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The Palliative Care Handbook 8TH EDITION | 2016 The Palliative Care Handbook guidelines for clinical management and symptom control Rod MacLeod, Jane Vella-Brincat, Sandy Macleod THE PALLIATIVE CARE HANDBOOK GUIDELINES FOR CLINICAL MANAGEMENT AND SYMPTOM CONTROL 8TH EDITION 2016 WRITTEN BY: Rod MacLeod Senior Staff Specialist in Palliative Care, HammondCare, Conjoint Professor, Palliative Care, University of Sydney, Sydney A.D. (Sandy) Macleod Health Science Department, University of Canterbury, Psychiatrist and Palliative Medicine Specialist, Burwood Hospital Christchurch Jane Vella-Brincat Clinical Pharmacist, Christchurch Hospital THE PALLIATIVE CARE HANDBOOK | 1 ACKNOWLEDGEMENTS We are grateful to the Genesis Oncology Trust and Pub Charity for funding the printing and distribution of this edition. The organ failure at the end-of-life section and much of the drug interaction data is based on part of the Canterbury District Health Board’s Preferred Medicines List, Antimicrobial Guidelines and Pharmacology Guidelines 19th Ed. 2015 Thanks to Dr Helen Lunt for the diabetes section, Ms Elaine Rogers for the cachexia section and Dr Richard Egan for input into the spirituality section. Nutrition in palliative care is written by Melissa Scattergood, Clinical Dietitian and the section on deprescribing by Andriana Colic, Clinical Oncology Pharmacist – Royal North Shore Hospital, Sydney. We are grateful to all for their expertise and to other colleagues at HammondCare who have made helpful suggestions for improvements. Many of the medications listed are being used outside their product licence. Prescription of a drug (whether licensed use/route or not) requires the prescriber, in the light of published evidence, to balance both the potential good and the potential harm which might ensue. Prescribers have a duty to act with reasonable care and skill in a manner consistent with the practice of professional colleagues of similar standing. Thus, when prescribing outside the terms of the licence, prescribers must be fully informed about the actions and uses of the drug, and be assured of the quality of the particular product (www.palliativedrugs.com/ using-licensed-drugs-for-unlicensed-purposes). Prescribers also have a duty to inform patients that drugs are being used outside their licence and to inform them of any expected effects and side effects. Care has been taken to ensure accuracy of information at time of printing. This information may change and final responsibility lies with the prescriber.Some medication will incur a cost to the user, it is important to consider this before prescribing This Handbook should be used in conjunction with Therapeutic Guidelines – Palliative Care – version 3 (Therapeutic Guidelines Limited, Melbourne) where possible Throughout the book, drugs that are either not available or not funded in New Zealand are marked with * Abbreviations subcut subcutaneous CNS central nervous system bd twice daily LFTs liver function tests tds three times daily MAOIs monoamine oxidase inhibitors qid four times daily NSAIDs nonsteroidal anti-inflammatory drugs Printed by Crucial Colour ISBN: 978-0-473-36095-5 2 | THE PALLIATIVE CARE HANDBOOK FOREWORD Palliative care has come a long way since the inception of the modern hospice movement in the UK in the 1960s. It is now recognised as an integral and important part of health care in over 100 countries throughout the world. In New Zealand, the growth of the specialty has been significant and now people throughout New Zealand should expect that those who are care for people at the end of life should have access to the best quality of care. This handbook – which started life as a small pocket book written by Rod MacLeod and Jane Vella-Brincat in Bath, England in 1994 has now grown to become an invaluable resource for practitioners throughout the country. Its popularity stems from the ease of use, the basic layout and the uncomplicated explanations of how to manage challenging symptoms that the authors have developed. This handbook finds its place in all areas where palliative care happens; it gives confidence to those who use it and hopefully therefore comfort to those approaching death so that they live every moment. Mary Schumacher Hospice New Zealand Wellington, NZ THE PALLIATIVE CARE HANDBOOK | 3 CONTENTS Introduction 6 Palliative care aims ............................................................................................... 7 General symptom management ........................................................................... 7 SECTION 1: Symptom control 7 Pain 8 Neuropathic pain ................................................................................................ 13 Gastrointestinal symptoms 15 Nausea/vomiting................................................................................................. 15 Bowel management ............................................................................................ 17 Constipation ....................................................................................................... 17 Diarrhoea ..................................................................................................... 19 Intestinal obstruction .......................................................................................... 20 Mouth care ......................................................................................................... 21 Taste alteration .................................................................................................... 22 Swallowing difficulties ......................................................................................... 23 Malignant ascites ................................................................................................ 24 Central nervous system 25 Depression ......................................................................................................... 25 Delirium ............................................................................................................... 27 Dementia ............................................................................................................ 29 Disorders of sleep and wakefulness ................................................................... 31 Insomnia ...................................................................................................... 31 Drowsiness/hypersomnia ............................................................................ 32 Sleep phase (circadian) disorder ................................................................. 32 Terminal restlessness ......................................................................................... 33 Palliative sedation ............................................................................................... 34 Fear and anxiety ................................................................................................. 34 Raised intracranial pressure ............................................................................... 36 Convulsions ........................................................................................................ 36 Respiratory system 38 Dyspnoea (breathlessness) ................................................................................ 38 Cough ................................................................................................................. 40 Hiccup ................................................................................................................ 41 Excessive (retained) secretions .......................................................................... 42 Haemoptysis ....................................................................................................... 43 4 | THE PALLIATIVE CARE HANDBOOK Skin 44 Itch (pruritus) ....................................................................................................... 44 Sweating ............................................................................................................. 45 Pressure injury care ............................................................................................ 46 Lymphoedema .................................................................................................... 47 Fungating wounds and tumours ......................................................................... 48 Systemic effects of terminal diseases 49 Paraneoplastic syndromes ................................................................................. 49 Venous thromboembolism.................................................................................. 50 Weakness/fatigue ............................................................................................... 51 Cachexia ............................................................................................................. 53 Anaemia .............................................................................................................. 54 Hypercalcaemia of malignant disease ................................................................ 55 Nutrition in palliative care .................................................................................... 56 Organ failure ....................................................................................................... 56 Deprescribing ..................................................................................................... 58 Palliative care emergencies 61 Haemorrhage .....................................................................................................
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