Clinical Resource Palliative Care Program Symptom Guidelines 4th Edition 10-513-6034 (WRD Rev. 10/19) October 2019 Author(s): Endorsed by NH Medical Advisory Committee Revised by: Northern Health Palliative Care Consultation Team Palliative Care Symptom Guidelines 4th Edition Page 2 of 142 IMPORTANT NOTICE In Northern Health there is an interdisciplinary consult team available for support in the management of palliative patients. For support and education, and including: • Patient Assessment • Pain and Symptom Management • End-of-Life Decision Making Nurse Consultants are available Monday through Friday (excluding statutory holidays) and can be reached at: Northeast: 250-795-6134 Northwest: 250-631-4191 Northern Interior/Prince George: 250-565-7318 Pharmacist Lead: 250-649-7599 In the event the Nurse Consultants are unavailable, and there is urgent advice needed, physicians can: 1. Contact the Northern Health Palliative Care Physician on-call at 250-565-2000. Palliative on-call physicians are available 24hrs a day to assist physicians across Northern Health manage their palliative patients. 2. Provincial Palliative Care Consultation line at 1-877-711-5757 Author(s): Endorsed by NH Medical Advisory Committee Date Issued (I), REVISED (R), reviewed (r): October 2008(I), November 2017(R), October 2019 (R) This material has been prepared solely for use at Northern Health (NH). NH accepts no responsibility for use of this material by any person or organization not associated with NH. No part of this document may be reproduced in any form for publication without permission of NH. A printed copy of this document may not reflect the current, electronic version on OurNH. Palliative Care Symptom Guidelines 4th Edition Page 3 of 142 Copyright © Northern Health Authority 2008 The Northern Health Authority (“NHA”) authorizes the use, reproduction and/or modification of this publication for purposes other than commercial redistribution. In consideration for this authorization, the user agrees that any unmodified reproduction of this publication shall retain all copyright and proprietary notices. If the user modifies the content of this publication, all NHA copyright notices shall be removed, however NHA and its source authors shall be acknowledged. Reproduction or storage of this publication in any form by any means for the purpose of commercial redistribution is strictly prohibited. While care has been taken to ensure the accuracy of the information contained in this publication as of the date of publication, the Northern Health Authority makes no warranty, express or implied, as to accuracy, completeness or currency. New knowledge, new technologies, clinical and research data, and clinical experiences may provide sound reasons for adopting alternative clinical practices. The ultimate judgment regarding the propriety of any specific clinical practice must be made by the health professional in light of the circumstances presented by the patient. Northern Health Regional Palliative Care Consultation Team 101-155 McDermid Drive Prince George, BC V2M 4T8 [email protected] Northernhealth.ca Author(s): Endorsed by NH Medical Advisory Committee Date Issued (I), REVISED (R), reviewed (r): October 2008(I), November 2017(R), October 2019 (R) This material has been prepared solely for use at Northern Health (NH). NH accepts no responsibility for use of this material by any person or organization not associated with NH. No part of this document may be reproduced in any form for publication without permission of NH. A printed copy of this document may not reflect the current, electronic version on OurNH. Palliative Care Symptom Guidelines 4th Edition Page 4 of 142 TABLE OF CONTENTS Acknowledgements ........................................................................................................... 6 The Authors ........................................................................................................................ 7 Introduction ...................................................................................................................... 10 Symptom Assessment Acronym ................................................................................... 14 Ascites .............................................................................................................................. 16 Recommendation 1 - Assessment of Ascites ............................................................... 16 Recommendation 2 - Diagnosis .................................................................................... 18 Recommendation 3 - Education .................................................................................... 19 Recommendation 4 - Treatment: Non-pharmacological............................................... 19 Recommendation 5 - Pharmacological ......................................................................... 20 Depression in the Terminally Ill ..................................................................................... 22 Recommendation 1 - Incidence and Risk Factors ........................................................ 23 Recommendation 2 - Assessment of Depression ........................................................ 24 Recommendation 3 - Diagnosis .................................................................................... 25 Recommendation 4 - Education .................................................................................... 26 Recommendation 5 - Treatment: Non-pharmacological............................................... 26 Recommendation 6 - Treatment: Pharmacological ...................................................... 26 Hypercalcemia in Malignant Disease (Palliative Management) ................................. 31 Recommendation 1 - Hypercalcemia Assessment ....................................................... 31 Recommendation 2 - Diagnosis .................................................................................... 34 Recommendation 3 - Education .................................................................................... 35 Recommendation 4 - Treatment: Non-pharmacological............................................... 35 Recommendation 5 - Treatment: Pharmacological ...................................................... 35 Malignant Bowel Obstruction ........................................................................................ 39 Recommendation 1 - Assessment of Bowel Obstruction ............................................. 40 Recommendation 2 - Diagnosis .................................................................................... 41 Recommendation 3 - Education .................................................................................... 42 Recommendation 4 - Treatment: Non pharmacological ............................................... 42 Recommendation 5 - Treatment: Pharmacological ...................................................... 43 Principles of Opioid Management ................................................................................. 46 Recommendation 1 – Opioid Principles ........................................................................ 48 Recommendation 2 – Screen for Sensitivity or Allergy to Specific Opioid .................. 49 Recommendation 3 – Assessment of Pain ................................................................... 49 Recommendation 4 – Diagnosis ................................................................................... 50 Recommendation 5 – Pain Management...................................................................... 50 Author(s): Endorsed by NH Medical Advisory Committee Date Issued (I), REVISED (R), reviewed (r): October 2008(I), November 2017(R), October 2019 (R) This material has been prepared solely for use at Northern Health (NH). NH accepts no responsibility for use of this material by any person or organization not associated with NH. No part of this document may be reproduced in any form for publication without permission of NH. A printed copy of this document may not reflect the current, electronic version on OurNH. Palliative Care Symptom Guidelines 4th Edition Page 5 of 142 Recommendation 6 – Treatment with Opioids.............................................................. 51 Recommendation 7 – Routes of Administration of Opioids ...………………………….54 Recommendation 8 – Adverse Effects of Opioids..…………………………………… 55 Recommendation 9 – Opioid Titration.……………………………………………………56 Recommendation 10 – Use of Long Acting Or Sustained Release Opioids………….57 Recommendation 11 – Opioid Rotation……………………………………………….....58 Recommendation 12 – Opioid Withdrawal………………………………………………59 Recommendation 13 – Treatment: Pharmacological……………………………………59 Appendix A: FentaNYL Transdermal……………………………………………………..64 Appendix B: Methadone…………………………………………………………………. 104 Appendix C: Tramadol…………………………………………………………………….117 Appendix D: SUFentanil…………………………………………………………………..122 Spinal Cord Compression ............................................................................................131 Recommendation 1 - Assessment of Spinal Cord Compression ...............................131 Recommendation 2 - Diagnosis ..................................................................................134 Recommendation 3 - Prognosis ..................................................................................135 Recommendation 4 - Education ..................................................................................135 Recommendation