Table of contents
.
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
ORMethotrimeprazine (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 q1-2hSecretions 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
- “Please help me convince her to eat. I don’t want her to starve to death!”
- Megestrol Acetate (Megace)
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:
- Calculate 24hr dose.
- Adjust
- Divide for multiple daily dosing (i.e. divide by 6 for q4h dose)
Switching opioids
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
Comments