Table of Contents General Principles of Pain and Symptom Management .................................................................................................................... 1 Pain Management ................................................................................................................................................................................ Assessment ................................................................................................................................................................................. 2-3 Select Opiate Products .................................................................................................................................................................. 4

Equianalgesic Dosing .................................................................................................................................................................... 5 Patient Controlled Analgesia (PCA) .................................................................................................................................. 6 Bowel Protocol (and Constipation) ............................................................................................................................................. 7-8 Naloxone .....................................................................................................................................................................................9-10

Dyspnea ............................................................................................................................................................................................... Assessment................................................................................................................................................................................... 11 Treatment ...................................................................................................................................................................................... 12

Nausea and Vomiting Treatment Options ........................................................................................................................................ 13 Delirium ................................................................................................................................................................................................ Diagnosis.................................................................................................................................................................... 14-16 Treatment ..................................................................................................................................................................................17-18

Depression and Anxiety Treatment .............................................................................................................................................19-20 Spirituality Pearls ............................................................................................................................................................................... 21 Oral Secretions ................................................................................................................................................................................. 22 Interventional Pain Management ..................................................................................................................................................... 23 Palliative Care and Pain Resources........................................................................................................................................... 24-25 Notes ................................................................................................................................................................................................... 26 Acknowledgements ............................................................................................................................................................................. 27

Palliative Care Symptom Guide June 2016

Patients with life-limiting illness can experience a wide variety of symptoms. The median number of symptoms is 10.

Principles for the Pharmacologic Management of Pain and Symptoms

1. Inquire about symptoms- It is important to ask patients about each symptom individually, as patients may not volunteer

information

- Example: Screening Tool for Depression 1. Are you feeling either depressed or hopeless most of the time over the last 2 weeks? 2. Have you found little brings you pleasure or joy over the last 2 weeks?

1.2. Prioritize based on degree of severity and bothersome to patient 3. Understand and identify potential etiologies and/or pathophysiologies 4. Utilize medications that work within perceived pathophysiology 5. Consider PRN “rescue dosing” for breakthrough symptoms6. Reassess often

* Select information regarding antidepressants on pages 19-20

References: Homsi J, Walsh D, Rivera N, Rybicki LA, Nelson KA, Legrand SB, Davis M, Naughton M, Gvozdjan D, Pham H. Symptom evaluation in palliative medicine: patient report vs systematic assessment. Support Care Cancer. 2006 May;14(5):444-53. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method of the assessment of palliative care patients. J Palliat Care. 1991; 7:6-9.

General Principles of Pain and Symptom Management

1

Assessment of PainFor Patients Who Can Communicate:

P: Palliative and Precipitating Factors Q: Quality R: Region or Radiating S: Severity

- When questioning patients about severity it is important to ask what their acceptable or tolerability score is T: Time (onset) and Temporal (changes throughout the dayU: previous Utilization V: Values

For Patients Who Are Cognitively Impaired, or Cannot Communicate:

Pain Assessment in Advanced Dementia (PAIN-AD) Scale: 0 1 2

Breathing Independent of vocalization Normal Occasional labored breathing.

Short period of hyperventilation Noisy labored breathing. Long

period of hyperventilation. Cheyne-stokes respirations

Negative Vocalization None Occasional moan or groan. Low level speech with a negative or

disapproving quality.

Repeated troubled calling out. Loud moaning or groaning.

Crying Facial Expression Smiling, or inexpressive Sad, frightened or frowning Facial grimacing

Body Language Relaxed Tense, distressed pacing, or fidgeting

Rigid. Fist clenches, knees pulled up. Pulling or pushing

away. Striking out

Consolability No need to console Distracted or reassured by voice or touch

Unable to console, distract or reassure.

TOTAL:

References:Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003 Jan-Feb;4(1):9-15.

2

1. Utilize assessment methods (as described on the previous slide) based on whether the patient can communicate (or self-report).2. In opiate naive patients, start with short-acting opioids

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

3. When titrating or changing opiate dose, start by calculating the previous day’s Oral Morphine Equivalent (OME). a. Since all potent opioids produce analgesia by the same

mechanism, they will produce the same degree of analgesia if provided in equianalgesic doses (see equanalgesic table).

b. Rectal=oral c. SQ=IM=IV

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

as often as every four hours when using IV opioids and the pain is severe.

b. Increase dose 25-50% for moderate pain and 50-100% for severe pain.

5. Determine the opiate that will be used and dose adjust for incomplete 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. 6. Determine the route the opiate will be given.

a. IM should never be given.

7. Determine the dosing schedule.a. For non-opiate naive patients, use long-acting pain medicine for

ongoing pain, not PRN; for opiate naive patients use only prn until you have a sense of how much medicine the patient needs.

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

unknown. 8. Determine break through dose (for acute pain in patient with

otherwise controlled pain). a. Use the same opiate for short- and long-acting pain when possible. b. 5-15% of total daily long acting opiate dose every 3 hr prn.

9. Manage opiate side effects. Constipation must be treated prophylactically (see pages 7-8).

10. Determine whether co-analgesics would help.

Assessment of Pain (cont.)

3

SELECT NON-INJECTABLE OPIOID PRODUCTS

SELECT COMBINATION OPIOID PRODUCTS Drug Formulation/Strength (mg/mg) Norco (Hydrocodone/acetaminophen) () () Tabs 5/325, 7.5/325, 10/325 Percocet (oxycodone/acetaminophen) () Tabs 2.5/325, 5/325, 7.5/325, 10/325 Percodan (oxycodone/aspirin) Tabs 5/325 Tylenol with Codeine (codeine/acetaminophen) () Tabs 30/300 (#3) Oral Solution 12/120 per 5 mL ()

Information on newer restricted analgesics: Tapentadol (Nucynta and Nucynta ER) are not on the UPMC formulary but patients will be allowed to continue outpatient therapy. It is not covered by outpatient insuranceTransmucosal Immediate Release Fentanyl (Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys) are formulary restricted products. Hysingla ER and Zohydro (hydrocodone ER) are not on formulary at UPMC health system.

Drug Short Acting (mg) Long Acting (mg) Morphine Tabs(15, 30)

MSIR Oral Solution (10 mg/5 mL, 20 mg/5 mL) Supp(10, 20)

MS Contin Tabs(q12hr) (15, 30, 60, 100)Kadian Caps (q12hr or q24hr) (10, 20, 30, 50)() Avinza Caps (q24hr) (30)()

Oxycodone OxyContin Tabs(q12hr) (10, 15, 20, 30, 40, 80) Roxicodone Tabs(5, 10, 15, 30) ()Roxicodone Oral Solution (5mg/5mL)OxyFAST, Oxydose, Roxicodone Intensol Oral Concentrate (20 mg/mL) ()

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

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

() Orders for concentrated oral opioid solutions must include drug name and strength (e.g. 100 mg/5mL) to avoid confusion with other oral solutions. () Maximum daily dose of acetaminophen is 4 grams in patients with normal liver function. () Many other brand name products contain similar combinations of opioids. () Formulary restricted. () Non-formulary. () Prescribers must complete Transmucosal Immediate Release Fentanyl (TIRF) Risk Evaluation and Mitigation Strategy (REMS). () Oxycodone CR (Oxycontin®) will be formulary-restricted to continuation of home therapy only. No new inpatient starts will be permitted.

4

Δ TWENTY-FOUR HOUR ORAL MORPHINE EQUIVALENT DIVIDED BY 2 IS EQUAL TO FENTANYL PATCH DOSE IN MCG/HR.

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.

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) Oral (mg) Comments Morphine 10 30 • Not recommended in renal dysfunction (CrCl <30 mL/min). Metabolites can

be neurotoxic. • Not dialyzed • Use with caution in patients with hepatic dysfunction

Oxycodone 20-30 • Reduce dose in patients with hepatic dysfunction Oxymorphone 1 10 • Reduce dose in patients with renal dysfunction (CrCl <50 mL/min)

• Contraindicated in patients with moderate or severe hepatic impariment.Reduce dose in patients with mild impairment

Hydromorphone 1.5 7.5 • Consider safe in dialysis patients • Use with caution in patients with hepatic dysfunction

Hydrocodone 25-30 • Reduce dose in patients with severe renal and hepatic impairment Tramadol 120 • Maximum daily dose: 300 mg FentanylΔ For patch conversion, see box below

0.1 (100 mcg) ** • Safe in renal dysfunction. No active metabolites • Pharmacokinetics were not altered in patients with cirrhosis • Consider major interactions with CYP 3A4 inhibitors and inducers

*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.

- Parenteral opioid: onset of action, 5 minutes; peak, 15 minutes; duration of effect, 1-2 hours (fentanyl) to 3-4 hours (other opioids)

- Oral opioid: onset of action, 15–30 minutes; peak, 45–60 minutes; 3-4 hours

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.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).

5

Patient Controlled Analgesia (PCA) The following are suggestions for the PCA order for adults. Like all opioid orders, doses must be individualized.

EDUCATE FAMILIES NOT TO PRESS THE PCA BUTTON!

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

- Capnography (EtCO2) monitoring is mandatory for all patients receiving PCA therapy. See updated PCA policy for exemptions. In patients with a RR <6 bpm for 1-2 minutes, PCA pump will alarm and pause from administering medication. - PCA alone is a maintenance technique. Patients should receive loading doses (delivered through the infuser) that are titrated to achieve an adequate level of analgesia (pain score less than or equal to 4/10). - Quantity delivered when button is pressed. Reduce doses by 30-50%in elderly and patients with liver disease. Do not increase dose based on increased body weight; this is especially important in patients with Obstructive Sleep Apnea. Dosing depends on the patient—young vs. elderly/opioid naive vs. tolerant.

- How frequently demand dose can be activated. Patient must be able to press the button and be able to comprehend instructions on when to press the button. In the elderly, consider a longer lockout interval. - The hour limit should not be less than the available total hourly patient administered dose. Bolus doses and the continuous infusion are included in the one-hour dose limit count. - Not recommended for patients who are opioid naive, the elderly,patients with altered mentation, or with Obstructive Sleep Apnea, COPD, or asthma. - Morphine is generally the opioid of choice. Hydromorphone is preferred in patients with impaired renal function. If pain unrelieved following administration of loading dose(s), increase loading dose by 50% and titrate to pain score less than or equal to 4/10.

Loading dose(s)

Starting Patient Administered Dose*

Lockout Interval

One-hour Dose Limit (optional)

Continuous infusion rate in mg/hr

Morphine (6) Opioid naive: 2-4 mg q 15 min

1 mg 8–20 min. 7–10 mg

When indicated, calculate based on intermittent PCA use or previous opioid

requirement.

Elderly (>70 yrs.) 2mg q 20 min.

titrated to pain relief

0.5 mg 8–20 min. 4–6 mg

Hydromorphone (Dilaudid)

Opioid naive: 0.2–0.3 mg q 15 min

0.2 mg 8–20 min. 0.7–1.4 mg

Elderly (>70 yrs.) 0.2mg q 20 min

titrated to pain relief

Elderly: 0.1 mg 8–20 min. 0.4–0.6 mg

6

Bowel Regimen (and Constipation) Any given time if there is no bowel movement for 4 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. Except on neutropenic patients, 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, oxybutynin, promethazine, diphenhydramine), lithium, verapamil, bismuth, iron, aluminium, calcium salts.

Medication Usual Starting Dose Maximum Daily Dose Site and Mechanism of Action

Onset of Action

Stimulant Laxatives Bisacodyl 5-15 mg x1 30 mg Colon; stimulates peristalsis 6-10 hr Bisacodyl (PR) 10 mg x1 10 mg Colon; stimulates peristalsis 15 min-1 hr Senna 2 tabs qhs 34.4 mg Colon; stimulate myenteric

plexus, alters water and electrolyte secretion

6-10 hr

Osmotic Laxatives Lactulose 15-30 ml q12-24 hr 60 mL (or 40 g) Colon; osmotic effect 24-48 hr Polyethlyene Glycol 17g (1tbsp) powder in 8oz

water q24 hr 17 g GI tract; osmotic effect 48-96 hr

Sorbitol 15-30 ml q12-24 hr, max150 ml/d

27-40 g Colon; delivers osmotically active molecules to the colon

24-48 hr

Saline Laxatives * Magneisum Citrate 120-240 ml x1; 10 oz q24

hr 6.5-10 ounces Small and large bowel;

attracts and retains water in the bowel lumen

30 min-3 hr

Magnesium Hydroxide (MoM)

30 ml q12-24h 8 tablets or 60 mL Colon; osmotic effect & increased peristalsis

30 min-3 hr

Surface Laxatives Docusate Δ 100 mg q12-24 hr 200 mg Small and large bowel;

detergent activity; softens feces

24-72 hr

Δ Docusate is no better than placebo (in combination with senna) in improving bowel movements

*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

References: Tarumi Y, Wilson MP, Szafran O, Spooner GR. Randomized, double-blind, placebo-controlled trial of oral docusate in the management of constipation in hospice patients. J Pain Symptom Manage. 2013 Jan;45(1):2-13.

7

• Requires approval by pain, palliative care, oncology, critical care, or GI service • Dosing:

Patient weight Dose Pounds Kilograms <84 <38 0.15mg/kg 84-136 38-62 8mg 137-251 63-114 12mg

>251 >114 0.15mg/kg

• In patients with severe renal impairment (CrCl <30ml/min), reduce doses by half• About 50% of patients will experience a bowel movement within 4 hours of a given dose

Naloxegol (Movantik): PO Requires approval by pain, palliative care, oncology, critical care and GI services. May continue inpatient if home therapy.

• Dosing: 25mg PO once daily on an empty stomach • In patients with CrCl <60ml/min, reduce dose to 12.5mg PO once daily • All other laxatives should be discontinued prior to initiation of naloxegol. Patients may resume laxative therapy if OIC symptoms continue after 3 days of

naloxegol therapy.

References: Product Information: RELISTOR(R) subcutaneous injection, methylnaltrexone bromide subcutaneous injection. Salix Pharmaceuticals, Inc. (per FDA), Raleigh, NC, 2014. Product Information: MOVANTIK(TM) oral tablets, naloxegol oral tablets. AstraZeneca (per manufacturer), Wilmington, DE, 2014.

Agents for Refractory Opioid Induced Constipation (OIC)

Few exceptions, all patients on opioid therapy needed individualized bowel regimen. When the effective regimen is found it must be continued for the duration of the opioid therapy. Bulk laxatives alone are not useful in the treatment of opioid induced constipation.

Refractory OIC is defined as less than 3 spontaneous bowel movements/week, despite laxative therapy. Peripherally acting Mu opioid receptor antagonists can only be considered for patients who have been receiving opioid therapy for at least 2-4 weeks.

Currently approved and available Peripherally Acting Mu Opioid Receptor Antagonists (PAMORAs) are:

Methylnaltrexone (Relistor): SQ

8

Guidelines for Inpatient 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 nurseassesses the need, a “Condition C” should be called.

6. Titrate the prescribed naloxone until the patient is responsive. The half-life of naloxone (ONE HOUR) is shorter than the half-life of opioid agonists. Naloxone administration should not cause pain to return or precipitate opioid withdrawal. If a response is not obtained after one ampule of naloxone (10 cc of diluted solu- tion) is administered, examine the patient for alternate causes of sedation and respiratory depression. For assistance with further naloxone dosing, please contact the UPMC MedCall (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.

9

Guidelines for Outpatient Intranasal Naloxone Prescribing

Patients that should be considered for outpatient intranasal prescribing at discharge:

PA Act 139:

References: Zedler B, Xie L, Wang L, Joyce A, et al. Development of a risk index for serious prescription opioid-induced respiratory depression or overdose in Veterans' Health Administration patients. Pain Med. 2015 Aug;16(8):1566-1579.

1) >100mg oral morphine equivalents/day2) Recent (within previous 6 months) healthcare visit for opioid dependence3) Recent (within previous 6 months) ER visit (for any indication)

Others include:

- In the previous 6 months the patient has a healthcare visit involving: chronic hepatitis or cirrhosis, bipolar or schizophrenia, chronic pulmonary disease (i.e., emphysema, chronic bronchitis, asthma, pneumoconiosis), chronic kidney disease with clinically significant impairment, an active traumatic injury (excluding burns), or sleep apnea

- If the patient consumes: an extended-release or long-acting (ER/LA) formulation of any prescription opioid, methadone, or oxycodone immediate release (IR)

- If the patient’s current prescribed opioid dose is: 50-100mg oral morphine equivalents/day

• This legislation allows first responders including law enforcement, fire fighters, EMS or other organizations the ability to administer naloxone

• The law also allows individuals such as friends or family members that may be in a position to assist a person at risk of experiencing an opioid related overdose to obtain a prescription for naloxone

• Additionally, Act 139 provides immunity from prosecution for those responding to and reporting overdoses

In May 2015, ACHD Director Dr. Karen Hacker issued a county-wide standing order, citing PA Act 139 , allowing licensed pharmacies (which choose to participate) to dispense naloxone to individuals at risk of a heroin or opioid-related overdose, or those who may witness one.

• Communicate with your hospital’s ER to see if intranasal naloxone kits are available• To find a local pharmacy that carries intranasal naloxone visit: http://www.overdosefreepa.pitt.edu/find-naloxone/

10

Dyspnea: Assessment

For Patients Who Can Self Report: (similar to the assessment of pain) S: Severity:

0 1 2 3 4 5 6 7 8 9 10

No Shortness of Breath Worse Shortness of Breath Imaginable

For Patients Who Are Unable Self Report:

Respiratory Distress Observation Scale (RDOS)

0 Points 1 Point 2 Points

Heart Rate < 90 bpm

Respiratory Rate ≤ 18 breaths/min 19-30 breaths/min > 30 breaths/min

Restlessness (non purposeful

movements)

None Occasional, slight

movements

Frequent movements

Paradoxical Breathing Pattern

(abdomen moves on inspiration)

None Present

Accessory Respiratory Muscle Use

(rise in clavicle during inspiration)

None Slight rise Pronounced rise

Grunting at End-Expiration (guttural

sound)

None Present

Nasal Flaring (involuntary

movements in nares)

None Present

Look of Fear None Eyes wide open, facial

muscles tense, etc.

References: Campbell ML, Templin T, Walch J. A Respiratory Distress Observation Scale for patients unable to self-report dyspnea. J Palliat Med. 2010 Mar;13(3):285-90.

Instructions for Use:

• RDOS is not a substitute for patient self-report

if able.

• RDOS is an adult assessment tool.

• RDOS cannot be used when the patient is

paralyzed with a neuromuscular blocking agent.

• RDOS is not valid in bulbar ALS or

quadriplegia.

• Count respirations and heart rate for one

minute; auscultate if necessary.

• Grunting may be audible with intubated

patients on auscultation.

• Fearful facial expressions

• A score of 7 or higher should prompt a call

to the physician/NP/PA.

RDOS

Total

Respiratory

Distress Level

0-2 Minimal

3 Mild

4-6 Moderate

≥7 Severe

11

Dyspnea: Treatment

1. Opioid Naive Patients (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 equalto the last given bolus dose every 30 minutes as needed.

• If using more than 2 bolus doses over a 6-hour period, consider starting a continuous infusion. To calculate the continuous infusion rate divide the total dose over last 6 hours by 6.

2. Non-Opioid-Naive (or Opioid-Tolerant) 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 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.

12

Nausea and Vomiting: Treatment

Drug Common Clinical Indications

Starting Dose/Route

Maximum Daily Dose(for nausea)

Comments/ Side Effects

Cost

Haloperidol Opioid Induced N/V 0.5-4 mg PO or SQ or IV Q6h

5 mg IV has less EPS compared to PO

$

Metoclopramide* Impared GI motilityOpioid Induced N/V

5-20 mg PO orSQ or IV AC andHS

60 mg EPS, esophageal spasm, and colic in GI tract obstruction

$

Prochlorperazine Opioid induced N/VN/V of unknown etiology

5-10 mg PO or IVevery 6 h or 25mg PR Q6h

40 mg EPS and sedation $

Scopolamine Motion induced N/V 1.5 mg Transdermal patch every 3 d

1 patch q72 h Dry mouth, blurred vision, ileus,urinary retention, and confusion

$

Ondansetron Chemotherapy or radiation induced N/V

4-8 mg PO as apill or dissolvabletablet or IV every4-8 h

32 mg Headache, fatigue, and constipation

$

Dexamethasone N/V related to Increased ICP

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

8-16mg Agitation, Insomnia, Hyperglycemia

$

*Metoclopramide is first line for empiric therapyOther agents should be utilized based on perceived pathophysiology

13

Delirium: Diagnosis

DSM IV criteria for delirium include four components: A. Acute onset, over hours to daysB. Behavioral disturbands, marked by reduce clarity in the patient’s awareness of the environment, with impaired ability to focus,

sustain or shift attention. The patient may be agitated, irritable, and emotionally labile, OR drowsy, quiet, and withdrawn C. Consciousness level fluctuates over the course of the dayD. Different from dementia, delirium cannot be accounted for by a patient’s preexisting, established, or evolving dementia

Delirium is conceptualized as a reversible illness, except in the last 24-48 hours of life 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. Differential diagnosis D: Drugs (Opioids, anticholinergics, sedatives, benzodiazepines, steroids, chemo - and immunotherapies, some antibiotics) E: Eyes and Ears (poor vision, hearing, isolation) L: Low flow states (hypoxia, MI, CHF, COPD, shock) I: Infections R: Retention (urine/stool) I: Intracranial (CNS metastases, seizures, subdural, CVA, hypertensive encephalopathy) U: Under hydration, Under - nutrition, Under - sleep M: Metabolic disorders (sodium, glucose, thyroid, hepatic, deficiencies of Vitamin B12, folate, niacin, and thiamine) and Toxic (lead, manganese, mercury, alcohol)

14

Delirium: Diagnosis 3D CAM (Confusion Assessment Method) for the diagnosis of Delirium Diagnosis positive with 1 and 2 and either 3 or 4.

*Questions are numbered in the order of their listing in the 3D CAM instrument.11 Incorrect also includes "I don't know", and No response/non-sensical responses.Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Medicine. 1990;113:941-8.

Feature Questions asked* Observations at bedside Positive Answer 11

1. Acute Onset -OR- Fluctuation

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

Fluctuation in level of consciousness

Fluctuation in attention during interview

Fluctuation in speech or thinking

Any answer other than 'no' is positive

Any positive observation is a yes

-AND-

2. Inattention

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

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

Did the patient appear inappropriately distracted by environmental stimuli?

Anything other than 'correct' is coded as positive

Either observation is positive

-AND EITHER-

3. Disorganized Thinking

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

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

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

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

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

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

Any answer other than 'correct' is coded as positive

Answer is 'yes'

-OR-

4. Altered LevelOf Consciousness

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

Either observation is positive

15

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)

Level of consciousness: A: no response No score B: response to intense and repeated stimulation (loud voice and pain) Noscore 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

Patient evaluation Day 1 Day 2 Day 3 Day 4 Day 5 Altered Level of consciousness

If A or B do not complete patient evaluation for the period Inattention Disorientation Hallucinations-delusion-psychosis Psychomotor agitation or retardation Inappropriate speech or mood Sleep/wake cycle disturbance Symptom fluctuation Total Score

16

Sedation Dosing interval

Startingdose

Delirium: Treatment 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.

Formulation EPS Comments**

Haloperidol (Haldol®)

0.5-1 mg (2 mg in ICU*)

0.5-1 hourfor urgent symptoms. Otherwise or Q8H

20 mg Tabs: 0.5, 1, 2, 5 Oral Solution 25 mg/ml injectable solution

+++ + ++ IV has lessEPS comparedto PO.***

(continued)

Generic name (Common brand)

Max q24h dose

Anti-cholinergic

QTc prolongation

17PO:+ (IV:++)

Delirium: Treatment (cont.)

Abbreviations: EPS: extrapyramidal symptoms; IM: intramuscular; IV: intravenous; ODT: oral disintegrating tablet; SQ: subcutaneous. Deinition: †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.

Risperidone(Risperdal®)

0.25-1 mg BID or up toQ6H PRN

6 mg Tabs: 0.25, 0.5, 1, 2, 3, 4 mgOral solution 1 mg/mlM Tabs (ODTs): 0.5, 1, 2,4 mg

Caution renal failure.

Olanzapine(Zyprexa®)

DAILY

IM: Q2H

20 mg Tabs: 2.5, 7.5, 10, 15, 20 mg Injectable product 10 mg IM ODTs: 5, 10, 15, 20 mg

2.5-10 mg

Debilitatedor elderly:2.5 mg.

Quetiapine(Seroquel®)

12.5- 50mg

BID 800 mg Tabs: 25, 50, 100, 200, 300, 400 mg

Start DAILY at 4pm for sundowning † and then time subsequent, additional doses based on symptoms.

Aripiprazole(Abilify®)

5-15 mg Q AM 30 mg Tabs: 2, 5, 10, 15, 20, 30 mgOral Solution 5 mg/5mL Discmelt ODTs: 10, 15mg

Useful for hypoactive delirium. Can cause insomnia if given at night

Patients with hypoactivedelirium, >70years CNSmalignancy may notrespond well.

++ +

+

+

++

+

+++

++

+

++

+++

++

Sedation Dosing interval

Startingdose

Formulation EPS Comments** Generic name (Common brand)

Max q24h dose

Anti-cholinergic

QTc prolongation

18

++

+

++

0/-

Depression and Anxiety

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.

Category Generic (Common Brand Name)

Starting PO dose (depression)*

Dosing interval

Target dose /day range*

Formulations (mg)

SSRIs Citalopram (Celexa®)

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

Escitalopram (Lexapro®)

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

Sertraline (Zoloft®)

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

SNRIs Venlafaxine (Effexor®)

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

Venlafaxine XR (Effexor XR®)

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

Duloxetine (Cymbalta®)

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

Stimulants Methylphenidate (Ritalin®)

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

5, 10, 20 mg (tablets)

Commonly used antidepressants: dosing, formulations

19

Commonly used antidepressants: costs, side effects, comments

Abbreviations: ODT: oral disintegrating tablet; t1/2 : half-life. *Cost per day of a typical daily dose was calculated based on generic products when available. Cost data was extrapolated from www.drugstore.com.**Activating antidepressants tend to cause insomnia.***Not FDA-approved for treatment of depression. Differences in arrythmogenicity are not clinically relevant among these groups.

Drug (Common brand name)

Anticholinergic Insomnia GI Distress Comments**

Citalopram (Celexa®)

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

Escitalopram (Lexapro®)

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

Sertraline (Zoloft®)

-- + +++ Moderately activating.

Venlafaxine (Effexor®)

+ +++ +++ Dual serotonin/norepinephrine action at doses of 150-225mg which is effective in neuropathic pain and is mildly activating. On switching from 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.

Venlafaxine XR (Effexor® XR)

+ +++ ++

Duloxetine (Cymbalta®)

++ ++ ++ FDA-approved for diabetic neuropathy and off-label use for urinary incontinence. Do not use in patients with liver dysfunction. Use caution in patients with seizure disorder.

Methylphenidate (Ritalin®)***

-- +++ + Energizing, may increase appetite.

20

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

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

Religious faiths and practices during sickness and end of life

Catholic OrthodoxChristian

Islamic Amish Jewish Protestan

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

Sacrament of the sick

Unction Recite Quran Special prayers

Psalms “shema” Varies (anointing)

Same gender caregiver

No Yes Yes Varies Yes No

Caregiver present at all times also after death

No Yes Yes No Yes No

Body positioning after death

Face Mecca Eyes closed arms/fingers extended

Life support No extraordinary measures necessary

Family decides Hastening death notPermitted Patient and/or familydecide

*Family may consult for health care decisions.

Resources: keyword: interfaith guide (infonet) keyword: Loma Linda religion health care (internet) FICA mnemonic for taking a spiritual history found at www.capc.org Contact chaplain: chaplains available 24 hours 7 days a week. Call the hospital operator to page the chaplain on call.1. Puchalski CM, Ferrell B, Viriani R, et al. Improving the quality of spiritual care as a dimension of palliative care: Consensus conference report. J Palliat Med. 2009;12(10): 885-903.

21

Oral Secretions at the End of Life As the level of consciousness decreases in the dying process, patients lose their ability to swallow and clear oral secretions. As air moves over the secretions, the resulting turbulence produces noisy ventilation with each breath, described as gurgling or rattling noises. Death rattle is a good predictor of near death; one study indicated the median time from the onset of death rattle to death was 16 hours.

Non-pharmacological treatments: Position the patient on their side or in a semi-prone position to facilitate postural drainage. Reassure family about noise; can compare to snoring. While there are no evidence-based guidelines, the standard of care is to use muscarinic receptor blockers (anti-cholinergic drugs).

Reference:K Bickel; R Arnold. Fast Fact and Concept #109: Death Rattle and Oral Secretions, 2nd Edition. End-of-Life/Palliative Education Resource Center (www.eperc.mcw.edu) 2003.

Drug Route

Scopolamine Transdermal

Levsin Drops, Tabs (oral)

Glycopyrrolate PO

Glycopyrrolate SC, IV

Atropine Inj

Atropine SL drops

Maximum Daily Dose

1 patch q72h

1.5 mg

8 mg

800 mcg

2 mg

48 drops

Starting Dose

1 (~1 mg/3 days)

0.125 mg

1 mg

0.2 mg

0.1 mg

1 gtt (1%)

Onset

12 hrs.

30 min.

30 min.

1 min.

1 min.

30 min

*Use atropine ophthalmic drops. Tertiary amines which cross the blood-brain barrier (all but glycopyrrolate) cause CNS toxicity (sedation, delirium).

22

COMMON NERVE BLOCKS Block Type Indications

Celiac Plexus Block Abdominal visceral pain from:- pancreatic cancer- other upper abdominal tumors

Superior Hypogastric Block Pelvic visceral pain from:- gynecological, colorectal or GU cancers

Lumbar Sympathetic Block Intractable LE pain: - Peripheral Vascular Disease- Chronic Regional Pain Syndrome

Pudendal Nerve Block Vaginal PainPenile/Scrotal PainPerineal Pain

Sphenopalatine/Trigeminal Nerve Blocks Facial Pain

Epidural Steroid Injection Low back pain – often for non-malignant pain

CENTRALLY IMPLANTED PUMPS/STIMULATORS Hardware Type Indications

Intrathecal pump - Pain refractory to systemic opioids; and - Prognosis > 3 months for insurance to cover

Tunneled epidural catheter - Pain refractory to systemic opioids; and - Prognosis < 3 months

Spinal cord stimulator - Most helpful in refractory neuropathic limb pain (especially in non-operative ischemic limb)

Exclude patients who are: • Neutropenic/Septic • Infection in the region of the proposed procedure• Coagulopathic (INR>1.4 or platelets<100K) • On anticoagulants/antiplatelet agents that are not safe to hold or reverse

Interventional Pain Management

Interventions that minimize systemic opioids and help with pain relief in a targeted fashion can be considered for a lot of patients. At UPMC, the chronic pain and palliative care services collaborate to identify patients who are most likely to benefit from such interventions. Examples of available interventions which are best supported by evidence are listed below:

23

UPMC Palliative Care and Pain Treatment Resources Inpatient Supportive and Palliative Care Services

PUH/MUH Supportive & Palliative Care Service 412-647-7243, pager: 8511Shadyside Supportive & Palliative Care Service 412-647-7243, pager: 8513Magee Womens Hospital of UPMC Supportive and Palliative Care Service 412-647-7243, pager: 8510

Children's Hospital of Pittsburgh of UPMC Supportive Care Program 412-692-3234

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

UPMC Altoona Supportive and Palliative Care Service 814-889-2701UPMC East Supportive and Palliative Care Service 412-858-9565UPMC Hamot Supportive and Palliative Care Service 814-877-5987UPMC McKeesport Supportive and Palliative Care Service 412-664-2717UPMC Mercy Supportive and Palliative Care Service 412-232-7549UPMC Northwest Supportive and Palliative Care Service 814-677-7440UPMC Passavant Supportive and Palliative Care Service 412-367-6700UPMC St Margaret Supportive and Palliative Care Service

Inpatient Medical Ethics Services PUH/MUH Medical Ethics 647-7243, pager: 2881Shadyside Medical Ethics 263-8347

Pain Treatment Services (inpatient) PUH/MUH Chronic Pain Service 412-647-4991Shadyside Chronic Pain Service 412-665-8030, after hours call 412-665-8031PUH/MUH Acute Interventional Perioperative Pain Service (AIPPS) 412-647-7243, pager: 7246 (PAIN)

Shadyside Acute Interventional Perioperative Pain Service (AIPPS) 412-692-2333

412-784-5111 24

Outpatient Services Benedum Geriatric Center Supportive Care Clinic 412-692-4200

Hillman Cancer Center's Cancer Pain and Supportive Care Program 412-692-4724

UPMC Heart and Vascular Institute's Advanced Heart Failure Clinic 412-647-6000

Magee Women's Cancer Center 412-641-4530Magee Gynecologic Cancer Program 412-641-5411 or 412-641-5566Renal Supportive Care Clinic 412-802-3043Magee - Chronic non malignant/spine/muscular skeletal pain (outpatient) 412-901-2891

UPMC Presbyterian Pain Medicine (outpatient) 412-692-2234St. Mar

garet Pain Medicine (outpatient) and Chronic Pain

412-784-5119 (outpatient) or 412-784-4000 (Hospital)

Family Hospice and Palliative Care 412-572-8800

25

Notes

26

Notes

27

Notes

28

29

Questions or comments regarding this information, contact Robert Arnold, MD (rabob@pitt.edu), 692-4834. This information provided by the UPMC Supportive and Palliative Care Programs are merely in the form of recommendations and do not replace the service of a physician. Authors: Mamta Bhatnagar, MD with Jennifer Pruskowski, PharmD and contributions from Monika Holbein, MD and Scott Freeman, MD. This pain card was made possible with the assistance of Colleen Kosky and the generous support of the UPMC Palliative and Supportive Institute. Produced in cooperation with the University of Pittsburgh. UMC-1486-0416

VERSION 10.0 PAIN CARD UPMC-1486-0416

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

30