Palli

ativ

e

Care

Info

rmat

ion

If yo

u ne

ed fu

rthe

r inf

orm

atio

n to

ass

ist i

n

the

prov

isio

n of

Pal

liati

ve C

are

cont

act:

Clar

e H

olla

nd H

ouse

62

73 0

336

(24h

rs)

Hom

e Ba

sed

Palli

ativ

e Ca

re

6273

033

6 (2

4 hr

s)

Palli

ativ

e Ca

re M

edic

al S

peci

alis

t 62

73 0

336

(24

hrs)

The

Canb

erra

Hos

pita

l – P

allia

tive

Car

e Li

aiso

n N

urse

6244

222

2 (M

onda

y –

Frid

ay 9

am-5

pm)

Ackn

owle

dgm

ents

Th

is re

sour

ce b

ookl

et h

as b

een

adap

ted

for t

he A

CT fr

om a

reso

urce

de

velo

ped

by th

e Ad

elai

de N

orth

Eas

t and

Ade

laid

e Ce

ntra

l and

Ea

ster

n D

ivis

ions

of G

ener

al P

ract

ice.

It w

as w

ritt

en in

reco

gnit

ion

of th

e ne

ed to

enc

oura

ge g

ener

al p

ract

itio

ners

and

nur

sing

sta

ff in

re

side

ntia

l age

d ca

re fa

cilit

ies

to s

uppo

rt o

lder

peo

ple’

s de

sire

to d

ie

wit

h di

gnit

y in

thei

r hom

e, th

e re

side

ntia

l age

d ca

re fa

cilit

y.

Key

cont

ribu

tion

s fr

om s

taff

at

•AC

TDivisionofGen

eralPractice’sAg

edCareGPPa

nel

•ClareHolland

Hou

se•

DrA

ndrewSke

els,M

edicalDirec

torA

CTPallia

tive

CareService

•Pr

ogramofE

xperienc

einth

ePa

lliativeAp

proa

ch(P

EPA–ACT

)•

Resp

ecting

PatientCho

ices

Program

(ACT

)

Thisdoc

umen

tisagu

ideon

lyand

sho

uldbe

che

cked

withsp

ecificpr

escribinginform

ationas

wella

s

supp

ortthr

ough

ACT

Pallia

tive

CareService

atC

lareHolland

Hou

seasrequ

ired

.The

senotes

wereup

datedin200

7.

The

Ther

apeu

tic G

uide

lines

, Pal

liativ

e Ca

re, v

ersi

on 2

: 20

05

unde

rpin

s th

is re

sour

ce.

Wha

t is

Palli

ativ

e ca

re?

Intr

oduc

tion

PalliativeCa

reAus

tralia(2

005)states:

‘Pal

liativ

e Ca

re is

car

e pr

ovid

ed fo

r peo

ple

of a

ll ag

es w

ho h

ave

a lif

e lim

iting

illn

ess,

with

litt

le o

r no

pro

spec

t of c

ure,

and

for w

hom

the

prim

ary

trea

tmen

t goa

l is

qual

ity o

f life

’.

WHOstatesPa

lliativeCa

re:

• Pr

ovid

es re

lief f

rom

pai

n an

d ot

her d

istr

essi

ng

sym

ptom

s•

Affir

mslifean

drega

rdsdy

ingas

anormalproce

ss•

Inte

nds

neit

her t

o ha

sten

nor

pos

tpon

e de

ath

• In

tegr

ates

psy

chos

ocia

l and

spi

ritu

al a

spec

ts o

f ca

re•

Sup

portspe

opleto

live

asac

tive

lyaspo

ssible

unti

l dea

th•

Sup

portsfamilies

dur

ingth

eillne

ssand

in

bere

avem

ent

• U

ses

a te

am a

ppro

ach

A pa

lliat

ive

appr

oach

is li

nked

to p

allia

tive

car

e an

d is

use

d by

pri

mar

y ca

re s

ervi

ces

and

prac

titi

oner

s toim

prov

eth

equ

alityoflifefo

rtho

sew

itha

life

limit

ing

illne

ss. A

pplic

atio

n of

the

palli

ativ

e ap

proa

ch to

car

e is

not

del

ayed

unt

il th

e en

d st

ages

of

an

illne

ss.

Spe

cialistp

allia

tive

carebu

ildson

thepa

lliative

appr

oach

ado

pted

by

prim

ary

care

pro

vide

rs a

nd

refle

ctsahigh

erle

velo

fexp

ertise

fort

hose

perso

ns

andth

eirfam

ilies

withco

mplex

carene

eds.

Sym

ptom

Man

agem

ent i

n Pa

lliat

ive

Care

The

follo

win

g is

an

outl

ine

of s

ome

of th

e us

ual

appr

oach

es in

man

agin

g th

e sy

mpt

oms

of a

dvan

ced

illne

ss.Itisno

tinten

dedtobeex

haus

tive

,but

willm

ention

themos

tfrequ

entlyen

coun

tered

sym

ptom

s.

No

pati

ent s

houl

d be

left

wit

hout

sat

isfa

ctor

y sy

mptom

man

agem

ent.Reg

ularand

freq

uent

review

,and

cha

ngeofm

anag

emen

tifreq

uired,is

es

sent

ial.

Dos

es m

ay n

eed

adju

stin

g as

pat

ient

s lo

se w

eigh

t, o

r whe

n liv

er a

nd p

arti

cula

rly

rena

l fu

ncti

on a

re im

pair

ed.

Cons

ulta

tion

wit

h a

spec

ialis

t Pal

liati

ve C

are

serv

ice

is e

ncou

rage

d w

hene

ver a

par

ticu

lar s

ympt

om

prov

es re

frac

tory

to u

sual

mea

sure

s.

The

emph

asis

is o

n an

tici

pati

on a

nd, w

here

po

ssib

le, p

reve

ntio

n of

pro

blem

s ra

ther

than

cri

sis

inte

rven

tion

.

N.B

. Som

e of

the

drug

s us

ed, p

artic

ular

ly ro

utes

of

adm

inis

trat

ion,

hav

e be

en a

dopt

ed to

add

ress

pa

rtic

ular

pro

blem

s in

Pal

liativ

e Ca

re a

nd a

re n

ot

regi

ster

ed u

ses

or ro

utes

for t

hat d

rug.

Ple

ase

be a

war

e of

pre

scri

bing

regu

latio

ns a

nd w

here

va

riat

ions

mig

ht n

eed

to b

e ex

plai

ned

to p

atie

nts.

Refe

r to

the

sect

ion

on R

esou

rces

for s

peci

fic te

xt

to s

uppo

rt e

vide

nce-

base

d pr

actic

e. In

cas

e of

any

do

ubt,

dis

cuss

with

spe

cial

ist P

allia

tive

Care

ser

vice

.

Prin

cipl

es o

f sym

ptom

man

agem

ent:

Dia

gnos

is a

nd a

sses

smen

tEx

plan

ation

Trea

tmen

t bas

ed o

n:•

Aeti

olog

y•

Options

• Pa

tien

t pre

fere

nce

• D

ose

titr

atio

n w

ith

mon

itor

ing

of re

spon

se•

Freq

uentre

view

Suff

erin

g an

d Sy

mpt

oms

Remem

bert

hesuffering

ofa

patientm

ayarise

from

pa

in o

r oth

er p

hysi

cal s

ympt

oms

due

to th

eir i

llnes

s,

but m

ay a

lso

deri

ve fr

om m

any

othe

r asp

ects

of

thei

r life

suc

h as

soc

ial o

r spi

ritu

al is

sues

. Whi

lst

the

emph

asis

her

e is

on

relie

f of p

hysi

cal s

ympt

oms,

th

is m

ay n

ot b

e po

ssib

le if

oth

er d

imen

sion

s ar

e ov

erlo

oked

or i

gnor

ed.

(Bro

oksb

ank,

M. 2

003

)

Gen

eral

Sym

ptom

Man

agem

ent

Asth

enia

This

is th

e m

ost c

omm

on s

ympt

om o

f adv

ance

d ill

ness

and

incl

udes

:•

Leth

argy

– c

an n

ot g

et g

oing

•Tiredn

ess–exh

austed

afterany

activity

• W

eakn

ess

– c

an n

ot g

et u

p

Look

for d

epre

ssio

n, a

naem

ia, s

tero

id e

ffec

ts a

s w

ell

as d

isea

se p

rogr

essi

on.

Patie

nts

shou

ld b

e en

cour

aged

and

sup

port

ed in

w

hat t

hey

wan

t or f

eel a

ble

to d

o.

Oed

ema,

Lym

phoe

dem

a, A

scit

es•

Peri

pher

al o

edem

aOften

due

toacom

bina

tion

oflow

serum

album

in,

lym

phat

ic o

bstr

ucti

on, c

ardi

ac fa

ilure

and

im

mob

ility

:–

May

be

limit

ed re

spon

se to

diu

reti

cs–

Ele

vati

ng le

gs m

ay b

e he

lpfu

l

• Ly

mph

oede

ma

Com

plic

atio

n of

lym

phat

ic o

bstr

ucti

on in

m

alig

nant

dis

ease

:–M

ayben

efitfromeleva

tion

,mas

sage

,su

ppor

tive

ban

dagi

ng to

avo

id ly

mph

orrh

oea

–S

eekad

vice

from

phy

siothe

rapistand

/or

Lymph

oede

maClinicatC

alva

ryHos

pital

– B

ewar

e of

cel

lulit

is

• As

cite

s –

Par

acen

tesi

s (d

rain

age

of a

scit

es) o

nly

prov

ides

te

mpo

rary

relie

f but

can

be

cons

ider

ed–

Diu

reti

cs: S

piro

nola

cton

e50

to100

mgda

ily

and

Frus

emid

e20

to40m

gda

ilyors

econ

dda

ily m

ay b

e co

nsid

ered

wit

h ca

utio

n–

Diu

reti

cs m

ay c

ause

wor

seni

ng re

nal f

unct

ion

or lo

wer

ing

of b

lood

pre

ssur

e

Gas

tro-

inte

stin

al S

ympt

oms

Anor

exia

Very

com

mon

at e

nd o

f life

but

can

cau

se

cons

ider

able

fam

ily d

istr

ess.

Look

forp

ossiblereve

rsiblecau

sesfora

norexia:

• D

ry m

outh

•

Oralthr

ush

• N

ause

a •

Cons

tipa

tion

• Pa

in

• D

epre

ssio

n•

Mou

th u

lcer

s •

Dru

g ef

fect

s

Man

agem

ent:

•Serve

smallm

eals,s

nack

s•

Sup

portfa

mily

• Co

rtic

oste

roid

s ca

n te

mpo

rari

ly b

oost

app

etit

e:

– P

redn

isol

one12

.5to

25m

gman

e

– D

exam

etha

sone

2 to

4m

g m

ane

Cach

exia

Very

com

mon

in te

rmin

al il

lnes

s. U

sual

ly a

sec

onda

ry

resp

onse

to tu

mou

r rat

her t

han

mal

nutr

ition

. Fam

ily

freq

uentlyre

quires

sup

portto

und

erstan

dredu

cing

nu

trition

alin

take

and

requ

irem

ents.

Nau

sea

and

vom

itin

gOften

multifactorialb

utclin

icaldiagn

osiscan

help

guid

e an

ti-e

met

ic p

resc

ribi

ng.

Cons

ider

– M

etoc

lopr

amid

e10

mgS/C

oro

ral

4

hour

ly u

nles

s ot

herw

ise

indi

cate

d

Toxi

c ca

uses

• D

rugs

•

Rena

lfailure

• Li

ver f

ailu

re

•Sep

sis

Cons

ider

– H

alop

erid

ol1-2mgoralors

cbd

–

Ste

met

il 5m

g or

al td

s(N

OTsu

bcut)

Gas

troi

ntes

tinal

cau

ses

•Sub

acu

tebow

elobs

truc

tion

• Pa

raly

tic

Ileus

•Ex

tens

ivepe

ritone

aldisea

seCo

nsid

er –

Phe

nerg

an10-25

mgoraltd

sor25-75

mg

in

syr

inge

driv

er o

ver 2

4 ho

urs

–

Cyc

lizin

e m

ay b

e co

nsid

ered

(con

tact

PalliativeCa

reSpe

cialist)

Vest

ibul

ar c

ause

s•

Strok

eCo

nsid

er –

Phe

nerg

an A/A

Intr

a cr

ania

l cau

ses

•Ra

ised

intracran

ialp

ress

ure

Cons

ider

– S

tero

ids4-16

mg/

daygive

nas

am

+

mid

day

dose

to a

void

inso

mni

a

– O

ndan

setr

on u

sed

pred

omin

antl

y

fo

r the

pre

vent

ion

of n

ause

a

follo

win

g ch

emot

hera

py.

–

May

be

effe

ctiv

e in

som

e in

divi

dual

s

bu

t oft

en n

ot u

sefu

l in

chro

nic

naus

ea

(if

use

d, b

ewar

e of

con

stip

atio

n).

•An

xietymay

beaca

useofong

oing

nau

sea

Cons

ider

– B

enzo

diaz

epin

es

e.

g. L

oraz

epam

0.5-1mgbd

Seek

sup

portfrom

aPallia

tiveCa

reservice

asrequ

ired

Cons

tipa

tion

Ther

e is

an

incr

ease

d ri

sk o

f con

stip

atio

n in

Pa

lliat

ive

Care

for v

ario

us re

ason

s in

clud

ing

decrea

sedflu

idand

dietaryin

take

,red

uced

m

obili

ty, d

rugs

suc

h as

opi

oids

; thi

s is

com

poun

ded

in th

e fr

ail e

lder

ly p

atie

nt.

• Fl

uid

inta

ke c

an b

e en

cour

aged

•Re

gularfae

cals

oftene

rand

bow

elstimulan

tor

osmoticla

xative

mus

tbegive

nwhe

nco

mmen

cing

op

ioid

s

Laxa

tives

in P

allia

tive

Care

• Co

mbi

ned

soft

enin

g ag

ent a

nd p

eris

talt

ic

stim

ulan

tCo

nsid

er –

Col

oxyl

with

Sen

na1to

6ta

bletsda

ily

•Osm

oticla

xative

sCo

nsid

er –

Mov

icol

•Av

oidlaxa

tive

sthatre

quirealargevo

lumeof

wat

er, e

.g. l

actu

lose

Mal

igna

nt b

owel

obs

truc

tion

in te

rmin

al il

lnes

s requ

ires

spe

cialistP

allia

tive

Careco

nsultation

.

(Bro

oksb

ank,

M. 2

003

)

Gas

tro-

inte

stin

al S

ympt

oms

Resp

irat

ory

Sym

ptom

sD

yspn

oea

Cons

ider

dia

gnos

is a

nd lo

ok fo

r rev

ersi

ble

caus

es:

•Hea

rtfa

ilure

•CO

PD•

Anae

mia

• Pu

lmon

ary

embo

lus

• In

fect

ion

•SV

Cob

stru

ction

• Pe

rica

rdia

l dis

ease

• M

ajor

air

way

obs

truc

tion

• Ly

mph

atic

car

cino

mat

osis

• Lu

ng c

ance

r

Trea

t und

erly

ing

caus

e if

poss

ible

and

app

ropr

iate

.

Sym

ptom

atic

relie

f of d

yspn

oea:

• N

on-p

harm

acol

ogic

al m

easu

res:

– W

ell v

enti

late

d ro

om–

Fan

blo

win

g on

face

–R

elax

ation

•Opioids

inlo

wdos

esre

lieve

these

nsation

of d

yspn

oea

wit

hout

dep

ress

ing

resp

irat

ory

func

tion

. Co

nsid

er –

Mor

phin

e1to2.5mgorally(o

pioi

d

na

ïve)

or t

itra

te u

pwar

ds fr

om u

sual

back

grou

nd d

ose

–O

rald

osingiseffec

tive

–

Lon

g ac

ting

opi

oids

are

eff

ecti

ve,

e.

g. M

S Co

ntin10m

gbd

.

SCad

ministrationmay

beus

ed

• B

enzo

diaz

epin

es w

ill h

elp

wit

h th

e as

soci

ated

an

xiety.Startgen

tlycrea

ting

anon

-sed

ating

back

grou

nd in

itia

lly, w

ith

the

oppo

rtun

ity

for

resc

uedos

esors

edationifrequ

ired

.

Cons

ider

– L

oraz

epam

sub

lingu

al0.5mg

for

m

ediu

m to

long

term

use

–

Mid

azol

am1to

5mgS/C

asho

urly

bo

luse

s or

by

cont

inuo

us in

fusi

on

–

end

of l

ife re

late

d

•Steroidsmay

behe

lpfulinairw

aysob

stru

ction

from

carcino

ma,COPD

and

lymph

angitis

carc

inom

atos

is.

Cons

ider

– D

exam

etha

sone

4 to

8m

g da

ily o

ral

or

S/C

•Oxy

genmay

provide

sym

ptom

aticre

liefa

ndis

av

aila

ble

for p

allia

tive

car

e pa

tien

ts

•Sev

eredy

spno

eais

one

sym

ptom

thatm

ay

requ

irese

dation

forr

eliefinth

eterm

inalstage

s

Resp

irat

ory

Sym

ptom

s

Coug

h•

Dry

, non

-pro

duct

ive

coug

h, a

im fo

r cou

gh

supp

ress

ion

wit

h op

ioid

s or

opi

oid

anal

ogue

s Co

nsid

er –

Dex

trom

etho

rpha

n sy

rup

–

Pho

lcod

ine

or c

odei

ne li

nctu

s

–O

pioids

,e.g.M

orph

ine1to2.5mg

orally1to

2hou

rlypr

n in

opi

oid

naïv

e

pati

ent o

r neb

ulis

ed n

orm

al s

alin

e

•Moistprodu

ctiveco

ugh,ass

iste

xpec

toration

:

–H

umidifica

tion

:steam

,inh

alations

(e.g

. euc

alyp

tus)

, neb

ulis

ed s

alin

e

– B

ronc

hodi

lato

rs (e

.g. S

albu

tam

ol)

–

Ant

ibio

tics

– c

onsi

der f

or s

ympt

om

re

lief

–O

pioids

tosup

pres

sco

ugh

• W

hen

pati

ent i

s un

able

to c

ough

, in

the

term

inal

ph

ase,orifthe

reareexc

essse

cretions

which

ca

nnotbeex

pectorated

con

side

r:

– H

yosc

ine

hydr

obro

mid

e0.4m

gS/C

3

to

4 h

ourl

y pr

n, o

nly

usef

ul fo

r

rete

ntio

n of

ora

l sec

reti

ons

–

Gly

copy

rrol

ate0.4mgS/C

q1H

prn

is p

refe

rred

as

it d

oes

not c

ross

bloo

d-br

ain-

barr

ier a

nd c

ause

delir

ium

Cogn

itiv

e an

d Em

otio

nal

Cogn

itiv

e an

d Em

otio

nal

Acut

e D

elir

ium

Charac

terise

dby

fluc

tuatingde

lusion

s,

hallu

cina

tion

s, c

onfu

sion

, mem

ory

loss

, di

sori

enta

tion

. Pat

ient

may

be

agit

ated

or

somno

lentorm

ayfluc

tuatebe

twee

nbo

th.D

elirium

is c

hara

cter

isti

cally

wor

se in

the

even

ing.

Corr

ecta

ble

caus

es to

con

side

r inc

lude

:•

Sep

sis,e.g.u

rine

,che

st•

Metab

olic,e

.g.h

ypox

ia,h

yperca

lcae

mia,ren

al

failu

re, h

ypon

atra

emia

• D

rugs

, e.g

. ant

icho

liner

gics

, opi

oids

• Ph

ysic

al s

tim

uli,

e.g.

con

stip

atio

n, u

rina

ry

rete

ntio

n•

Intr

acra

nial

pat

holo

gy (l

ess

com

mon

ly)

Man

agem

ent

• D

iagn

osis

and

ass

essm

ent:

– L

ook

for r

ever

sibl

e ca

uses

but

intr

usiv

e in

vest

igat

ions

may

no

long

er b

e ap

prop

riat

e–R

eviewand

sim

plifydr

ugre

gimen

s,e.g.m

any

drug

s ha

ve a

nti-c

holin

ergi

c si

de e

ffec

ts th

at

may

bec

ome

cum

ulat

ive

to p

rodu

ce d

elir

ium

“a

ntic

holin

ergi

c lo

ad”

–R

eass

uran

ce,reo

rien

tation

totr

ytore

duce

m

ispe

rcep

tion

s an

d al

lay

fear

s–

Avo

id re

stra

ints

• D

rug

man

agem

ent:

– H

alop

erid

ol1.5to

10m

gorallydailyin

divided

do

sesor2.5to

5mgS/C

2to

3times

dailyas

nece

ssar

y–

Aty

pica

l ant

ipsy

chot

ics,

e.g

. Ola

nzep

ine

2.5

to

10mgda

ily–

Ben

zodi

azep

ines

, e.g

. Mid

azol

am 2

.5 to

5m

g S/C

hou

rlypr

n or

Dia

zepa

m2.5to

10mgorally,

or re

ctal

ly. (

IM w

hen

pati

ent i

s ag

itat

ed).

Do

not

usewitho

utm

ajortran

quilise

raswillw

orse

nco

nfus

ion

Anxi

ety

Fearofd

eath

and

anx

ietyabo

utdying

arecom

mon

re

acti

ons

to a

ppro

achi

ng d

eath

. Fea

r of d

ying

may

ca

use

brea

thle

ssne

ss.

• In

itia

lly m

anag

ed b

y go

od s

ympt

om c

ontr

ol,

emot

iona

l and

spi

ritu

al s

uppo

rt fo

r pat

ient

and

family

,and

sup

portiveco

unse

lling

/care

•May

alsobe

nefitfrom

spe

cific

anx

iolytic

med

icat

ion,

e.g

. Ben

zodi

azep

ines

Dep

ress

ion

Often

und

er-diagn

osed

inte

rminalillnes

s.Aw

ishto

hast

en d

eath

is a

n im

port

ant p

rom

pt to

ask

abo

ut

depr

essi

on.

•Sim

plyas

k,“Ar

eyo

ude

pres

sed?

”or

“How

wou

ld

youde

scribe

you

rmoo

d?”

•Co

nsiderspe

cific

anti-d

epress

anttreatmen

t•

Occ

ursinupto50%

ofp

allia

tive

patientsan

dis

trea

tabl

e

Phys

ical

sig

ns o

f dep

ress

ion

ofte

n oc

cur w

ith

diag

nosi

s of

pri

mar

y di

seas

e. L

ook

for e

mot

iona

l sy

mpt

oms

such

as

anhe

doni

a.

Pain

Painis

defi

nedby

theInternationa

lAss

ociatio

nforthe

Stud

yofPaininth

eTh

erap

eutic

Guide

lines

(200

5:16

7)

as “

an u

nple

asan

t sen

sory

and

em

otio

nal e

xper

ienc

e as

soci

ated

with

act

ual o

r pot

entia

l tis

sue

dam

age,

or

des

crib

ed in

term

s of

suc

h da

mag

e”. I

n cl

inic

al

prac

ticepa

inis

und

erstoo

dinte

rmsofth

eex

perie

nce

of th

e in

divi

dual

.

Ove

rall

pain

in th

e el

derl

y is

oft

en u

nder

trea

ted.

TheAC

TMed

icalTreatmen

tAct200

6,Part3

, Sec

tion

15sp

ecifica

llystates:

• Th

e pe

rson

has

a ri

ght t

o re

lief f

rom

pai

n an

dsu

fferingtoth

emax

imum

exten

ttha

tis

reas

onab

le u

nder

the

circ

umst

ance

s

• In

pro

vidi

ng re

lief f

rom

pai

n an

d su

ffer

ing

to

the

pers

on, t

he h

ealt

h pr

ofes

sion

al m

ust g

ive

adeq

uatecon

side

ration

toth

epe

rson

’saccou

nt

of th

e pe

rson

’s le

vel o

f pai

n an

d su

ffer

ing.

Anal

gesi

cs fo

r use

in c

ance

r pai

n

Dru

g ch

oice

dep

ends

on

mec

hani

sm a

nd s

ever

ity

of p

ain.

Epi

sodi

c pa

in c

an b

e m

anag

ed w

ith

prn

analge

sia,persisten

toro

ngoing

painrequ

ires

pain

relie

f.

1.Parac

etam

ol

• U

se fo

r mild

to m

oder

ate

skel

etal

and

sof

t tis

sue

pain.D

ose50

0to100

0mgev

ery4to6hou

rs

oral

ly o

r by

rect

al s

uppo

sito

ry u

p to

4g

daily

.

2. F

or m

ore

seve

re m

uscu

lo-s

kele

tal p

ain

•NSA

IDS(rem

embe

rtoco

nsiderprotonpu

mp

inhi

bito

r).

3.Use

opioids

whe

npa

indoe

sno

tres

pond

to

simplemea

sures.Patientswho

take

opioids

/morph

ineforo

pioidresp

onsive

painDONOT

beco

me

addi

cted

to th

em.

• Co

dein

e is

not

reco

mm

ende

d fo

r ong

oing

pai

n du

e to

con

stip

atin

g ef

fect

.

Usi

ng S

ubcu

tane

ous

Mor

phin

e, a

n ex

ampl

eA

pati

ent u

sing

ora

l Mor

phin

e su

ch a

s M

S Co

ntin

30

mgbd

(totaldailydos

eof60m

g)w

illnee

dS/

C M

orph

ine20

mg/

24ho

urs

whi

ch c

ould

be

give

n as

a c

onti

nuou

s in

fusi

on v

ia a

syr

inge

dri

ver

(rem

embe

ring

toord

erS/C

break

throug

hdo

seof

1/6to1/10totald

ailydos

e).

• O

pioi

ds

Whilere

gularimmed

iatere

leas

e(IR

)opioids

are

ofte

n re

com

men

ded

to ti

trat

e pa

in re

lief,

this

may

beim

prac

tica

land

slowre

leas

e(S

R)opioids

,w

heth

er o

ral,

by p

atch

or i

n sy

ring

e dr

iver

may

be

pref

erab

le.

Com

men

cing

opi

oids

in o

pioi

d na

ïve

pati

ents

:>

Startw

ithlowes

tdos

e>

Review

regu

larlyafterd

rugha

sreac

hedstea

dy

state:

–For

IR/S

R24

hou

rs

– F

or D

urog

esic72ho

urs

–

For

Nor

span

1w

eek

Poss

ible

Opt

ions

:–

MS

Cont

in o

r Oxy

cont

in10m

gbd

– N

orsp

an 5

mcg

pat

ch w

eekl

y–Immed

iatere

leas

e(IR

)mor

phin

e or

oxy

codo

ne

2.5m

gqid

Issu

es to

con

side

r:–

Alw

ays

prov

ide

brea

kthr

ough

dos

e (fo

r Nor

span

&

Dur

oges

ic u

se o

ral M

orph

ine

or O

xyco

done

). –D

oseus

ually

1/6

to1/10da

ilydos

e.R

emem

ber

as d

aily

dos

e in

crea

ses

brea

kthr

ough

dos

es

will

nee

d to

be

incr

ease

d–C

onstipation–alw

ayspr

escribealaxa

tive

in

conj

unct

ion

wit

h op

ioid

(Col

oxyl

with

sen

na,

Mov

icol

)–P

atch

esorS

yringe

Drive

rsho

uldbe

use

dwhe

re

patien

tshav

edifficu

ltysw

allowing

– M

orph

ine

accu

mul

ates

in p

atie

nts

wit

h re

nal

impa

irm

ent a

nd O

xyco

done

, Bup

reno

rphi

ne

and

Fent

anyl

pre

para

tion

s ar

e sa

fer

Ifapa

tientexp

erienc

essideeffectsfrom

morph

ine

cons

ider

cha

ngin

g to

an

alte

rnat

ive

opio

id.

Equi

vale

nce

Char

ts

Alle

quivalen

cecha

rtsareap

prox

imations

and

th

ere

are

larg

e va

riat

ions

bet

wee

n in

divi

dual

s–

Mor

phin

e pa

rent

eral

(SCI/IMI/IVI)Morph

ine

isx3m

orepo

tentth

anorald

ueto

increa

sed

bioa

vaila

bilit

y, i.

e. M

orph

ine10

mgsc

i=

30mgpo

– O

xyco

done

x1.5m

orepo

tentth

anM

orph

ine,

i.e

. Oxy

codo

ne10m

gpo

=M

orph

ine15

mgpo

– H

ydro

mor

phon

ex5morepo

tentth

an

Mor

phin

e, i.

e. H

ydro

mor

phon

e1m

gpo

=

Mor

phin

e 5m

g po

– M

etha

done

com

plex

opioidan

dsh

ouldonlybe

us

edw

ithad

vice

from

Pallia

tive

CareSpe

cialist

– B

upre

norp

hine

5mcg

patch

=O

xyco

done

20m

gda

ily–

Fen

tany

l12m

cgpatch

=M

orph

ine30

mg/

day

Not

e: P

ethi

dine

is n

ot re

com

men

ded

for u

se in

on

goin

g ca

ncer

pai

n.

• Co

ana

lges

ics

in N

euro

path

ic p

ain

– T

ricy

clic

ant

idep

ress

ants

resp

onse

is u

sual

ly in

th

efir

stfe

wday

sbu

twor

thperse

vering

ingfor

2 w

eeks

(e.g

. Am

itrip

tylin

e10

to50m

gorally

noct

e, s

tart

wit

h th

e lo

wes

t dos

e an

d ti

trat

e)

– A

ntic

onvu

lsan

ts w

orth

a tr

y in

neu

ropa

thic

pai

n e.

g. S

odiu

m V

alpr

oate100

-200

mgbd

oral w

ith

m

eals

or T

egre

tol1

00mgbd (B

rook

sban

k, M

. 20

03)

If pa

in d

oes

not s

ettl

e re

fer t

o Pa

lliat

ive

Care

Spe

cialist.

Palli

atio

n of

non

-can

cer p

atie

nts

Thepr

inciples

ofp

allia

tive

careap

plyeq

ually

to

pati

ents

wit

h a

non-

canc

er d

iagn

osis

. The

focu

s w

ill

varydep

ending

onth

esy

mptom

sex

perien

cedby

th

epa

tien

t.Painisfreq

uentlyprese

ntand

nee

ds

to b

e ad

dres

sed.

Cau

ses

of p

ain

in th

e no

n-ca

ncer

pa

tien

tmay

beno

n-sp

ecifican

ddiffus

e.The

ymay

be

rela

ted

to:

• Ar

thri

tis

• Im

mob

ility

• Pr

essu

re a

reas

•Ar

terial/v

enou

spr

oblems

• Co

ntra

ctur

es

Para

ceta

mol

is u

sefu

l in

this

set

ting

and

low

dos

e op

ioidsmay

beabe

ttersec

ondch

oice

than

NSA

IDS

whe

re re

nal f

unct

ion

and

GIT

sym

ptom

s ar

e a

conc

ern.

Opioidofcho

ice:

– O

xyco

ntin

5m

g bd

and

titr

ate

– N

orsp

an 5

mcg

pat

ch a

nd ti

trat

e

Prog

nosi

s is

oft

en le

ss c

erta

in th

an in

pat

ient

s w

ith

a ca

ncer

dia

gnos

is b

ut s

houl

d no

t be

prec

lusi

on to

go

od s

ympt

om m

anag

emen

t.

Pain

Palli

ativ

e Ca

re E

mer

genc

ies Pa

lliat

ive

Care

Em

erge

ncie

s

Torr

enti

al B

leed

ing

•Hae

mop

tysis

•Hae

matem

esis

• M

elae

na

Aim

is to

pro

vide

rapi

d se

dati

on a

nd c

omfo

rt

Nee

d to

ant

icip

ate

and

prov

ide

orde

rs in

adv

ance

Trea

tmen

t–

Mid

azol

am10-20

mgsc

istat

– C

lona

zepa

m1-2mgsc

istat

Maj

or A

irw

ay O

bstr

ucti

on

Trea

tmen

t as

abov

e

Sev

ere

Pain

Patien

tsm

ayexp

erienc

eon

seto

fsev

erepa

indue

to

a n

umbe

r of c

ause

s•

Acut

e bl

eed

into

live

r•

Tum

our m

ass

• Pa

thol

ogic

al fr

actu

re•

Ner

ve c

ompr

essi

on w

ith

seve

re n

euro

path

ic

pain

Trea

tmen

t–

Im

med

iate

ly g

ive

brea

kthr

ough

opi

oid

analge

siaan

drepe

ateve

ry30m

in+

benz

odia

zepi

ne

e.g.

Mid

azol

am 2

.5-5

mg

sci

If no

t set

tlin

g se

ek P

allia

tive

Car

e Sp

ecia

list

advi

ce.

Wha

t are

Adv

ance

Car

e Pl

ans?

An A

dvan

ce C

are

Plan

is a

ny w

ritt

en s

tate

men

t thatexp

ress

esaperso

n’swishe

sordirec

tion

sin

adva

nce,

sho

uld

men

tal c

apac

ity

(com

pete

nce)

be

lost

in th

e fu

ture

.

In th

e AC

T, a

pat

ient

can

com

plet

e an

end

urin

g po

wer

of a

ttor

ney

form

to a

ppoi

nt s

omeo

ne to

mak

e th

eir p

erso

nal o

r med

ical

dec

isio

ns in

cas

e th

ey a

re

unab

le to

dec

ide

for t

hem

selv

es d

ue to

impa

ired

ca

paci

ty. I

f the

y ca

nnot

app

oint

any

one

to m

ake

theird

ecisions

,the

irspo

useornex

tofk

inis

not

lega

lly e

ntit

led

to m

ake

form

al d

ecis

ions

on

thei

r be

half.O

nceapa

tien

t’sde

cision

-mak

ingab

ilityis

lo

st, t

he G

uard

ians

hip

and

Man

agem

ent o

f Pro

pert

y Tribun

alw

illapp

ointagua

rdianan

d/orm

anag

er.

The

pers

on a

pat

ient

app

oint

s un

der e

ndur

ing

pow

er o

f att

orne

y m

ust c

ompl

ete

the

sect

ion

of th

e fo

rm to

sho

w th

at th

ey u

nder

stan

d an

d ac

cept

thei

r re

spon

sibi

litie

s.

The

lega

l fra

me

wor

k th

at s

uppo

rts

the

reco

rdin

g of

an

Adv

ance

Car

e Pl

an in

clud

e:

• En

duri

ng P

ower

if A

ttor

ney

(EPA

) (Po

wer

s of

At

torn

eyAct200

6)

• G

uard

ians

hip

and

Man

agem

ent o

f Pro

pert

y Ac

t 19

91

•Med

icalTreatmen

t(Hea

lthDirec

tion

s)Act200

6

Whe

n a

pers

on e

nter

s an

age

d ca

re fa

cilit

y th

ey

shou

ld b

e of

fere

d th

e fo

llow

ing

advi

ce.

• If

they

hav

e ca

paci

ty:

– G

iven

info

rmat

ion

abou

t var

ious

opt

ions

av

aila

ble

to m

ake

an A

dvan

ce C

are

Plan

–

Pro

vide

d in

form

atio

n on

how

to a

ppoi

nt a

n al

tern

ativ

e de

cisi

on m

aker

via

the

Pow

ers

of

Attorn

eyAct200

6form

atterspertainingto

finan

cial,p

erso

nalm

attersand

/orm

edical

deci

sion

s.

An A

dvan

ce C

are

Plan

neg

ates

the

need

for a

ny

info

rmal

not

es in

the

pers

on’s

med

ical

reco

rds.

If th

e pe

rson

who

mak

es th

e Ad

vanc

e Ca

re

Plan

lose

s ca

paci

ty, i

t giv

es d

irec

tion

to th

ose

prov

idin

g ca

re a

bout

end

of l

ife d

ecis

ions

as

a gu

ide.

Men

tally

com

pete

nt p

eopl

e w

anti

ng

to m

ake

thei

r wis

hes

know

n ab

out e

nd o

f life

de

cisi

ons,

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