014 6

Bladder Spasms Treatment

Obtain urinalysis and culture of clean catch

urine

If indwelling catheter is present assess if

absolutely needs to be left in

Negative urinalysis

Positive urinalysis

Assess catheter function; irrigate gently with NS

Consider replacing if nonfunctioning or present for days-

weeks

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)

Treat UTI as appropriate based on rest of historical data

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

Use anticholinergic agents carefully in patients who are

high risk for delirium; monitor closely

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 analyzing cause

Alternative to oxybutynins:Tolterodine usual dose 1-2 mg PO BIDNewer agents: solifenacin,Trospium, darifenacinNewer agents non-formulary


November 2014 7

Bowel treatment – stepped care program

Senokot 1-2 tab dayif 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*consider KUB to r/o bowel obstruction

before adding laxatives

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.


For opioid induced constipation, consider methylnaltrexone SQ injection

(< 38kg: 0.15mg/kg (round up to nearest 0.1mL volume, 2mg/0.1mL

concentration), 38-62kg=8mg, >62kg=12mg SQ every other day until

BM)

Follow up with tap water enema until clear

November 2014 8

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 IF NO BENEFIT consider lasix nebulizer

40 mg

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.


Consider non-pharmacologic options (e.g. fans, relaxation, CPAP or BiPAP, physical comfort measures, relaxation)

November 2014 9

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

May refer to Cerner "Neutropenic Fever" care set for neutropenic

patients

Acetaminophen 650 mg PO/PR every 4 hours or 1,000 mg IV scheduled every 6 hrs scheduled x 24 hours (max 48 hrs, avoid other tylenol

containing products) if symptomatic or temp > 101 PO

Reassess 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.


November 2014 10

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


November 2014 11

Oral 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

PCA OPIOID, viscous lidocaine, topical cocaine.

Contact oral surgery re laser therapy 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


Consider non-pharmacologic measures (e.g. removal of dentures; avoiding salty, acidic or dry foods; change PO to IV formulation as appropriate/able)

November 2014 12

Pruritus

Establish probable cause:

Consider medications**, liver injury, renal failure, skin irritants, neoplasm

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 -Consider ondansetron 8mg iv qd or po q8h- If not on SSRI or SNRI anti-depressant, consider PO Sertraline 50 mg daily & titrate up to 100 mg after a week


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 naloxone infusion (2.5 mg in 250

ml, start @ 4ml/hr & titrate to max. rate of 12 ml/hr) or opioid rotation.

Also consider ondansetron 8mg po q8 or iv qd

13

SecretionsAssess saliva

Diminished saliva (xerostomia)

Increased secretions without trach in an end-of-life (EOL) patient

(Note: with trach, evaluate risk of obstruction from excessively dry

secretions)

Thick secretions in patients with good

cough

Guaifenesin 400 mg PO every 4 hours prn

ANDIncrease fluid intake

Encourage oral fluid intake and good oral care

Use saliva substitute 1 application swish and

spit prn dry mouth

Use sugarless (xylitol-containing)

candy or 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 trial of scopolamine patch 1.5mg

(onset in 12h) every 72 hoursAND

scopolamine 0.4 mg SQ/IV now and every 4 hours prn

No relief

If 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 every 2-4h prn

Consider Palliative service consultation

Oral or airway lubrication. Increased secretions may cause excessive, noisy respirations. Decreased secretions may cause uncomfortable dry mouth.

If patient unconscious, consider suction for accessible secretions


Increased secretions without trach in a non-EOL patient

Glycopyrrolate 0.2-0.4 mg PO tid (does not cross

blood-brain barrier, lower risk for CNS toxicity)

November 2014

November 2014

14

Wound Odor

Use room deodorizer

For wound with drainage, apply absorptive dressing with wound cover using:•Calcium alginate•Gauze packing•Foam dressing or thick pads for heavy drainage

For dry wounds or bleeding risk, apply non-adherent (oil emulsion) gauze as first layer

In the meantime, cleanse with normal saline or wound cleanser

Consider topical 0.75% metronidazole gel twice daily (use systemic antibiotics only if evidence of deep wound

infection)

Continue

A strong, noticeable, offensive smell emanating from a non-healing 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..

Consult Wound Care Team

Evidence-Based References

Delirium –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. (2011). Anxiety and depression. In B. R. Ferrell, & N. Coyle. (Eds.), Textbook of palliative nursing (3nd ed.). New York, NY: Oxford University Press..

–LeGrand, S., Delirium in Palliative Medicine: A Review, Journal of Pain and Symptom Management Volume 44, Issue 4, October 2012, Pages

583–594

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, 6 th Edition, 2008 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.

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.–Nazarko L. Bladder pain from indwelling urinary catheterization: a case study. Br J Nurs 2007;16(9):511-4.–Cravens DD, Zweig S. Urinary catheter management. Am Fam Physician 2000;61(2):369-76.

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.–Locke, GR III, Pemberton, JH, Phillips, SF. AGA technical review on constipation. Gastroenterology 2000; 119:1766. Tarumi Y1, Wilson MP, Szafran O, Spooner GR. Randomized, double-blind, placebo-controlled trial of oral docusate in the management of constipation in hospice patients. J Pain Symptom Manage. 2013 Jan;45(1):2-13

November 2014 15



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 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.

– Sheikh Motahar Vahedi H1, Mahshidfar B, Rabiee H, Saadat S, Shokoohi H, Chardoli M, Rahimi-Movaghar V. The adjunctive effect of nebulized furosemide in COPD exacerbation: a randomized controlled clinical trial. Respir Care. 2013 Nov;58(11):1873-7. doi: 10.4187/respcare.02160. Epub 2013 Apr 30.

– Smith TJ, Coyne P, French W, Ramakrishnan V, Corrigan P. Failure to accrue to a study of nebulized fentanyl for dyspnea: lessons learned. J Palliat Med. 2009 Sep;12(9):771-2. doi: 10.1089/jpm.2009.0113.

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.– Larkin P. Pruritis, Fever, and Sweats. In: Ferrel BR, Coyle, N. Oxford Textbook of Palliative Nursing, 3rd ed. Oxford: Oxford University Press,

2010:405-413.– Bobb B, Lyckholm L, Coyne P. Fever and Sweats. In: Walsh D, Caraceni AT, Fainsinger R, et al., eds. Palliative Medicine. Philadelphia:

Saunders Elsevier, 2008:890-893.

November 2014 16



• 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.– Lalla RV1, Bowen J, Barasch A, Elting L, Epstein J, Keefe DM, McGuire DB, Migliorati C, Nicolatou-Galitis O, Peterson DE, Raber-Durlacher

JE, Sonis ST, Elad S; Mucositis Guidelines Leadership Group of the Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO). MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014 May 15;120(10):1453-61. doi: 10.1002/cncr.28592. Epub 2014 Feb 25.

– Jan E Clarkson, Helen V Worthington,*, Susan Furness, Martin McCabe, Tasneem Khalid, Stefan Meyer. Interventions for treating oral mucositis for patients with cancer receiving treatment. 31 MAY 2010. DOI: 10.1002/14651858.CD001973.pub4

• 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.– Tejesh Patel, Gil Yosipovitch: Therapy of Pruritis. Expert Opin Pharmacother. Author manuscript; available in PMC 2011 July 1. Published in

final edited form as: Expert Opin Pharmacother. 2010 July; 11(10): 1673–1682. doi: 10.1517/14656566.2010.484420 PMCID: PMC2885583– Martin Steinhoff, Ferda Cevikbas, Akihiko Ikoma, Timothy G. Berger. Pruritis: Management Algorithms and Experimental Therapies. Semin

Cutan Med Surg. 2011 June; 30(2): 127–137. doi: 10.1016/j.sder.2011.05.001

November 2014 17



• 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.– Napenas JJ, Brennan MT, Fox PC. Diagnosis and treatment of xerostomia (dry mouth). Odontology 2009;97:76-83.– 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. – Bennett M, Lucas V, Brennan M, et al. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative

care. Palliat Med 2002;16:369-74.– Clark, K; Butler, M, Noisy respiratory secretions at the end of life. Current Opinion in Supportive & Palliative Care: June 2009 - Volume 3 -

Issue 2 - p 120–124

• 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.– Patel B, Cox-Hayley D. Managing wound odor #218. J Palliat Med 2010;13:1286-7.

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