palliative care algorithms -...

April 2010

Palliative Care Algorithms These are to be used as general guidelines. They do not replace the traditional nurse-doctor-patient relationship. Please review carefully before using. Please note the PO route is always the initial route when possible.

Palliative Care Algorithms

Thomas Palliative Care ServicesVCU Massey Cancer Center

VCU Health System

April 2010


3

Table of Contents

Approved for use on palliative care patient where written order states: “May use palliative care orders…”

Agitation 3

Alternative Route for Opioid Administration 4

Anorexia 5

Anuria 6

Bladder Spasms Treatment 7

Bowel treatment – stepped care program 8

Candidiasis – Oral 9

Candidiasis – Perineal 10

Dyspnea 11

Fever 12

Hiccough 13

Mucositis 14

Pruritus 15

Secretions 16

Seizures – Acute Management 17

Sleep Disturbance 18

Wound Odor 19

Name DateMedical Director, Thomas Palliative Care Unit

Name DateDirector, Nursing

April 2010 4

Agitation

Haloperidol 0.5 mg PO/IV/SC every 4 hours as needed

Continue same doseHaloperidol every 12 hrs scheduled

Evaluate to continue, taper or dc

Titrate up by 1 mg every 1 hour until desired effect achieved (1mg, 2 mg, 3 mg, etc); MDD 30 mg

Lorazepam 0.5mg PO/IV/SLevery 1 hour as needed

(notify MD before initiating this step)MDD 12 mg

Continue LorazepamEvaluate regularly to taper or

discontinue

Physician/Nurse/Pharmacist consultation

relief no relief

relief

no relief after MDD Haldol

no relief after 24 hours

Excessive physical or mental restlessness. Increased activity that is generally not purposeful and associated with anxiety.

Depending on appropriateness, evaluate for reversible causes, including delirium and treat the underlying etiology if possible.Symptom control may begin concurrent with diagnositic work up.

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

Consult MD:atypical antipsychotic medsstarting doses for delirium

Olanzapine 2.5mg q12hrsRisperidone 0.25mg q12hrsQuetiapine 12.5mg q12hrs


April 2010 5

Alternative Route for Opioid Administration

If patient is unable to take PO analgesicAND

IV access is not available

Example: 360 mg of PO MSO4every day divided by 3 = 120

divided by 24 hrs = basal rate of 5 mg/hr IV MsO4

PCA dose would be 2.5 mg q 6 minBolus = 3 times basal dose = 15 mg

q 1hr

Convert 24-hour opioidrequirement of continuous

infusion of Basal Opioid via PCA pump. May add PCA dose of

atleast 50% of basal rate every 6 min w/ bolus 3 times basal rate

of every1 hrConsult physician for orders

Convert to Fentanyl patch using equianalgesic coversion card,

continue to give Fentanylsublingual at dose of 25 mcg

every ½ hour prn(Note: no benefit from patch for

8-14 hours)

Convert to subcutaneous infusion of PCA using 27 gauge needle (PCA dose remains the same, change lock out to every 15 min). Infusion volume not to

exceed 2 ml/hr.Remember can call pharmacy for assistance in how to order

SQ PCA.

Convert to rectal, vaginal or stoma route for long acting opioid (same dose) using

Fentanyl injection sublingual 25 mcg every 30 min prn.

Can give Roxanol(morphine20mg/ml) and it can be given to

patients that aren’t awake. Document patient ability to

maintain internally.

OPTIONS

May also place subcutaneous needle for use if only intermittent opioids required, convert PO dose to parenteral dose using equianalgesic

conversion card. Continue prn schedule.

** Physicians NOTE: Please consider incomplete cross tolerance in your conversions.

If IV access is no longer availableAND

Patient is able to take PO medications, select appropriate long and short acting opioids and

convert dosage requirements using equianalgesicconversion card


April 2010 6

Anorexia

Appetite SuppressionIF BOTHERSOME TO PATIENT

Continue megestrol at current dose

Trial of megestrol acetate (Megace)400 mg liquid PO daily

Reassess at 1 week for efficacy

Trial of Ritalin 5mg daily at 8am and noon(see effect in 2-3 days)

Continue RitalinReassess at regular intervals

relief no relief

relief

A loss of appetite with noted weight loss which is bothersome to the patient.

Supportive counseling for patient and family:anorexia as a natural symptom of disease, validation of normalcy, dietary and nutritionalchanges and counseling

Prednisone 20mg daily (considered most useful if estimatedprognosis less than 6 weeks)

HIV Patients: Dronabinolstarting dose 2.5mg bid MDD 20mg daily Trial of Ritalin 10mg bid

8am and noon


April 2010 7

Anuria

Catheterize for residual urine or perform bedside bladder scan if available

Less than 250 mlsOver 250 mls

Leave catheter in place,Consult MD

Evaluate volume statusConsult MD/RN/Rx

Re-asses catheter need periodicallyIf catheter becomes plugged irrigate with

normal saline prn

Minimal to no urine output.

Review medications: anticholinergic, opioids ascause

BPH: initiate treatmentas appropriate

Anuria can be part of dying process, enact algorithm if unexpected or patient symptomatic, eg pain, agitation.


April 2010 8

Bladder Spasms Treatment

Obtain urinalysis and culture of clean catch

urine

If indwelling catheter is present would do this

first

Negative urinalysis

Positive urinalysisContact MD

Anticipate TMP/SMX

Assess catheter function; irrigate gently with NS

Consider replacing if catheter present

greater than 5 days

Oxybutynin 5 mg PO TID x 48 hours-

MDD 20 mg. If PO difficult, available in

patch 3.9mg/day twice a week

Start TMP/SMX DS PO twice/day; if sulfa allergic, cipro 250mg

PO bidDuration determined

by MD

No further intervention is

needed

Oxybutynin 5 mg TID x 48 hours

MDD 20 mgOR

Scopolamine 0.4mg IV or sub

cutaneously every 4 hours prn

Continue Oxybutynin

MD/RN/Rx consult Beladonna & Opiumsuppository ½-1 PR every day-twice/day

ORScopolamine patch

every 72 hoursOR

scopolamine 0.4mg IV every 4 hours prn

Promote increased fluid intake as appropriate

Oxybutynin 5 mg PO TID x 48 hours

MDD 20 mg

An intermittent cramping sensation of the bladder resulting in discomfort and/or pain.

Treat pain with prnanalgesic while analysing cause

Alternative to oxybutynins:Tolterodine

Newer agents: solifenacin,Trospium, darifenacin


April 2010 9Bowel treatment – stepped care program

Stool softener and/or gentle laxativeDocusate 100 mg twice/day (taking no

opioids)Senokot 1 tab twice/day (taking opioids)

If no bowel movement for 48 hour period add one of these:

Milk of magnesia concentrate 10 ml poevery day

ORBisacodyl 10 mg PO/PR every day if po

not tolerated or refused

If no bowel movement in next 12 hours, perform rectal exam

to rule out impaction

If not impacted, Magnesium citrate 8 oz

ORFleets enema

Soften with glycerin suppository then manually disimpact

Follow up with a tap water enema until clear and increase

intensity of bowel regimen

Increase the prophylactic regimen

Consult MD/RN/Rx

If impacted, Fleets enema

Increase the prophylactic regimen

Consult MD/RN/Rx

Treatment to alleviate hard stools and/or constipation associated with opioid administration.


April 2010 10

Candidiasis – Oral

Nystatin susp 400,000-600,000 swish and swallow four times/day; hold in

mouth 2-5 minutesOR

Clotrimazole troche 10 mg five times a day

Improved after 48 hours

Continue 7 days or per MD orders

Not improved and patient using appropriately, or not able

to swallow

Fluconazole 200 mg Loading Dose then 100 mg every day x 14 days.

Consider MD/RN/Rx consult.

Whitish patches on the inner oral cavity, tongue or throat, which may or may not cause discomfort.

Remember someone who is immunocompromised may need to get fluconazole from the beginning.


April 2010 11

Candidiasis – Perineal

Clotrimazole lotion 1% applied twice/day

Improved after 48 hours

Continue clotrimazole7-14 days

No improvement after 48 hours

Fluconazole 200 mg one time dose. Consider MD/RN/Rx consult.

Reddened areas between skin folds in the genital area, which may or may not cause discomfort.


April 2010 12

DyspneaComplete respiratory assessmentIf oxygen sats <90% give oxygen

2L/min.Check hemoglobin and transfuse if

consistent with care goals established on signout.

Complains of dyspnea

Bronchospasm with audible wheeze

If mild CHF(crackles on

exam), with respiratory distress

Furosemide 40 mg PO/IV for one dose

Monitor for improvement. Consider MD consult

For end stage, consider fentanyl nebulizer 25 mcg every 2 hours prn with 2.5

ml of NS

Trial of oxygen 2 liters/min

Reassess every 2 hours

If no relief, Consider Morphine 10 mg PO every

2 hours prn or 3 mg subcutaneous or IV; monitor respirations

Fentanyl nebulizer 25 mcg in 2.5 ml of NS every 2 hours prn

If no relief, lorazepam 0.5 mg every 4 hours prn.

Monitor respirations

If relief, continue lorazepam prn

MDD 10 mg/day

Albuterol 2 inhalations every 4 hours prn or 3ml

nebulized every 2 hours prn

If no relief, add oxygen 2 liters/min and ipatropium 1-2 inhalations every 4-6 hours

prn or 2.5 ml nebulized every 4 hours prn

If relief, continue

If improvement, continue

If no relief, add fentanylnebulizer 25 mcg in 2.5 ml NS

every 2 hours prn.Consider MD/RN/Rx consult.

Consider adding oxygen 2 liters/min

The sensation of air hunger. May be exhibited by gasping, accessory muscle involvement in

breathing, tachypnea, discomfort.


April 2010 13

Fever

Symptomatic Fever or RigorsRefer to signout to see goals of care.

Workup needed?

Source of infection is suspected by history or exam

Treat symptomatically, especially end stage disease

MD/RN/Rx consult for workup and possible antibiotic therapy

Acetaminophen 650 mg PO/PR every 4 hours scheduled x 24 hours if symptomatic or temp > 101 PO

Reassess after 24 hours

If no relief, try Ibuprofen 400 mg or ketorolac IV (15 mg)every 6 hrs x 24 hrs

If no relief, consider MD/RN/Rx consult

yes no

A temperature of over 101.4 (orally), 100.4 (axillary), or 100.4 (for patients with known neutropenia.


April 2010 14

Hiccough

Baclofen 5mg poevery 6 hours prn,

can increase to 10mg every 6hrs if

CrCl >30

Can continue baclofen. Haloperidol 2 mg PO/Subcutaneous/IV

Maintenance 2 mg PO three times/day

Continue as neededConsider scheduling

Metoclopramide 10 mg PO/IV every 6 hours prn

Maintenance 10-20 mg po 4 times/day

Continue as needed

If no relief, consider anesthesia consult for block

Continue as needed

No effect

EffectIf no effect or unable to take PO

Effect

A spasmodic intermittent closure of the glottis following lowering of the diaphragm causing a short, sharp, inspiratory cough.

Nonpharmological treatment:Holding breath, mild irritation of nasopharynxValsalva, sipping liquids slowly, 5th vertebrae rubbing

If GERD: maalox 30ml prn, canStart PPI on formularyEg: omeprazole 40mg daily

Gabapentin 300mg tid


April 2010 15

Mucositis(without obvious infection)

Sodium bicarbonate rinsesOR

1:1 Isotonic saline/sodium bicarbonate rinses every 2 hours while awake

If relief, continue rinses as needed. Reassess in 7 days.

If no relief, start trivalent mouth wash (Benadryl, maalox, lidocaine mixture)5 ml

swish/spit every hourOR

swish/swallow every 4 hours

Consider other analgesic interventions such as PCA, viscous lidocaine, topical cocaine. Physician/RN/Rx

consult.

No relief after 24 hours

Inflammation of the mucus membranes. Generally causes pain in the oral cavity and throat and exhibited by excessive drooling, spitting and mucus production.

Evaluate for and treat thrush if present


April 2010 16

Pruritus

Establish probable cause:

Consider medications, high bilirubin, skin irritants

Hydroxyzine 10 mg every 6 hours PO prn

If obstructive jaundice-cholestyramine 4gm PO every day.

Contact physician for order.

Hysricortisone/Pramoxine foam 4 times/day prn

ORDiphenhydramine 25 mg PO/IV

every 6 hours

Improved after 24 hours, continue prn

No improvement after 48 hours

Increase cholestyramine to 4gm PO twice/day

MD/RN/Rx consult

Severe itching.

If opioid induced, contact physician, consider narcan infusion


April 2010 17

Secretions

Assess saliva

Diminished saliva (xerostomia)

Increased secretions without trach(Note: with trach evaluate risk of excessively drying up secretions)

Thick secretions

Guafenesin 200 mg PO every 4 hours prn

Increase fluid intakeEncourage oral fluid intake and good oral care

Use artificial saliva

Suck on sugarless candy, chew

sugarless gum

If history of radiation to head/neck Pilocarpine 4%

opthalmic drops 5 drops PO three times/day

If disturbing to pt/family, consider a trial of scopolamine patch every 72

hours and scopolamine 0.4 mg subcutaneous/IV now and every 4

hours prn

No reliefIf relief, continue treatment

Add a second scopolamine patch every 72 hoursOR

Increase scopolamine to 0.6mg subcutaneous/IVevery 4 hours prn

If no relief, MD/RN consult

Oral or airway lubrication. May be noted by excessive, noisy respirations

If patient unconscious, consider suction


April 2010 18

Seizures – Acute Management

Seizure

Lorazepam 2 mg IV/Sublingual/Subcutaneous statNotify physician

May repeat in 15 min prnMAXIMUM 8 mg

Is it appropriate to escalate care for this patient?

Notify family, consider chronic suppression with lorazepam

Notify physician for appropriate work-up, monitoring and medication load for chronic suppression therapy

Yes No

Sudden, non-purposeful, rhythmic movement of any part of the body or facial muscles lasting from less to a minute to more that several minutes.


April 2010 19

Sleep Disturbance(consider etiology, treat cause)

Consider cause including pain, anxiety, agitation, caffeine, medications

Zolpidem 5 mg PO at bedtime, may repeat in one hour

If sleep loss related depression, Consult physician

If relief, continue as needed

If no relief after 2 nights, notify physicianConsider a trial of temazepam 15 mg PO qhs

Use with caution in > 60 yr old

If relief, continue as needed

An inability to fall asleep and or stay asleep causing discomfort or fatigue.

Control environmental factors: minimize nighttime interruptions, lights, television, late meals, caffeine encourage daytime OOB, and lights


April 2010 20

Wound Odor

Use room deodorizer

Apply absorptive dressing with wound cover using:•Calcium alginate•Gauze apcking•4x4s or kerlix roll gauze with NS•Foam dressing, or•Baby diapers for heavy drainage

Apply non-adherent (oil emulsion) gauze as first layer on wounds that are dry, when dressings stick,

or bleeding is a factor

Cleanse with normal saline or wound cleanser

Consider topical metrogel (in a heavily draining wound this may increase drainage and not help odor)

Consult Wound Care TeamContinue

Lightly spray outer dressing with Enzymatic Rain with each change

A strong, noticeable, offensive smell emanating from a wound.


April 2010 21Algorithm Evidence-Based References

• Agitation– Jackson, KC, Lipman, AG. Drug therapy for delirium in terminally ill patients. In: The Cochrane Library, Issue 2, Chichester, UK:

John Wiley Sons, 2004.– Breitbart W, Marotta R, Platt MM, Weisman H, Derevenco M, Grau C, Corbera K, Raymond S, Lund S, Jacobson P. A double-

blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J.Psych1996 ;153:231-7.

– Stahl, S. Essential Psychopharmacology: Neuroscientific Basis and Practical Applications 2nd ed. Cambridge University Press 2000.

– Pasacreta, J., Minarik, P., & Nield-Anderson, L. (2006). Anxiety and depression. In B. R. Ferrell, & N. Coyle. (Eds.), Textbook of palliative nursing (2nd ed., pp. 375-400). New York, NY: Oxford University Press.

• Alternative Route for Opioid Administration– Bruera E, Brenneis C, Michaud M, et al. Use of the subcutaneous route for the administration of narcotics in patients with cancer

pain. Cancer 1988; 62: 407-411. – Principles of analgesic use in the treatment of acute pain and cancer pain. American Pain Society, 5 th Edition, 2003

www.ampainsoc.org– Pereira J et al. Equianalgesic dose rations for opioids: a critical review and proposals for long-term dosing. J Pain Sym Manage

2001;22:672-687.– Gourlay GK. Treatment of cancer pain with transdermal fentanyl. The Lancet Oncology 2001; 2:165-172.

• Anorexia– Jatoi A, Windschitl HE, et al. Dronabinol Versus Megestrol Acetate Versus Combination Therapy for Cancer-Associated Anorexia:

A North Central Cancer Treatment Group Study. Journal of Clinical Oncology, Volume 20, Number 2, 2002; 567-573.– Inui, A., Cancer Anorexia-Cachexia Syndrome: Current issues in research and management, CA Cancer J Clin 2002; 52: 72-91.– Jatoi, A. On appetite and its loss, Classic Papers, Supplement to JCO, Vol 21, No 9 (May 1), 2003: pp 79s-81s.– Bistrian, B. (1999). Clinical trials for the treatment of secondary wasting and cachexia. Journal of Nutrition, 129(1S Suppl), 290 S-

294 S – Fainsinger, R. L., & Periera, J. (2004). Clinical assessment and decision-making in cachexia and anorexia. In D. Doyle, G.W.C.

Hanks, N. Cherney, & K. Calman. Oxford textbook of palliative medicine (3rd ed., pp. 533-560). Oxford, UK: Oxford University Press

• Anuria– Cravens (2000) Am Fam Physician 61(2): 369-76– Walsh (1998) Campbell's Urology, Saunders, p. 159-62



• Bladder Spasms Treatment– Herbison, P, Hay-Smith, J, Ellis, G, Moore, K. Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive

bladder: systematic review. BMJ 2003; 326:841.– Nicolle, LE, Bradley, S, Colgan, R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic

bacteriuria in adults. Clin Infect Dis 2005; 40:643.– Howe, RA, Spencer, RC. Cotrimoxazole. Rationale for re-examining its indications for use. Drug Saf 1996; 14:213.

• Bowel Treatment – stepped care program– Klaschik E, Nauck F, Ostgathe C. Constipation--modern laxative therapy. Support Care Cancer. 2003;11(11):679-685. Epub 2003 Sep 2020.– Mancini I, Bruera E. Constipation in advanced cancer patients. Support Care Cancer. 1998; 6(4):356-364.– Locke, GR III, Pemberton, JH, Phillips, SF. AGA technical review on constipation. Gastroenterology 2000; 119:1766.

• Candidiasis – Oral– Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004; 38:161-89.– Sweeney MP, Bagg J. The mouth and palliative care. Am J Hosp & Pall Care 2000; 17(2):118-124.

• Candidiasis – Perineal– Sobel JD, Brooker D, Stein GE, Thomason JL, Wermeling DP, Bradley B, Weinstein L. Single oral dose fluconazole compared with conventional

clotrimazole topical therapy of Candida vaginitis. Fluconazole Vaginitis Study Group. Am J Obstet Gynecol. 1995 Apr;172(4 Pt 1):1263-8. – National guideline for the management of vulvovaginal candidiasis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the

Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999; 75 Suppl 1:S19.– Rex, JH, Walsh, TJ, Sobel, JD, et al. Practice guidelines for treatment of candidiasis. Clin Infect Dis 2000; 30:662.

• Dyspnea– Bruera E, Sweeny C and Ripamonti C. Dyspnea in patients with advanced cancer. In: Principles and Practice of Palliative Care and Supportive

Oncology. 2 nd Ed Berger A, Portenoy R and Weissman DE (eds). Lippincott-Raven, 2002. – Chan KS et al. Palliative Medicine in malignant respiratory diseases. In Oxford Textbook of Palliative Medicine 3 rd Ed. Doyle D, Hanks G,

Cherney N and Calman N. Oxford, 2005 – Fohr SA. The double effect of pain medication: separating myth from reality. J Pall Med 1998; 1:315-328.– Coyne, P. J., Lyne, M.E., & Watson, A. C. (2002). Symptom management in people with AIDS. American Journal of Nursing, 102(9), 48-56. – Coyne, P., J., Viswanathan, R., and Smith, T., "Nebulized Fentanyl Citrate Improves Patients Perception of Breathing, Respiratory Rate, and

Oxygen Saturation in Dyspnea." Journal of Pain and Symptom Management. February, 23 (2), 2002, pp. 157-160. • Fever

– Zell JA, Chang JC. Neoplastic fever: a neglected paraneoplastic syndrome. Support Care Cancer. 2005 Nov;13(11):863-4. – Oh DY, Kim JH, Kim DW, Im SA, Kim TY, Heo DS, Bang YJ, Kim NK Antibiotic use during the last days of life in cancer patients. Eur J Cancer

Care (Engl). 2006 Mar;15(1):74-9.– Boulant JA: Thermoregulation. In: Machowiak PA, ed.: Fever: Basic Mechanisms and Management. New York, NY: Raven Press, 1991, pp 1-22– Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: Toxicity And Response Criteria The Eastern

Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982.– Young LS: Fever and septicemia. In: Rubin RH, Young LS, eds.: Clinical Approach to Infection in the Compromised Host. 2nd ed. New York,

NY: Plenum Medical, 1988, pp 75-114– Zhukovsky DS: Fever and sweats in the patient with advanced cancer. Hematol Oncol Clin North Am 16 (3): 579-88, viii, 2002.

• Hiccough– Kolodzik PW, Eilers, MA: Hiccups (singultus): Review and approach to management. Ann Emerg Med 1991; 20:565-573.– Rousseau, P. Hiccups. Southern Med J 1995; 2: 175-181. – Lewis J. Hiccups: Causes and cures. J Clin Gastro 1985; 7:539-552.



• Mucositis– Dodd MJ, et al. Radiation-induced mucositis: a randomized clinical trial of micronized sucralfate versus salt & soda mouthwashes. Cancer

Invest. 2003;21(1):21-33. – Shih A, Miaskowski C, Dodd MJ, Stotts NA, MacPhail L. A research review of the current treatments for radiation-induced oral mucositis in

patients with head and neck cancer. Oncol Nurs Forum. 2002 Aug;29(7):1063-80. Links– Berger AM and Kilroy TJ. Oral Complications. in DeVita V et al (eds) Cancer: Principles and Practices of Oncology. 6 th edition. Lippincott

Williams & Wilkins. 2001.– Rubenstein, EB, Peterson, DE, Schubert, M, et al. Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral

and gastrointestinal mucositis. Cancer 2004; 100: 2026.– Epstein, JB, Schubert, MM. Oropharyngeal mucositis in cancer therapy. Review of pathogenesis, diagnosis, and management. Oncology

(Huntingt) 2003; 17:1767.• Pruritus

– Alan B. Fleisher, Jr and Jason R. Michaels. Pruritus. In: Principles & Practice of supportive Oncology. Eds: Ann Berger, Russell K. Portenoy, David E. Weissman. Lippincott-Raven Publishers Philadelphia 1998; 245-250.

– Krajnik M and Zylicz. Understanding pruritis in systemic disease. J Pain Symp Manage 2001; 21:151-168.• Secretions

– Wilders H, Menten J. Death rattle: prevalence, prevention and treatment. J Pain Symptom Manage 2002; 23:310-317.– Cooke, C, Ahmedzai, S, Mayberry, J. Xerostomia--a review. Palliat Med 1996; 10:284.– Richardson, PS, Phipps, RJ. The anatomy, physiology, pharmacology and pathology of tracheobronchial mucus secretion and the use of

expectorant drugs in human disease. Pharmacol Ther [B] 1978; 3:441.• Seizures – Acute Management

– DroneyJ, Hall E, Status Epilepticus in a Hospice Inpatient Setting. Journal of Pain and Symptom Management Vol36 No 1 July 2008– Cereghino, J. Rectal Diazepam for threayment of Acute Repetitive Seizures in Adults. Archives of Neurology Vol 159 Decemver 2002– Treiman, DM. Pharmacokinetics and clinical use of benzodiazepines in the management of status epilepticus. Epilepsia 1989; 30(suppl 2):s4.– Chapman, MG, Smith, M, Hirsch, NP. Status epilepticus. Anaesthesia 2001; 56:648.

• Sleep Disturbance– Carlos H. Schenck, Mark W. Mahowald, and Robert L. Sack.Assessment and Management of Insomnia JAMA 2003 289: 2475-2479.

• Wound Odor– Paul Walker. The pathophysiology and management of pressure ulcers. In: Topics in Palliative Care, Volume 3. Eds. Russell K. Portenoy and

Eduardo Bruera. Oxford University Press 1998. Pp 253-270.– Grocott P. The palliative management of fungating malignant wounds. J Wound Care. 2000; 9 (1):4-9. – Newman V, Allwood M, Oakes RA. The use of metronidazole gel to control the smell of malodorous lesions. Palliat Med. 1989; 3: 303-305.– Bates-Jensen, B.M. (2006). Skin disorders: Pressure ulcers – assessment and management. In B.R. Ferrell, & N. Coyle (Eds.), Textbook of

palliative nursing (2nd ed., pp. 301-328.). New York, NY: Oxford University Press. – Bates-Jensen B.M., Seaman, S. & Early, L. (2006). Skin disorders: Tumor necrosis, fistules, and stoma. In B.R. Ferrell, & N. Coyle (Eds.),

Textbook of palliative nursing (2nd ed., pp. 329-344.). New York, NY: Oxford University Press– Grocott, P., & Dealey, C. (2004). Symptom management: Nursing aspects. In D. Doyle, G. Hanks, N. Cherney, & K. Calman (Eds.) Oxford

textbook of palliative medicine (3rd ed., pp. 628-640). Oxford, UK: Oxford University Press.


palliative care algorithms -...

Documents