an introduction to the Medication Management Guidelines Good management of symptoms in the last days of life is one of the main concerns of patients and their families Clinicians have a duty to ensure patients receive appropriate and timely relief from symptoms and ID: 634704
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Slide1
Last Days of Life Toolkit:an introduction to the Medication Management GuidelinesSlide2
Good management of symptoms in the last days of life is one of the main concerns of patients and their familiesClinicians
have a duty to ensure patients receive appropriate and timely relief from symptoms and
distressPrinciples of symptom management in last days of lifeDying patients are assessed regularly to allow existing and emerging symptoms to be detected, assessed and treated effectivelyIf symptom(s) are present, non-pharmacological measures are instigated in the first instanceIf non-pharmacological measures are ineffective, as required (PRN) medication is given If the medication ineffective, the patient is reassess and further intervention and/or escalation is implemented to manage the symptom(s)The likely cause and management of the symptom(s) is communicated and explained to patient and their family
Purpose of Medication Management guides Slide3
In line withRelevant NSW Health PolicyMedication Handling in NSW Public Health Facilities – PD2013_043
ACSQHC
National Consensus Statement: Essential Elements for Safe & High Quality End of Life CareNational Standards Standard 1 – Governance for Safety and Quality in Health Service Organisations Standard 2 – Partnering with Consumers Standard 4 – Medication Safety Standard 6 – Clinical Handover Standard 9 – Recognising and Responding to Clinical Deterioration in Acute Health Care Slide4
Standardised prescribing guidelinePre-emptive subcutaneous medications for last days of lifeI
n
line with national medication chart and prescribing terminologyFive symptom management flowchartsPain, breathlessness, nausea and/or vomiting, restlessness and/or agitation, and respiratory tract secretionsSymptom assessmentNon-pharmacological & pharmacological managementReview, escalation and consult recommendations
Written for generalist
(JMO/GP/RN) clinicians
Principles transferrable
into community and Residential Aged Care
settings
The toolsSlide5
Provides direction on prescribing ANTICIPATORY subcutaneous medications for the five most common symptomsRecommended STARTING
PRN
dosesRecommended STARTING regular doses of medication either regularly or via a 24 hour syringe driverAdvice regarding medication titration and escalation Includes general prescribing recommendations Starting dosesMedication titration Patients with pre-existing end stage kidney diseasePatients dying in ICUC
ontact details for advice from local Specialist Palliative Care service
Incudes oral/transdermal to subcutaneous opioid
conversation
table
Anticipatory Prescribing Recommendations Slide6
PRESENTATION NAME – MONTH YYYYPRESENTER NAME6Slide7
PRESENTATION NAME – MONTH YYYYPRESENTER NAME7Slide8
Opioid of choice for management of pain and breathlessnessWell-known amongst generalist prescribersEasily accessible from hospital and community pharmacies on PBS subsidy
Used safely in most patients in the last days of life
Cautious use in mild to moderate renal impairment: lower starting doses, longer dose intervals, regular monitoring and dose adjustment if requiredIf required for both pain and breathlessness, a single order should be prescribed for both indicationsHYDROmorphone is NOT recommended in this guide It is 5 to 7 times more potent than morphinePatients requiring symptom management with this highly potent opioid should be referred to their local Specialist Palliative Care service to ensure care is overseen by a specialist who is familiar with the drug and can ensure it’s safe prescription and
administrationMorphineSlide9
Management of nausea and/or vomitingWell-known amongst generalist prescribers
Easily accessible from hospital and community
pharmacies on PBS subsidyMaximum subcutaneous stat dose = 10mg = 2mLsMaximum recommended daily dose = 30mg due to increased adverse effect profile with higher doses and/or prolonged use; balance symptom control needs against adverse effect burden in last days of lifeUse cautiously in abdominal colicDo not use if bowel obstruction is suspectedAvoid in Parkinson’s Disease and
Lewy Body Dementia; beware extrapyramidal features side effects (repetitive
and involuntary movements, abnormal restlessness and parkinsonism such as tremor, rigidity and bradykinesia)
MetoclopramideSlide10
Management of nausea and/or vomiting and restlessness and/or agitation Preferred antiemetic in renal impairment
Easily accessible from hospital and community pharmacies on PBS
subsidyAvoid in Parkinson’s Disease and Lewy Body Dementia; beware extrapyramidal features side effects (repetitive and involuntary movements, abnormal restlessness and parkinsonism such as tremor, rigidity and bradykinesia) If required for both nausea/vomiting and restlessness/agitation, a single order should be prescribed for both indicationsUse of haloperidol in palliative care Recent evidence published and differing interpretations acknowledgedCurrent
published studies excluded patients in the last days of life
Included in these recommendations
in
line with current national guidelines
and
expert consensus
opinion
These recommendations
will be reviewed and
amended if further evidence becomes available in the future that demonstrates that haloperidol
is not effective and/or causes harm in this specific
patient
population (in the last days of life
)
HaloperidolSlide11
Management of breathlessness and restlessness and/or agitation
Midazolam
Rapid onset of action and short half-lifeBenzodiazepine of choice by PRN and regular dosing in a syringe driver NOT drug of choice when regular dosing is required, but administration via a syringe driver is not available or possibleNot available by PBS subsidy for these indicationsClonazepamLonger half life than midazolamBenzodiazepine of choice
when regular dosing is required, but administration via a syringe driver is not available or possibleCan also be given by sublingual
route as alternative to
subcutaneous route: clonazepam 0.5mg sublingual
dose
= 0.5mg drops
of
2.5mg/mL
oral
liquid (count drops onto spoon then administer; do not count
directly into mouth) Not subsidised by the PBS for these indication
s
Benzodiazepines: Midazolam and ClonazepamSlide12
Management of respiratory tract secretionsNormal part of dying process that require prompt management if they
occur
Are usually not distressing to patient, but often are for family, carers and staff Non-pharmacological measures are essential first step, along with provision of information, explanation and reassurance for the family and carers.Limited level of evidence to support anti-secretories is acknowledged; a trial with review for effect has been recommended in line with current national guidelines and expert consensus opinion; as further evidence becomes available in the future, these recommendations will be reviewed and amended accordingly
Not available by PBS subsidy for this indication
Glycopyrrolate
/
Glycopyrronium
and
Hyoscine
Butylbromide
(
Buscopan) No conclusive evidence of superior efficacy between different anti-secretories
Glycopyrrolate
/
Glycopyrronium
and Hyoscine
Butylbromide
(
Buscopan
)
do
not cross
blood-brain
barrier
so
are unlikely to cause central neurological side
effects
No distinction necessary between conscious and unconscious patients
Hyoscine
Hydrobromide
is
N
OT
recommended
as
contraindicated
in renal impairment
and crosses blood-brain barrier so may
potentiate delirium and sedation
Anti-secretoriesSlide13
Documenting the medications:
PRN chart
NB:Reason for medication documented Route clearly documentedMaximum dose documented Generic names used Slide14
Morphine and Haloperidol given regularly in a syringe driver Slide15
Midazolam and Hyoscine
Buytlbromide
(Buscopan)given regularly in a syringe driver Slide16
Clonazepam given regularlySlide17
Step by step guidance of five most common symptoms in last days of life
Symptom assessment
Instigation of non-pharmacological measuresPrescription and administration of PRN and regular medicationsReview of symptoms following interventionRegular review and assessment of symptom controlEscalation and seeking advice from local Specialist Palliative Care serviceSymptom Management Flowcharts Pain (includes guide to switch to subcutaneous opioids)BreathlessnessNausea and/or vomiting
Restlessness and/or agitation Respiratory tract secretions Slide18
PRESENTATION NAME – MONTH YYYYPRESENTER NAME18Slide19
PRESENTATION NAME – MONTH YYYYPRESENTER NAME19
IF PATIENT IS NOT ON AN OPIOIDSlide20
PRESENTATION NAME – MONTH YYYYPRESENTER NAME20
IF PATIENT IS ON AN OPIOIDSlide21
PRESENTATION NAME – MONTH YYYYPRESENTER NAME21
IF PATIENT IS ON A TRANSDERMAL OPIOID PATCHSlide22
PRESENTATION NAME – MONTH YYYYPRESENTER NAME22Slide23
PRESENTATION NAME – MONTH YYYYPRESENTER NAME23Slide24
Conversion from oral morphine SR (MS
Contin
)to subcutaneous morphine in a syringe driver Slide25
PRESENTATION NAME – MONTH YYYYPRESENTER NAME25Slide26
Conversion from oral oxycodone SR (OxyContin) to subcutaneous morphine in a syringe driver Slide27Slide28
28Slide29Slide30
30Slide31
Before prescribing medication ordersDiscuss need for medication with patient and familyReview current medication and cease non-beneficial/burdensome medication
Continue essential medications via subcutaneous route where possible
When prescribing medication ordersNomenclature: generic drug names, other than for hyoscine butylbromide (Buscopan) where trade name should also be prescribed to avoid risk of confusion with hyoscine hydrobromide (often referred to only as ‘hyoscine’)Dose: single dose only (not dose ranges)
Route: single route only;
subcutaneous as
‘
subcut
’
and
sublingual as
‘
subling’
Indication: document in ‘indication’ box of each medication using terms consistent with symptoms
listed in
prescribing
guide and
flowcharts
After medication orders are prescribed
Include in clinical handover to all medical and nursing staff involved
Monitor symptoms, and for response to medications and side effects
Adjust as clinically indicated; escalate and seek advice if
reqiured
Safe Prescribing of Last Days of Life Medication Slide32
Contact DetailsEnd of Life ProgramClinical Excellence Commission Telephone: 02
9269
5500E-mail: CEC-EOL@health.nsw.gov.au