PAIN / SYMPTOM ASSESSMENT HISTORY FOR EACH PAIN / SYMPTOM

BEHAVIORAL CHANGES

1. Location

Activities, eating, sleeping, mood,

2. Description Nociceptive, e.g., aching, throbbing Neuropathic, e.g., burning, shooting, stabbing, electrical, numbness Associated allodynia or hyperalgesia

PSYCHOLOGICAL, SOCIAL, SPIRITUAL FACTORS Anxiety, depression, Family or other social stresses, burdens

Mixed

Meaning and value, why me?

3. Change over time (Temporal profile)

PHYSICAL EXAM Constant

Breakthrough

Intermittent Acute

At rest, on movement, on palpation

4. Severity (0 - 10) 5. Effect of medications, other therapies Beneficial, adverse/side effects

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

A1A

ASSESS EVERY VISIT: THE 4Ps PAIN Are you having pain or discomfort? Check if yes. Location: Where? Description: What does it feel like? (e.g. stabbing, dull, throbbing…) Severity: On a scale of 0 to 10 with 0 being "no pain" and 10 being "the worst possible pain", how severe is your pain now? Change over time: Has it been better or worse in the last 24 hours? Effects: What medications or treatment have you taken for pain in the last 24 hours? Have you had any effects you do not like?

PILLS Pills / prescriptions renewed / refilled? How are you taking your medications? How are they working for you? What adverse effects have you noticed? What concerns or questions do you have about your medications?

POOP ( CONSTIPATION ) Describe your bowel movements Frequency / Regularity Comfort / Straining

Quality (small, medium, large) Quality (hard, soft, diarrhea) Sensation of incomplete evacuation/obstruction

Do you have difficulty passing stool? What do you take to help your bowels?

PROBLEMS What other problems are you having? What questions do you have? COMMUNICATE ISSUES OF CONCERN TO THE CARE TEAM. DO NOT FORGET TO DOCUMENT THE OUTCOME OF THE 4 Ps. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

A1B

SEVERITY ASSESSMENT SCALES NONE

0

WORST

1

2

3

4

5

6

7

8

9

10

None

Annoying

Uncomfortable

Distressing

Horrible

Unbearable

NONE

LITTLE BIT

LITTLE MORE

EVEN MORE

WHOLE LOT

WORST

FACES

VERBAL

VISUAL

THE WONG-BAKER FACES PAIN RATING SCALE

FACES from Hockenberry MJ, Wilson D, Winkelstein ML: Wong’s Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. ©, Mosby. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

A2A

PAIN ASSESSMENT IN THE COGNITIVELY IMPAIRED ( PAINAD ) ITEMS*

0

Breathing independent None of vocalization

1

2

SCORE

Occasional labored breathing. Short period of hyperventilation.

Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations

Occasional moaning or groaning. Low level speech with a negative or disapproving quality.

Repeated troubled, calling out. Loud moaning or groaning. Crying.

Negative Vocalization

None

Facial Expression

Smiling/inexpressive

Sad. Frightened. Frowning.

Facial grimacing.

Body Language

Relaxed

Tense. Distressed pacing. Fidgeting.

Rigid. Fists clenched. 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 The PAINAD was developed and tested by clinicians and researchers at the New England Geriatric Research Education and Clinical Center, a Department of Veterans Affairs center of excellence with divisions at EN Rogers Memorial Veterans Hospital, Bedford, MA, and VA Boston Health System. Used with permission. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

A2B

SBAR REPORT TO PHYSICIAN

S

SITUATION To get attention & convey immediate need, provide a brief description.

B

BACKGROUND Sets the context Only the facts & circumstances relevant to this situation

This is: (identify yourself) I am calling about: (patient name) ______________________________ ID#: ________ Age: ________ Sex: ________ The patient’s primary physician is: (and why you have not gotten orders from this doctor) ____________________ The hospice diagnosis is: _______________________________________________________________________________ The patient’s other active medical conditions are: _________________________________________________________ Patient lives at: (home, long-term care facility, hospital, other) ______________________________________________ The patient’s code status is: __________________________________________________________________ The problem I am calling about is: (e.g. Patient has pain out of control; Pulse because it is irregular) _________ I have just assessed the patient personally: ______ Recent changes in the patient’s condition are: ______________ The patient’s mental status is: (e.g., Alert and oriented to person, place, and time; Confused; Non-responsive, etc.) Which < is or is not > typical for this patient. Vital signs are: Temperature ________, Pulse ________, Respiration ________ , and Blood pressure ________ Other significant symptoms and findings are: __________________________ The patient is allergic to: ______ ______ ________________________________ The patient < is or is not > on oxygen. (Liter flow, continuous/intermittent, via nasal cannula or mask or ?) ________ The patient is on the following medications: (List RELEVANT medications, but know all of them if asked) ______ The patient has < no or the following > parenteral access: (CADD Pump, IV, PICC line, Central line, Port-A-Cath, etc.) _____________________________ The patient a pacemaker (if present is it also a defibrillator, is feature active?) __________ Goals of Care (GOC) _________________________________________________

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

A3A

SBAR REPORT TO PHYSICIAN

A

ASSESSMENT

I think the problem is: (say what you think is the problem) _________________________________________________ Or I am not sure what the problem is but the patient is deteriorating. Or The patient seems to be unstable and may get worse, we need to do something.

Specifically what you think the problem is.

R

RECOMMENDATION What you suggest/ recommend be done Be specific

To prevent multiple calls, before you contact the physician, please consider and ask for ALL orders you may need, in addition to the primary reason for the call: (Medication refills needed?; Additional medical equipment?; Change in bowel regimen? etc.) ________________________________________________________________________ I suggest or request that you: (say what you would like to see done for the primary problem) ___________________ If calling a physician who gives a response similar to “Do what you think is best,” remember that a nurse may not prescribe. You may recommend (“I suggest we increase the Morphine from 5 mg an hour to 10 mg an hour prn breakthrough pain, is that OK“) or you may say (“If you like I will call one of our Hospice physicians for recommendations. Would you like me to call you back for approval or should I tell our physician you would like them to order?”) Do you have any questions for me? I can be contacted at (phone number); my shift ends at __________________ Obtain Physician Orders & Document If a change in treatment is ordered then ask: “If the patient does not improve, when would you want us to call again?”

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

A3B

CHOOSING AN ANALGESIC WHO 3-STEP LADDER When first starting an analgesic, choose one based on the severity of the patient’s pain. Within a step, choose the analgesics most appropriate for each patient:

3 severe (7-10) Morphine

Severity 1-3 4-6 7 - 10

Start at Step 1 2 3

2 moderate (4-6) Codeine

1 mild (1-3) Acetaminophen / Paracetamol

Tramadol A / Codeine

Fentanyl Hydromorphone Methadone Oxycodone + _ Adjuvants

A / Hydrocodone

ASA / NSAIDs

A / Oxycodone

+ _ Adjuvants

+ _ Adjuvants

(Propoxyphene not recommended)

(Meperidine/pethidine & pentazocine not recommended)

A = Acetaminophen / Paracetamol ASA = Acetylsalicylic Acid NSAID = Non-steroidal Antiinflammatory

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

P1A

DOSING – FIRST ORDER KINETICS Immediate-release codeine, dihydrocodeine, fentanyl, hydrocodone, hydromorphone, morphine, oxycodone, all follow first-order kinetics, e.g., steady-state serum drug concentrations change proportionally with dosing.

PLASMA CONCENTRATION

IV

• For constant pain / symptom, dose once every half-life t½; steady state is reached after 5 half-lives • For breakthrough or intermittent acute pain / symptom, dose once every time to maximum concentration tCmax as needed:

SC / IM

Cmax

PO / PR: provide 10% of 24 hrs dose q 60 min prn

PO / PR

SC / IV infusions: provide 50% of 1 hr dose q 30 min SC prn or q 15 min IV prn • Once pain is controlled, convert routine doses to extended-release formulations

0

tCmax

HALF-LIFE ( t½

)

Time

Opioids

tCmax

t½

IV: SC / IM: PO / PR:

15 min 30 min 60 min

4 hrs 4 hrs 4 hrs

See Medication Kinetic Parameter cards for other tCmax and t½ NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

P1B

EQUIANALGESIC DOSING GUIDELINE FOR CHRONIC PAIN CHANGING ROUTES OF ADMINISTRATION PO / PR 3

IV / SC / IM :

1

METHADONE

Epidural :

0.1

Intrathecal :

0.01

CHANGING ANALGESICS OPIOIDS Oral / Rectal Dose (mg)

Analgesic

Parenteral SC / IV / IM Dose (mg)

150 150 150 15 15 10 5 3 2 -

Meperidine Tramadol Codeine Hydrocodone Morphine Oxycodone Oxymorphone Hydromorphone Levorphanol Fentanyl

50 50 5 1 1 0.050 mg*

*1000 mcg = 1 mg; must convert to mg to calculate equianalgesic dose

TRANSDERMAL FENTANYL Morphine 50 mg PO in 24 hrs

≈ Fentanyl 25 mcg transdermal patch q 72 hrs

Daily Morphine Dose (mg/24 hrs PO) 1001

Conversion Ratios Morphine Methadone PO PO 3 5 10 12 15 20

: : : : : :

1 1 1 1 1 1

METHADONE SC / IV DOSING 1. Convert from daily Morphine Equivalent PO Dose/24 hrs to Methadone PO Dose/24 hrs using the Methadone PO Dosing Table above 2. Then ÷ 3 to convert to Methadone SC Dose/24 hrs

ADJUSTING FOR INCOMPLETE CROSS TOLERANCE Poor Moderate Excellent

100% 75% 50%

Ferris FD and Pirrello RD: Improving Equianalgesic Dosing for Chronic Pain Management, American Association for Cancer Education Annual Meeting, oral presentation, Cincinnati, Ohio, September 2005. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

P2A

EQUIANALGESIC DOSING GUIDELINE FOR CHRONIC PAIN COMBINATION PRODUCTS Acetaminophen 325 mg + Codeine 30 mg PO (aka Tylenol #3)

≈

Morphine 3-4 mg PO

Acetaminophen 500 mg + Hydrocodone 5 mg PO (aka Vicodin)

≈

Morphine 5-6 mg PO

Acetaminophen 325 mg + Oxycodone 5 mg PO (aka Percocet)

≈

Morphine 7-8 mg PO

CALCULATION FORMULA To convert from one analgesic/route of administration to another analgesic/route of administration:

X mg analgesic 1/route 1 Y mg analgesic 2/route 2

=

analgesic 1/route 1 value from table analgesic 2/route 2 value from table

EXAMPLE To calculate the dose of morphine PO q 4 hrs equivalent to hydromorphone 2 mg/hr IV (without adjusting for incomplete cross-tolerance):

1. Calculate the total dose of hydromorphone q 24 hrs = 2 x 24 = 48 mg q 24 hrs 2. Convert to an equianalgesic dose of morphine PO q 24 hrs: X mg morphine PO Y mg hydromorphone IV

=

15 for morphine PO 1 for hydromorphone IV

X mg morphine PO 48 mg hydromorphone IV

=

15 1

X mg morphine PO = 48 x 15 = 720 mg morphine PO q 24 hrs 3. Calculate the dose q 4 hrs = 720/6 = 120 mg morphine PO q 4 hrs NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

P2B

COMMON ORAL / TRANSDERMAL OPIOID ANALGESICS IN USA OPIOID

FORM

STRENGTH

Fentanyl (e.g., Actiq, Duragesic)

Transmucosal

200, 400, 600, 800, 1200, 1600 mcg

Transdermal Patches

12 (delivers 12.5), 25, 50, 75, 100 mcg

Hydromorphone (e.g., Dilaudid)

Oral Solution

1 mg/mL

Suppository

3 mg

Tablets (IR)

2, 4, 8 mg

Oral Solution

1, 2, 10 mg/mL

Tablets

5, 10, 40 mg (in US, 40 mg only for methadone maintenance)

Oral Solution

2, 4, 20 mg/mL

Tablets (ER q 12 hrs)

15, 30, 60, 100, 200 mg

Tablets (ER q 24 hrs)

Kadian: 10, 20, 30, 50, 60, 80, 100, 150, 200 mg Avinza: 30, 45, 60, 75, 90, 120 mg

Tablets IR

10, 15, 30 mg

Oral Solution

1, 20 mg/mL, 5 mg/mL

Tablets (ER q 12 hrs)

10, 15, 20, 30, 40, 60, 80 mg

Tablets (IR)

5, 10, 15 mg

Tablets (ER q 12 hrs)

7.5, 10, 15, 20, 30, 40 mg

Tablets (IR)

5,10 mg

Methadone Morphine (e.g., Avinza, Kadian, MS-Contin, MS-IR, Roxanol)

Oxycodone (e.g., OxyContin, Oxydose, OxyFAST, OxyIR, Roxicodone) Oxymorphone (Opana) IR = Immediate Release ER = Extended Release

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

P3A

OPIOID COST RATIO CALCULATOR PARENTERAL OPIOIDS

EQUIANALGESIC DOSE*

QUANTITY ( 1 MONTH SUPPLY )

RELATIVE COST INDEX**

Fentanyl

8.3 mcg/hr

50 mcg/mL - 2.5 x 50 mL

1.1

Hydromorphone

0.17 mg/hr

1 mg/mL - 2.5 x 50 mL

10.3

Methadone

0.28 mg/hr

1 mg/mL - 2 x 50 mL

11.6

Morphine

0.83 mg/hr

1 mg/mL - 12 x 50 mL

4.0

Sufentanil

0.7 mcg/hr

50 mcg/mL - 2 x 5 mL

1.6

EQUIANALGESIC DOSE*

QUANTITY ( 1 MONTH SUPPLY )

RELATIVE COST INDEX**

25 mcg q 72 hrs

# 10 (Duragesic)

27.7

# 10 (generic)

4.4

ORAL / TRANSDERMAL OPIOIDS Fentanyl Hydromorphone

2 mg q 4 hrs

# 180 (generic-IR)

1.5

Methadone

7.5 mg q 8 hrs

# 90 x 10mg (generic)

0.8

Morphine

10 mg q 4 hrs

# 120 x 15mg (generic IR tabs)

1.0

10 mg q 4 hrs

90 mL (20 mg/mL elixir)

2.4

# 60 (generic-ER)

1.7

# 60 (MS Contin)

16.1

60 mg q 24 hrs

# 30 (Kadian)

23.3

Oxycodone

20 mg q 12 hrs

# 60 (OxyContin)

24.3

Oxymorphone

10 mg q 12 hrs

# 60 (Opana)

24.1

30 mg q 12 hrs

* Equianalgesic dose relative to Morphine 10 mg PO q 4 h. ** Relative cost in USA for a one-month supply as of January 2013 compared to Morphine PO. Visit IPCRC.net to download a customizable Excel opioid cost ratio calculator.

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

P3B

NEUROPATHIC PAIN MANAGEMENT DEFINITION Delayed-ongoing response to nerve damage that is no longer acute but which continues to be expressed as painful sensations

DESCRIPTION Electric shock, burning, tingling, cold, stabbing, itching May be associated numbness

SYMPTOMS AND SIGNS ALLODYNIA - pain to non-painful stimuli, e.g. light touch, e.g., bedding, clothing

HYPERALGESIA - exaggerated response to painful stimuli ANESTHESIA - loss of normal sensation DYSESTHESIA - unpleasant abnormal sensation HYPOESTHESIA - reduction of normal sensation, e.g., loss of sensation in diabetic feet PARESTHESIAS - non-painful spontaneous abnormal sensation, e.g. tingling in diabetic feet PHANTOM PAIN - pain from site removed REFERRED PAIN - pain in region remote from source, e.g., shooting pain down limb from nerve root compression

ASSESSMENT & TREATMENT Similar mechanism, various etiologies. Conceptualize neurotransmitters and channels. Select medications. Do not overlap mechanisms of action. Titrate to effect. Combine medications from different classes. Evidence base: medications with greatest net benefit include opioids, gabapentin/pregabalin, tricyclics, SNRIs, lidocaine and ketamine.

Galluzzi KE. Managing Neuropathic Pain. JAOA 2007; 107(11) 56: ES 39-48. Used with permission. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

P4A

NEUROPATHIC PAIN MANAGEMENT DOSING Listed therapeutic range. Start low and titrate up slowly over weeks.

OPIOIDS Opioid dosing is based on all the pain assessment and management cards

ANTIEPILEPTIC DRUGS

STRONG MU AGONIST

Ca2+ CHANNEL BLOCKADE Gabapentin 900-3600 mg PO/24 hrs div q 8 hrs Pregabalin 200-600 mg PO/24 hrs div q 8-12 hrs Na+ CHANNEL BLOCKADE CarbamazepineD 800-1200 mg PO/24 hrs div q 8-12 hrs Na+/Ca2+ CHANNEL BLOCKADE LamotrigineN 200-400 mg PO/24 hrs div q 12 hrs TopiramateN 200-400 mg PO/24 hrs div q 12 hrs OTHER Levetiracetam 1000-3000 mg PO/IV/24 hrs div q 12 hrs Valproic acidD 1000-2000 mg PO/IV daily or div q 12 hrs

Morphine Oxycodone Fentanyl Hydromorphone MethadoneN (mu and NMDA receptor antagonist)

STRONG KAPPA AGONIST

WEAK MU AGONIST (WITH 5HT/NE REUPTAKE INHIBITION) Tramadol 100-400 mg PO/24 hrs div q 6 h Tramadol ER 100-300 mg PO daily Tramadol / Acetaminophen (37.5mg/325mg) 4-8 tablets PO/24 hrs div q 6 h

SNRI Venlafaxine 37.5-225mg daily PO Duloxetine 60-120mg daily PO

TRICYCLICS

LIDOCAINE

TERTIARY AMINE (MORE SEDATING) Amitriptyline 10-150 mg PO daily Imipramine 10-150 mg PO daily SECONDARY AMINE (LESS SEDATING, PREFERRED) Nortriptyline 10-100 mg PO daily (amitriptyline metabolite) Desipramine 10-150 mg PO daily (imipramine metabolite)

• Lidocaine 5% patch: Apply 1-3 patches daily (local effect only) • Lidocaine IV (2 gm/500 mL)D • Loading dose: 2 mg/kg IV over 15-20 min • Then start continuous infusion at 1 mg/kg/hr • Check Lidocaine plasma level 8-10 hrs after start of infusion, target level 2-6 mcg/mL N

= NMDA receptor antagonism div = In divided doses

D

= Monitor drug levels for toxicity J. Mangham, PharmD 6/08

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

P4B

NAUSEA MANAGEMENT Assessment: Conceptualize Underlying Causes: 13 "M's" of Emesis Above Neck

1. Masses 2. Meningeal Irritation 3. Migraine / other headaches 4. Movement

Causes Above Neck 1. Masses

2. Meningeal Irritation

Below Neck 5. 6. 7. 8. 9.

Motility Mucositis Mechanical obstruction Myocardial infarction Maternity

Systemic 10. 11. 12. 13.

Mentation Medication Microbes Metabolic

Treat Underlying Cause

Treat Nausea

• Dexamethasone to  inflammation / edema • If tumor, treat to  mass effect • If fluid collection, drain fluid

CTZ: 1. Dexamethasone 2. DA antagonist 3. H1 antagonist

• Dexamethasone to  inflammation / edema • If a tumor, treat to  mass effect

CTZ: 1. Dexamethasone 2. DA antagonist 3. H1 antagonist

3. Migraine or other headache

Treat headache to  pain, associated symptoms

CTZ: 1. DA antagonist 2. H1 antagonist

4. MovementVestibular stimulation

•  motion • Treat inner ear infections •  or stop offending medications

CTZ: 1. DA antagonist 2. H1 antagonist

Management 1. Treat underlying cause 2. Treat experience of nausea Conceptualize likely neurotransmitters. Dopamine antagonists are first choice. Titrate to effect using tCmax. Add medications from different classes. Do not overlap mechanisms of action. Causes Below Neck 5. Motility

Treat Underlying Cause

Treat Nausea

If due to medications: •  or stop responsible medications •  motility with prokinetic medication •  opioid inhibition of bowel function with methylnaltrexone

CTZ: 1. DA antagonist 2. H1 antagonist

If due to gastroparesis, e.g., Diabetes:  motility with prokinetic medication

CTZ: 1. DA antagonist 2. H1 antagonist

CTZ: Chemo Trigger Zone

Adapted from Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J. EPEC-O: Education in Palliative and End-of-life Care for Oncology. © The EPEC Project,™ Chicago, IL, 2005. Open Access at www. IPCRC.net. Wood GJ, Shega JW, Lynch B, Von Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life. JAMA 2007; 298(10): 1196-1207. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

N1A

NAUSEA MANAGEMENT Causes Below Neck

Treat Underlying Cause

Treat Nausea

If due to gastric H+;  gastric pH with: • Liquid antacid • H2 blocker • Proton Pump Inhibitor

6. Mucositis

If due to ASA or NSAIDs ( Prostaglandin E  relative ischemia   mucous production): • Ensure well hydrated • Misoprostol (Prostaglandin E analogue) to perfusion • Proton Pump Inhibitor to  gastric pH

CTZ: 1. DA antagonist 2. H1 antagonist

Causes Below Neck

Treat Underlying Cause

Treat Nausea

7. Mechanical obstruction (continued)

If extraluminal compression, e.g., adhesions, tumor: • Dexamethasone to  inflammation / edema • If tumor, treat to  mass effect • Surgery to stent or bypass • Octreotide to  intestinal volume

CTZ: 1. DA antagonist 2. H1 antagonist

8. Myocardial Infarction

• Nitrates to  angina • Optimize oxygenation / cardiac perfusion • Opioid analgesics to  intractable pain

CTZ: 1. DA antagonist 2. H1 antagonist

If due to infection, e.g., H. Pylori, Candida, CMV, Herpetic  gastric erosions: • Treat infection •  gastric pH with H2 blocker or Proton Pump Inhibitor

7. Mechanical obstruction

If intraluminal obstruction, e.g., constipation obstipation: • Relieve impaction with enemas, disimpaction •  constipation with stimulant ± osmotic laxatives

If 1st trimester,  estrogen / progesterone   gastric emptying: • Eat small, frequent low-fat meals 9. Maternity CTZ: 1. DA antagonist 2. H1 antagonist

If 3rd trimester, mass effect  mechanical obstruction of bowel: • Reposition • Keep stool soft / moving with stimulant ± osmotic laxatives

——————

Adapted from Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J. EPEC-O: Education in Palliative and End-of-life Care for Oncology. © The EPEC Project,™ Chicago, IL, 2005. Open Access at www. IPCRC.net. Wood GJ, Shega JW, Lynch B, Von Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life. JAMA 2007; 298(10): 1196-1207. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

N1B

NAUSEA MANAGEMENT Systemic Causes 10. Mentation, e.g., anxiety, stress

11. Medications/ Treatments

12. Microbes

Treat Underlying Cause

Treat Nausea

Supportive care to reduce anxiety, underlying stress: • Behavior modification • Guided imagery • Hypnosis

Diffuse effect: Centrally acting medications

If during chemotherapy • Prophylactic antinauseants • Modify dose of chemotherapy

See Chemotherapy Emetogenicity Table

If during radiation therapy • Prophylactic antinauseants • Modify dose of chemotherapy

See Radiation Emetogenicity Table

If other medications, e.g., opioids, anticholinergics • Prophylactic anti-nauseants •  or stop responsible medications

CTZ: 1. DA antagonist 2. H1 antagonist

If due to systemic infections / sepsis: • Treat underlying infection • Reduce fever

Systemic Causes

Treat Underlying Cause

Treat Nausea

If hypercalcemia due to metastases: • Rehydrate with NaCl; diurese with furosemide • Dexamethasone • Bisphosphonates, e.g., pamidronate, zoledronic acid; if caused treatable

13. Metabolic

If hyponatremia due to dehydration: • Stop diuretics, including alcohol and caffeine, e.g., coffee, tea • Rehydrate with NaCl containing fluids: - Orally: soups, sport drinks, red vegetable juices - Parenterally: 0.9% NaCl

CTZ: 1. DA antagonist 2. H1 antagonist

If liver failure, reduce toxins with lactulose, rifaximin, neomycin If renal failure, dialyze to reduce toxins

CTZ: 1. DA antagonist 2. H1 antagonist

Adapted from Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J. EPEC-O: Education in Palliative and End-of-life Care for Oncology. © The EPEC Project,™ Chicago, IL, 2005. Open Access at www. IPCRC.net. Wood GJ, Shega JW, Lynch B, Von Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life. JAMA 2007; 298(10): 1196-1207. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

N2A

NAUSEA MANAGEMENT Non-Pharmacological Management: Acupuncture, behavior modification, hypnosis, imagery, modification of eating habits / odors Pharmacological Management

DA: Dopamine Antagonists Haloperidol 0.5-2 mg PO / SC / IV q 12-24 hrs Metoclopramide 10-20 mg PO / SC / IV q 6 hrs Prochlorperazine 10-20 mg PO q 6 hrs Prochlorperazine 25 mg PR q 12 hrs Olanzapine 5-10 mg PO daily

5HT3: Serotonin Antagonists Ondansetron 4-8 mg PO / SC / IV q 6 hrs Granisetron 1 mg PO / IV daily or q 12 hrs Dolasetron 200 mg PO / IV daily Palonosetron 0.25 mg PO / IV daily

H 1: Histamine Antagonists Diphenhydramine 25-50 mg PO / SC / IV Meclizine 25-50 mg PO q 6 hrs Hydroxyzine 25-50 mg PO q 6 hrs Promethazine 25 mg PO / PR q 6 hrs Promethazine 12.5-25 mg IV q 6 hrs

Ach: Acetylcholine Antagonists Scopolamine patch 1-3 TD q 72 hrs Scopolamine 0.1-0.4 mg SC / IV q 4 hrs

Central Action Dexamethasone 2-20 mg PO / SC / IV daily Dronabinol 5-25 mg PO/24 hrs div q 2-4 hrs Lorazepam 0.5-2 mg PO / SC / IV q 8 hrs

Inoperable Obstruction Octreotide 100-400 mcg or more SC / IV q 8 hrs or 10-80+ mcg/hr SC infusion Scopolamine 0.1-1.0+ mg/hr SC infusion Glycopyrolate 0.1-1.0+ mg/hr SC infusion

div = In divided doses Adapted from Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J. EPEC-O: Education in Palliative and End-of-life Care for Oncology. © The EPEC Project,™ Chicago, IL, 2005. Open Access at www. IPCRC.net. Wood GJ, Shega JW, Lynch B, Von Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life. JAMA 2007; 298(10): 1196-1207. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

N2B

ASSESS POOP ( CONSTIPATION ) Constipation refers to bowel movements that are infrequent or hard to pass. Obstipation is a failure to pass stools or gas. Always ask about the bowels. Trust but verify. Even a glacier moves with small bits dropping off each day. For You

With Your Patient

Step 1: Initiate Conversation • Patients receiving palliative care are frequently constipated. Yet, they are reluctant to talk about it. • Initiating a conversation as part of routine care. • Try to prevent constipation rather than treat it.

• Many patients are reluctant to describe their bowels, is that true for you? • Ensuring continuing bowel function is very important to your care and comfort. • People with your condition usually experience bowel problems, especially when using pain medications. It is better to prevent than treat.

Step 2: Assess • Don’t assume that a report of a bowel movement excludes constipation. • Explore further to understand what has taken place, what is normal for them, and what they are doing to address any constipation issues.

• • • • •

Have you had a bowel movement today? Please describe it. Size? Consistency? When was your last bowel movement? What is your normal pattern? Is it difficult to move your bowels? What are you taking to help your bowels?

Step 3: Communicate Findings • Acknowledge and praise the patient for giving you the information you need. • Communicate the information to the physician and others who need to know in order to best care for the patient.

• Thank you for the information. I appreciate your willingness to describe this to me. It helps me to ensure we are doing the best in caring for you. • Now I will …(share the actions you will take as a result of the information given).

Examine the Patient • Examine the patient's abdomen for stool content; Examine the rectum to ensure no impaction • KUB radiograph (flat plate X-ray of abdomen, kidney, ureter, bladder) to assess volume of stool — read film yourself. Radiology does not read stool content. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

S2A

CONSTIPATION MANAGEMENT Stool Softeners

Bulking Agents

If there is no sqeeze, e.g., with opioids, stool softeners lead to softer stool that still doesn't move • Docusate Na 100-250 mg PO bid

Not recommended with chronic opioid use • Methylcellulose 1 tbsp bid • Psyllium 1 tbsp bid

Stimulants

Osmotics

Possible Causes • • • • • • •

Diet Dehydration Dysmotility Mechanical obstruction Carcinomatosis Hypercalcemia Diabetes Mellitus

• Opioids • Anticholinergics • Calcium channel blockers • 5-HT3 receptor antagonists • Ca2+ / Al3+ antacids

Management Pearls • Bowel peristalsis is stimulated by intraluminal volume • Anticipate opioid-induced constipation; treat prophylactically: • Titrate stimulant laxatives to effective doses • Add osmotic laxatives to draw water into the stool, increase its volume, and stimulate peristalsis • If obstipaton occurs, before starting stimulant or osmotic laxatives ensure no impaction • If diarrhea occurs with obstipation, i.e., overflow incontinence, check for impaction, then decrease laxative doses, don't stop them • Bowels do NOT become inactive and never work again because of laxatives • Soap suds enemas are NOT recommended; they can damage bowel wall and lead to perforation

• • • •

Senna 2-9 tabs or Senna tea daily Bisacodyl 2 x 5-10 mg PO daily Cascara extract 50 mg PO daily Metoclopramide 10 mg PO qid ac & hs • Erythromycin 250 mg PO tid

• Polyethylene glycol 17 gm PO daily or bid • Magnesium Hydroxide 30 mL PO bid • Magnesium Citrate ½ bottle PO bid • Lactulose 30 mL PO bid-tid • Sorbitol 30 mL PO bid

Emollients

Enemas

• Mineral or other oil, 30-60 mL PO daily (risk of aspiration) • Glycerine suppository PR daily

• Phosphosoda (osmotic) • Mineral or other oil 50-100 mL to soften leading edge • Tap Water 0.5-1L PR daily to increase volume, stiumlate peristalsis

Peripheral Opioid Mu Receptor Antagonist Before starting, ensure some stool moving, no hard leading edge Methylnaltrexone 0.15 mg/kg SC q 24 hrs prn, if no bowel movement in the last 48 hrs; approximated to 8 mg (if 84 to 50% waking hours in bed, limited selfcare Bed or chair bound Dead

Activities of Daily Living Primary Bathing Toileting Continence Dressing Feeding Transferring

Secondary Use of telephone Travel by car, public transit Meal preparation Housework, i.e., cleaning, laundry Medication management Money management

Normal, no symptoms Normal activity, minor symptoms Normal activity, moderate symptoms Unable to continue normal activity Requires occasional assistance Considerable assistance, medical care Disabled, special assistance & care Severely disabled, constant care Very sick, active treatment needed Moribund, fatal processes active Dead

Adapted from, S.P.I.K.E.S., Robert Buckman, M.D. Baile WE, Buckman R, Lenzi R et al, Oncologist 2000;5(4):302-1. Used with permission NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

C2

DETERMINING PROGNOSIS PPSv2: Palliative Performance Scale version 2 PPS Level

Ambulation

Activity & Evidence of Disease

100%

Full

90%

Self Care

Intake

Conscious Level

Normal activity & work No evidence of disease

Full

Normal

Full

Full

Normal activity & work Some evidence of disease

Full

Normal

Full

80%

Full

Normal activity with effort Some evidence of disease

Full

Normal or reduced

Full

70%

Reduced

Unable normal job / work Significant disease

Full

Normal or reduced

Full

60%

Reduced

Unable hobby / house work Significant disease

Occasional assistance necessary

Normal or reduced

Full or confusion

50%

Mainly sit / lie

Unable to do any work Extensive disease

Considerable assistance required

Normal or reduced

Full or confusion

40%

Mainly in bed

Unable to do any activity Extensive disease

Mainly assistance

Normal or reduced

Full or drowsy +/- confusion

30%

Totally bed bound

Unable to do any activity Extensive disease

Total care

Normal or reduced

Full or drowsy +/- confusion

20%

Totally bed bound

Unable to do any activity Extensive disease

Total care

Minimal to sips

Full or drowsy +/- confusion

10%

Totally bed bound

Unable to do any activity Extensive disease

Total care

Mouth care only

Drowsy or coma +/- confusion

0%

Dead

Prognosis in Cancer, Median Survival

90 days

50 days

17 days

Palliative Performance Scale (PPSv2) version 2. Medical Care of the Dying, 4th ed.; p. 120. ©Victoria Hospice Society, 2006. Used with Permission. Anderson F, Downing G, Hil J, Casorso L, Lerch N. Palliative performance scale: A new tool. J Palliat Care 1996;12(1):511. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

C3

DETERMINING PROGNOSIS FAST: Functional Assessment Staging for Patients with Dementia Score

Criteria

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, difficulty marketing, etc.).

5

Requires assistance in choosing proper clothing to wear for the day, season or occasion, (e.g. patient may wear the same clothing repeatedly, unless supervised).

6A

Improperly putting on clothes without assistance or cueing (e.g., may put street clothes on over night cloths, or put shoes on wrong feet, or have difficulty buttoning clothing) (Occasionally or more frequently over the past weeks).

B

Unable to bathe properly (e.g., difficulty adjusting bath-water temperature) (Occasionally or more frequently over the past weeks).

C

Inability to handle mechanics of toileting (e.g., forget to flush the toilet, does not wipe properly or properly dispose of toilet tissue) (Occasionally or more frequently over the past weeks).

D

Urinary incontinence (Occasionally or more frequently over the past weeks).

E

Fecal incontinence (Occasionally or more frequently over the past weeks).

7A

Ability to speak limited to approximately a half a dozen intelligible different words or fewer, 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 (the person may repeat the word over and over).

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.

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

C4

PROGNOSIS IN CANCER Unresectable ( Advanced ) or Metastatic Disease

Prognostic Indicators

Maximal Therapy

% Alive 1 yr.

Median Survival ( Months )

Indicator

Criteria

Medial Survival

Bladder (TCC)

26%

12

KPS

50-60%

90 days

Brain Metastases (all comers)

—

7

KPS

20-30%

50 days

Brain - Glioblastoma Multiforme

30%

14

KPS

10-20%

17 days

Breast

72%

24

ECOG

3

3 months

Cervix - Squamous

20%

9

ECOG

4

1 month

Colorectal

36%

20-24

Anorexia

Persistent

< 6 months

Carcinoma Unknown Primary

35%

8-13

Serum Albumin

< 2.5 mg/dL

< 6 months

Esophageal

20%

10-12

Weight Loss

> 10%

< 6 months

Gastric

23%

6-12

Brain Mets multiple

XRT

7 months

Head and Neck

26%

7-10

Brain Mets multiple

Steroids

3 months

Kidney

—

15-24

Brain Mets multiple

No Treatment

1 month

Liver

—

8-10

Delirium

Persistent

6 weeks

Lung Cancer, Non-small Cell

25%

6-15

Dyspnea

Persistent

< 6 months

Lung Cancer, Small Cell Extensive

—

6-12

Hypercalcemia

Persistent

1 month

Melanoma

70-80%

20-24

Malignant Pleural Effusion

Persistent

4 months

Ovarian

59%

15-24

Pancreatic

27%

6-11

Prostatic

—

49

Sarcoma

—

12-14

Updated and enhanced from Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J. EPEC-O: Education in Palliative and End-of-life Care for Oncology. © The EPEC Project,™ Chicago, IL, 2005. Open Access at IPCRC.net.

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

C5

HEART FAILURE When Is It Time For Hospice Care?

What Do I Say?

ONE OR MORE OF THE FOLLOWING: • Symptoms at rest despite optimal medical management • Dependent in > 2 activities of daily living • Frequent Emergency Department (ED) visits • Hospitalized > 3 times in 6 months • Unintentional weight loss > 10% • Albumin < 2.5 gm/dL • Ejection Fraction < 20% • Persistent serum sodium < 135 mEq/L • Prior CPR • Prior syncope • Embolic stroke

1. What do you understand about your diagnosis of heart failure? 2. What would you like to know? 3. Some people want to know their prognosis, do you? 4. Knowing that, tell me how you hope the future will be? 5. To achieve your goals to be as comfortable as possible, to stay out of the hospital and ED and to be the least burden on your family, the best way I know is to get home hospice care involved. 6. Let me arrange an informational visit so you get more information about what hospice care can provide. Then, we can talk about whether this is the right time at your next appointment.

Seattle Heart Failure Prognosis Calculator http://depts.washington.edu/shfm/app.php New York Heart Association ( NYHA ) Functional Classification NYHA Class

Exercise Tolerance

Symptoms

Class I ( Mild )

No limitation

Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea

Class II ( Mild )

Mild limitation

Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea

Class III ( Moderate )

Marked limitation

Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea

Class IV ( Severe )

Unable to carry out any physical activity without discomfort

Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

D1A

MANAGING SHORTNESS OF BREATH Opioids Relieve a Patient’s Sense of Shortness of Breath ( SOB ) Without Depressing Respiratory Drive Treat underlying causes of SOB + manage patient's report of SOB For an opioid-naive patient, starting equianalgesic doses are: • Morphine 2.5 mg PO q 1 hr prn • Morphine 1 mg SC q 30 min prn or 1 mg IV q 15 min prn • Oxycodone 2 mg orally PO q 1 hr prn • Hydromorphone 0.5 mg PO q 1 hr prn • Hydromorphone 0.1 mg SC q 30 min prn or 0.1 mg IV q 15 min prn Typical doses in opioid naive patients are morphine 30-60 mg PO/24 hrs or equivalent For patients receiving an opioid, use breakthrough doses to relieve SOB, or change to an alternate opioid Clinical Pearl: Titrate opioids to patient report of SOB Do not titrate to respiratory rate or family / caregiver report of how SOB the patient looks Chlorpromazine 25-50 mg PO q 1 hr prn may also help relieve SOB Benzodiazepines treat anxiety, not SOB. If anxious, consider adding: • Trazodone 50-100 mg PO q 1 hr prn (especially in the elderly) • Clonazepam 0.25 mg PO q 24 hrs ( longer acting better → steady blood levels ) • Lorazepam 0.5 mg PO/SL q 12 hrs A fan blowing air on the face relieves SOB through stimulation of Cranial Nerve V (facial nerve) NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

D1B

CANCER METASTATIC SPREAD Cancer

Main Sites of Metastases

Metastatic Site

Cancers

Bladder

Bone, liver, lung

Adrenal gland

Kidney, lung, prostate

Breast

Bone, brain, liver, lung

Bone

Bladder, breast, kidney, lung, melanoma, prostate, thyroid, uterus

Colorectal

Liver, lung, peritoneum

Brain

Breast, kidney, lung, melanoma

Kidney

Adrenal gland, bone, brain, liver, lung

Liver

Bladder, breast, colorectal, kidney, lung, melanoma, ovary, pancreas, prostate, stomach, thyroid, uterus

Lung

Adrenal gland, bone, brain, liver, other lung

Lung

Bladder, breast, colorectal, kidney, melanoma, ovary, pancreas, prostate, stomach, thyroid, uterus

Melanoma

Bone, brain, liver, lung, skin/muscle

Other lung

Lung

Ovary

Liver, lung, peritoneum

Peritoneum

Colorectal, ovary, pancreas, stomach, uterus

Pancreas

Liver, lung, peritoneum

Skin / muscle

Melanoma

Prostate

Adrenal gland, bone, liver, lung

Vagina

Uterus

Stomach

Liver, lung, peritoneum

Thyroid

Bone, liver, lung

Uterus

Bone, liver, lung, peritoneum, vagina

From “Metastatic Cancer Fact Sheet, National Cancer Institute, Bethesda, MD. Open Access, see http://www.cancer.gov/cancertopics/factsheet/Sites-Types/metastatic. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

D2

SIGNS & SYMPTOMS CLOSE TO TIME OF DEATH OBSERVATIONS OF HOSPICE NURSES BIOLOGICAL AND PHYSICAL SIGNS & SYMPTOMS MONTHS NOT WEEKS

WEEKS NOT MONTHS

DAYS NOT WEEKS

NEXT FEW DAYS

TODAY OR TOMORROW

Increasing weakness & Increasing weakness & fatigue. Extreme weakness & Extreme weakness, mouth fatigue. Assistance with Bedbound ECOG 4. Assistance fatigue. Unable to get droop, minimal voluntary ADLs. ECOG 3 with all ADLs. up to commode movement. No muscle tone. NUTRITION Normal. Some change Decreased appetite, Decreased intake dehydration. Dehydration, dysphagia, emaciDysphagia, no oral intake increased weight loss Some dysphagia dry skin. ated (dry eyes, pinched nose, HYDRATION in food likes & dislikes. Some weight loss. (>10%) bitemporal wasting Skin tenting. ketotic breath) ELIMINATION No urine, bowel incontinence/ Normal. Some Increased constipation Some bladder incontinence. Bowel/bladder incontinence diarrhea constipation. PAIN Increased pain/pain changes due, perPain may be increased or Usual Increased pain Possible pain haps, to emotional, spiritual causes. decreased SKIN Normal Thin, increased fragility Decreased peripheral circulation Mottling cyanotic toes, heels, Possible breakdown possible. Bruising (mottling, temperature decrease, fingers, livedo reticularis cyanotic nail beds) color changes (jaundice/grey/ashen/pale) SLEEP Some insomnia Spends >50% waking hours Increased sleeping Decreased responsiveness, Bed & chair existence. hours in bed. frequently unarousable May be restless at night. EYES Glazed fixed stare, partly open, Normal Dull, cloudy, look inward, distant. Glazed, staring, sunken Dull fixed or dilated pupils Increased congestion, rattle, RESPIRATIONS Normal Dyspneic. May or may not Irregular breathing patterns. Death rattle, apnea, periods of apnea or Cheynehave hypoxia. Oxygen Congestion. Cheyne-Stokes pattern Stokes pattern may be helpful. Increased agitation-no purpose- Delirium, decreased arousal, unarousNEUROLOGICAL Normal Normal Changes: picking, twitching, ful movement, twitching, ‘near able occasionally a mysterious ‘rally’ seizures, delirium death awareness’ non-distressing or ‘the rise before the fall’, sometimes related to out-of-town family. visual hallucinations, delirium Increased or decreased distenASCITES - EDEMA Abdominal distention, Increased distension, Decreased distension, Continued distension, sion, decreased edema increased edema. leg edema. Patient is decreased edema edema. not dehydrated. ACTIVITY

Up & about ECOG 2

From “Markers Noted by Home Hospice Nurses Related to Time Remaining in the Dying Process”, Master’s Thesis of Carol McCrann McShane, RN, MS, Creighton University Lincoln, NE, 1991. Used with Permission NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

LH1A

SIGNS & SYMPTOMS CLOSE TO TIME OF DEATH OBSERVATIONS OF HOSPICE NURSES MONTHS NOT WEEKS

WEEKS NOT MONTHS

DAYS NOT WEEKS

NEXT FEW DAYS

TODAY OR TOMORROW

PSYCHOLOGICAL SIGNS & SYMPTOMS EMOTIONS

Maintains control, Increased anxiety re: unfinished Increased apprehension, increased sense of humor, anger business, distancing, increased fear, increased peacefulness expression of anger/feelings

FACING REALITY

Information-seeking, denial, will to live, refers to future, concern re: taking medications

Increased peacefulness, fear of being alone

Peacefulness, fear of being alone

Information-seeking (how am I doing? What can I expect?), speaks of death

Wants to die, acceptance, saying goodbyes, family wondering (asking) ‘how long’ in order to pace themselves

Wants to die, intuitive, “I’m dying,” reassuring others

Acceptance, goodbyes

Withdrawal, decreased outside interests

Withdrawal increases, especially from close family

Increased withdrawal

Inability or unwillingness to express self

Putting affairs in order Closure for affairs, decisions re: Rx (food, hydration), deciding who to see

Stops unnecessary medications, treatments

Decreased decision-making, very definite in wishes

Unable to make decisions

SOCIAL MARKERS INTERACTIONS

Normal

SPIRITUAL MARKERS Plans funeral

Final funeral arrangements, Dreams of dead/spiritual figures dreams of dead/spiritual figures

May see people who are dead

FAMILY MARKERS Observations reported by family, acceptance/ denial/anger

Instinct, statements by significant other/family re: dying

Information-seeking: “how long,” report changes, anxiety about being able to see death through, gives permission to die

Ready for patient to die (may feel guilt), burn-out

Gives permission to die, lets go

From “Markers Noted by Home Hospice Nurses Related to Time Remaining in the Dying Process”, Master’s Thesis of Carol McCrann McShane, RN, MS, Creighton University Lincoln, NE, 1991. Used with permission. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

LH1B

COMMUNICATION AT THE TIME OF DEATH 6 STEPS FOR PRONOUNCING DEATH 1. PREPARE Contact nurse. What happened? Who is here? 2. PERCEPTION What do they know? “Tell me what you understand” “What happened?” 3. PREPARE I need to examine him/her to confirm that death has occurred. Family can be present. 4. EXAMINE Pupils fixed and dilated? Absence of respirations (observe) Absence of heart beat (auscultate) Absence of response (touch) No need to assess deep pain response 5. EMOTION Manage acute grief SILENCE is the most effective initial response “What questions do you have?” “I can see this makes you sad” “Tell me what you are thinking” 6. SUBSEQUENT What next? Make a plan, get more information, get help

LANGUAGE TO AVOID It must be a blessing that she has died. He lived a long, good life. You’ll have other children. I know how you feel. Cheer up, life is for the living. Don’t cry. You’ll get over it.

POSITIVE LANGUAGE I want to answer your questions. Sit in silence. Tell me about him/her. Tell a positive story of what he/she did for you or how you know him/her.

NEWS OF DEATH ON PHONE

CONDOLENCE CARD

Sit down. Not rushed. Best done in person, “There’s been a change, please come to the hospital.”

1. Write in long hand 2. Statement of condolence 3. Statement of what you observed patient to be 4. Tell any pertinent story from your direct care 5. Statement of admiration, praise for care family gave or love they showed 6. Say something that you will always remember about the patient

1. With whom am I speaking? 2. Who is there with you? 3. Warning shot: I have bad news 4. Tell of death 5. Respond to emotion 6. Invite to come see the body. Determine who is decision-maker for final arrangements

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

LH2

MEDICATION KINETICS Generic Name

Time Cmax

Elimination t½

NON-OPIOID ANALGESICS

Generic Name

Time Cmax

OPIOID ANALGESICS

Acetaminophen/Paracetamol PO: 1 hr (1-2) † aka Tylenol PR: 1 hr (1.8-4.8)

4 hrs (2-4)

Acetylsalicylic acid (ASA) (salicylic acid derivative)

PO: buffered tab: 20 min PO: effervescent solution: 15 min

6 hrs (4.7-9, dose-related)

Diclofenac (acetic acid derivative) aka Cataflam, Voltaren

IR PO: (Diclofenac K): 1 hr (0.33-2) ER PO: (Diclofenac Na): 2 hrs (1-4) PR: 30 min

2 hrs

Celecoxib (COX-2) aka Celebrex

PO: 3 hrs

11 hrs

Ibuprofen † (propionic acid derivative) aka Advil, Motrin

PO: 1 hr (1.4-1.9 hrs)

4 hrs (2-4)

Ketorolac (acetic acid derivative) aka Toradol

PO: 1 hr SC/IM: 1 hr IV: 1-3 min

6 hrs (2.4-9)

PO: 1 hr (1-2) PR: 30 min IM: 30 min Fentanyl Epi: 30 min TM: 24 min (20-40) SC/IM: 30 min IV: 15 min (6-15) PO IR: 1 hr (1.3) Hydrocodone in combination products with acetaminophen PO ER: 5 hrs aka Lortab, Vicodin Hydromorphone PO IR: 1 hr (48-60 min) aka Dilaudid SC/IM: 30 min IV: 15 min (6-15) Epi: 8 min Methadone (not 1st order PO: 2-4 hrs kinetics) aka Dolophine

Naproxen (propionic acid derivative) aka Aleve, Naprosyn

IR PO: 2 hrs (2-4)

12 hrs (12-15)

Morphine † IR aka Roxanol, ER aka MS Contin

Indomethacin (Indole acetic acid derivative) aka Indocin

PO/PR: 2 hrs

4.5 hrs (2.6-11)

See card M2 for Medication Information Sources

Elimination t½

Codeine † (methylmorphine)

Oxycodone ER aka OxyContin Remifentanil Sufentanil Tramadol aka Ultram

PO IR: 1 hr SC/IM: 30 min IV: 15 min (6-15) PO IR: 1 hr 1-3 min SC: 30 min IV: 15 min (6-10) PO: 2 hrs

4 hrs (3.5-5.3)

4 hrs (3.3-4.1)

PO IR: 4 hrs (3.8-4.5) PO ER: 8 hr 4 hrs (3-4)

Biphasic (variable) Initial phase 12-24 hrs Second up to 55+ hrs 4 hrs

PO IR: 4 hrs (3-5) 5 min (3-10) 2.5 hrs Tramadol: 6.3 hrs Metabolite: 7.4 hrs

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

M1

MEDICATION KINETICS Generic Name

Time Cmax

Elimination t½

Equivalent Dose

Generic Name

Elimination t½

Time Cmax

LAXATIVES

STEROIDS

Bisacodyl † (stimulant) aka Dulcolax

Initial response: PO: 6-12 hrs PR: 15-60 min

NA

Docusate Na+ or Ca2+ (surfactant) aka Colace (Na+), Surfak Ca2+)

PO initial response: 1-3 days

NA

Glycerin (irritant)

PR initial response: 15-30 min

NA

Lactulose (osmotic) aka Kristalose, Enulose

PO initial response: 24-48 hrs

NA

5 mg

Magnesium citrate (osmotic)

PO initial response: 0.5-3 hrs

NA

Biological: 12-36 hrs

4 mg

SC: 30 min

SC: 2 hrs

Biological: 8-12 hrs

20 mg

Methylnaltrexone (peripheral opioid receptor antagonist) aka Relistor Polyethylene Glycol aka PEG, MiraLAX

PO initial response with daily use: 24-72 hr

NA

Psyllium (not absorbed) aka Metamucil

PO initial response: 12-24 hrs (up to 3 days)

NA

Sennosides † (stimulant) aka Senna

Initial response: PO: 6-12 hrs PR: 0.5 -2 hrs

NA

Sodium phosphate (osmotic) ala Fleets

PR initial response: 0.5-3 hrs

NA

Sorbitol (osmotic)

PO initial response: 0.5-3 hrs

NA

Dexamethasone † (effect follows biological t½, not plasma t½)

PO tabs/elixir: 1 hr (1-2) SC/IM: 30 min IV: 15 min (6-15)

Plasma: 2 hrs (1.8-3.5) Biological: 36-54 hrs

0.75 mg

Prednisone (effect follows biological t½, not plasma t½)

PO: 1.5 hrs (1-2)

Plasma: 2.5 hrs (2-3) Biological: 18-36 hrs

5 mg

Prednisolone

PO: 1 hr

Biological: 18-36 hrs

Methylprednisolone

PO: 1 hr IV: 30 min

Hydrocortisone

PO: 1 hr

aka = also known as IR = Immediate Release ER = Extended Release † = An essential medication as defined by WHO: World Health Organization SC dosing is preferable over IM dosing Avoid medications with short half-lives in patients with short life expectancy who may experience withdrawal when these medications are stopped at end of life

Medication Information Sources Micromedex Healthcare Series, Truven Health Analytics Inc., 2012-2014 Clinical Pharmacology, Elsevier/Gold Standard 2013 Goodman & Gilman's The Pharmacologic Basis of Therapeutics, Twelfth Edition, McGraw-Hill Medical Publishing Division, 2011 American Hospital Formulary Service (AHFS) Drug Information, 2012, American Society of Health-System Pharmacists, Bethesda, MD

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

M2

MEDICATION KINETICS Generic Name

Time Cmax

Elimination t½

Equivalent Dose

Generic Name

Time Cmax

Elimination t½

Equivalent Dose

BENZODIAZEPINES

ANTIPSYCHOTICS

Alprazolam aka Xanax

PO: 1 hr

11 hrs

0.5 mg

Clonazepam aka Klonopin

PO: 2 hrs (1-4) PR: 10-30 min

30 hrs (19-50)

0.25 mg

Diazepam † aka Valium

PO: 1 hr (0.89-1.32) PR gel: 1.5 hrs IM: 1 hr IV: 8 min

45 hrs Metabolites: 30-100 hrs

5 mg

Lorazepam aka Ativan

PO: 1 hr SC/IM: 30 min

12 hrs Metabolites: 12-18 hrs

1 mg

125 mg

Midazolam † aka Versed

SC/IM: 30 min IV: 15 min (6-15)

2 hrs (1-3)

Oxazepam aka Serax

PO: 1 hr

12 hrs (5-15)

15 mg

1 mg

2.5 hrs (1.5-7)

5 mg

Chlorpromazine (sedating) aka Thorazine

PO: 1 hr SC/IM: 30 min IV: 15 min (6-15)

24 hrs (23-37)

100 mg

Haloperidol † (non-sedating) aka Haldol

PO: 1 hr SC/IM: 30 min IV: 15 min (6-15)

21 hrs (10-38)

2 mg

Olanzapine(sedating) aka Zyprexa

PO: 6 hrs IM: 30 min (15-45)

30 hrs (21-54)

4 mg

Prochlorperazine aka Compazine

PO/PR: 2 hrs (1.5-5)

8 hrs (6.8-9)

Quetiapine (sedating) aka Seroquel

PO: 1.5 hrs

6 hrs

Risperidone (non-sedating) aka Risperdal

PO: 1 hr (1-2)

PO: 3 hrs Metabolites: 21-30 hrs

aka = also known as IR = Immediate Release ER = Extended Release † = An essential medication as defined by WHO: World Health Organization SC dosing is preferable over IM dosing Avoid medications with short half-lives in patients with short life expectancy who may experience withdrawal when these medications are stopped at end of life

BENZODIAZEPINES Zolpidem (non-benzo hypnotic) aka Ambien

PO: 1.6 hrs

See card M2 for Medication Information Sources NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

M3

MEDICATION KINETICS Generic Name

Time Cmax

Elimination t½

Generic Name

Elimination t½

ANTICONVULSANTS

ANTIDEPRESSANTS Amitriptyline † aka Elavil

PO: 4 hrs (2-12)

15 hrs (10-50) Metabolite: Nortriptyline

Carbamazepine aka Tegretol

Citalopram aka Celexa

PO: 4 hrs

35 hrs

Desipramine aka Norpramin

PO: 3-6 hrs

14.3-24.7 hrs (variable 1st pass)

Fosphenytoin (prodrug of phenytoin, not 1st order kinetics) aka Cerebyx

PO: 1 hr Doxepin Potent H1 antagonist aka Sinequan

16.8 hrs (8-25) Metabolites: 51.3 hrs (33.2-80.7)

Duloxetine aka Cymbalta

PO: 6 hrs

12.5 hrs (9.2-19.1)

Escitalopram aka Lexapro

PO: 5 hrs

30 hrs (27-32)

Fluoxetine † aka Prozac

PO: 7 hrs (6-8)

5 days (4-6) Metabolites: 16 days

Imipramine aka Tofranil

PO: 1 hr

12 hrs (8-12) Metabolite: Desipramine

Nortriptyline aka Pamelor

PO: 1 hr

40 hrs (20-100)

Sertraline aka Zoloft

PO: 4 hrs (4-8)

24 hrs Metabolites: 35 hrs (62-104)

Trazodone † aka Desyrel

PO: 1.5 hrs (0.5-2)

7 hrs

Venlafaxine aka Effexor

PO IR: 2 hrs (1-2) PO ER: 5.5 hrs

5 hrs Metabolite: 11 hrs

aka = also known as

Time Cmax

† = An essential medication as defined by WHO: World Health Organization

See card M2 for Medication Information Sources

Gabapentin aka Neurontin Levetiracetam aka Keppra

Phenobarbital

Phenytoin (not 1st order kinetics) aka Dilantin Pregabalin aka Lyrica Valproic acid aka Depakene, Depakote

PO IR: 4 hrs PO chew tab: 6 hrs PO suspension: 1.5 hrs SC/IM: 30 min IV: immediate (at end of infusion) PO: 2 hrs (1.5-4) PO IR: 1 hr PO Solution: 1 hr PO ER: 4 hrs SC/IV: 1 hr PO: 10 hrs (8-12) SC/IM: 2 hrs (1-3) IV: 30 min PO IR: 1-2 hrs IV: 25 min (20-25) 1.5 hrs (1-1.5) PO: Valproic acid capsules Depakene: 2 hrs (1-4) PO: Divalproex tab: 4-8 hrs PO: Divalproex sprinkle capsule: 3.3-4.8 hrs PO: Na valproate solution: 1.2 hrs PR: Diluted valproic acid syrup: 3.1 hr IV: Depacon: at end of 1 hr infusion

12 hrs (12-17)

Conversion to phenytoin: 15 min Phenytoin: 7-42 hrs 6 hrs (5-7) 7 hrs (6-8)

96 hrs (50-120)

PO: 7-42 hrs (Polymorphic saturable enzyme) 6 hrs (5-6.5) 12 hrs (6-17)

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

M4

MEDICATION KINETICS Generic Name

Time Cmax

Elimination t½

ANTICHOLINERGICS Atropine

Glycopyrrolate aka Robinul Hyoscyamine † aka Levsin PO IR: 30 min PO ER: 2.5 hrs Scopolamine PO: 1 hr SC: 30 min Patch: 4 hrs

Elimination t½

Biphasic: Initial ̴ 2 hrs Second: 12.5-38 hrs 1 hr (0.55-1.25)

Cimetidine (H2 receptor antagonist) aka Tagamet

PO: 60 min (45-90) IM:15 min

2 hrs Metabolites: 2.2 hrs

PO: 2 hrs (1-3.5)

3 hrs (2.5-3.5)

PO IR: 3.5 hrs PO ER: 7 hrs 8 hrs (7-9)

Famotidine (H2 receptor antagonist) aka Pepcid Lansoprazole (PPI) aka Prevacid

Enteric-coated granules: 2 hrs (1.5-3) ODT: 1.8-2.0 hrs

< 2 hrs Metabolites: 3 hrs

Omeprazole (PPI) aka Prilosec

PO: 2 hrs (0.5-3.5)

1 hr

Pantoprazole (PPI) aka Protonix

PO: 2.5 hr

1 hr

Ranitidine (H2 receptor antagonist) aka Zantac

PO: 1 hr (0.5-2) IM: 15 min

2.5 hrs (2-3)

Sucralfate aka Carafate

PO Initial response: 1 hr

Duration: 6 hrs

DIURETICS PO: 1-2 hrs IM: 30 min IV: 5 min

60–90 min

Furosemide aka Lasix

PO: 30-60 min IV: 6-10 min

60 min (30-120)

Metolazone aka Zaroxolyn

PO: 8 hrs

10 hrs (8–14)

Spironolactone aka Aldactone

PO: 2 hrs (1-3)

1.5 hrs (1.3-2) Active metabolite: 24 hrs (10-35)

Torsemide aka Demadex

PO: 1 hr

4 hrs (3–6)

aka = also known as

Time Cmax

ANTACIDS PO: 1 hr IM: 30 min SC/IM/IV: 10 min

Bumetanide aka Bumex

Generic Name

aka = also known as IR = Immediate Release ER = Extended Release † = An essential medication as defined by WHO: World Health Organization SC dosing is preferable over IM dosing Avoid medications with short half-lives in patients with short life expectancy who may experience withdrawal when these medications are stopped at end of life

† = An essential medication as defined by WHO: World Health Organization

See =card M5 for Medication Table Resources NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

M5

MEDICATION KINETICS Generic Name

Time Cmax

Elimination t½

ANAESTHETICS

Time Cmax

Elimination t½

OTHERS

Lidocaine

IM: 30 min

2 hrs

Nitrous oxide

Rapid

5 min

PO IR: 1-3 hrs PO ER: 6-8 hrs

PO: 3 hrs (2-7)

Baclofen aka Lioresal

PO: 2 hrs

3 hrs (2.5-4)

Cyclizine † (H1 receptor antagonist) aka Marezine

PO: 2 hr

13 hr (7-48)

Cyclobenzaprine aka Flexeril

PO: 4 hr

18 hr (9-41)

Diphenhydramine (H1 receptor antagonist) aka Benadryl

PO: 2 hrs (2-4)

6 hrs (2-8) Metabolites: 8.6-10 hrs

Flecainide (class 1C antiarrhythmic, neuropathic pain) aka Tambocor

PO: 3 hrs (1-6) PO cap: 1-8 hrs IV: 15 min

20 hrs (12-30)

STIMULANTS Methylphenidate aka Ritalin

Generic Name

OTHERS

aka = also known as IR = Immediate Release ER = Extended Release † = An essential medication as defined by WHO: World Health Organization SC dosing is preferable over IM dosing Avoid medications with short half-lives in patients with short life expectancy who may experience withdrawal when these medications are stopped at end of life

Loperamide (antidiarrheal) aka Imodium

PO: 4-5 hr

10-12 hr

Meperidine / Pethidine (rigors) aka Demerol

IM: 30 min

3 hr Toxic metabolite 6 hr

Metoclopramide † (dopaminergic, prokinetic) aka Reglan

PO/PR: 1hr (1-3) SC: 30 min IV: 15 min

6 hrs (5-6)

Metronidazole aka Flagyl, MetroGel

PO/PR: 1 hr (1-3) SC: 30 min IV: 15 min

6-14 hr

Mexiletine (class 1B antiarrhythmic, neuropathic pain) aka Mexitil

PO: 2.5 hrs (2-3)

PO: 8 hrs (7-12)

Misoprostol (prostaglandin E1 analogue) aka Cytotec

Plasma: 15 min Max ↓ H+: 60-90 min

Plasma: 30 min (20-40)

Octreotide † (somatostatin analogue) aka Sandostatin

SC: 15-30 min

1.5 hrs

Ondansetron (serotonin receptor antagonist) aka Zofran

PO: 1hr (1-2.2) IM: 0.7 hrs IV: 10 min after end of infusion

6 hrs (3.1-5.8)

Oxybutynin (overactive bladder activity / spasms) aka Ditropan

PO: 1hr TD Patch:17 hrs (10-28)

3 hrs (2-5) TD: 7.5 hrs (7-8)

Tamsulosin aka Flomax

PO: 4-5 hr

12 hr (9-15)

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

M6

SPIRITUAL SCREENING Spirituality = 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.

FICA F – Faith, belief, meaning

• Do you consider yourself spiritual or religious? • Do you have spiritual beliefs that help you cope with stress?

I – Importance or Influence of religious and spiritual beliefs and practices • What importance does your faith or belief have in your life? • Have your beliefs influenced how you take care of yourself in this illness? • What role do your beliefs play in regaining your health?

C – Community connections

• Are you part of a spiritual or religious community? • Is this of support to you and how? • Is there a group of people you really love or who are important to you

A – Address / action in the context of medical care

• How would you like me, your healthcare provider, to address these issues in your healthcare?

J Palliat Medicine, Oct 2009 Report of the Consensus Conference, Pulchalski, C and Ferrell, B. PMID: 19807235. Used with permission. Puchalski & Romer, 2000, see smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool. Used with permission. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

SP1

SPIRITUAL ASSESSMENT Spiritual Distress Severity Scale INTEGRATION & ‘HEALTH’

0 HOPE

DISINTEGRATION

2

4

Hope filled, optimistic

6

8

10

Deep distress, hopelessness, suicidal

What are you dreaming of? If you had a magic wand, what would you wish to have happen? In what way might you be experiencing depression or loss of hope?

FORGIVENESS Strong sense of

reconciliation with self andd others h

Deep unforgiveness and judgment toward self and others

Life is filled with purpose and meaning

Life is meaningless and without purpose

Is there anything or anyone you feel you need to forgive? Is there anything or anyone you might want to ask for forgiveness?

MEANING

What is giving you life and energy right now? Who or what keeps you from feeling fully alive?

RELATEDNESS Strong connection to all that matters

Deeply alienated from all that matters

Who or what do you feel the most connected to right now? Who or what do you fear losing? Richard Groves, Sacred Art of Living Center www.SALC.org. Used with permission. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

SP2

DEEPENING SPIRITUAL UNDERSTANDING Dignity Therapy Brief Dignity Question ( inviting heartfelt connection ) “Tell me something about yourself that will help me provide better care for you today” • What are the most important roles you have played in your life? ( mother, professor, priest, etc. ) • What are your most important accomplishments, and what makes you feel most proud? • What are your hopes and dreams for your loved ones? • When did you feel most alive? Chochinov H. J Clin Oncology 2005 PMID: 16110012

Connecting / Therapeutic Questions • How has your sense of peace changed because of your illness? • Illness is a hard thing physically. Has it been a hard thing spiritually for you? • Would you like to speak with someone about your spiritual concerns?

NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

SP3

ESCALA DE LA INTENSIDAD DE SÍNTOMAS

NADA

0

LO PEOR

1

2

3

4

5

6

7

8

9

10

Nada

Irritante

Incomodo

Angustia

Horrible

Insoportable

NADA

POQUITO

UN POCO

TODAVIA UN POCO MAS

MUCHO

LO PEOR

CARAS

VERBAL

VISUAL

WONG-BAKER FACES ESCALA DE DOLOR

FACES from Hockenberry MJ, Wilson D, Winkelstein ML: Wong’s Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. ©, Mosby. NB: These Palliative Cards are guidelines only and do not replace careful clinical judgment specific to each patient / family situation. Palliative Cards are Copyright 2013, 2014 OhioHealth Corporation, All rights reserved. Permission to reproduce Palliative Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris, Palliative & Hospice Care, OhioHealth, 1-888-389-6231 or +1-614-533-6299 or visit IPCRC.net. V6, Sept 2014

P2B