Table of Contents

General Principles of Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Select Opiate Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Equianalgesic Dosing (Opioid conversion) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Patient Controlled Analgesia (PCA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Opioid Dosing in Renal or Hepatic Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Guidelines for Naloxone Administration and Patient Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Constipation and Bowel Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-10Delirium Diagnosis (3D CAM and the ICDSC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-13Delirium: Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-15Depression: Screening Tools and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-18

End of Life Care: Symptom ManagementTreatment of Dyspnea and Pain at the End of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Oral Secretions at the End of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Palliative Care and Pain Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-23Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

June 2015Palliative Care Symptom Guide

Spirituality Screen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1

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. Pain is a subjective feeling: ask the patient using the above 0-10 scale. If the patient is cognitively impaired, use the Abbey

pain scale. (See page 2.) Frequency of assessment: at the time of the initial interview, every eight hours, and PRN (at least every two hours when pain is severe).2. In opiate naive patients, start with short-acting opioids (morphine, hydromor-

phone, and oxycodone) to control acute, moderate to severe pain. Never use long-acting opioids to control acute pain.

3. When titrating or changing opiate dose, start by calculating theprevious day’s Oral Morphine Equivalent (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 (see equanalgesic table).

b. Rectal=oralc. SQ=IM=IV

4. Determine if the dose is adequate for the pain and dose adjust.a. Titrate at least every 24 hours when the pain is moderate and as often as every

four hours when using IV opioids and the pain is severe.b. Increase dose 25-50% for moderate pain and 50-100% for severe pain.

5. Determine the opiate that will be used and dose adjust for incompletecross tolerance.a. The only reason to change from one opiate to another is side effects or

renal failure.b. When rotating opiate, decrease the dose 25-50% to correct for incomplete cross

tolerance.

6. Determine the route the opiate will be given.a. IM should never be given.

7. Determine the dosing schedule.a. For non-opiate naive patients, use long-acting pain medicine for ongoing pain, not

prn; for opiate naive patients use only prn until you have a sense of how much medicine the patient needs.

b. Give 66-75% of patient’s stable daily OME as long acting.c. Consider a pca if the pain requirements are rapidly increasing or unknown.

8. Determine break through dose (for acute pain in patient with otherwisecontrolled pain).a. Use the same opiate for short- and long-acting pain when possible.b. 5-15% of total daily long acting opiate dose every 3 hr prn.

9. Manage opiate side effects. Constipation must be treated prophylactically(see page 6).

10. Determine whether co-analgesics would help.

1 2 3 4 5 6 7 8 9 100

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.

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2

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)Hydrocodone/APAP Oral Solution 7.5/325 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, 10/325Percodan (oxycodone/aspirin) (4) Tabs 5/325 Roxicet (oxycodone/acetaminophen) (4) Tabs 5/325 Oral Solution 5/325 per 5 mLTylenol with Codeine (codeine/acetaminophen) (3) Tabs 30/300 (#3) Oral Solution 12/120 per 5 mL

Drug Short Acting (mg) Long Acting (mg)Morphine MS Contin Tabs (q12hr) (15, 30, 60, 100) Tabs (15, 30)

MSIR Oral SolutionSupp (5, 10, 20, 30) Kadian Caps (q12hr o

Avinza Caps (q24hr) (30, 60)Oxycodone OxyContin Tabs (q12hr) (10, 15, 20, 30, 40, 80) Roxicodone Tabs (

Roxicodone Oral Solution (5mg/5 mL) OxyFAST, Oxydose, Roxicodone Intensol Oral Concentrate (20 mg/mL) (1,6)

Hydromorphone (Dilaudid)

Dilaudid Tabs (2, 4, 8) (8 mg brand-name scored) Dilaudid Oral Solution (5 mg/5 mL) Supp (3)

Codeine Tabs (15, 30, 60)Fentanyl See note (7) Duragesic Transdermal Patch (12.5, 25, 50, 75, 100 mcg/hr)Oxymorphone Opana (5, 10) Opana ER (5, 7.5, 10, 15, 20, 30, 40)

(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

SELECT COMBINATION OPIOID PRODUCTS

(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 gramsin patients with normal liver function. (4) Many other brand name products contain similar combinations of opioids. (5) Formulary restricted. (6) Non-formulary. (7)Prescribers must complete TransmucosalImmediate Release Fentanyl (TIRF) Risk Evaluation and Mitigation Strategy (REMS) (8) As of Fall 2008, all combination opiates with more than 325 mg of acetaminophen will be non-formulary.

5, 10, 15, 30)

(10 mg/5 mL, 20 mg/5 mL) r q24hr) (10, 20, 30, 50) (5)

3

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 box below.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.

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 EffectMorphine 10 30 3–4 hours

Oxycodone 20–30 3–4 hoursHydromorphone 1.5 7.5 3–4 hours

Meperidine (1) (not recommended) 75 300 3 hoursFentanyl (4) 0.1** 1–2 hours

Codeine 130 200 3–4 hoursHydrocodone 25–30Oxymorphone 1 10 3–6 hours

TWENTY-FOUR HOUR ORAL MORPHINE EQUIVALENT DIVIDED BY 2 IS EQUAL TO FENTANYL PATCH DOSE IN MCG/HR.IV FENTANYL DOSE/HR=TRANSDERMAL FENTANYL DOSENOTE: PATCH TAKES 12–24 HRS TO ACHIEVE FULL EFFECT. WHEN REMOVING A PATCH, REMEMBER THE ANALGESIC EFFECT CAN STILL LAST 24 HRS.

4

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!

*Opioid tolerant and chronic/cancer pain patients may require higher doses and continuous infusions.

1.PCA alone is a maintenance technique. Patients should receive loading doses (delivered through the infuser) that are titrated to achieve an adequate level of analgesia (pain score less than or equal to 4/10).

2.Quantity delivered when button is pressed. Reduce doses by 30-50% in elderly and patients with liver disease. Do not increase dose based on increased body weight; this is especially important in patients with Obstructive Sleep Apnea. Dosing depends on the patient—young vs. elderly/opioid naive vs. tolerant.

3.How frequently demand dose can be activated. Patient must be able to

press the button and be able to comprehend instructions on when to press the button. In the elderly, consider a longer lockout interval.

4.The hour limit should not be less than the available total hourly patient administered dose. Bolus doses and the continuous infusion are included in the one-hour dose limit count.

5.Not recommended for patients who are opioid naive, the elderly, patients with altered mentation, or with Obstructive Sleep Apnea, COPD, or asthma.

6.Morphine is generally the opioid of choice. Hydromorphone is preferred in patients with impaired renal function.

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 minElderly (>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 mg0.2mg q 20 min

titrated to pain relief

When indicated, calculate based on

intermittent PCA use or previous opioid

requirement.

5

Opioid Dosing in Renal or Hepatic DysfunctionGiven the paucity of pharmacokinetic and pharmacodynamic data of opioids in renal failure, it is difficult to advocate for specific analgesic treatment algorithms. However, the following guide has been proposed for the initial dosing of the safer opioids in renal failure.

Opioid name Recommendation CommentsCodeine Not recommended Causes profound toxicity which can be delayed and may occur after trivial dosesFentanyl Considered safe Has no active metabolicsHydromorphone Use with caution Considered safe in dialysis patientsMeperidine Not recommended Accumulation of normeperidine can cause seizuresMethadone Considered safe No active metabolites; has several other precautionsMorphine Not recommended Rapid accumulation of nondialyzable metabolites that are neurotoxic, avoid long acting preparationsOxycodone Use with caution Can accumulated resulting in CNS toxicity and sedationOxymorphone Use with caution May accumulate resulting in respiratory depression and oversedation

Opioid name Recommendation CommentsCodeine Not recommended Impaired conversion of codeine to the active compound, morphine, in the liver to be active

Fentanyl Considered safe Pharmacokinetics were not altered in patients with cirrhosis. With continued use, recovery time after termination of infusion may be longer

Hydromorphone Use with caution Risk of accumulation of parent drug due to decreased conversion to metabolites and decreased elimination. Recommended to decrease dose by 50% of the usual amount.

Meperidine Not recommended Accumulation of toxic metabolite, normeperidine, may cause CNS toxicity Methadone Not recommended Risk of accumulation with severe liver disease.

Morphine Use with caution Recommended to decrease frequency of administration and dosage because of decreased clearance and increased t1/2 and oral bioavailability

Oxycodone Use with caution Risk of accumulation of parent drug due to decreased conversion to metabolites and decreased elimination.Recommended to reduce dose by 1/2 to 1/3 of the usual amount and avoid in severe cirrhosis

Oxymorphone Not recommended Contraindicated in moderate to severe liver dysfunction. Recommend 1/2 of the usual dose in mild hepatic impairment

References:Arnold RM, Verrico P, and Davison SN. Opioid Use in Renal Failure #161. J Palliat Med. 2007. 10(6):1403.Gina Carbonara, PharmD. Opioids in Patients with Renal or Hepatic Dysfunction. Practical Pain Management Volume 8, Issue 4

General Opioid safety recommendations in renal insufficiency:

General Opioid safety recommendations in hepatic insufficiency:

6

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:

OR

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 0.4mgnaloxone (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 opioidadministration when the patient is easily aroused, is beginning to experience pain, and after the RR increases to > 9.

Information on newer restricted analgesics:Tapentadol (Nucynta and Nucynta ER) are not on the UPMC formulary but patients will be allowed to continue outpatient therapy. It is not covered by outpatient insurance Transmucosal Immediate Release Fentanyl (Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys) are formulary restricted products. Zohydro (extended release hydrocodone) not on formulary at UPMC health system. More detailed information on these products including their titration and conversion is available in the online version of the pain card.

Insomnia

Class

BZDs

Non-BZDs**

Antidepressant

Drug(Generic Name)Temazepam

Lorazepam

Oxazepam

Zolpidem

Zaleplon

Eszopiclone

Trazodone

Starting po dose

15-30 mg, Elderly: 7.5 mg

1 mg, Elderly: 0.5 mg

15 mg

10 mg, Elderly: 5 mg

10 mg, Elderly: 5 mg

2-3 mg, Elderly: 1-2 mg

25-100 mg

AvailableDosage Forms7.5, 15, 30 mg

0.25, 0.5, 1, 2 mg

10, 15, 30 mg

5, 10 mgControlled Release 6.25, 12.5 mg

5, 10 mg 1, 2, 3 mg

12.5, 25, 50, 75, 100, 150 mg

Onset of Action

30 min - 1 hr

30 min

No Data

No Data

No DataNo Data

No Data

T max

1.4 hrs

0.5-3 hrs

2-3 hrs

1.6 hrs

1 hr1 hr

0.5-2 hrs

T1/2

3-18 hrs

12 hrs

3-9 hrs

2.5 hrs

1 hr6 hrs

7.1 hrs

Glucuronidation*

Y

Y

Y

N

NN

N

Comments:Daytime sedation, anterograde amnesia, falls, rebound insomnia are found with all. Rebound insomnia was not reported in studies of Non-BZDs.

Agitation, disorientation, headache have been reported with Non-BZDs. Zolpidem is also associated with complex sleep behaviors (sleep driving, sleep eating) but may occur more with concimitant alcohol and antidepressants.

Not FDA approved. Is an automatic substitution for diphenhydramine for use in insomnia in elderly.

7

8

Drug (Generic Name)

Receptoractivity

Common ClinicalIndications Dosage/Route Cost Comments/

Side Effects

Haloperidol D2 Opioid Induced N/V 0.5-4 mg PO or SQ or IV Q6h $ IV has less EPS compared to PO

Metoclopramide Peripheral D2 Impaired GI motility Opioid Induced N/V

5-20 mg PO or SQ or IV AC and HS $ EPS, esophageal spasm,and colic inGI tract obstruction

Prochlorperazine D2 Opioid Induced N/V N/V of unknown etiology

5-10 mg PO or IV every 6 h or 25mg PR Q6h

$ EPS and sedation

Scopolamine Ach, H1 Motion induced N/V 1.5 mg Transdermal patch every 3 d $ Dry mouth, blurred vision, ileus, urinary retention, and confusion

Ondansetron 5HT 3 Chemotherapy or radiation induced N/V

4-8 mg PO as a pill or dissolvable tablet or IV every 4-8 h

$$ Headache, fatigue, and constipation

Dexamethasone Decrease ICP N/V related to Increased ICP

4-8 mg QAM or BID, PO (as pill or liquid) and IV

$ Agitation, Insomnia, Hyperglycemia

N/V: Nausea/Vomiting

Nausea and Vomiting: Treatment

9

Medication Onset of action Usual starting dosage Site and Mechanism of ActionOsmotic laxatives

Lactulose 24-48 hr 15-30 ml q12-24 hr Colon; osmotic effect

Polyethylene Glycol 48-96 hr 17g (1tbsp) powder in 8oz water q24 hr GI tract; osmotic effect

Sorbitol 24-48 hr 15-30 ml q12-24 hr, max 150 ml/d Colon; delivers osmotically active molecules to the colon

Saline Laxatives*

Magnesium citrate 30 min-3 hr 120-240 ml x1; 10 oz q24 hr Small and large bowel; attracts and retains water in the bowel lumen

Magnesium hydroxide (MOM) 30 min-3 hr 30 ml q12-24h Colon; osmotic effect & increased peristalsis

Stimulant laxatives

Bisacodyl 6-10 hr 5-15 mg x1 Colon; stimulates peristalsis

Bisacodyl (PR) 15 min-1 hr 10 mg x1 Colon; stimulates peristalsis

Senna 6-10 hr 2 tabs qhs Colon; stimulate myenteric plexus, alters water and electrolyte secretion

Surface laxatives

Docusate 24-72 hr 100 mg q12-24 hr Small and large bowel; detergent activity; softens feces

Constipation and Bowel Protocol

Bulk laxatives alone are not useful in the treatment of opiate induced constipation*Avoid use of MOM and related products (including sodium phosphate enema products) in patients with renal dysfunction because of risk of hyperphosphatemiaReference: Reuben DB, Herr KA, Pacala JT, et al. Geriatrics at Your Fingertips 2009, 11th edition. New York: The American Geriatrics Society; 2009

10

Constipation and Bowel Protocol (page2)

BOWEL REGIMEN: With few exceptions, all patients on opioid therapy need an individualized bowel regimen. When and effective regimen is found it must be continued for the duration of the opioid therapy. If a patient has not been on a bowel regimen, the step 1 regimen should be started. If there is no response in 24 hours, move to the next step. At any given time, if there has been no bowel movement in four or more days, a sodium phosphate or mineral oil enema should be administered. If this is not effective, a high colonic tap water enema should be administered. Be aware of the possibility of bowel obstruction or fecal impaction. A digital rectal exam should be performed prior to starting a bowel regimen and if no BM for 4 days.

Other drugs that can exacerbate constipation: anticholinergics (tricyclic antidepressants, scopolamine, oxybutinin, promethazine, diphenhydramine), lithium, verapamil, bismuth, iron, aluminium, calcium salts.

Opiod Antagonists to treat refractory constipation: Methylnaltrexone (MNTX) is a quaternary amine which does not cross the blood brain barrier to cause reversal of opioid analgesia or withdrawal. Use of oral naloxone for constipation has been associated with these effects. MNTX is approved for use in patients who have been on a steady opioid regimen for 2 weeks and laxative regimen for 3 days. Greater than 50% of patients will have a bowel movement within 4 hours of being given the dose by subcutaneous injection. In general, it is recommended that oral and rectal laxative regimens should have been tried, prior to utilizing MNTX. Pts with fecal ostomy bags and PD catheters were excluded from the studies. There is a dosing order set in the EMR.

11

Delirium: Diagnosis

DSM IV criteria for delirium include four components:A. Acute onset, over hours to daysB. Behavioral disturbands, marked by reduce 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 withdrawnC. Consciousness level fluctuates over the course of the dayD. 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 lifeDelirium 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.Differential diagnosisD: Drugs (Opioids, anticholinergics, sedatives, benzodiazepines, steroids, chemo - and immunotherapies, some antibiotics) E: Eyes and Ears (poor vision, hearing, isolation)L: Low flow states (hypoxia, MI, CHF, COPD, shock)I: InfectionsR: Retention (urine/stool)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)

3D CAM (Confusion Assessment Method) for the diagnosis of DeliriumDiagnosis positive with 1 and 2 and either 3 or 4.Feature Questions asked* Observations at bedside Positive Answer ^

1. Acute Onset -OR- Fluctuation

8. During the past day have you feltconfused? 9. During the past day did you think that you were not really in the hospital?10.During the past day did you see things that were not really there?

Fluctuation in level of consciousness

Fluctuation in attention during interview

Fluctuation in speech or thinking

Any answer other than ‘no’ is positive

Any positive observation is a yes

-AND-

2. Inattention

4. I am going to read some numbers. I want you to repeat them in backwards order fromthe way I read them to you. For instance, if I say “5 – 2”, you would say “2 -5”. OK? The first one is "7-5-1" (1-5-7)5. The second is "8-2-4-3" (3-4-2-8).6. Can you tell me the days of the weekbackwards, starting with Saturday?.7. Can you tell me the months of the year backwards, starting with December?

Did the patient have trouble keeping track of what was being said during the interview?

Did the patient appear inappropriately distracted by environmental stimuli?

Anything other than ‘correct’ is coded as positive

Either observation is positive

-AND EITHER-

3. Disorganized Thinking

1. Can you tell me the year we are in right now?

2. Can you tell me the day of the week?

3. Can you tell me what type of place is this?

Was the patient's flow of ideas unclear or illogical, for example tell a story unrelated to the interview (tangential)?

Was the patient's conversation rambling, for example did he/she give inappropriately verbose and off target responses

Was the patient's speech unusually limited or sparse? (e.g. yes/no answers

Any answer other than ‘correct’ is coded as positive

Answer is ‘yes’

-OR-

4. Altered LevelOf Consciousness

Was the patient's speech unusually limited or sparse? (e.g. yes/no answers)

Either observation is positive

*Questions are numbered in the order of their listing in the 3D CAM instrument.^ Incorrect also includes "I don't know", and No response/non-sensical responses.Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Medicine. 1990; 113:941-8.

12

Delirium: Diagnosis

13

Delirium: Diagnosis The scale is completed based on information collected from each item over an 8 hour shift or the previous 24 hours. Obvious manifestation of an item = 1 pointNo manifestation of an item or no assessment possible = 0 point

Patient evaluation Day 1 Day 2 Day 3 Day 4 Day 5

Altered Level of consciousness

If A or B do not complete patient evaluation for the period

Inattention

Disorientation

Hallucinations-delusion-psychosis

Psychomotor agitation or retardation

Inappropriate speech or mood

Sleep/wake cycle disturbance

Symptom fluctuation

Total ScoreLevel of consciousness: A: no response No score

B: response to intense and repeated stimulation (loud voice and pain) No scoreC: Response to mild or moderate stimulation 1D: normal wakefulness 1E: exaggerated response to normal stimulation 1

Inattention: Difficulty in following a conversation or instructionsDisorientation: Any obvious mistake in time, place, personHallucinations, delusion or psychosis: Overt clinical manifestation of hallucination or behavior related to hallucination or delusionPsychomotor agitation or retardation: Hyperactivity requiring restraints or drugs, clinically noticeable psychomotor slowingInappropriate speech or mood: Disorganized or incoherent or inappropriate speech. Inappropriate display of emotion related to events of situationSleep/wake cycle disturbance: Sleeping <4 hours or waking frequently at night (not initiated by staff or loud environment), sleeping during most of the daySymptom fluctuation: Fluctuation of any item over 24 hoursReference: See www.icudelirium.org for more information

The Intensive Care Delirium Screening Checklist (ICDSC)

14

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 settingGeneric name(Common brandname)

Starting dose

Dosing interval

Max q24hdose

Formulation EPS Anti-cholinergic

Sedation Comments**

Haloperidol(Haldol®)

0.5-1 mg(2 mg in ICU*)

0.5-1 hour forurgentsymptoms.Otherwise Q6Hor Q8H

20 mg

Oral Solution 2 mg/ml5 mg/ml injectablesolution

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

(continued)

Tabs: 0.25, 0.5, 1, 2, 5, 10mg

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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®)

0.25-1 mg BID or up to Q6HPRN

6 mgOral solution 1 mg/mlM Tabs (ODTs): 0.5, 1, 2, 3, 4 mg

++ + +renal failure.

Olanzapine(Zyprexa®)

2.5-10 mg

Debilitatedor elderly:2.5 mg.

DAILY

IM: Q2H

20 mg20 mgInjectable product 10 mg IMODTs: 5, 10, 15, 20 mg

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

Quetiapine(Seroquel®)

12.5- 50 mg

BID 800 mg400 mg

+ ++ +++sundowning † and then time subsequent, additional dosesbased on symptoms.

Aripiprazole(Abilify®)

5-15 mg Q AM 30 mg 30 mg

++ + ++delirium. Can cause insomnia if given at night

Delirium: Treatment

Caution

Patients with

Start DAILY at 4pm for

Tabs: 1, 2, 2.5, 5, 7.5, 10, 15, 20 Useful for hypoactive

Tabs: 0.125, 0.25, 0.5, 1, 2, 3, 4 mg

Tabs: 0.625, 1.25, 2.5, 7.5, 10, 15

Tabs: 12.5, 25, 50, 100, 200, 300

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

1. Are you feeling either depressed or hopeless most of the time overthe 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

Some select antidepressants are listed in the table next page:

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Category Generic(Common Brand Name)

Starting PO dose(depression)*

Dosinginterval

Therapeuticdose/day range*

Generic(Y/N)

Formulations (mg)

SSRIs Citalopram(Celexa®)

10-20 mg DAILY 10-60 mg Y 2.5, 5, 10, 20, 40 mg (tablets)Oral Solution 10 mg/5 mL

Escitalopram(Lexapro®)

5-10 mg DAILY 10-20 mg Y 2.5, 5, 10, 20 mg (tablets)Oral Solution 5 mg/5 mL

Sertraline(Zoloft®)

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

SNRIs Venlafaxine(Effexor®)

75 mg/day divided BID-TID 150-375 mg Y 25, 37.5, 50, 75, 100 mg (tablets)

Venlafaxine XR(Effexor XR®)

37.5-75 mg DAILY 75-225 mg Y 37.5, 75, 150 mg (capsules)

Duloxetine(Cymbalta®)

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

Stimulants Methylphenidate(Ritalin®)

2.5-5 mg BID 8a,12p 5-40 mg (fordepression)

Y 2.5, 5, 10, 20 mg(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 mgof 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.

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Drug (Commonbrand name)

Cost perday*

Anticholinergic Insomnia GI Distress Comments**

Citalopram(Celexa®)

+ + ++ Mild to moderately activating, few drug interactions.

Escitalopram(Lexapro®)

+ +++ ++ t1/2 similar to Sertraline and Citalopram

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. Differences in arrythmogenicity are not clinically relevant among these groups.

Spirituality Pearls

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Spirituality is defined as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred” 1

How to ask:What gives you strength?What helps you during difficult times?Who /what is important to you?

Resources:keyword: interfaith guide (infonet) keyword: Loma Linda religion health care (internet) FICA mnemonic for taking a spiritual history found at www.capc.orgContact chaplain: chaplains available 24 hours 7 days a week. Call the hospital operator to page the chaplain on call.

1. Puchalski CM, Ferrell B, Viriani R, et al. Improving the quality of spiritual care as a dimension of palliative care: Consensus conference report. J Palliat Med. 2009;12(10): 885-903.

Religious faiths and practices during sickness and end of life

Catholic Orthodox Christian Islamic Amish Jewish Protestan

Religious leader Priest Priest Imam* Elders* Rabbi* Minister/Pastor/Other Specific prayer for sick/dying

Sacrament of the sick

Unction Recite Quran Special prayers

Psalms “shema” Varies (anointing)

Same gender care giver

No Yes Yes Varies Yes No

Caregiver present at all times also after death

No Yes Yes No Yes No

Body positioning after death

Face Mecca Eyes closed arms/fingers extended

Life support No extraordinary measures necessary

Family decides Hastening death not permitted

Patient and/or family decide

*Family may consult for health care decisions.

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Treatment of Dyspnea and Pain at the End of Life 1. The following guidelines are for “comfort measures” patients

ONLY. See CPOE CMO order sets.

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):

give bolus equal the loading dose increased by 50 percent. If severe distress persists repeat the dose every 15 minutes until comfortable.

last given bolus dose every 30 minutes as needed.

starting a continuous infusion. To calculate the continuous infusion rate divide the total dose over last 6 hours by 6.

3. Non-naive patients:

within last 24 hours calculate the equianalgesic parenteral dose of morphine for the last 24 hrs (see page 4 for opioid equivalencies).

initial hourly infusion rate (mg/hour, IV). Start continuous infusion at this rate.

infusion rate.

the patient in increased pain/distress, administer the loading dose increased by 50 percent and repeat every 15 minutes until comfortable.

-mine new continuous infusion rate by recalculating total dose given over last 6 hours and dividing it by 6.

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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

UPMC Palliative Care and Pain Treatment Resources

Inpatient Supportive and Palliative Care ServicesPUH/MUH Supportive & Palliative Care Service 412-647-7243, pager: 8511Shadyside Supportive & Palliative Care Service 412-647-7243, pager: 8513Magee Womens Hospital of UPMC Supportive and Palliative Care Service

412-647-7243, pager: 8510

Children’s Hospital of Pittsburgh of UPMC Supportive Care Program

412-692-3234

VA Palliative Care Program Inpatient and Oncology: 412-688-6000 Ext. 816178; or pager - 645-2345Geriatric palliative care: pager 412-958-0215

UPMC East Supportive and Palliative Care Service 412-858-9565UPMC Hamot Supportive and Palliative Care Service 814-877-5987UPMC Mckeesport Supportive and Palliative Care Service 412-664-2717UPMC Mercy Supportive and Palliative Care Service 412-232-7549UPMC NorthWest Supportive and Palliative Care Service 814-677-7440UPMC Passavant Supportive and Palliative Care Service 412-367-6700UPMC St Margaret’s Supportive and Palliative Care Service 412-784-5111Inpatient Medical Ethics Services PUH/MUH Medical Ethi 1882 :regap ,3427-746 sc Shadyside Medical Ethics 263-8347Pain Treatment Services (inpatient) PUH/MUH Chronic Pain ServiceShadyside Chronic Pain ServicePUH/MUH Acute Interventional Perioperative Pain Service (AIPPS)Shadyside Acute Interventional Perioperative Pain Service (AIPPS)

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UPMC Altoona Supportive and Palliative Care Service 814-889-2701

412-647-4991412-665-8030, after hours call 412-665-8031412-647-7243, pager: 7246 (PAIN)

412-692-2333

Outpatient Services Benedum Geriatric Center Supportive Care Clinic 412-692-4200Hillman Cancer Center’s Cancer Pain and Supportive Care Program

412-692-4724

UPMC Heart and Vascular Institute’s Advanced Heart Failure Clinic

412-647-6000

Magee Women’s Cancer Center 412-641-4530 Magee Gynecologic Cancer Program 412-641-5411 or 412-641-5566Renal Supportive Care Clinic 412-802-3043Magee - Chronic non malignant/spine/muscular skeletal pain (outpatient)

412-901-2891

UPMC Presbyterian Pain Medicine (outpatient) 412-692-2234St. Margaret Pain Medicine (outpatient) and Chronic Pain Service 412-784-5119 (outpatient) or 412-784-4000 (Hospital Operator)Family Hospice and Palliative Care 412-572-8800 23

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Questions or comments regarding this information, contact Robert Arnold, MD (rabob@pitt.edu), 692-4834, pager 2322. This information provided bythe UPMC Supportive and Palliative Care Program is merely in the form of recommendations and does not replace the service of a physician. Author:Mamta Bhatnagar, MD with Jennifer Pruskowski, PharmD and contributions from Monika Holbein MD. This pain card was made possible with the assistanceof Colleen Kosky and the generous support of the UPMC Palliative and Supportive Institute. Produced in cooperation with the University of Pittsburgh. UMC90239-0413

Psychological or spiritual counseling for patients and their familiesDischarge planning and interface with local hospicesBereavement services in the event of deathOutpatient palliative care follow-up

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

VERSION 9.0 PAIN CARDUPMC-1486-0615