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Palliative Care Symptom Guide
July 2013
Table of Contents
General Principles of Pain Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Select Opiate Products. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Equianalgesic Dosing (Opioid conversion). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Patient Controlled Analgesia (PCA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Opioid Dosing in Renal or Hepatic Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Guidelines for Naloxone Administration and Patient Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Insomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-8
Nausea and Vomiting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-10
Constipation and Bowel Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-12
Delirium Diagnosis (CAM-ICU and the ICDSC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-14
Delirium: Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-16
Depression: Screening Tools and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17-19
End of Life Care: Symptom Management
Treatment of Dyspnea and Pain at the End of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Oral Secretions at the End of Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Palliative Care and Pain Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
1
Pain Scale
0
1
2
3
4
5
6
7
8
No Pain
None = 0; Mild = 2.5; Moderate = 5; Severe = 7.5; Excruciating = 10
9
10
Worst Pain Imaginable
General Principles of Pain Management
1. 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).
6.
Determine the route the opiate will be given.
2. In opiate naive patients, start with short-acting opioids (morphine, hydromorphone, and oxycodone) to control acute, moderate to severe pain.
a.IM should never be given.
Never use long-acting opioids to control acute pain.
7.
Determine the dosing schedule.
3.When titrating or changing opiate dose, start by calculating the
a.For non-opiate naive patients, use long-acting pain medicine for ongoing pain, not
previous day’s Oral Morphine Equivalent (OME).
prn; for opiate naive patients use only prn until you have a sense of how much
a.Since all potent opioids produce analgesia by the same mechanism, they
medicine the patient needs.
will produce the same degree of analgesia if provided in equianalgesic
b.Give 66-75% of patient’s stable daily OME as long acting.
doses (see equanalgesic table).
c.Consider a pca if the pain requirements are rapidly increasing or unknown.
b.Rectal=oral
8.
Determine break through dose (for acute pain in patient with otherwise
c.SQ=IM=IV
controlled pain).
4.Determine if the dose is adequate for the pain and dose adjust.
a.Use the same opiate for short- and long-acting pain when possible.
a.Titrate at least every 24 hours when the pain is moderate and as often as every
b.5-15% of total daily long acting opiate dose every 3 hr prn.
four hours when using IV opioids and the pain is severe.
9.
Manage opiate side effects. Constipation must be treated prophylactically
b. Increase dose 25-50% for moderate pain and 50-100% for severe pain.
(see page 6).
5.
Determine the opiate that will be used and dose adjust for incomplete
10. Determine whether co-analgesics would help.
cross 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.
1
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
Short Acting (mg)
Long Acting (mg)
Morphine
Tabs (15, 30 mg) Caps (15, 30 mg) MS Contin Tabs (q12hr) (15, 30, 60, 100, 200 mg)
MSIR Oral Solution (10 mg/5 mL, 20 mg/5 mL)
Oramorph SR Tabs (q12hr) (15, 30, 60, 100 mg)
MSIR, Roxanol Oral Concentrate (100 mg/5mL) (1)Kadian Caps (q12hr or q24hr) (10, 20, 30, 40, 50, 60, 70, 80, 100, 130, 150,200mg) (2, 5)
Supp (5, 10, 20, 30 mg)
Avinza Caps (q24hr) (30, 60, 90, 120 mg) (2, 5)
OxycodoneRoxicodone Tabs (5, 15, 30 mg) OxyIR Caps (5 mg) OxyContin Tabs (q12hr) (10, 15, 20, 30, 40, 60, 80 mg)
Roxicodone Oral Solution (5 mg/5 mL)
OxyFAST, Oxydose, Roxicodone Intensol Oral Concentrate (20 mg/mL) (1,6)
Hydromorphone Dilaudid Tabs (2, 4, 8 mg) (8 mg brand-name scored) Exalgo Tabs (q24h) (8, 12, 16, 32 mg)
(Dilaudid)Dilaudid Oral Solution (5 mg/5 mL) Supp (3 mg) Codeine
Tabs (15, 30, 60 mg) Solution or Elixir (15 mg/5 mL)
Fentanyl
See note (7)Duragesic Transdermal Patch (12.5, 25, 50, 75, 100 mcg/hr)
Oxymorphone
Opana (5, 10 mg)
Opana ER (5, 7.5, 10, 15, 20, 30, 40 mg)
SELECT COMBINATION OPIOID PRODUCTS
Drug Formulation/Strength (mg/mg) (8)
Anexsia (hydrocodone/acetaminophen) (4,6)
Empirin with Codeine (codeine/aspirin) (4,6)
Lorcet (hydrocodone/acetaminophen) (3,4)
Lortab (hydrocodone/acetaminophen) (3,4) Norco (Hydrocodone/acetaminophen) (3,4)
Percocet (oxycodone/acetaminophen) (3,4)
Percodan (oxycodone/aspirin) (4)
Roxicet (oxycodone/acetaminophen) (4)
Tylenol with Codeine (codeine/acetaminophen) (3)
Vicodin (hydrocodone/acetaminophen) (3,4)
Vicoprofen (hydrocodone/ibuprofen) (6)
Zydone (hydrocodone/acetaminophen) (4,6)
Tabs 5/325 (scored), 5/500 (scored), 7.5/325, 7.5/650 (scored), 10/660 (scored)
Tabs 30/325 (#3), 60/325 (#4)
Tabs 7.5/650 (scored), 10/650 (scored) Caps 5/500
Tabs 2.5/500, 5/500 (scored), 7.5/500 (scored), 10/500 Elixir 7.5/500 per 15 mL
Tabs 5/325, 7.5/325, 10/325
Tabs 2.5/325, 5/325, 7.5/325, 7.5/500, 10/325, 10/650
Tabs 5/325
Tabs 5/325 Caps 5/500 Oral Solution 5/325 per 5 mL
Tabs 15/300 (#2), 30/300 (#3), 60/300 (#4) Oral Solution 12/120 per 5 mL
Tabs 5/300, 7.5/300 (ES), 10/300 (HP)
Tabs 7.5/200
Tabs 5/400, 7.5/400, 10/400
(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
(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 grams
in 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 Transmucosal
Immediate 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.
2
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 different 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.
Opioid Agonists
Parenteral mg (2)
Oral mg (3)
Duration of Effect
Morphine
10
30
3–4 hours
Oxycodone
20–30
3–4 hours
Hydromorphone
1.5
7.5
3–4 hours
Meperidine (1) (not recommended)
75
300
3 hours
Fentanyl (4)
0.1**
1–2 hours
Codeine
130
200
3–4 hours
Hydrocodone
25–30
Oxymorphone
1
10
3–6 hours
*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.
TWENTY-FOUR HOUR ORAL MORPHINE EQUIVALENT DIVIDED BY 2 IS EQUAL
2) Parenteral opioid: onset of action, 5 minutes; peak, 15 min.
TO FENTANYL PATCH DOSE IN MCG/HR.
3) Oral opioid: onset of action, 15–30 minutes; peak, 45–60 min.
IV fentanyl dose/hr=transdermal fentanyl dose
NOTE: PATCH TAKES 12–24 HRS TO ACHIEVE FULL EFFECT. WHEN REMOVING
A PATCH, REMEMBER THE ANALGESIC EFFECT CAN STILL LAST 24 HRS.
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).
3
Patient Controlled Analgesia (PCA)
Use the preprinted PCA order form for all new PCA orders and dose
The following are suggestions for the PCA order for adults.
Like all opioid orders, doses must be individualized.
changes. EDUCATE FAMILIES NOT TO PRESS THE PCA BUTTON!
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 min
Elderly (>70 yrs.)
0.5 mg
8 –20 min.
4– 6 mg
When indicated,
2mg q 20 min.
calculate based on
titrated to pain relief
intermittent PCA use
Hydromorphone Opioid naive:
0.2 mg
8 –20 min.
0.7–1.4 mg
or previous opioid
(Dilaudid)
0.2–0.3 mg q 15 min
requirement.
Elderly (>70 yrs.)
Elderly: 0.1 mg
8 –20 min.
0.4–0.6 mg
0.2mg q 20 min
titrated to pain relief
4
*Opioid tolerant and chronic/cancer pain patients may require higher doses
press the button and be able to comprehend instructions on when to press
and continuous infusions.
the button. In the elderly, consider a longer lockout interval.
1.PCA alone is a maintenance technique. Patients should receive loading
4.The hour limit should not be less than the available total hourly patient
doses (delivered through the infuser) that are titrated to achieve an adequate administered dose. Bolus doses and the continuous infusion are included
level of analgesia (pain score less than or equal to 4/10).
in the one-hour dose limit count.
2.Quantity delivered when button is pressed. Reduce doses by 30-50%
5.Not recommended for patients who are opioid naive, the elderly, patients
in elderly and patients with liver disease. Do not increase dose based
with altered mentation, or with Obstructive Sleep Apnea, COPD, or asthma.
on increased body weight; this is especially important in patients with
6.Morphine is generally the opioid of choice. Hydromorphone is preferred in
Obstructive Sleep Apnea. Dosing depends on the patient—young vs.
patients with impaired renal function.
elderly/opioid naive vs. tolerant.
If pain unrelieved following administration of loading dose(s), increase
3.How frequently demand dose can be activated. Patient must be able to
loading dose by 50% and titrate to pain score less than or equal to 4/10.
Opioid Dosing in Renal or Hepatic Dysfunction
Given 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.
• Creatinine Clearance > 50 mL/min: normal dosing.
• Creatining Clearance < 10 mL/min: 50% of normal
• Creatinine Clearance of 10-50 mL/min: 75% of normal.
General Opioid safety recommendations in renal insufficiency:
Opioid name
Recommendation
Comments
Codeine
Not recommended
Causes profound toxicity which can be delayed and may occur after trivial doses
Fentanyl
Considered safe
Has no active metabolics
Hydromorphone
Use with caution
Considered safe in dialysis patients
Meperidine
Not recommended
Accumulation of normeperidine can cause seizures
Methadone
Considered safe
No active metabolites; has several other precautions
Morphine
Not recommended
Rapid accumulation of nondialyzable metabolites that are neurotoxic, avoid long acting preparations
Oxycodone
Use with caution
Can accumulated resulting in CNS toxicity and sedation
Oxymorphone
Use with caution
May accumulate resulting in respiratory depression and oversedation
General Opioid safety recommendations in hepatic insufficiency:
Opioid name
Recommendation
Comments
Codeine
Not recommended
Impaired conversion of codeine to the active compound, morphine, in the liver to be active
Pharmacokinetics were not altered in patients with cirrhosis. With continued use, recovery time after termination of
Fentanyl
Considered safe
infusion may be longer
Hydromorphone
Meperidine
Methadone
Morphine
Use with caution
Not recommended
Not recommended
Use with caution
Oxycodone
Oxymorphone
Use with caution
Not recommended
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.
Accumulation of toxic metabolite, normeperidine, may cause CNS toxicity
Risk of accumulation with severe liver disease.
Recommended to decrease frequency of administration and dosage because of decreased clearance and increased t1/2
and oral bioavailability
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
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
5
Guidelines for Naloxone Administration and Patient Monitoring
1. Nurses may administer naloxone without a physician’s order
when patients who have received an opioid meet the following
criteria:
(a) Sedation Scale = 3 (Somnolent; Difficult to arouse), (b) RR < 8 OR Oxygen Saturation < 92% and RR < 12
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 0.4mg
naloxone (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 solution) 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 opioid
administration when the patient is easily aroused, is beginning to
experience pain, and after the RR increases to > 9. 
6
Non Pharmacologic and Indirect Measures for Treatment of Insomnia
Insomnia is most often secondary and attributable to underlying medical or psychological conditions, medications or other substances that interfere with sleep
or poor sleep environment.
Non-pharmacologic
Components
Evidence
Good sleep hygiene behaviors
Stable bedtimes and rising times, no napping
Regular daytime light exposure
Quiet dark room at night; no TV while trying to sleep
Family should place familiar items in the patient’s room
Avoid evening intake of caffeine, nicotine, alcohol, and diuretics
Minimize nighttime procedures and noise
Minimize administration of steroids, beta blockers,
psychostimulants at nighttime
Maintain adequate nutrition
No heavy exercise/ bright lights before bedtime
Encourage a 30 min relaxation period before bedtime
Can improve time to onset of sleep and total
sleep time
Treating underlying disorders and symptoms
Use of BIPAP for obstructive sleep apnea
Manage pain, dyspnea, nausea and vomiting
Look for heart failure, gastroesophageal reflux and chronic
obstructive pulmonary disease
Some patients report difficulty becoming
accustomed to sleeping with the BiPAP mask on,
this therapy can dramatically improve symptoms
Address spiritual concerns
Directly address a patient questions, spiritual concerns, worries,
and fears
Can request for pastoral care or psychologist input
7
Other measures such as sleep restriction, cognitive behavioral therapy and biofeedback with progressive muscle relaxation are implemented as outpatient therapies usually
under the guidance of a specialist
References:
1. Wilson JF. In the clinic. Insomnia Ann Intern Med. 2008 Jan 1;148(1):ITC13-1-ITC13-16.
2. UPMC Presbyterian Shadyside, Pharmacy & Therapeutics Committee Drug Use and Disease State Management Program: Therapeutic Approaches to Acute Insomnia in
Hospitalized Patients.
3. M Miller; R Arnold. Fast Fast Fact and Concept #104: Non-pharmacological Therapy for Insomnia. End-of-Life/Palliative Education Resource Center (www.eperc.mcw.edu).
Accessed April 15, 2013
Pharmacologic treatments for insomnia:
Class
BZDs
Non-BZDs**
Antidepressant
Drug
(Generic name)
Temazepam
Starting po dose
15-30 mg,Elderly:7.5 mg
Onset of action
T max
T1/2
Glucuronidation*
Comments
30 min-1 hr
1.4 hrs
3-18 hrs
Y
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 concomitant alcohol and
antidepressants
Not FDA approved. Is an
automatic substitution for
diphenhydramine for use in
insomnia in elderly
Lorazepam
1 mg Elderly:0.5 mg
30 min
0.5-3 hrs
12 hrs
Y
Oxazepam
15 mg
No Data
2-3 hrs
3-9 hrs
Y
Zolpidem
10 mg.Elderly: 5 mg
No Data
1.6 hrs
2.5 hrs
N
Zaleplon
10 mg Elderly: 5 mg
No Data
1 hr
1 hr
N
Eszopiclone
2-3 mg Elderly: 1-2 mg
No Data
1 hr
6 hrs
N
Trazodone
25-100 mg
No Data
0.5-2 hrs
7.1 hrs
N
BZDs: Benzodiazepines, Non-BZDs: Non-Benzodiazepines
*Only intermediate half life benzodiazepines are recommended for pharmacologic treatment of insomnia. Those with non-oxidative (glucuronidation) metabolism are preferred
in the elderly. Oxidation for all except Zaleplon is via the cytochrome P450 pathway
**UPMC preferred
Other sedating antidepressants such as Tricyclics, Mirtazapine are not recommended for the treatment of pure insomnia without underlying depression because of higher
incidence of anticholinergic and cardiac conduction side effects.
For Restless Legs Syndrome, start Pergolide at a dose of 0.05 mg and increase to 0.2-0.5 mg taken in divided doses before bedtime). Side effects of pergolide include
abdominal pain, nasal stuffiness, nightmares, and recurrence of symptoms earlier in the day. Other dopamine agonists such as bromocriptine, pramipexole, and ropinirole can
also be used. If poorly tolerated, benzodiazepine agents, opiates or gabapentin may be used.
8
Nausea and Vomiting: Treatment
Mechanism-based therapy involves the following
steps:
1. A complete history and physical including oropharyngeal, abdominal, rectal and neurological exams
2. Consider labs: BUN/Cr, Na, LFT’s, amylase/lipase,
Ca, drug levels
3. Consider imaging: flat plate of the abdomen to
assess for constipation, Abdominal CT to evaluate
for obstruction, Head CT/MRI
4. Determine which receptors are mediating the
symptoms (see below)
5. Choose an antiemetic to block the implicated receptors (see next page)
Pathophysiology of nausea and vomiting.
Nausea and vomiting are triggered by activation of
one of four main pathways:
1. Chemoreceptor Trigger Zone (CTZ): Main receptors:
D2, 5HT3, NK1
2. Cortex: Main receptors are in the vomiting center.
3. Vestibular apparatus: Main receptors: Ach, H1
4. Peripheral pathways: Mediates nausea from triggering of GI/visceral chemoreceptors (local toxins) and
mechanoreceptors (stretch). Enterochromaffin cells
release 5HT3 when damaged (ie by chemotherapy or
radiation) which activates local 5HT3 receptors.
These four pathways send signals to the vomiting center
(main receptors: H1, Ach, 5HT2) which triggers nausea
and vomiting when thresholds are reached.
If nausea is persistent, severe or refractory:
• Schedule antiemetics around the clock, not PRN
• Choose second and third antiemetics which work on
different receptors.
• Consider Palliative Care consult for second and third
line therapies
IN ADDITION TO USING ANTIEMETICS, ALWAYS TREAT
ANY REVERSIBLE CAUSES (medications, anxiety,
constipation, hypercalcemia, thrush, increased ICP,
GERD, pain)
ALWAYS EVALUATE FOR CONSTIPATION AND PERFORM
A RECTAL EXAM
Avoid use of promethazine because of adverse effects
including sedation and respiratory depression
Avoid benzodiazepines unless the nausea is from anxiety
because they can sedate the patient and increase risk
of aspiration
For nausea associated with vomiting, give antiemetics
via the IV route until symptoms are controlled
Evaluate for clinical signs of bowel obstruction (persistent nausea briefly relieved by vomiting, abdominal pain,
distended abdomen, obstipation)
If bowel obstruction, consider surgery and/or GI consults
for possible surgical repair or venting PEG tube
Consider palliative care consult for medical management
of bowel obstruction.
References:
Wood GJ, Shega JW, Lynch B, Von Roenn JH.
Management of intractable nausea and vomiting in
patients at the end of life “I was feeling nauseous all of
the time…nothing was working.” JAMA. 2007;298(10):
1196-1207.
Receptors:
D2: Dopamine type 2 receptor, 5HT3: 5-hydroxytryptamine type 3 receptor, 5HT2: 5-hydroxytryptamine type
2 receptor, Achm: muscarinic acetylcholine receptor,
H1: histamine type 1 receptor, NK1: Neurokinin type
1 receptor
9
Nausea and Vomiting: Treatment
Drug
(Generic Name)
Receptor
activity
Common Clinical
Indications
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 in
GI 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
10
Constipation and Bowel Protocol
Medication
Osmotic laxatives
Onset of action
Usual starting dosage
Site and Mechanism of Action
Lactulose
24-48 hr
15-30 ml q12-24 hr
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
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
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
24-72 hr
100 mg q12-24 hr
Small and large bowel; detergent activity; softens feces
Colon; osmotic effect
Saline Laxatives*
Stimulant laxatives
Surface laxatives
Docusate
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 hyperphosphatemia
Reference: Reuben DB, Herr KA, Pacala JT, et al. Geriatrics at Your Fingertips 2009, 11th edition. New York: The American Geriatrics Society; 2009
11
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.
12
Delirium: Diagnosis
DSM-IV criteria for delirium include four components:
A. Acute onset, over hours to days.
B. Behavioral disturbance, marked by a reduced 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 withdrawn.
C. Consciousness level fluctuates over the course of the day.
D. 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 life.
1. Delirium 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.
2. Differential diagnosis: D: Drugs (opioids, anticholinergics, sedatives,
benzodiazepines, steroids, chemo- and immunotherapies, some antibiotics); E: Eyes and Ears (poor vision and hearing, isolation); L: Low flow
states (hypoxia, MI, CHF, COPD, shock); I: Infections; R: Retention (urine/
stool), Restraints; 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).
3. Routinely screen for delirium, and monitor delirious patients frequently.
Confusion Assessment Method (CAM) ICU for the Diagnosis of Delirium
Diagnosis positive with 1 and 2, plus 3 or 4
Feature
1. Acute onset and fluctuating course
AND
2.Inattention
PLUS
3. Disorganized thinking
>2 errors
OR
4. Altered level of consciousness
Assessment
Ask family or friends of patient
Patient is easily distracted. Abnormal Digit Span: Inability to repeat a series of five digits (start with reading
aloud a string of two random digits, then increase) and Vigilance A: At least two errors (read aloud in neutral
normal tone a list of 10 letters with four A’s. Patient taps when A is read).
Rambling or irrelevant conversation, unclear or illogical flow of ideas, or topic switching, or ask patient’s family.
Ask: 1) Can a rock float? 2) Are there fish in the sea? 3) Is one pound more than two pounds? 4) Do you use a
hammer to pound a nail? 5) Command say to patient, “Hold up this many fingers.” (Examiner holds two fingers
in front of patient.) Next, do the same thing with the other hand (not repeating holding up the number of fingers).
Hyper-alert, drowsy, stuporous, or unarousable
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 point
No manifestation of an item or no assessment possible = 0 point
The Intensive Care Delirium Screening Checklist (ICDSC)
Patient evaluation
Altered Level of consciousness
Day 1
Day 2
Day 3
Day 4
Day 5
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 Score
Level of consciousness: A: no response
No score
B: response to intense and repeated stimulation (loud voice and pain) No score
C: Response to mild or moderate stimulation
1
D: normal wakefulness
1
E: exaggerated response to normal stimulation
1
Inattention: Difficulty in following a conversation or instructions
Disorientation: Any obvious mistake in time, place, person
Hallucinations, delusion or psychosis: Overt clinical manifestation of hallucination or behavior related to hallucination or delusion
Psychomotor agitation or retardation: Hyperactivity requiring restraints or drugs, clinically noticeable psychomotor slowing
Inappropriate speech or mood: Disorganized or incoherent or inappropriate speech. Inappropriate display of emotion related to events of situation
Sleep/wake cycle disturbance: Sleeping <4 hours or waking frequently at night (not initiated by staff or loud environment), sleeping during most of the day
Symptom fluctuation: Fluctuation of any item over 24 hours
Reference: See www.icudelirium.org for more information
14
Delirium: Treatment
Rule out other medical causes of delirium. Review medications, and discontinue or decrease anticholinergic and/or benzodiazepine doses. Check for drugdrug 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.
15
Table 2: Drugs used for treatment of delirium in the hospital setting
Generic name
(Common brand
name)
Starting
dose
Dosing
interval
Max q24h
dose
Haloperidol
(Haldol®)
0.5-1 mg
(2 mg in
ICU*)
0.5-1 hour for 20 mg
urgent
symptoms.
Otherwise Q6H
or Q8H
Formulations
EPS
Anticholinergic
Sedation
Comments**
0.5, 1, 2, 5, 10 mg
tablets. Available as
oral solution and as
an injectable
product.
+++
+
++
IV has less EPS
compared to PO.***
(continued)
Delirium: Treatment
Generic name
(Common brand
name)
Risperidone
(Risperdal®)
Starting
dose
Dosing
interval
Max q24h
dose
Formulations
EPS
Anticholinergic
Sedation
Comments**
0.25-1 mg
6 mg
+
+
Caution with
renal failure.
2.5-10 mg
+
+++
++
Debilitated
or elderly:
2.5 mg.
IM: Q2H
Quetiapine
(Seroquel®)
12.5- 50
mg
BID
800 mg
0.25, 0.5, 1, 2, 3,
4 mg tablets.
Available as ODT (not for 0.25)
2.5, 5, 7.5, 10, 15,
20 mg tablets.
Available as ODT (5, 10,15 &
20 mg)
and IM injection
25, 50, 100, 200,
300, 400 mg tablets
++
Olanzapine
(Zyprexa®)
BID or up to
Q6H
PRN
DAILY
+
++
+++
Patients with
hypoactive
delirium, >70years
CNS malignancy
may not respond well.
Start DAILY at 4pm for
sundowning† and
then time subsequent,
additional doses
based on symptoms.
Aripiprazole
(Abilify®)
5-15 mg
Q AM
30 mg
2, 5, 10. 15, 20,
30 mg. Available as
IM and oral solution. Available
as ODT (10 & 15 mg)
++
+
++
20 mg
Useful for hypoactive
delirium. Can cause
insomnia if given
at night
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.
16
Depression: Screening Tools and Treatment
A shorter screening test for depression is to ask:
Spiritual Distress Screen—A Quick Screen
1. Are you feeling either depressed or hopeless most of the time over
the last 2 weeks?
1. Ask “Are you at peace?”
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:
2. If the answer is no, ask the patient if he/she would like to see a chaplain.
Source: Archives of Internal Med 2006:166:101-5.
17
Commonly used antidepressants: dosing, formulations
Category
Generic
(Common Brand Name)
Starting PO dose
(depression)*
Dosing
interval
Therapeutic
dose/day range*
SSRIs
Citalopram
(Celexa®)
10-20 mg
DAILY
10-60 mg
Y
10, 20, 40 (tablets)
10 mg/5 mL (solution)
Escitalopram
(Lexapro®)
5-10 mg
DAILY
10-20 mg
N
5,10, 20 (tablets)
5 mg/5 mL (solution)
Sertraline
(Zoloft®)
25-50 mg
DAILY
50-200 mg
Y
25, 50, 100 (tablets)
100 mg/5 mL (solution)
Venlafaxine
(Effexor®)
Venlafaxine XR
(Effexor XR®)
75 mg/day divided
BID-TID
150-375 mg
Y
25, 37.5, 50, 75, 100 (tablets)
37.5-75 mg
DAILY
75-225 mg
N
37.5, 75, 150 (capsules)
Duloxetine
(Cymbalta®)
Methylphenidate
(Ritalin®)
20 mg
BID
30-60 mg
N
2.5-5 mg
BID 8a,12p
5-40 mg (for
depression)
Y
20, 30, 60 (delayed-released
capsules)
5, 10, 20
(tablets)
SNRIs
Stimulants
Generic
(Y/N)
Formulations (mg)
Abbreviations: CR, SR, XL, XR: sustained-release products SSRIs: Serotonic Specific Reuptake Inhibitors, SNRIs: Serotonin Norepinephrine Reuptake Inhibitors
Others: Use the following w/caution in renally impaired patients: all SNRIs, all formulations of buproprion and mirtazapine
Use 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 mg
of 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.
18
Commonly used antidepressants: costs, side effects, comments
Drug (Common
brand name)
Citalopram
(Celexa®)
Escitalopram
(Lexapro®)
Sertraline
(Zoloft®)
Venlafaxine
(Effexor®)
Venlafaxine XR
(Effexor® XR)
Cost per
day*
<$
Anticholinergic
Insomnia
GI Distress
Comments**
+
+
++
Mild to moderately activating, few drug interactions.
$
+
+++
++
t1/2 similar to Sertraline and Citalopram
$
--
+
+++
Moderately activating.
$$
+
+++
+++
$$$$
+
+++
++
Duloxetine
(Cymbalta®)
$$$$
++
++
++
Methylphenidate
(Ritalin®)***
<$
--
+++
+
Dual serotonin/norepinephrine action at doses of
150-225mg which is effective in neuropathic pain
and is mildly activating. On switching from the
venlafaxine 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.
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.
Energizing, may increase appetite.
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.
19
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.
• “Titrate to comfort” medication orders are not acceptable.
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):
• Loading dose: 2–5 mg IV push.
• If distress not relieved in 15 minutes after initial loading dose,
give bolus equal the loading dose increased by 50 percent. If
severe distress persists repeat the dose every 15 minutes until
comfortable.
• For increased pain/distress give extra bolus dose/s equal to the
last given bolus dose every 30 minutes as needed.
• If using more than 2 bolus doses over 6-hour period, consider
starting a continuous infusion. To calculate the continuous
infusion rate divide the total dose over last 6 hours by 6.
3. Non-naive patients:
• For patients who have been taking opioid pain medications
within last 24 hours calculate the equianalgesic parenteral
dose of morphine for the last 24 hrs (see page 4 for opioid
equivalencies).
• Divide the total 24 hour IV morphine dose by 24 to determine
initial hourly infusion rate (mg/hour, IV). Start continuous
infusion at this rate.
• If patient in pain/distress use loading dose = hourly
infusion rate.
• If distress not relieved in 15 minutes after initial loading dose or
the patient in increased pain/distress, administer the loading
dose increased by 50 percent and repeat every 15 minutes until
comfortable.
• If using more than two bolus doses over 6-hour period, determine new continuous infusion rate by recalculating total dose
given over last 6 hours and dividing it by 6.
20
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.
Drug
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).
(Trade Name)
Route
Starting Dose
Onset
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
hyoscyamine hydrochloride
*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.
21
UPMC Palliative Care and Pain Treatment Resources (area code 412)
Inpatient Supportive and Palliative Care Services
PUH/MUH Supportive & Palliative Care Service
Shadyside Supportive & Palliative Care Service
Magee Womens Hospital of UPMC Supportive and Palliative Care Service
Children’s Hospital of Pittsburgh of UPMC Supportive Care Program
VA Palliative Care Program
647-7243, pager: 8511
647-7243, pager: 8513
647-7243, pager: 8510
692-3234
Inpatient and oncology: 688-6000 Ext. 816178; or pager - 645-2345
Geriatric palliative care: pager - 958-0215
Inpatient Medical Ethics Services
PUH/MUH Medical Ethics
Shadyside Medical Ethics
647-7243, pager: 2881
263-8347
Pain Treatment Services
PUH/MUH Chronic Pain Service
Shadyside Chronic Pain Service
PUH/MUH Acute Interventional Perioperative Pain Service (AIPPS)
Shadyside Acute Interventional Perioperative Pain Service (AIPPS)
647-4991
665-8030, after hours call 665-8031
647-7243, pager: 7246 (PAIN)
692-2333
Outpatient Services
UPMC Hillman Cancer Center’s Cancer Pain and Supportive Care Program
UPMC Heart and Vascular Institute’s Advanced Heart Failure Clinic
Magee Women’s Cancer Center
Magee Gynecologic Cancer Program
Benedum Geriatric Center Supportive Care Clinic
Renal Supportive Care Clinic
Magee - Chronic non malignant/spine/muscular skeletal pain (outpatient)
UPMC Presbyterian Pain Medicine (outpatient)
St. Margaret Pain Medicine (outpatient) and Chronic Pain Service
692-4724
647-6000
641-4530
641-5411 or 641-5566
692-4200
802-3043
901-2891
692-2234
784-5119 (outpatient) or 784-4000 (Hospital Operator)
Family Hospice and Palliative Care
572-8800
22
Indications for Palliative Care Referral:
•Pain in patients with life-limiting illness
•Management of other symptoms such as nausea, vomiting, shortness of breath, delirium
•Negotiating goals of treatment or end-of-life decision making
•Family support for a patient with a life-limiting illness
•Psychological or spiritual counseling for patients and
their families
•Discharge planning and interface with local hospices
•Bereavement services in the event of death
•Outpatient palliative care follow-up
Questions or comments regarding this information, contact Robert Arnold, MD ([email protected]), 692-4834, pager 2322. This information provided by
the 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 Lisa Podgurski, MD; Susan Skledar, RPh, MPH; Peg Verrico, RPh; and Robert Arnold, MD. This pain card was made
possible with the assistance of Kimberly L. Gottschalk, MBA and the generous support of the UPMC Palliative and Supportive Institute. Produced in
cooperation with the University of Pittsburgh. UMC90239-0413
VERSION 9.0 PAIN CARD
23