palliative care part 1 dr christine hirsch school of pharmacy, aston university, birmingham b4 7et
TRANSCRIPT
![Page 1: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/1.jpg)
Palliative CarePart 1
Dr Christine HirschSchool of Pharmacy, Aston University, Birmingham B4 7ET
![Page 2: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/2.jpg)
What is Palliative Care?
“Palliative care is an approach that improves quality of life of patients and their families facing the problems associated with life threatening illness, through prevention & relief of suffering by means of early identification, impeccable assessment and treatment of pain and other problems physical, psychosocial and spiritual.”
WHO 2004 www.who.int
![Page 3: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/3.jpg)
Team Approach
![Page 4: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/4.jpg)
Symptom prevalence patients with advanced cancerC. Faull and R. Woof .Palliative Care 2002 Oxford University Press
Symptom % Cancer
Pain 60
Anorexia 60
Fatigue / weakness 50
Sleep disturbance 50
Constipation 50
Depression 45
Nausea or vomiting 40
Trouble breathing 40
Incontinence 40
Anxiety 40
Confusion 30
![Page 5: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/5.jpg)
Objectives Part 1- Pain
Develop an individualised, safe, rational and stepwise approach to pain management in palliative careBe able to advise on management of breakthrough painBe able to ‘convert with confidence’Understand the appropriate use of adjuvant analgesics
![Page 6: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/6.jpg)
Part 1 Patient 1
Mr S is a 78 year old man with advanced prostate cancer and bone metastases. He has been admitted via casualty drowsy and confused. He has a supply of paracetamol 1g qds and tramadol 100mg qds which were his own medications brought with him on admission. The label on the tramadol indicates that it had been dispensed three days earlier.
![Page 7: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/7.jpg)
Assessment of pain
An unpleasant sensory and emotional experienceIs what the patient says it isLocation – underlying pathology (related to cancer? Treatment?)Duration and timingIntensity and natureWhat if anything eases it or makes it go away.
![Page 8: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/8.jpg)
Pain management in cancer patients
Visceral pain - usually opioid sensitive “deep ache”, “pressure”, “throbbing”Bone pain – localised, “aching” variable response to opioids, traditionally NSAID sensitive, radiotherapy or bisphosphonates may be appropriateNeuropathic pain – difficult to describe, dysaesthesia, may respond poorly to opioids, adjuvant analgesics may be helpfulIncident pain - episodic
![Page 9: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/9.jpg)
Pain due to cancer
30% do not develop painPain may be:cancer relatedtreatment relatedrelated to consequent disabilitydue to concurrent disordermay be controlled in 80% of patients
![Page 10: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/10.jpg)
Tramadol
Opioid and non-opioid actionMetabolised to M1(O-desmethyltramadol) in liver,
2-4 x more potent than tramadol via CYP2D65-10% caucasians lack CYP2D6Much lower affinity for opioid receptors than morphineInhibits re-uptake of noradrenaline and serotoninDrug interactions
Analgesic effect reduced by ondansetronWarfarin - may prolong INR
![Page 11: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/11.jpg)
WHO three-step analgesic ladder
e.gParacetamol
NSAIDs
e.g. Codeine
DihydrocodeineTramadol
e.g. Morphine
DiamorphineFentanyl
OxycodoneHydromorphone
Methadone
Non-opioids +/- adjuvant/s
Opioid for mild to moderate pain +/-
non-opioid +/- adjuvant
Opioid for moderate to
severe pain +/- non-opioid +/-
adjuvant
1 2 3
![Page 12: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/12.jpg)
Analgesia in advanced cancerWhere possible give analgesia:
Regularly
By mouth
By the WHO analgesic ladder
![Page 13: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/13.jpg)
Initiating morphine as a ‘strong opioid’If previously on weak opioid give 10mg morphine 4-hourly or mr 20-30mg bdIf frail or elderly 5mg morphine 4-hourlyIn reduced renal function reduce dose or lengthen dose interval or both.If two or more prn doses taken in 24 hours increase by 30-50% every 2-3 days as long as pain is opioid responsive.If using mr morphine also provide ‘immediate release’ morphine liquid or tabletsGoal: pain free, mentally alert
![Page 14: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/14.jpg)
Anticipate – ‘Rescue’ doses
Choose opioid prescribed for regular medication (exceptions may be fentanyl & methadone)
Dose = up to 1/6 of 24 hour dose of baseline analgesia
![Page 15: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/15.jpg)
TOTAL PAIN
PHYSICAL
SOCIAL
PSYCHOLOGICAL
SPIRITUAL
![Page 16: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/16.jpg)
Alternative opioids
When would you use ?Which would you use?
![Page 17: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/17.jpg)
Patient 2 part 1
Mrs. B. A 65 year old lady with advanced ovarian carcinoma has had her pain controlled previously on Zomorph 60mg bd.Very unwell
vomiting for 3 days severe abdominal painUnable to take her usual modified release morphine because of the vomiting
![Page 18: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/18.jpg)
Alternative Step 3 opioid analgesics:
Fentanyl - (transdermal patch – reservoir & matrix, transmucosal lozenge/ sl, buccal, alfentanil injection-sc infusion)Hydromorphone – (normal release capsules, modified release capsules,‘Special’ – injectable)Oxycodone – (normal release caps and liquid, modified release tabs, injection)Methadone - (liquid, caps/tabs, injection) - specialist use only.Transdermal buprenorphine- (place in palliative pain control still not determined)
![Page 19: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/19.jpg)
‘Converting’ doses of opioid
Refer to tables- as guidance onlyNB : Opioid metabolism varies between individualsTitrate to individual requirementsNB: Compromised renal or hepatic function and concomitant drugs.
![Page 20: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/20.jpg)
Episodic pain
Breakthrough pain – (exacerbations against a background on controlled pain or occurring before next opioid dose is due).Spontaneous pain - ‘idiopathic pain’ unpredictableIncident pain – (predictable) related to specific actions e.g. movement, dressing change, coughingEnd-of-dose failure
‘Any acute transient pain that is severe and has an intensity that flares over the baseline’ EAPC working group 2002
![Page 21: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/21.jpg)
Patient 3 – Part 1
A 72 year-old manProstate cancer, diagnosed 2002Bone secondaries, March 2007Spinal cord compression recentlyHis assessment – ’20 year-old, locked in an old body’Problems: mobility, pain, constipation
![Page 22: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/22.jpg)
Drug history on admission
Co-codamol 8/500 2 qds (not taken)Diethylstilbestrol 1mg odLansoprazole 30mg odDexamethasone 8mg bdCyclizine 50mg tdsAspirin 150mg odLactulose 10ml bd
![Page 23: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/23.jpg)
Adjuvant analgesics
CorticosteroidsAntidepressantsAntiepilepticsBisphosphonatesMNDA receptor blockade
AntispasmodicsMuscle relaxantsTENS / AcupunctureRadiotherapy
![Page 24: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/24.jpg)
Patient 4 Part 1 - BS 49 year old female
Bilateral carcinoma of breastLong standing back painSevere painStraining to pass urinePain lower abdomenNumbness in handsNIDDM
![Page 25: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/25.jpg)
Prescribed drugs
Zomorph 60mg bdParacetamol 1g qdsLansoprazole 30mg odCo-danthramer 2 nocteDiclofenac 75mg MR bdSodium clodronate 1600mg odGabapentin 300mg tdsDexamethasone 2mg odGliclazide 40mg od plus BM measurement.
Temazepam 10mg prnHyoscine Hydrobromide 400mcg prnMidazolam 2.5mg prnLevomepromazine 6mg po prn/ 5mg scOromorph 20mg prnDiamorphine 5mg sc prn
![Page 26: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/26.jpg)
Gold Standards Framework
CommunicationCo-ordination Control of symptoms Continuity out of hours
Continued learning Carer support Care in the dying phase
![Page 27: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/27.jpg)
Availability of drugs in the community
AnticipationIn-hours availabilityOut of hours availability
Gold Standards FrameworkLiverpool Care Pathway
Communication
![Page 28: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/28.jpg)
References:
West Midlands Palliative Care Physicians - Guidelines for the use of drugs in symptom control 4th Ed 2007.Faull C, Carter Y,Daniels, 2005 Handbook of Palliative Care Blackwells Oxford.Twycross R, Wilcock A. Palliative Care Formulary 3rd Ed. 2007.Dickman A,Schneider J, Varga J. The syringe driver in palliative care.2nd Ed, 2005 Oxford University Press. Oxford.Dickman A. Basics of managing breakthrough cancer pain. The Pharmaceutical Journal 2009;283,21
![Page 29: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/29.jpg)
References cntd:
Fallon M, Hanks G. ABC of Palliative Care. 2nd Ed 2006. Blackwell Publishing.Dickman A. Chronic pain management: advances. Pharm J. 2007;279:354-356.Palliative drugs website: www.palliativedrugs.comScottish intercollegiate guidelines network website www.sign.ac.uk
![Page 30: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/30.jpg)
Palliative CarePart 2
Dr Christine HirschSchool of Pharmacy, Aston University, Birmingham B4 7ET
![Page 31: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/31.jpg)
Objectives Part 2
To advise on aspects of symptom control other than painTo understand the place of the syringe driver in symptom control in palliative care
PainNauseaAgitationSecretions
![Page 32: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/32.jpg)
Pathway for care of the dying
Integrated care pathway e.g. Liverpool Care Pathway
Initial assessmentOngoing careCare after death
![Page 33: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/33.jpg)
When should a syringe driver be started?
Persistent nausea & vomitingDifficulty swallowingPoor alimentary absorptionIntestinal obstructionUnconscious or profoundly weak
![Page 34: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/34.jpg)
Opioids via syringe driver willNOTgive better analgesia
unless there is a problem withabsorption or administration
![Page 35: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/35.jpg)
Patient 1 Part 2 Mrs BS 49 year old female
Bilateral carcinoma of breastLong standing back painSevere painStraining to pass urinePain lower abdomenNumbness in handsNIDDM
![Page 36: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/36.jpg)
Prescribed drugs
Zomorph 60mg bdParacetamol 1g qdsLansoprazole 30mg odCo-danthramer 2 nocteDiclofenac 75mg MR bdSodium clodronate 1600mg odGabapentin 300mg tdsDexamethasone 2mg odGliclazide 40mg od plus BM measurement.
Temazepam 10mg prnHyoscine Hydrobromide 400mcg prnMidazolam 2.5mg prnLevomepromazine 6mg po prn/ 5mg scOromorph 20mg prnDiamorphine 5mg sc prn
![Page 37: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/37.jpg)
Data on drug compatibility and stability is limited:
Generally dilute with water - unless 0.9% saline is specified – debate!
Avoid mixing more than two drugs in a syringe, unless stability data is available
![Page 38: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/38.jpg)
Analgesia - usually diamorphine
Alternatives: Morphine, Oxycodone, Hydromorphone, AlfentanilDose conversions – consult local palliative care guidelinesConsider, renal failure, liver failure, stable painTiming
![Page 39: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/39.jpg)
Antiemetics
First line agent - based on underlying cause: haloperidol, metoclopramide, cyclizineSecond line, add another first line or change to ‘broad spectrum e.g. LevomepromazineThird line, if other agents not controlling try 3 days 5HT3 receptor antagonist
![Page 40: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/40.jpg)
Antiemetics - in syringe drivers
Cyclizine & levomepromazine (Nozinan) - irritation at infusion site.Try saline as diluent for levomepromazineDo not use saline to dilute cyclizineCyclizine / diamorphine mixture may precipitate if cyclizine conc >10mg/ml or either drug > 25mg/ml. Use larger volumeDo not mix cyclizine and oxycodone
![Page 41: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/41.jpg)
Agitation and delirium
Consider causes; e.g. drugs (opioids), biochemistry (e.g. calcium) infection, constipationDelirium/psychosis:
Haloperidol Levomepromazine
![Page 42: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/42.jpg)
Restlessness & agitation
Where agitation & anxiety are predominant features:
Midazolam Levomepromazine
![Page 43: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/43.jpg)
Myoclonic jerking
May be exacerbated by drugs, rapid escalation of opioid dose and anticholinergics
Midazolam Clonazepam (specialist use only)
![Page 44: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/44.jpg)
Terminal respiratory secretions
PositioningReassurance
Hyoscine hydrobromide -crosses blood brain barrier, absorbed transdermally, paradoxical agitation, sedation. Hyoscine butylbromide - for colic with intestinal obstruction, may be used to control secretions. Does not cross blood brain barrier. Glycopyrronium - for excessive respiratory secretions and bowel colic. Does not cross blood brain barrier. Unstable above pH6, avoid mixing with dexamethasone.
![Page 45: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/45.jpg)
Prescribed drugs
Zomorph 60mg bdParacetamol 1g qdsLansoprazole 30mg odCo-danthramer 2 nocteDiclofenac 75mg MR bdSodium clodronate 1600mg odGabapentin 300mg tdsDexamethasone 2mg odGliclazide 40mg od plus BM measurement.
Temazepam 10mg prnHyoscine Hydrobromide 400mcg prnMidazolam 2.5mg prnLevomepromazine 6mg po prn/ 5mg scOromorph 20mg prnDiamorphine 5mg sc prn
![Page 46: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/46.jpg)
BS syringe driver
Diamorphine 40mg over 24 hoursCyclizine 150mg over 24 hours
Increased by 10mg diamorphine after 3 days and to 60mg diamorphine after further 3 days.
![Page 47: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/47.jpg)
High gastric output, obstruction, fistulae:
•Opioids, regular or continuous
•Octreotide 0.1-0.6mg per day (may be given as continuous infusion.)
![Page 48: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/48.jpg)
Dyspnoea
Diazepam 2.5-10mgLorazepam 0.5mg sublinguallyMidazolam 2.5-5mg 4 hourly subcutaneouslyOpioids, 2.5-5mg diamorphine 4 hourly s.c. for opioid naïve patientsLevomepromazine 25-50mg 6-8 hourly if extreme agitation
![Page 49: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/49.jpg)
Other symptoms: Mouth Care
•Water sips, ice chips, mouth swabs
•Emollients, paraffin jelly
•Artificial saliva - not glycerin
•Candidiasis
•Benzydamine
![Page 50: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/50.jpg)
Use of drugs beyond licence-
‘a legitimate aspect of clinical practice’‘currently both necessary and common’‘..professionals should inform, change & monitor……… in light of evidence from audit and published research.’
Association for Palliative Medicine and the Pain Society – position statement 2001.
![Page 51: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/51.jpg)
Gold Standards Framework
CommunicationCo-ordination Control of symptoms Continuity out of hours
Continued learning Carer support Care in the dying phase
![Page 52: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/52.jpg)
Availability of drugs in the community
AnticipationIn-hours availabilityOut of hours availability
Gold Standards FrameworkLiverpool Care Pathway
Communication
![Page 53: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/53.jpg)
References:
West Midlands Palliative Care Physicians - Guidelines for the use of drugs in symptom control 4th Ed 2007.Faull C, Carter Y,Daniels, 2005 Handbook of Palliative Care Blackwells Oxford.Twycross R, Wilcock A. Palliative Care Formulary 3rd Ed. 2007.Dickman A,Schneider J, Varga J. The syringe driver in palliative care.2nd Ed, 2005 Oxford University Press. Oxford.Dickman A. Basics of managing breakthrough cancer pain. The Pharmaceutical Journal 2009;283,21
![Page 54: Palliative Care Part 1 Dr Christine Hirsch School of Pharmacy, Aston University, Birmingham B4 7ET](https://reader035.vdocument.in/reader035/viewer/2022081513/56649e545503460f94b4baeb/html5/thumbnails/54.jpg)
References cntd:
Fallon M, Hanks G. ABC of Palliative Care. 2nd Ed 2006. Blackwell Publishing.Dickman A. Chronic pain management: advances. Pharm J. 2007;279:354-356.Palliative drugs website: www.palliativedrugs.comScottish intercollegiate guidelines network website www.sign.ac.uk