. BERKSHIRE ADULT PALLIATIVE CARE GUIDELINES BEST PRACTICE DOCUMENT . Did you print this document yourself? Please be advised that the retention of hard copies is discouraged. Please check for up to date version on your organisation website/intranet Date of Approval: Review Date: Issued: Version: 3 POLICY DEVELOPMENT ADULT PALLIATIVE CARE GUIDELINES SECTION 1: PAIN – BEST PRACTICE DOCUMENT SECTION 2: OTHER SYMPTOMS – BEST PRACTICE DOCUMENT History These guidelines cover all services in Berkshire including Wexham Park Hospital, Royal Berks Hospital, BHFT, East Berkshire CCGs, Sue Ryder Hospices & Thames Hospice. They are to be read in conjunction with Organisational Policies on Medicines Management, Prescribing and administration of medicines and use of Oxygen appropriate to each organization. Original Policy Dr. Paul Howard, Palliative Care Consultant Sue Ryder Consultants Dr. Fiona Lisney, Palliative Care Consultant Wexham Park Hospital Fiona Dorrington, Specialist Palliative Care Pharmacist Cathy Goddard, Lead Pharmacist Palliative Care, West Berkshire Rosemary Martin, End of Life Care Lead BHFT Dr Anant Sachdev, GPSI End of Life Care Anne Gates, District Nurse Team Leader Viv Tight, District Nurse Policy Review Specialist Palliative Care Medical Teams East Berkshire (Thames Jan – August 2015 by Hospice/HWPH) and West Berkshire (Sue Ryder Duchess of Kent and Nettlebed and RBHFT) Edited by: Fiona Dorrington, Macmillan Specialist Pharmacist, East Berkshire Dr Jane Bywater, Consultant in Palliative Care, Sue Ryder West Berkshire Cathy Goddard, Lead Pharmacist Palliative Care, West Berkshire Policy review February Specialist Palliative Care Teams: Thames Hospice (Drs C Wright, S Price, S 2018 – January 2019 Mulumudi, G Gupta, C Harris, A Martin. F Dorrington Macmillan Pharmacist) Sue Ryder Hospices (Duchess of Kent and Nettlebed) Wexham Park Hospital Dr F Lisney Royal Berkshire Hospital Edited by: Fiona Dorrington Macmillan Principal Pharmacist (Thames Hospice and Wexham Park hospital) Dr Jane Bywater, Consultant in Palliative Care, Sue Ryder West Berkshire BHFT Clinical Development Group –Community Nursing May 2019 BHFT Community Inpatient Mangagers group May 2019 Substantive Changes as a result of Review 1 Addition of Guidance on Hepatic and Renal insufficiency 2. Addition of Appendix: Anticipatory Prescribing Guidance 3. Addition of Appendices Opioid Patient information leaflets 4. Update of advice on oral to subcutaneous Cyclizine Use 5. Information of use of subcutaneous Ranitidine 6. Information of use of subcutaneous Levetiracetam 2 | P a g e Symptom Control Best Practice Guidelines Updated January 2019, Next review September 2022 7. Advice on management of fits Table of Contents Page 3 - 4 Who are these guidelines intended for? 5 Where to get advice and further information 6 Section One PAIN 1. Introduction to pain management 7 - 8 1.1 Pain assessment: how and why? 7 1.2 Pain treatment: The WHO ladder versus problem-specific approaches 8 2. Broad-spectrum analgesics 9 - 21 2.1 WHO ladder drugs Paracetamol and weak opioids 9 Strong opioids: starting; titrating 10 - 12 NSAIDs 13 - 14 2.2 Difficulties with opioids: adverse effects and switching between opioids 15- 21 Assessing opioid-responsiveness and Managing opioid adverse effects 15 - 16 Switching opioids (opioid conversion ratios) 16 - 18 2.3 Opioids in Chronic Pain 19 - 20 2.4 Opioid induced hyperalgesia 21 3. Pain amenable to specific approaches 22 - 31 3.1 Neuropathic pain 22 1st line drugs: amitriptyline, gabapentin 23 2nd line drugs: nortriptyline, pregabalin, carbamazepine, duloxetine, sodium valproate 24 Non-drug approaches (TENS, acupuncture) 25 Topical approaches (capsaicin, lidocaine patches) 25 3.2 Skeletal muscle spasm 26 - 27 3.3 Smooth muscle spasm (colic) 28 3.4 Malignant bone pain 29 3.5 Incident pain and other episodic pains 30 - 31 4. Difficult circumstances 32 - 38 4.1 Driving and analgesia (including a patient information leaflet) 32 - 33 4.2 Pain with concurrent drug misuse 34 - 35 4.3 Pain assessment in cognitive impairment 36 - 37 4.4 Checklist for analgesic-resistant pain 38 References 39 - 43 3 | P a g e Symptom Control Best Practice Guidelines Updated January 2019, Next review September 2022 Section Two OTHER SYMPTOMS 1. Respiratory ........................................................................................................................... 44 - 50 1.1 Breathlessness ............................................................................................................... 44 - 47 Opioids for breathlessness ............................................................................................. 45 Medication for anxiety and panic .................................................................................. 46 Nebulisers ...................................................................................................................... 46 Oxygen therapy ............................................................................................................. 47 1.2 Cough ............................................................................................................................. 48 - 49 Dry cough ....................................................................................................................... 49 Wet cough ...................................................................................................................... 49 Viscous sputum .............................................................................................................. 49 EOLC and retained secretions ........................................................................................ 49 2. Gastrointestinal ...................................................................................................................... 50 - 69 2.1 Hiccup……………………………………………………………………………………………………………………….. 50 - 51 2.2 Nausea and Vomiting ...................................................................................................... 52 - 56 Choosing an Antiemetic ................................................................................................. 53 - 54 Specific causes: .............................................................................................................. 54 - 56 Gastric stasis Chemical/ toxic Other causes 2.3 GI Obstruction ................................................................................................................ 57 - 60 2.4 Mouth ............................................................................................................................ 61 - 62 2.5 Constipation…………………………………………………………………………………………………… .......... 63 - 65 2.6 Diarrhoea ....................................................................................................................... 66 - 67 3. Skin ……………………………………………………………………………………………………………………… ............. 68 - 81 3.1 Lymphoedema …………………………………………………………………………………………………… ...... 68 - 74 3.2 Cellulitis .......................................................................................................................... 75 - 76 3.3 Itching ............................................................................................................................. 77 - 79 4. Emergencies and cancer related complications……………………………………………………… ........... 80 - 88 4.1 Hypercalcaemia …………………………………………………………………………………………………. ...... 80 4.2 Spinal Cord Compression………………………………………………………………………………………………. 81 4.3 Superior vena cava obstruction ...................................................................................... 81 4.4 Bronchial obstruction ..................................................................................................... 82 4.5 Ascites ………………………………………………………………………………………………………………… ..... 83 - 84 4.6 Haemorrhage………………………………………………………………………………………………………. ..... 85 4.7 Seizures ........................................................................................................................... 86 – 87 5. Prescribing in Renal Insufficiency ........................................................................................... 88 – 92 6. Prescribing in Hepatic Insufficiency ........................................................................................ 93 - 95 1. Appendix 1 – Summary of Anticipatory Prescribing Guidance ............................................ 96 2. Appendix 2 – Patient Information Leaflets- Morphine, Oxycodone, Fentanyl .................... 97 - 108 References……………………………………………………………………………………………………………………. ........ 109 - 113 4 | P a g e Symptom Control Best Practice Guidelines Updated January 2019, Next review September 2022 Who are these guidelines intended for? Which patients? These palliative care guidelines are intended to help alleviate symptoms in adults with advanced life-limiting illnesses, including both malignant and non-malignant conditions. Whilst some of the principles of symptom control presented here are applicable to adults with potentially curable illnesses, there are often important differences. The likely causes, underlying pathophysiology and therapeutic aims may differ, making these guidelines inappropriate for use in the non-palliative setting. Which healthcare professionals? These guidelines are aimed at all members of the multi-disciplinary healthcare team, regardless of specialty and profession, providing palliative care wherever it is required (in hospitals, nursing homes or the patient’s own home). They are designed to aid decision-making