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  1. Approach To Medicine
  2. Internal Medicine
  3. Palliative Care

Palliative Care

Modified 22:05, 30 May 2016 by apavel | Page History
    Table of Contents
    1. 1. Palliative Care Order Set
    2. 2. Opioids
    3. 3. Dosing
    4. 4. Switching opioids
    5. 5. Mechanical Bowel Obstruction
    6. 6. Reference

    .

     

    UNDER CONSTRUCTION    

     

    Palliative Care Order Set

    • Indication Order Notes
      Nausea Haloperidol (Haldol) 0.5mg SC q8h PRN for nausea - Can increase to 1mg and q6h if nausea worsens
      Agitation

      During Day: Haldol 1mg SC q0600 and q1400

      During Night: Methotrimeprazine (Nozinan) 6.25mg SC q2200
      OR

      Methotrimeprazine (Nozinan) 6.25mg SC q8h PRN for agitation

      		 - 12.5mg considered if very agitated
      Pain/SOB

      (If naive)

      Hydromorphone 0.5mg SC q4h standing

      Hydromorphone 0.25mg SC q1h PRN for pain/SOB

      - Adjust standing and PRN frequently.

      - Breakthrough is usually 10% of 24hr dose
        given q1-2h​
      Secretions

      Glycopyrrolate 0.4-0.6mg SC q4-6h PRN for secretions

      OR

      Scopolamine 0.4-0.6mg SC q4-6h PRN for secretions

      Suction only if causing discomfort

      		 - Glycopyrrolate is not as sedating
        (less crossing of blood brain barrier)
      Constipation
      (ON OPIOIDS)

      Senna 1-2 tabs qHS
      PLUS:

      PEG or Lactulose or Methylnaltrexone

      		  

       

    • Please note: Doses vary with each patient.
    • Delirium:
      • 1st line: Haloperidovl
      • 2nd line: Methotrimeprazine.
    • Anorexia
      • Megestrol Acetate (Megace)
        • 160-800mg daily
        • Increases appetite
      • Steroids
        • Dexamethasone 2-4mg daily
      • Mirtazapine
      • Cannabinoids
      • ​Coaching Family:
        • “Please help me convince her to eat. I don’t want her to starve to death!”
          • Cachexia is not Starvation – the body knows that it can’t use the food and the brain sends signals to decrease hunger/intake
          • Forcing her to eat will worsen the Anorexia
        • “If only she could eat, she would regain her strength and be able to walk!”
          • Anorexia, Cachexia, and Asthenia often come together but they are all a result of the disease, so fixing one will not fix the other

    Opioids

    • Advantages of Opioids:
      • Pain
      • Breathlessness
      • No ceiling effect
      • Few drug interactions
      • Predictable - effectiveness and side effects
      • Rare allergy
      • Multiple routes: PO, SC, IV, SL
      • Inexpensive
    • Opioid Toxicity:
      • ***Myoclonus***
      • Somnolence
      • Delirium
      • Hyperalgesia - paradoxial increase in pain.
      • Respiratory Depression
    • How to avoid neurotoxicity?
      • Reduce opioids (25-50% reduction)
      • Hydration
      • Antipsychotics
      • Opioid Rotation

    Dosing

    • Starting dose for opioid-naive patients:
      • Morphine 2.5-5mg PO q4h standing and q1h PRN
    • If already on opioids, then increase by 25%
       
    • Generally dosed q4h
    • breakthrough is 10% of 24hr dose given q1-2h PRN.
    • Tolerance develops after ~2 weeks of use, but different to different opioids.
    • Approach to opioid dosing:
      1. Calculate 24hr dose.
      2. Adjust
      3. Divide for multiple daily dosing (i.e. divide by 6 for q4h dose)

     

    Switching opioids

    • Must correct for cross-tolerance by decreasing dose by 25-50%.
    • opioidEquivalency.png
    • Fentanyl Patch:
      • Example:
      • Morphine 20mg PO q4h to Fentanyl Patch: (20*6=120mg daily of morphine = 25 mcg/h patch)
    • fentanyleq.jpeg

    Mechanical Bowel Obstruction

    • I.e. if cannot be corrected surgically
    • Management:
      • NG Tube
      • IV Hydration
      • Medication Dose Notes
        Octreotide 50-300mcg q8h SC  
             
             

    Reference

    • Based on a lecture given by Dr. Roger Ghoche, MDCM, CCFP, MTS at the University of Toronto Palliative Care Team
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