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Hospice And Palliative Care – Chronic Pain Management SECTION: 23.01

Strength of Evidence Level: 3

PURPOSE:

To establish accountability for pain management, and ensure a standard for pain assessment, scoring and documentation.

CONSIDERATIONS:

1. Inadequate treatment of pain: a. decreases patient’s quality of life. b. increases cost of healthcare. c. may adversely affect treatment of patient’s

primary condition. 2. Oral or rectal are preferred methods of entry. 3. Dose and class of medication should be in

accordance with the WHO Analgesic ladder for pain management of a. Somatic pain – dull/aching pain, well localized.

Responds well to NSAIND’s, Acetaminophen, prednisone.

b. Visceral Pain – dull/aching/sharp, focal or referred. Responds well to anti-inflammatory agents.

c. Neuropathic Pain – burning/shock-like/tingling. Responds well to adjuvants such as anticonvulsants and antidepressants.

4. Pain is assessed and documented at each visit. 5. Be sure to use around the clock scheduling of

medication to keep ahead of pain. 6. If there is an increase in an opioid, be sure to advise

an increase in laxatives or stool softeners.

EQUIPMENT:

Guidelines for Analgesic drug orders

Hospice Pharmacy resources

Pain Rating Scales

World Health Organization (WHO) Analgesic Ladder

PROCEDURE:

1. Using the patient’s Plan of Care determine which pain scale is being used to assess pain. Be sure to document which scale is being used and: a. Type of pain. b. Quality of pain. c. Location of pain. d. Duration of pain. e. Pattern of pain. f. Contributing factors to pain. g. Alleviating factors of pain (including

psychosocial-spiritual assessment. h. Current pain medication used. i. Effect of pain on the patient’s sleep habits. j. Nausea and bowel habits.

2. Report findings to physician: a. Patient pain goal. b. Current pain rating. c. Current activities/side effects. d. Current dose. e. 24 hours total of medication used.

f. Suggestion for changes in medication and dosage.

3. Make recommendation for medication change when a. Pain is rated 5 or greater on 0-10 scale for 24

hours. b. More than 3 doses of breakthrough medication

within 24 hours. c. Patient’ pain goal was not achieved.

4. Pain needs to be reassessed 24 hours after the initiation of a new pharmacological or non-pharmacological intervention.

5. Consult and educate patient and family about any potential side effects associated with new medications.

AFTER CARE:

1. Notify physician on change in patient condition 2. Document pain assessment, and pain management

interventions. 3. Document all communications and care

coordination efforts with physicians. 4. Be sure to document any teachings and client

responses. 5. Advise patient and care givers of non

pharmacological approaches towards pain management. These include: a. Relaxation techniques. b. Breathing techniques. c. Application of warm or cold. d. Massage Therapy. e. Music Therapy. f. Distractions. g. Electrical Stimulation.

6. Advise caregivers to identify and help curtail additional symptoms that can cause or exacerbate pain. This can include: a. Multiple Physical Problems. b. Social Problems. c. Spiritual Problems.

RESOURCES:

VNA Home Health and Hospice. (2009 January). Clinical Policy: Chronic Pain Management. Clinical Policy Manual. 18.07

Hospice And Palliative Care – Complimentary Interventions SECTION: 23.02


PURPOSE:

To identify complimentary interventions that are useful for individuals suffering or in pain.

CONSIDERATIONS:

1. Complimentary interventions or practices compliment traditional or conventional medicines.

2. Terminal illness causes stress that can provoke and make symptoms worse. This decreases your ability to enjoy today.

3. Complimentary interventions stimulate the body to secrete its own natural fighters of pain and stress called endorphins and serotonin

4. Natural endorphins and serotonin work with medications to decrease symptoms and restore a balance in body, mind and spirit.

5. Complimentary interventions use the senses of sight, vision, smell, touch and imagination to promote comfort and well being.

6. Patients and caregivers can experience relaxation and enjoy the moments of each day by using complimentary interventions.

7. Many interventions are considered complimentary. 8. Complimentary Interventions include:

a. Prayer/spiritual practices. b. Living in the Moment Training (smelling the

roses). c. Guided imagery/Visualization (using

imagination to go anywhere). d. Progressive muscle relaxation (tensing & then

relaxing muscles). e. Gentle Yoga (stretching exercises) f. Relaxation breathing. g. Affirmations (positive statements about life and

the day). h. Diary/journaling (writing about feelings and/or

your life). i. Hand, foot, backrubs. j. Aroma therapy (using comforting scents). k. Music. l. Pets. m. Expression of emotions through art (painting,

clay, crafting). n. Life review/reminiscing. o. Use of hot/cold. p. Humor. q. Diversional activities.

9. Each person will be very individual as to which interventions promote comfort and well-being of body, mind and spirit.

EQUIPMENT:

None

REFERENCES:

Introduction to Complimentary Interventions Hospice Teaching Tool. Home Nursing Agency Healthcare

Hospice And Palliative Care - Determining Hospice Eligibility SECTION: 23.03


PURPOSE:

To determine hospice eligibility criteria for a patient referred to hospice services.

CONSIDERATIONS:

1. Indicated for anyone wishing to receive hospice services.

2. Based on guidelines contained within the Centers for Medicare and Medicaid Services (CMS) Local Coverage Determinators (LCD’s).

3. Use of the following tools should be considered when completing the assessment: a. Karnofsky Scale (< 70% unless otherwise

indicated). b. Palliative Performance Scale (PPS) (< 70%

unless otherwise indicated). c. Functional Assessment Scale (FAST) Scale for

dementia (Stage 7 or beyond). d. New York Heart Association (NYHA) Functional

Classifications for Congestive Heart Failure (Class IV).

4. Terminal status is determined upon admission to a hospice program and documentation throughout the benefit period should reflect a decline in clinical status based on worsening signs/symptoms and laboratory results. a. Hospice eligibility is supported by

documentation that reflects a terminal prognosis of six months or less.

5. Certification of terminal illness should be obtained by the individual’s hospice attending physician and the hospice medical director upon the individual’s admission to hospice.

EQUIPMENT:

None

PROCEDURE:

1. The hospice agency will conduct a comprehensive assessment that includes determination of hospice eligibility on all patients who elect hospice benefits.

2. Review patient history including recent laboratory tests and diagnostic procedures.

3. Interview patient, family members and other caregivers.

4. Adhere to Standard Precautions.

AFTER CARE:

1. Document all pertinent clinical status findings. This may include, but is not limited to: a. Terminal diagnosis. b. Co-morbidities. c. Recent hospitalizations. d. Functional status and history. e. Nutritional status and history. f. Infections. g. Exacerbations of illnesses. h. Skin integrity. i. Acute clinical changes. j. Sustained clinical decline.

Hospice And Palliative Care – Guided Imagery SECTION: 23.04


PURPOSE:

To provide instructions on how to perform guided imagery.

CONSIDERATIONS:

1. Guided imagery is the use of your imagination to take you to a beautiful place you have been or to a safe, relaxing place you create for yourself in your mind.

2. Guided imagery helps you to focus your mind on positive, healing images and thoughts.

3. You are what you think. If you think sad, disturbing thoughts you feel unhappy. If you have comforting, healing thoughts you feel peace. If you have funny thoughts you laugh.

4. Guided imagery allows you to go anywhere you choose even though you can’t go physically.

EQUIPMENT:

All you need to do guided imagery is your imagination.

Involve all your senses:

visualization – god, forest, trees, ocean

hearing – religious songs, music, wind, waves, birds

smell – grass, woods, sea air

touch – feel of moss, moist sand, petals of flowers

You or someone else can make a tape of your guided imagery.

PROCEDURE:

An ocean example 1. Loosen your clothing and assume a comfortable

position lying or sitting. 2. Close your eyes 3. Imagine you are walking along a beautiful beach. 4. You come to a comfortable, beautifully colored

beach chair. 5. You sit down and take a deep breath in and blow it

out. 6. Looking out over the ocean you see the reflection of

the sun. 7. The waves rush in, break on the beach and gently

rush back out. You listen to each one. 8. The sun is a golden ball in a vibrant blue sky. 9. The waves come in and the bubbles tickle your

toes. 10. The waves rush out and you feel the warm moist

sand beneath your feet. 11. Taking a deep breath in, you smell the sea air. 12. The waves rush in and the waves rush out 13. You feel the warmth of the sun on your face and the

gentle breeze tickles your neck. 14. Sitting quietly taking relaxation breaths you

experience the sights, smells, feeling, and sounds of a beautiful beach and ocean.

Creating your Special Place 1. You are creating your retreat for relaxation,

guidance and growth. 2. This place can be indoors or out. 3. Make it beautiful, serene, comfortable and safe. 4. Allow a private walkway to your special place such

as a path, garden or field. 5. Fill this place with beautiful comforting details of

your favorite: a. Smells. b. Sights. c. Sounds. d. Touch/feelings.

Going to your Special Place 1. Assume a position of comfort. 2. Take a few relaxation breaths. 3. Close your eyes and slowly walk down your

entrance. 4. Unload your worries, fears and anxiety. 5. Notice the sights, smells, and sounds on your way. 6. Once you arrive notice all the comforting, aspects in

your special place. 7. Reach out and feel them, smell them, look at them. 8. Give yourself time to sit and experience the beauty

around you. 9. When you are ready, start back down your

entrance. 10. Take a few relaxation breaths. 11. Gently open your eyes.

REFERENCES:

Introduction to Complimentary Interventions Hospice Teaching Tool Home Nursing Agency Healthcare

Hospice And Palliative Care – Hospice Philosophy SECTION: 23.05


PURPOSE:

To ensure that all interdisciplinary team members, both inside and outside of the agency, are aware of the hospice philosophy as they relate to an individual’s care.

CONSIDERATIONS:

1. The hospice philosophy utilizes is an interdisciplinary approach to end-of-life care that offers physical, social, spiritual and emotional care. The team may include any combination of the following: a. Registered Nurse. b. Spiritual Counselor (hospice and/or

community). c. Patient’s Attending Physician. d. Hospice Physician. e. Social Worker. f. Hospice Aide. g. The individual. h. Family members/Caregivers.

(Facility staff, if the individual resides in an inpatient facility).

i. Bereavement Counselor. j. Volunteer. k. Contracted Service Providers. l. Others as appropriate.

2. Hospice treats the individual and family, not a condition or disease.

3. Hospice care is directed at support of the individual and family as well as palliation of symptoms, not curative measures, aimed at enhancing quality of life.

4. Hospice neither hastens nor postpones death. It affirms life and regards dying as part of a normal process.

5. Hospice encourages the individual and family to be involved in the decision-making process.

6. The individual’s choices and decisions regarding care are very important and should always be considered.

7. It is important when making contractual agreements with outside agencies or facilities, that an accurate understanding of this philosophy be in place and the contractor is agreeable to follow this philosophy to the extent possible, and in relation to the individuals care and/or services.

EQUIPMENT:

None

PROCEDURE:

1. Explain hospice philosophy to the individual and his/her family.

2. Answer questions that may arise to facilitate further understanding.

3. Evaluate the individual and family’s understanding of the hospice philosophy.

4. Have the acknowledgement of agreement to the hospice philosophy included in written contracts.

AFTER CARE:

1. Document the individual and/or family understanding/acceptance.

2. Document coordination of care/services, both inside and outside of the hospice agency.

Hospice And Palliative Care – Implant Defibrillator Device Deactivation SECTION: 23.06


PURPOSE:

To deactivate internal automatic defibrillator for patients who have a do not resuscitate (DNR) order.

CONSIDERATIONS:

1. A written document stating patient or caregiver is aware of the repercussions of turning off internal device is necessary.

2. Once a patient or caregiver has given consent to turn off the device, a written order by the physician is also required.

3. A pacemaker is not a resuscitative device, and therefore pacemakers are not generally considered for deactivation.

EQUIPMENT:

Internal defibrillator device manual

Written deactivation approval records

PROCEDURE:

1. Ascertain that the patient does have an internal defibrillator device and necessary written documents approving the deactivation of the device.

2. Verify the location of the device as well as the working condition. Also verify the model and make of the device.

3. Contact the manufacturer or vendor and notify them the type of device and make plans for deactivation.

4. Collaborate with physician to arrange deactivation. Qualified medical personnel may perform deactivation in the home setting.

5. If necessary, plan for a home visit by the vendor or manufacturer to come and deactivate the device.

6. Arrange a home visit from a clinician at the same time as deactivation, if necessary.

AFTER CARE:

1. Make sure patient choice in regards to deactivation is recorded in the patient medical record.

2. Educate patient and caregiver regarding the effects of deactivation of device, i.e., they understand that the patient will no longer be receiving life saving measures.

3. Document all the information including time of home visit for deactivation in patient record.

4. Contact physician in regards to timing of deactivation.

REFERENCES:

Implantable Cardiac Defibrillator. (n.d.).Maine General Health: Healthreach Homecare and Hospice.

Implanted defibrillator Devices. (n.d.).Pathways Home Health and Hospice Clinical Manual.

Hospice And Palliative Care – Mindfulness Therapy SECTION: 23.07


PURPOSE:

To provide instructions on how to focus your attention off stress and to the joy, pleasure and growth of the moment.

CONSIDERATIONS:

1. Mindfulness offers deep relaxation and provides opportunities for growth.

2. Mindfulness cultivates a relationship with “what is” without trying to change it.

3. Mindfulness promotes acceptance, pleasure, healing, peace and prayer for living in the moment.

4. The goal of mindfulness is to recognize stressful thoughts that cause suffering in your life and to make new choices about how to respond to that stress.

5. Caregivers and patients can both get relaxation and pleasures from practicing mindfulness together.

EQUIPMENT:

All you need to do to guided imagery is your mind, and a quiet place to sit and relax

PROCEDURE:

1. Sit or lie in a comfortable position. 2. Close your eyes 3. Place your right hand on your abdomen and your

left hand on your chest. 4. Breathe in through your nose. 5. Exhale through your mouth. 6. Pay attention to your breathing. 7. If a thought comes into your head don’t judge it, just

let it go. 8. Bring your attention back to your breathing. 9. Do this for 5 minutes. 10. Increase by 5 minutes each day until you reach 30

minutes. 11. The waves rush out and you feel the warm moist

sand beneath your feet. 12. Taking a deep breath in, you smell the sea air. 13. The waves rush in and the waves rush out 14. You feel the warmth of the sun on your face and the

gentle breeze tickles your neck. 15. Sitting quietly taking relaxation breaths you

experience the sights, smells, feeling, and sounds of a beautiful beach and ocean.

Other ways to be Mindful 1. Focus your vision on something beautiful such as

fish, candles, clouds, birds or leaves. 2. Sit quietly and listen to enjoyable music. This could

be birds, waterfalls, or the ocean. 3. Soothing scents, such as vanilla, lavender, grass or

cinnamon will also help you to relax your mind. 4. Touching something soft, or having a hand, face, or

back rub helps with relaxation. 5. Taste anything that is pleasurable to you.

6. Read comforting materials such as spiritual or religious passages will help sooth your mind and being comfort and peace.

REFERENCES:

Complimentary Therapies Mindfulness

Hospice Teaching Tool

Home Nursing Agency Healthcare

Hospice And Palliative Care – Plan of Care SECTION: 23.08


POLICY STATEMENT:

Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice interdisciplinary team (IDT) in collaboration with the patient’s attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver. The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments.

PROCEDURE:

1. The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive, and updated assessments of the patient.

2. The patient’s plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions.

3. The plan of care includes, but is not limited to: a. Interventions to manage pain and symptoms. b. A detailed statement of the scope and

frequency of services necessary to meet the specific patient and family needs.

c. Measurable outcomes anticipated from implementing and coordinating the plan of care.

d. Drugs and treatment necessary to meet the needs of the patient.

e. Medical supplies and appliances necessary to meet the needs of the patient.

f. Documentation from the IDT of the patient or representative’s level of understanding, involvement and agreement with the plan of care.

4. The services provided are explicitly linked to the assessed needs of the patient/family related to the patient’s terminal illness and related conditions.

5. Efforts to involve the patient’s attending physician (if there is one) in the development and updating of the hospice plan of care and the results of those efforts are documented in the patient’s clinical record.

6. Each patient and his or her primary caregiver(s) receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the plan of care.

7. When the patient/representative evidence impediments to participating in care planning and understanding the plan of care, those impediments are documented in the patient’s clinical record and the level of understanding or lack of understanding are recorded.

8. When the patient, representative or primary caregivers decline to be involved in actively developing the plan of care, this is documented in the patient’s clinical record.

9. The plan of care is reviewed and updated by the IDT every 15 days, or more frequently, if needed.

10. Revisions to the plan of care are based on information from the patient’s updated comprehensive assessment and the patient’s progress toward outcomes specified in the plan.

11. Reviews of, and changes to, the plan of care are documented and communicated to members of the IDT.

REFERENCES:

Wilson, H. (2008). CoPs in a Book: The Final Edition. Hyannis, MA: Weatherbee Resources, Inc.

Hospice And Palliative Care – Relaxation Breathing SECTION: 23.09


PURPOSE:

To provide instructions on utilizing breathing to reduce stress.

CONSIDERATIONS:

1. Proper breathing technique brings in necessary oxygen to the body and gets rid of carbon dioxide.

2. When we become stressed we being to breathe improperly.

3. Good breathing habits can promote physical and psychological well-being.

4. Deep breathing is effective to relieve tension, promote relaxation and relieve pain.

5. Tension, anxiety and stress are associated with improper breathing.

6. Abdominal breathing is deep breathing that brings in a large volume of oxygen.

7. High chest breathing, associated with stress, decreases the amount of oxygen your body takes in, and the amount carbon dioxide your body expels.

EQUIPMENT:

All you need is your body and a quiet place to sit

PROCEDURE:

Assess your Breathing style 1. Pay attention to your breathing style. 2. Assume a comfortable position, either sitting or

lying. 3. Place your right hand on our abdomen at the

waistline. 4. Place your left hand at the center of your chest. 5. Pay attention to which hand rises the most when

you inhale and exhale. 6. If your left hand moves more, you are breathing

improperly and you need to switch to abdominal breathing.

Switch to Abdominal Breathing 1. To switch to abdominal breathing lie down with your

legs straight, slightly apart, and toes turned outward. 2. Extend your arms away from your body with palms

up. 3. Place your right hand on your abdomen and left

hand on your chest. 4. Inhale deeply allowing your abdomen to expand.

Move your lower hand outward. 5. Once your abdomen is extended then allow your

chest to fill with air causing the upper hand to extend.

6. Hold the breathe in for a few seconds. 7. Slowly exhale this breathe through your mouth

making a swooshing sound as the air leaves your body.

8. Repeat this several times to focus on your breathing.

Relaxation Variations 1. With each inhalation, imagine white air and

relaxation coming into your body. 2. With each exhalation, imagine black air and stress

coming out of your body. 3. Try counting your breaths with each exhalation. 4. Relaxation breathing can be done several times a

day to focus the mind and enhance the effectiveness of medication.

REFERENCES:

Complimentary Therapies Relaxation Breathing Hospice Teaching Tool Home Nursing Agency Healthcare

Hospice And Palliative Care – Scope of Services Section 23.10


POLICY STATEMENT:

Hospice provides comprehensive services to provide end-of-life care to terminally ill patients and their families within its geographical service area and in the setting defined by the patient and family as the patient’s place of residence.

PROCEDURE:

1. Hospice provides four levels of care appropriate to the needs of the hospice patient: a. Routine homecare in the patient’s own

home or the facility in which he or she resides.

b. Continuous care when a hospice patient is experiencing an acute crisis.

c. Inpatient respite care in a contracted facility when necessary to provide respite to overwhelmed or otherwise unable caregivers.

d. General inpatient acute care in a contracted facility for the management of pain or symptoms that cannot be managed in the patient’s home.

2. Hospice patients and their families receive the services of the hospice’s (Interdisciplinary Team) IDT which include: a. Nursing services. b. Medical social services. c. Physician services (from the hospice

Medical Director and/or the patient’s attending physician).

d. Counseling services, including spiritual, dietary and bereavement.

e. Hospice aide services. f. Other therapies, including physical therapy,

occupational therapy, and speech-language pathology services, as identified in the patient’s plan of care

3. In addition to the services of the IDT, the hospice provides medical supplies, equipment and drugs that are used for the management of pain and symptom control related to the patient’s terminal illness.

4. The scope and frequency of services provided by the hospice are in accordance with each patient’s needs as identified in his or her plan of care.

5. Nursing services, physician services, and drugs and biologicals are routinely available on a 24 hour basis, 7 days a week. Other services are available on a 24 hour basis when reasonable and necessary to meet the needs of the patient and family.

EQUIPMENT:

None

REFERENCES:

www.weatherbeeresource.com

http://www.weatherbeeresource.com/

MILD PAIN

Pain Scale Rating 1/5 (0-5 Scale) or 1-3/10 (0-10 Scale)

Complete Pain Assessment. Establish probable cause of pain when possible. Determine goal for pain relief with patient and acceptable time frame for when relief will occur.

Always combine pharmacological interventions with non-pharmacological interventions. ANALGESICS SHOULD NOT BE HELD UNTIL CAUSE OF PAIN IS DETERMINED

Initiate Non-Pharmacological Intervention

*Partial Relief / No Relief: Pain Goal Not Met Relief: Pain Goal Met

EXAMPLES OF ANALGESIC CHOICES acetaminophen 650 mg q 4 hrs po or pr MDD 4000mg ibuprofen 200 mg 2-3 tabs q4hrs po MDD 3200 mg celecoxib (Celebrex) 100 mg po bid MDD 400mg refexocib (Vioxx) 12.5-25 mg po qd MDD 50mg

Continue Non-Pharmacological Interventions 1259

*Partial Relief / No Relief: Pain Goal Not Met

REASSESS 4Review initial pain assessment for changes 4Anaglesics given as ordered 4Need for upward titration 4Need for adjuvant meds?

4Need to give before activities? 4Is time interval appropriate?

*Partial Relief / No relief: Pain Goal Not Met Relief: Pain Goal Met *Consult physician. Develop plan for ongoing communication with physician

until patient’s pain goal is met. Consider initiation of Moderate Pain Algorithm

Continue interventions as needed Reassess at regular intervals Titrate as needed Last U

pdate 9/10

MDD = Maximum Daily dose

©MCW Research Foundation 2000 Permission granted to modify or adopt provided written credit is given to the Medical College of Wisconsin

MODERATE PAIN Pain Scale Rating 2-3/5 (0-5 Scale) or 4-6/10 (0-10 Scale)

Complete Pain Assessment. Establish probable cause of pain when possible. Determine goal for pain relief with patient and acceptable time frame for when relief will occur.

Always combine pharmacological interventions with non-pharmacological interventions. ANALGESICS SHOULD NOT BE HELD UNTIL CAUSE OF PAIN IS DETERMINED.

Initiate Non-Pharmacological Interventions

Examples of Analgesic Choices Tylenol # 2,3,4 (300mg acetaminophen/ 15mg (#2), 30mg (#3), 60mg (#4) mg codeine 1-2 tabs po q 4hrs Ultram (tramadol) 50 mg 1-2 tabs po q 6hrs Lortab 2.5/500 (2.5mg hydrocodone/500 mg acetaminophen) Roxicet (5mg oxycodone/325 mg. acetaminophen)

1-2 tabs po q 4hrs 1-2 tabs po q 4hrs

Percocet 2.5/325, 5/325, 7.5/500 mg of oxycodone/acetaminophen 1-2 tabs po q 4hrs Vicodin (5mg hydorcodone/500 acetaminophen) Vicodin ES (7.5 hydrocodone/750 mg acetaminophen) Lortab 7.5/500 (7.5mg hdyrocodone/500 mg acetaminophen) Vicoprofen 7.5/200 (7.5 hydrocodone/200 ibuprofen)

NOTE: Maximum Daily Dose (MDD) of acetaminophen is 4000 mgs

1-2 tabs po q 4hrs 1-2 tabs po q 4hrs 1-2 tabs po q 4hrs 1-2 tabs po q 4hrs 1

260

Continue Non-Pharmacological Interventions

*Partial Relief / No relief: Pain Goal Not Met

REASSESS

4Review initial pain assessment for changes 4Analgesics given as ordered? 4Need to give before activities? 4Need for upward titration? 4Is time interval appropriate? 4Need for adjuvant meds?

*Partial Relief / No Relief : Pain Goal Not Met Last U

pdate 9/10

*Consult physician. Develop plan for ongoing communication with physician until patient’s pain goal is met. Consider initiation of Severe Pain Algorithm

© MCW Research Foundation 2000 Permission granted to modify or adopt provided written credit is given to the Medical College of Wisconsin.

Relief: Pain Goal Met

Continue interventions as above. Reassess at regular intervals. Titrate as needed. If pain is constant, convert to long acting drug at equianalgesic dose. (See Reference Information)

SEVERE PAIN

Pain Scale rating 4-5/5 (0-5 Scale) or 7-10/10 (0-10 Scale)

Complete Pain Assessment.

Establish probable cause of pain when possible. Determine goal for pain relief with patient and acceptable time frame for when relief will occur. Always combine pharmacological interventions with non-pharmacological interventions. ANALGESICS SHOULD NOT BE HELD UNTIL CAUSE OF PAIN IS DETERMINED.

Initiate Non-Pharmacological Interventions

Examples of Analgesic Choices Immediate Release, Short Acting Drugs (lowest dose available is listed) Note: There is no ceiling dose or maximum daily dose for these drugs morphine sulfate

Tabs 10 mg q 2-4hr po or sl Elixir 20mg/ml or 2mg/ml q 2-4 hrs po or sl Suppository 10 mg q 2-4 hrs pr Parenteral 1-2mg q 15-30 min SC or IV

oxycodone Tabs 5mg q 2-4 hrs po Elixir 5mg/ml or 20mg/ml q 2-4 hrs po

hydromorphone (Dilaudid) Suppository 3mg q 4 hrs pr

NOTE: Dilaudid 3mg suppository is equianalgesic to morphine sulfate 15 mg po or pr

Continue Non-Pharmacologic Interventions

1261

*Partial Relief / No Relief : Pain Goal Not Met

REASSESS

4Review initial pain assessment for changes 4Analgesics given as ordered 4Need for change to different opioid 4Need to change route of administration 4Need for upward titration

4Need for adjuvant drugs? 4Need to give before activities? 4Is time interval appropriate?

*Partial Relief / No Relief. Pain Goal Not Met. Consult with physician. Develop plan for ongoing communication with physician until patient’s pain goal is met. Last U

pdate 9/10

©MCW Research Foundation 2000 Permission granted to modify or adopt provided written credit is given to the Medical College of Wisconsin.

Relief: Pain Goal Met Reassess at regular intervals. Titrate as necessary to maintain pain control. If pain is constant convert to long acting drugs, at equianalgesic dose. (See Reference Information)

REFERENCE INFORMATION

Opiod Equivalency Table REFERENCE TABLE Equianalgesic doses are approximate. Individual patient Long Acting Drug Strength available Duration/Hr response must be observed. Caution: The doses listed ARE Oramorph SR(1) 15, 30, 60, 100 mg 8 - 12 NOT recommended starting doses MS Contin(1) 15, 30, 60, 100, 200mg 8 - 12 Kadian(2) 20, 50, 100 mg 12 - 24

Oxycontin(1,3) 10, 20, 40, 80, 160 mg 8 - 12 Short Acting Drugs Dose (mg) Parenteral

(mg) Oral Duration (hour) Duragesic (4) 25,50,75,100 mcg 48 – 72

morphine (MS soluble, MSIR) 1,2,3

10 30 2-4 1. Must be given as intact pills, cannot be crushed or used in G or J tubes.

2. Capsule may be opened and sprinkled in food. hydromorphine (Dilaudid) 1,2,3

1.5 7.5 2-4 3. Consult package insert for conversions ratios for short acting to long acting

oxycodone 4 30 2-4 opioids. hydrocodone 5 30 2-4 4. 24 hour po morphine dose ÷ 2=mcg/hr for the transdermal fentanyl patch (Duragesic)

1 Available as a liquid. 2 Available as a suppository. 3 May be used as an IV or subcutaneous infusion. 4 Percocet contains varying strengths of oxycodone and acetaminophen per tablet. (2.5/325, 5/325,7.5/500) Read label carefully. 5 Available only in combination with acetaminophen, ASA, or NSAID in tablet form; dosages range from 2.5-10.0 mg/tablet.

1262

ADJUVANT ANALGESICS STARING DOSE Anticonvulsants Gabapentin (Neurontin) po 100 mg q 8 hrs Clonazepam (Klonopin) po 0.5 mg q 8 hrs Carbamazepin (Tegretol) po 100 mg BID Antidepressants Despiramine (Norpramin) po 10 mg QHS Corticoteroids Dexamethasone (Decadron) po 2-8 mg BID Prednisone 40-80 po 40-80 mg daily

Last Upd

ate 9/10

© MCW Research Foundation 2000 Permission granted to modify or adopt provided written credit is given to the Medical College of Wisconsin.

1 No difficulty either subjectively or objectively.

2 Complains of forgetting location of objects. Subjective work difficulties.

3 Decreased job functioning evident to co-workers. Difficulty in traveling to

new locations. Decreased organizational capacity. *

4 Decreased ability to perform complex task, (e.g., planning dinner for guests, handling personal finances, such as forgetting to pay bills, etc.)

5 Requires assistance in choosing proper clothing to wear for the day, season or occasion, (e.g. pt may wear the same clothing repeatedly, unless super-vised.*

6 Occasionally or more frequently over the past weeks. * for the following

A) Improperly putting on clothes without assistance or cueing .

B) Unable to bathe properly ( not able to choose proper water temp)

C) Inability to handle mechanics of toileting (e.g., forget to flush the toilet,

does not wipe properly or properly dispose of toilet tissue)

D) Urinary incontinence

E) Fecal incontinence

7

A)Ability to speak limited to approximately ≤ 6 intelligible different words in the course of an average day or in the course of an intensive interview. B) Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview C) Ambulatory ability is lost (cannot walk without personal assistance.) D) Cannot sit up without assistance (e.g., the individual will fall over if there are not lateral rests [arms] on the chair.) E) Loss of ability to smile. F) Loss of ability to hold up head independently.

*Scored primarily on information obtained from a knowledgeable informant. Psychopharmacology Bulletin, 1988 24:653-659.

Functional Assessment Scale (FAST)

Palliative Performance Scale (PPS)

Functional Assessment Scale (FAST)

A hospice is a program designed to care for the dying and their special needs. Among these services all hospice pro-grams should include: (a) Control of pain and other symptoms through medica-tion, environmental adjustment and education. (b) Psychosocial support for both the patient and family, including all phases from diagnosis through bereavement. (c) Medical services commensurate with the needs of the patient. (d) Interdisciplinary "team" approach to patient care, patient/ and family support, and education. (e) Integration into existing facilities where possible. (f) Specially trained personnel with expertise in care of the dying and their families.

GENERAL (NON-SPECIFIC) TERMINAL ILLNESS 1. Terminal condition cannot be attributed to a single spe-cific illness. And 2. Rapid decline over past 3-6months Evidenced by: Progression of disease evidenced by sx, signs & test results Decline in PPS to ≤ 50% Involuntary weight loss >10% and/or Albumin <2.5 (helpful) ADULT FAILURE TO THRIVE Patient meets ALL of the following: • Palliative performance Scale ≤ 40% • BMI <22 • Pt refusing enteral or parenteral nutrition support or has not responded to such nutritional support, despite adequate caloric intake

CANCER Patient meets ALL of the following: 1.Clinical findings of malignany with widespread, aggressive or progressive disease as evidenced by increasing sx, wors-ening lab values and/or evidence of metastatic disease 2.Palliative performance Scale (PPS) ≤ 70% 3.Refuses further life-prolonging therapy OR continues to decline in spite of definitive therapy Supporting documentation includes: Hypercalcemia > 12 Cachexia or weight loss of 5% in past 3 months Recurrent disease after surgery/radiation/chemotherapy Signs and sx of advanced disease (e.g. nausea, requirement for transfusions, malignant ascites or pleural effusion, etc.) DEMENTIA The patient has both 1 and 2: 1. Stage 7C or beyond according to the FAST Scale AND 2. One or more of the following conditions in the 12 months: Aspiration pneumonia Pyelonephritis Septicemia Multiple pressure ulcers ( stage 3-4) Recurrent Fever Other significant condition that suggests a limited prognosis Inability to maintain sufficient fluid and calorie intake in the past 6months ( 10% weight loss or albumin < 2.5 gm/dl)

Hospice Eligibility Criteria

Hospice Card

1255 Last Update 9/10

http://geriatrics.uthscsa.edu/resources.asp

HEART DISEASE The patient has 1 and either 2 or 3. 1. CHF with NYHA Class IV* sx and both : Significant sx at rest Inability to carry out even minimal physi-cal activity without dyspnea or angina 2. Patient is optimally treated (ie diuretics, vasodilators, ACEI, or hydralazine and ni-trates) 3. The patient has angina pectoris at rest, resistant to stan-dard nitrate therapy, and is either not a candidate for/or has declined invasive procedures. Supporting documentation includes: EF ≤ 20%, Treatment resistant symptomatic dysrythmias h/o cardiac related syncope, CVA 2/2 cardiac embolism H/o cardiac resuscitation, concomitant HIV disease HIV/AIDS The patient has either 1A or 1B and 2 and 3. 1A. CD4+ < 25 cells/mcL OR 1B. Viral load > 100,000 AND 2. At least one (1) : CNS lymphoma, untreated or refrac-tory wasting (loss of > 33% lean body mass), (MAC) bac-teremia, Progressive multifocal leukoencephalopathy Systemic lymphoma , visceral KS, Renal failure no HD, Cryptosporidium infection, Refractory toxoplasmosis AND 3. PPS* of < 50% LIVER DISEASE The patient has both 1 and 2. 1. End stage liver disease as demonstrated by A or B, & C: A. PT> 5 sec OR B. INR > 1.5 AND C. Serum albumin <2.5 gm / dl AND 2. One or more of the following conditions: Refractory Ascites, h/o spontaneous bacterial peritonitis, Hepatorenal syndrome , refrac-tory hepatic encephalopathy, h/o recurrent variceal bleed-ing Supporting Documents includes: Progressive malnutrition, Muscle wasting with dec. strength. Ongoing alcoholism (> 80 gm ethanol/day), Hepatocellular CA HBsAg positive, Hep. C refractory to treatment PULMONARY DISEASE Severe chronic lung disease as documented by 1, 2, and 3. 1. The patient has all of the following: Disabling dyspnea at rest Little of no response to bronchodilators Decreased functional capacity (e.g. bed to chair existence, fatigue and cough) AND 2. Progression of disease as evidenced by a recent h/o increasing office, home, or ED visits and/or hospitalizations for pulmonary infection and/or respiratory failure. AND 3. Documentation within the past 3 months ≥1: Hypoxemia at rest on room air (p02 < 55 mmHg by ABG) or oxygen saturation < 88% Hypercapnia evidenced by pC02 > 50 mmHg Supporting documentation includes: Cor pulmonal and right heart failure Unintentional progressive weight loss

NEUROLOGIC DISEASE (chronic degenerative con-ditions such as ALS, Parkinson’s, Muscular Dystro-phy, Myasthenia Gravis or Multiple Sclerosis) The patient must meet at least one of the following criteria (1 or 2A or 2B): 1. Critically impaired breathing capacity, with all: Dyspnea at rest, Vital capacity < 30%, Need O2 at rest, patient refuses artificial ventilation OR 2. Rapid disease progression with either A or B below: Progression from : independent ambulation to wheelchair or bed-bound status normal to barely intelligible or unintelligible speech normal to pureed diet independence in most ADLs to needing major assistance in all ADLs AND A. Critical nutritional impairment demonstrated by all of the following in the preceding 12 months: Oral intake of nutrients and fluids insufficient to sustain life Continuing weight loss Dehydration or hypovolemia Absence of artificial feeding methods OR B. Life-threatening complications in the past 12 months as demonstrated by ≥1: Recurrent aspiration pneumonia, Pyelonephritis, Sepsis, Recurrent fever, Stage 3 or 4 pressure ulcer(s RENAL FAILURE The patient has 1, 2, and 3. 1. The pat is not seeking dialysis or renal transplant AND 2. Creatinine clearance* is < 10 cc/min (<15 for diabetics) AND 3. Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetics) Supporting documentation for chronic renal failure in-cludes: Uremia, Oliguria (urine output < 400 cc in 24 hours), Intractable hyperkalemia (> 7.0), Uremic pericar-ditis, Hepatorenal syndrome, Intractable fluid overload. Supporting documentation for acute renal failure includes: Mechanical ventilation, Malignancy (other organ system) Chronic lung disease, Advanced cardiac disease, Advanced liver disease STROKE OR COMA The patient has both 1 and 2. 1. Poor functional status PPS* ≤ 40% AND 2. Poor nutritional status with inability to main-tain sufficient fluid and calorie intake with ≥1 of the following: ≥ 10% weight loss in past 6 months ≥7.5% weight loss in past 3 months Serum albumin <2.5 gm/dl Current history of pulmonary aspiration without effective response to speech therapy interventions to improve dysphagia and decrease aspiration events Supporting documentation includes: Coma (any etiology) with 3 of the following on the third (3rd) day of coma: Abnormal brain stem response Absent verbal responses Absent withdrawal response to pain Serum creatinine > 1.5 gm/dl



Hospice And Palliative Care – Appendix C-BLANK

Strength of Evidence Level: Blank

Hospice And Palliative Care – Appendix D-BLANK

Strength of Evidence Level: Blank

Hospice And Palliative Care – Appendix E – Pain Assessment Materials SECTION: 23

__RN__LPN/LVN__HHA


Hospice And Palliative Care – Appendix E – Pain Assessment Materials SECTION: 23

__RN__LPN/LVN__HHA

WHO’s Pain Ladder A three-step “ladder” developed for cancer pain relief

If pain occurs, there should be prompt oral administration of drugs in the following order: • Nonopioids (aspirin and paracetamol); then as necessary, • Mild opioids (codeine); then • Strong opioids (morphine) until the patient free of pain. To calm fears and anxiety, additional drugs – “adjuvants” – should be used. To maintain freedom form pain, drugs should be given “by the clock”, that is every 3-6 hours, rather than “on demand”. This tree-step approach of administering the right drug in the right dose at the right time is time inexpensive and 80-90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.


STEPS BOWEL REGIMENS

1 Docusate100 mg po bid+Senna 1tab qd/bid 2

Docusate100 mg po bid + Senna 2 tab bid

3

Docusate100 mg po bid + Senna 3 tab bid

4

Docusate100 mg po bid + Senna 4 tab bid Plus Lactulose or Sorbitol 15 cc po bid

5 Docusate100 mg po bid + Senna 4 tab bid Plus Lactulose or Sorbitol 30 cc po bid

6 Docusate100 mg po bid + Senna 4 tab bid Plus Lactulose or Sorbitol 30 cc po bid

Sanchez-Reilly/Ross 2008©

Nausea and vomiting * Change route Add anti-nausea ↓ opioid dose (by 10-25%) Add or ↑ the nonopioid analgesic for additional pain relief Switch to another analgesic Itching, Pruritus * ↓ opioid dose Consider antipruritic ( antihistamininc) Change route, switch analgesic Sedation* Evaluate the underlying cause Eliminate nonessential CNS-acting drugs ↑ dosing frequency with a lower opioid dose to decrease peak serum concentration ↓ opioid dose (by 10-25%) & Add or increase the nonopioid analgesic for additional pain relief If excessive sedation persists, switch opioid Respiratory depression* Monitor sedation level and respiratory status Evaluate the underlying cause ↓ opioid dose, ↑ interval Stop medication If patient is unresponsive to stimulation, respiration's are shallow or < 8 breaths/min or pupils are pinpoint, stop opioid administration and administer Naloxone (NarcanTM) To minimize opioid withdrawal symptoms (agitation, fever, emesis and pain) when Naloxone is needed. *dilute Naloxone 1 vial (0.4mg) in 10cc NS *administer 1 cc /min of diluted Naloxone Constipation¶ Manage Constipation prophylactically With few exceptions all patients on opioid therapy need an individualized bowel regimen (including a stool softener and mild stimulant laxative). See some suggested bowel regi-mens below. If the patient has not been on a bowel regimen then step 1 should be started. If there is no response in 24 hrs move to next step Polyethylene Glycol (Miralax TM), Naltrexone may be useful in managing Opioid induced constipation Maintain a high index of suspicion for the possibility of bowel obstruction/ fecal impaction.Rule out impactation with rectal examination or abdominal x-ray when clinical suspicion exist. Rectal disimpaction must occur before treating constipation with an oral laxative regimen

¶ Tolerance does not occur over time *Tolerance occurs over time to this symptom

Preventing & Managing Opioid Side Effects Pain Management Guide UTHSCSA/STVHCS

Pain

Sca

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UCL

A An

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logy

Dep

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ent

1. ASSESS PAIN: •Use the pain scale, Ask the patient. •Pain intensity, location, onset, duration, relieving or exacer-bating factors, quality (sharp, dull throbbing ) •If the patient is unable to communicate, assess pain based on behavioral cues. Such as facial grimacing, guarding an area of the body, crying, moaning, decrease in social inter-action, aggression, increase in body movements, irritability, confusion •Assess pain at each clinical interview, every 8 hrs, and PRN (at least every 1 hr for moderate to severe pain). •The cause of pain must always be properly addressed 2. PAIN TREATMENT •When the pain is not expected to resolve shortly, medications should be administered around the clock and additional prn doses should be available. •Patients who are already taking opioids will require higher doses to control new or worsening pain. • For Moderate-Severe pain use Short acting opioids •Only start long acting preparations of opioids after pain has been controlled on short acting opioids. •Never use long acting opioids for controlling acute pain •There is no maximum or ceiling dose for analgesia with opioids unless the opioid is in combination with acetaminophen or aspirin.



Equianalgesic Table : Changing OpioidOpioid agonist Oral/rectal mg IV/SC mg IV to

PO These aduce apTitratiopatientsdoses, t CONVE1mcg/hr25mcgr/ Oxycod(Percoce PREVEWhen coby 25-50(may ne OPIOIDMeperidbecauseMixed awith agopsychotoPropox OPIOIDMethadthe use 3-7 days

Morphine 30 10 3 Oxycodone 20 N/A Hydromorphone 7.5 1.5 5

Codeine 200 120 (IM) Hydrocodone 30 N/A N/A Oxymorphone 10 1 Fentanyl1 N/A 100mcgr

single dose

Methadone 2 1-20 1-10 1.5 Codeine 200 130 1.5

Equianalgesic Dose Conversion Formula

TREAT PAIN ACCORDING TO SEVERITY MILD PAIN: Acetaminophen 650-1000 mg po q 6hrs Ibuprofen 200-800mg po q 6 hrs MODERATE PAIN: Acetaminophen with oxycodone 5-10mg q 4hr Acetaminophen with codeine 30-60mg po q 4hr Maximum acetaminophen daily: *4gr/day adult, 3gr/day elderly, 2gr/day liver disease SEVERE PAIN: If the pain persists or increases despite the above meas-ures the patient should be re-evaluated.

Morphine 15-30 mg po q 3hrs or Hydromorphone 4-8 mg po q 3hr continue NSAID or Acetaminophen unless contraindicated If the pain is severe, strongly consider parenteral opioids repeated every 15- 30 minutes until the pain is controlled. Opioids dosing for the average adults are: *morphine 5-10 mg IV/SQ OR *hydromorphone 0.5-1.5 mg IV/SQ 3. OPIOID MEDICATIONS OPIODS FORMULATIONS Short acting opioids: Morphine, Hydromorphone, Codeine, Hydrocodone, Oxycodone Effect 5-15 min (IV) and 1 hrs (oral/rectal) Duration 3-4 hrs (oral/rectal) Dosing Can be increased q 2hrs Long acting preparations of opioids: sustained release morphine, sustained release oxycodone (duration 8-12 hr) Dosing Can be increased q 24hrs or transdermal Fentanyl patch (duration 48-72hr) Dosing Can be adjusted q 72hrs

Equianalgesic dose (route) current opioid

Equianalgesic dose (route) Desired opioid

24hr dose(route) current opioid

24hr dose (route) Desired opioid

=

d Administration Routes or Agents: are NOT suggested starting doses; these are doses of opioids that pro-pproximately the same amount of analgesia. on to clinical response is necessary. Recommended doses do not apply to with renal or hepatic insufficiency. Elderly patients generally require lower itrated slowly to the desired effect or intolerable side effects.

RTING TO/FROM FENTANYL PATCH r fentanyl transdermal ≈ 2mg total oral morphine/day /fentanyl transdermal ≈ 9 tabs per day of: done 5mgAPAP 325mg, Hydrocodone5mg/APAP500 ,Codeine 30mg/APAP et TM) (Lortab5TM) (Tylenol #3TM)

ENTING CROSS TOLERANCE onverting from one opioid to another decrease the equianalgesic dose 0% to allow for incomplete cross-tolerance between different opioids. eed to titrate rapidly to an analgesic dose within the first 24 hrs).

DS NOT RECOMMENDED FOR USE dine SHOULD NOT BE USED in older adults or patients with renal failure

e of CNS toxic metabolites. Contraindicated with MAOIs. agonist/ antagonist (pentazocine, butorphanol, nalbuphine) : compete onists leading to withdrawal. analgesic ceiling effect. high risk of omimetic adverse effects

xyphene: no better than placebo. toxic metabolite at high doses.

DS SPECIAL PRECAUTIONS done :Variable pharmacodynamic and pharmacokinetic effects complicate of methadone for analgesia. Symptoms of overdose may be delayed s after starting or increasing Methadone. Escalate methadone q4-7 days

OPIOIDS TITRATION •For moderate pain: titrate at least every 24hrs •For severe pain: titrate every 2 hrs •Increase opioids depending on pain level Mild-mod pain: dose 25-50% Mod-severe pain: dose 50-100% OPIOIDS AND BREAKTHROUGH PAIN •For acute pain in patients with otherwise controlled pain use short acting opioids. •Breakthrough dose is about 10 % of the 24hr standing opioid dose (scheduled dose) •Make breakthrough dose available every 1-2hrs •Example:pt on long acting Morphine 60 mg po q 12 hrs. the breakthrough dose would be 15 mg po q 1hr prn FENTANYL Indicated for patients with persistent, moderate to severe chronic pain who have been taking a regular, daily, around-the-clock opioid pain medicine for >1 week and are considered to be opioid-tolerant •For dosages of Fentanyl patch >100μg/hr multiple patches can be used

•Patch duration 48-72 hrs .It takes 12-24 hrs before achieving full analgesic effect after the 1st patch

•Prescribe a short acting opioid for breakthrough pain. •Increase the patch dose based on the average amount of additional short acting opioid required 72 hrs prior. PATIENT CONTROLLED ANALGESIA (PCA) Safe & effective way of delivering opioids for pain that is expected to resolve( post op pain) or Acute exacerbation of chronic pain. Patient self delivers fixed Opioid dose by press-ing a button. Overdose infrequent as patient has to be alert to press the button. Safe starting PCA Dose for average Adult * Morphine 1 mg every 10 minutes or * Hydromorphone 0.25mg every 10 minutes Use a continuous Opioid infusion for patients who are suffering from pain not expected to resolve shortly.

