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October 2012 Palliative Care Practice Guidelines Thomas Palliative Care Services VCU Massey Cancer Center VCU Health System.

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Presentation on theme: "October 2012 Palliative Care Practice Guidelines Thomas Palliative Care Services VCU Massey Cancer Center VCU Health System."— Presentation transcript:

1 October 2012 Palliative Care Practice Guidelines Thomas Palliative Care Services VCU Massey Cancer Center VCU Health System

2 Development and Verification The practice guidelines were developed by an interdisciplinary group of palliative care clinicians based on the best available research for each symptom addressed. If two medications seemed equally beneficial, medications were then selected based on cost, side effect profile, nursing time, and availability on our formulary. The practice guidelines are reviewed annually by our group of fellows, attending physicians, pharmacists, and nurses to determine if changes need to occur. The impact on symptoms are evaluated annually to determine if we have improved symptom burden within our population of patients. These practice guidelines have been reviewed by outside experts in the past. Nurses and fellows are educated on the use of the practice guidelines which also help instruct residents who are doing their palliative training on consistent research-based symptom management practice. We believe this has improved symptom management throughout the institution for those patients who do not receive or require a palliative care consult. October 2012

3 3 Table of Contents Agitation3 Alternative Route for Opioid Administration4 Anorexia5 Anuria6 Bladder Spasms Treatment7 Bowel treatment – stepped care program 8 Candidiasis – Oral 9 Candidiasis – Perineal 10 Dyspnea11 Fever12 Hiccough13 Mucositis14 Pruritus15 Secretions16 Seizures – Acute Management 17 Sleep Disturbance18 Wound Odor19 NameDate Medical Director, Thomas Palliative Care Unit NameDate Director, Nursing

4 October Agitation Haloperidol 0.5 mg PO/IV/SC every 4 hours as needed Continue same dose Haloperidol every 12 hrs scheduled Evaluate to continue, taper or dc Titrate up by 1 mg every 1 hour until desired effect achieved (1mg, 2 mg, 3 mg, etc); MDD 20 mg Lorazepam 0.5mg PO or IV every 1-2 hours as needed MDD* 12 mg Continue Lorazepam Evaluate regularly to taper or discontinue Consider Palliative Service consultation reliefno relief relief no relief after MDD Haldol no relief after 24 hours Excessive physical or mental restlessness. Increased activity that is generally not purposeful and associated with anxiety. Depending on appropriateness, evaluate for reversible causes, including delirium and treat the underlying etiology if possible. Symptom control may begin concurrently with diagnostic work-up. Nonpharmacological interventions: reorientation, maintaining sleep wake schedule Avoid restraints, minimize immobilizing treatments, maintain communication, med reconciliation Consider Palliative Service consultation atypical antipsychotic meds starting doses for delirium Olanzapine 2.5mg q12hrs Risperidone 0.25mg q12hrs Quetiapine 12.5mg q12hrs Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible. * MDD = Maximum Daily Dose Benzodiazepines may increase agitation and delirium; consider chlorpromazine 25 mg IV every 8 hrs

5 October Alternative Route for Opioid Administration If patient is unable to take PO analgesic AND IV access is not available Example: 360 mg of PO MSO 4 every day divided by 3 = 120 divided by 24 hrs = basal rate of 5 mg/hr IV MsO 4 PCA dose would be 2.5 mg q 6 min Bolus = 3 times basal dose = 15 mg q 1hr Convert 24-hour opioid requirement of continuous infusion of Basal Opioid via PCA pump. May add PCA dose of atleast 50% of basal rate every 6 min w/ bolus 3 times basal rate of every1 hr Convert to Fentanyl patch using equianalgesic coversion card, continue to give Fentanyl sublingual at dose of 25 mcg every ½ hour prn (Note: no benefit from patch for 8-14 hours) Convert to subcutaneous infusion of PCA using 27 gauge needle (PCA dose remains the same, change lock out to every 15 min). Infusion volume not to exceed 2 ml/hr so may need higher concentration. Remember can call pharmacy for assistance in how to order SQ PCA. Convert to rectal, vaginal or stoma route for long acting opioid (same dose) using Fentanyl injection sublingual 25 mcg every 30 min prn. Can give Roxanol(morphine 20mg/ml) sublingual and it can be given to patients that aren’t awake. Document patient ability to maintain internally. OPTIONS May also place subcutaneous needle for use if only intermittent opioids required, convert PO dose to parenteral dose using equianalgesic conversion card. Continue prn schedule. ** Physicians NOTE: Please consider incomplete cross tolerance in your conversions. If IV access is no longer available AND Patient is able to take PO medications, select appropriate long and short acting opioids and convert dosage requirements using equianalgesic conversion card Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

6 October Anorexia Appetite Suppression IF BOTHERSOME TO PATIENT Continue megestrol at current dose Trial of megestrol acetate (Megace) 400 mg liquid PO daily Reassess at 1 week for efficacy Prednisone 20mg daily (considered most useful if estimated prognosis less than 6 weeks) relief no relief A loss of appetite with noted weight loss which is bothersome to the patient. Supportive counseling for patient and family: anorexia as a natural symptom of disease, validation of normalcy, dietary and nutritional changes and counseling HIV Patients: Dronabinol starting dose 2.5mg bid MDD 20mg daily (NOTE: Dronabinol is non- formulary) Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible. Recommend increase dose of megestrol to 800 mg liquid PO daily Reassess at 1 week for efficacy (consider risk for DVT) Continue megestrol at current dose relief no relief

7 October Anuria Catheterize for residual urine or perform bedside bladder scan if available Less than 250 mlsOver 250 mls Leave catheter in place Evaluate volume status Re-asses catheter need periodically If catheter becomes plugged irrigate with normal saline prn Minimal to no urine output. Review medications: Anticholinergic, antidepressants, antihistamines, opioids as cause Management for BPH Anuria can be part of dying process, enact algorithm if unexpected or patient symptomatic, eg pain, agitation. Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

8 October Bladder Spasms Treatment Obtain urinalysis and culture of clean catch urine If indwelling catheter is present would do this first Negative urinalysis Positive urinalysis Contact MD Anticipate TMP/SMX Assess catheter function; irrigate gently with NS Consider replacing if catheter present greater than 5 days Oxybutynin 5 mg PO TID x 48 hours- MDD 20 mg. If PO difficult, available in patch 3.9mg/day twice a week (patch not in formulary) Start TMP/SMX DS PO twice/day; if sulfa allergic, ceftriaxone 1g IV daily No further intervention is needed Oxybutynin 5 mg TID x 48 hours MDD 20 mg OR Scopolamine 0.4mg IV or sub cutaneously every 4 hours prn Continue Oxybutynin MD/RN/Rx consult Scopolamine patch every 72 hours OR scopolamine 0.4mg IV every 4 hours prn Promote increased fluid intake as appropriate Oxybutynin 5 mg PO TID x 48 hours MDD 20 mg An intermittent cramping sensation of the bladder resulting in discomfort and/or pain. Treat pain with prn analgesic while analysing cause Alternative to oxybutynins: Tolterodine Newer agents: solifenacin, Trospium, darifenacin Newer agents are non-formulary Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

9 October Bowel treatment – stepped care program Stool softener and/or gentle laxative Docusate 100 mg twice/day (taking no opioids) Senokot 1 tab twice/day (taking opioids) If no bowel movement for 48 hour period add one of these: Milk of magnesia concentrate 10 ml po every day OR Bisacodyl 10 mg PO/PR every day if po not tolerated or refused If no bowel movement in next 12 hours, perform rectal exam to rule out impaction If not impacted, Magnesium citrate 8 oz OR Fleets enema Soften with glycerin suppository then manually disimpact Increase the prophylactic regimen to 2 tab Senokot twice/day Consider Palliative Service consultation If impacted, Fleets enema Increase the prophylactic regimen to 2 tab Senokot twice/day Consider Palliative Service consultation Treatment to alleviate hard stools and/or constipation associated with opioid administration. Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible. For opioid induced constipation, consider methylnaltrexone SQ injection ( 62kg=12mg SQ every other day until BM) Follow up with tap water enema until clear

10 October Candidiasis – Oral Nystatin susp 400, ,000 swish and swallow four times/day; hold in mouth 2-5 minutes OR Clotrimazole troche 10 mg five times a day Improved after 48 hours Continue 7 days Not improved and patient using appropriately, or not able to swallow Mucocutaneous candidiasis: Fluconazole 200 mg Loading Dose then 100 mg every day x 14 days. Whitish patches on the inner oral cavity, tongue or throat, which may or may not cause discomfort. Remember someone who is immunocompromised may need to get fluconazole from the beginning. Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible. Esophageal candidiasis: Fluconazole 400 mg Loading Dose then 200 mg every day x 14 days.

11 October Candidiasis – Perineal Clotrimazole cream 1% applied twice/day or nystatin powder tid & area kept dry Improved after 48 hours Continue clotrimazole or nystatin powder 7-14 days No improvement after 48 hours Fluconazole 150 mg one time dose. Reddened areas between skin folds in the genital area, which may or may not cause discomfort. Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

12 October Dyspnea Complete respiratory assessment If oxygen sats <90% give oxygen 2L/min. Check hemoglobin and transfuse if consistent with care goals established on signout. Complains of dyspneaBronchospasm with audible wheeze If mild CHF(crackles on exam), with respiratory distress Furosemide 40 mg PO/IV for one dose Monitor for improvement. Consider MD consult For end stage, consider fentanyl nebulizer 25 mcg every 2 hours prn with 2.5 ml of NS Trial of oxygen 2 liters/min Reassess every 2 hours If no relief, Consider Morphine 10 mg PO every 2 hours prn or 3 mg subcutaneous or IV hourly prn; monitor respirations Fentanyl nebulizer 25 mcg in 2.5 ml of NS every 2 hours prn If no relief, lorazepam 0.5 mg PO or IV every 4 hours prn. Monitor respirations If relief, continue lorazepam prn MDD 10 mg/day Albuterol 2 inhalations every 4 hours prn or 3ml nebulized every 2 hours prn If no relief, add oxygen 2 liters/min and ipratropium 1-2 inhalations every 4-6 hours prn or 2.5 ml nebulized every 4 hours prn If relief, continue If improvement, continue If no relief, add fentanyl nebulizer 25 mcg in 2.5 ml NS every 2 hours prn. Consider adding oxygen 2 liters/min The sensation of air hunger. May be exhibited by gasping, accessory muscle involvement in breathing, tachypnea, discomfort. Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible. Consider non-pharmacologic options (e.g. fans, relaxation, CPAP or BiPAP, physical comfort measures, relaxation)

13 October Fever Symptomatic Fever or Rigors Refer to signout to see goals of care. Workup needed? Source of infection is suspected by history or exam Treat symptomatically, especially end stage disease Consider workup and possible antibiotic therapy Acetaminophen 650 mg PO/PR every 4 hours scheduled x 24 hours (avoid other tylenol containing products) if symptomatic or temp > 101 PO Reassess after 24 hours If no relief, try Ibuprofen 400 mg PO or aspirin 650 mg PO or aspirin suppository 600 mg every 6 hours or ketorolac IV (15 mg) every 6 hrs x 24 hrs If no relief, consider Palliative Service consultation yesno A temperature of over (orally), (axillary), or (for patients with known neutropenia. Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

14 October Hiccough Baclofen 5mg po every 6 hours prn, can increase to 10mg every 6hrs if CrCl >30 Can continue baclofen. Haloperidol 2 mg PO/Subcutaneous/IV Maintenance 2 mg PO three times/day Continue as needed Consider scheduling Metoclopramide 10 mg PO/IV every 6 hours prn Maintenance mg po 4 times/day Continue as needed If no relief, consider anesthesia consult for block Continue as needed No effect EffectIf no effect or unable to take PO Effect A spasmodic intermittent closure of the glottis following lowering of the diaphragm causing a short, sharp, inspiratory cough. Non-pharmacological treatment: Holding breath, mild irritation of nasopharynx Valsalva, sipping liquids slowly, 5 th vertebrae rubbing If GERD: maalox 30ml PO every 4 hours prn, can Start PPI on formulary Eg: esomeprazole 40mg daily Consider Gabapentin 300mg PO 3 times/day OR Chlorpromazine 25 mg PO 3 times/day Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

15 October Mucositis (without obvious infection) Sodium bicarbonate rinses OR 1:1 Isotonic saline/sodium bicarbonate rinses every 2 hours while awake If relief, continue rinses as needed. Reassess in 7 days. If no relief, start trivalent mouth wash (Benadryl, maalox, lidocaine mixture)5 ml swish/spit every hour OR swish/swallow every 4 hours Consider other analgesic interventions such as PCA, viscous lidocaine, topical cocaine. Consider Palliative Service consultation No relief after 24 hours Inflammation of the mucus membranes. Generally causes pain in the oral cavity and throat and exhibited by excessive drooling, spitting and mucus production. Evaluate for and treat thrush if present (see oral candidiasis algorithm); consider evaluating for oral HSV Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible. Consider non-pharmacologic measures (e.g. removal of dentures; avoiding salty, acidic or dry foods; change PO to IV formulation as appropriate/able)

16 October Pruritus Establish probable cause: Consider medications, high bilirubin, skin irritants Hydroxyzine 10 mg every 6 hours PO prn If obstructive jaundice- cholestyramine 4gm PO every day before breakfast. Hydrocortisone/Pramoxine foam 4 times/day prn OR Diphenhydramine 25 mg PO/IV every 6 hours Improved after 24 hours, continue prn No improvement after 48 hours Increase cholestyramine to 4gm PO ac breakfast & dinner -Consider PO Rifampicin 150 mg daily & possible titration with monitoring of liver function & CYP450 drug interactions - If not on SSRI or SNRI anti-depressant, consider PO Sertraline 50 mg daily & titrate up to 100 mg after a week Consider Palliative Service consultation Severe itching. If opioid induced, trial another opioid – hydromorphone if currently on morphine or fentanyl if currently on hydromorphone Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.. Contact physician, consider narcan infusion (2.5 mg in 250 ml, 4ml/hr & titrate to max. rate of 12 ml/hr) or opioid rotation

17 October Secretions Assess saliva Diminished saliva (xerostomia) Increased secretions without trach (Note: with trach evaluate risk of excessively drying up secretions) Thick secretions Guaifenesin 200 mg PO every 4 hours prn Increase fluid intake Encourage oral fluid intake and good oral care Use artificial saliva Suck on sugarless candy, chew sugarless gum If history of radiation to head/neck Pilocarpine 5 mg PO tid, up to 10 mg tid if necessary If disturbing to pt/family, consider a trial of scopolamine patch every 72 hours and scopolamine 0.4 mg subcutaneous/IV now and every 4 hours prn No reliefIf relief, continue treatment Add a second scopolamine patch every 72 hours OR Increase scopolamine to 0.6mg subcutaneous/IV every 4 hours prn OR Glycopyrrolate mg IV/SQ q4-6h prn Consider Palliative service consultation Oral or airway lubrication. May be noted by excessive, noisy respirations If patient unconscious, consider suction Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

18 October Seizures – Acute Management Seizure Lorazepam 2 mg IV/Sublingual/Subcutaneous stat Notify physician May repeat in 15 min prn MAXIMUM 8 mg (Consider 2 mg IV midazolam or 5mg IV diazepam if lorazepam not available) Is it appropriate to escalate care for this patient? Notify family, consider chronic suppression with lorazepam Further work-up, monitoring and medication load for chronic suppression therapy Yes No Sudden, non-purposeful, rhythmic movement of any part of the body or facial muscles lasting from less to a minute to more that several minutes. Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

19 October Sleep Disturbance (consider etiology and r/o delirium, treat cause) Consider cause including pain, anxiety, agitation, caffeine, medications Zolpidem 5 mg PO at bedtime, may repeat in one hour if no delirium If sleep loss related to depression, consider treatment options accordingly If relief, continue as needed If no relief after 2 nights, notify physician Consider a trial of temazepam 15 mg PO qhs Use with caution in > 60 yr old & consider trazodone mg PO qhs instead If relief, continue as needed An inability to fall asleep and or stay asleep causing discomfort or fatigue. Control environmental factors: minimize nighttime interruptions, lights, television, late meals, caffeine encourage daytime OOB, and lights Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible. Is this daytime sedation? Considerations include: Caffeine 100 mg PO every 6 hours until 4 PM OR Methylphenidate mg 2 times per day (2 nd dose no later than noon, max. 10 mg bid) OR Modafinil 100 mg every morning

20 October Wound Odor Use room deodorizer Apply absorptive dressing with wound cover using: Calcium alginate Gauze packing 4x4s or kerlix roll gauze with NS Foam dressing, or Baby diapers for heavy drainage Apply non-adherent (oil emulsion) gauze as first layer on wounds that are dry, when dressings stick, or bleeding is a factor Cleanse with normal saline or wound cleanser Consider topical 0.75% metronidazole gel (in a heavily draining wound this may increase drainage and not help odor) Consult Wound Care Team Continue Lightly spray outer dressing with Enzymatic Rain with each change A strong, noticeable, offensive smell emanating from a wound. Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible..

21 Algorithm Evidence-Based References Agitation –Jackson, KC, Lipman, AG. Drug therapy for delirium in terminally ill patients. In: The Cochrane Library, Issue 2, Chichester, UK: John Wiley Sons, –Breitbart W, Marotta R, Platt MM, Weisman H, Derevenco M, Grau C, Corbera K, Raymond S, Lund S, Jacobson P. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J.Psych1996 ;153: –Stahl, S. Essential Psychopharmacology: Neuroscientific Basis and Practical Applications 2nd ed. Cambridge University Press –Pasacreta, J., Minarik, P., & Nield-Anderson, L. (2006). Anxiety and depression. In B. R. Ferrell, & N. Coyle. (Eds.), Textbook of palliative nursing (2nd ed., pp ). New York, NY: Oxford University Press. Alternative Route for Opioid Administration –Bruera E, Brenneis C, Michaud M, et al. Use of the subcutaneous route for the administration of narcotics in patients with cancer pain. Cancer 1988; 62: –Principles of analgesic use in the treatment of acute pain and cancer pain. American Pain Society, 5 th Edition, –Pereira J et al. Equianalgesic dose rations for opioids: a critical review and proposals for long-term dosing. J Pain Sym Manage 2001;22: –Gourlay GK. Treatment of cancer pain with transdermal fentanyl. The Lancet Oncology 2001; 2: Anorexia –Jatoi A, Windschitl HE, et al. Dronabinol Versus Megestrol Acetate Versus Combination Therapy for Cancer-Associated Anorexia: A North Central Cancer Treatment Group Study. Journal of Clinical Oncology, Volume 20, Number 2, 2002; –Inui, A., Cancer Anorexia-Cachexia Syndrome: Current issues in research and management, CA Cancer J Clin 2002; 52: –Jatoi, A. On appetite and its loss, Classic Papers, Supplement to JCO, Vol 21, No 9 (May 1), 2003: pp 79s-81s. – Bistrian, B. (1999). Clinical trials for the treatment of secondary wasting and cachexia. Journal of Nutrition, 129(1S Suppl), 290 S-294 S –Fainsinger, R. L., & Periera, J. (2004). Clinical assessment and decision-making in cachexia and anorexia. In D. Doyle, G.W.C. Hanks, N. Cherney, & K. Calman. Oxford textbook of palliative medicine (3rd ed., pp ). Oxford, UK: Oxford University Press Anuria –Cravens (2000) Am Fam Physician 61(2): –Walsh (1998) Campbell's Urology, Saunders, p Bladder Spasms Treatment –Herbison, P, Hay-Smith, J, Ellis, G, Moore, K. Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive bladder: systematic review. BMJ 2003; 326:841. –Nicolle, LE, Bradley, S, Colgan, R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005; 40:643. –Howe, RA, Spencer, RC. Cotrimoxazole. Rationale for re-examining its indications for use. Drug Saf 1996; 14:213. Bowel Treatment – stepped care program –Klaschik E, Nauck F, Ostgathe C. Constipation--modern laxative therapy. Support Care Cancer. 2003;11(11): Epub 2003 Sep –Mancini I, Bruera E. Constipation in advanced cancer patients. Support Care Cancer. 1998; 6(4): –Locke, GR III, Pemberton, JH, Phillips, SF. AGA technical review on constipation. Gastroenterology 2000; 119:1766. October Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

22 Algorithm Evidence-Based References Candidiasis – Oral –Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004; 38: –Sweeney MP, Bagg J. The mouth and palliative care. Am J Hosp & Pall Care 2000; 17(2): Candidiasis – Perineal –Sobel JD, Brooker D, Stein GE, Thomason JL, Wermeling DP, Bradley B, Weinstein L. Single oral dose fluconazole compared with conventional clotrimazole topical therapy of Candida vaginitis. Fluconazole Vaginitis Study Group. Am J Obstet Gynecol Apr;172(4 Pt 1): – National guideline for the management of vulvovaginal candidiasis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999; 75 Suppl 1:S19. –Rex, JH, Walsh, TJ, Sobel, JD, et al. Practice guidelines for treatment of candidiasis. Clin Infect Dis 2000; 30:662. Dyspnea –Bruera E, Sweeny C and Ripamonti C. Dyspnea in patients with advanced cancer. In: Principles and Practice of Palliative Care and Supportive Oncology. 2 nd Ed Berger A, Portenoy R and Weissman DE (eds). Lippincott-Raven, –Chan KS et al. Palliative Medicine in malignant respiratory diseases. In Oxford Textbook of Palliative Medicine 3 rd Ed. Doyle D, Hanks G, Cherney N and Calman N. Oxford, 2005 –Fohr SA. The double effect of pain medication: separating myth from reality. J Pall Med 1998; 1: –Coyne, P. J., Lyne, M.E., & Watson, A. C. (2002). Symptom management in people with AIDS. American Journal of Nursing, 102(9), –Coyne, P., J., Viswanathan, R., and Smith, T., "Nebulized Fentanyl Citrate Improves Patients Perception of Breathing, Respiratory Rate, and Oxygen Saturation in Dyspnea." Journal of Pain and Symptom Management. February, 23 (2), 2002, pp –NCCN Clinical Practice Guidelines in Oncology: Palliative Care. V Available at NCCN.org Jensen Jensen D, Alsuhail A, Viola R, Dudgeon DJ, Webb KA, O'Donnell DE J Pain Symptom Manage. Inhaled fentanyl citrate improves exercise endurance during high-intensity constant work rate cycle exercise in chronic obstructive pulmonary disease.Jensen DAlsuhail AViola RDudgeon DJWebb KAO'Donnell DEJ Pain Symptom Manage. –2012 Apr;43(4): Epub 2011 Dec 14. –. Fever –Zell JA, Chang JC. Neoplastic fever: a neglected paraneoplastic syndrome. Support Care Cancer Nov;13(11): –Oh DY, Kim JH, Kim DW, Im SA, Kim TY, Heo DS, Bang YJ, Kim NK Antibiotic use during the last days of life in cancer patients. Eur J Cancer Care (Engl) Mar;15(1):74-9. –Boulant JA: Thermoregulation. In: Machowiak PA, ed.: Fever: Basic Mechanisms and Management. New York, NY: Raven Press, 1991, pp 1-22 –Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: Toxicity And Response Criteria The Eastern Cooperative Oncology Group. Am J Clin Oncol 5: , –Young LS: Fever and septicemia. In: Rubin RH, Young LS, eds.: Clinical Approach to Infection in the Compromised Host. 2nd ed. New York, NY: Plenum Medical, 1988, pp –Zhukovsky DS: Fever and sweats in the patient with advanced cancer. Hematol Oncol Clin North Am 16 (3): , viii, October Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

23 Algorithm Evidence-Based References Hiccough –Kolodzik PW, Eilers, MA: Hiccups (singultus): Review and approach to management. Ann Emerg Med 1991; 20: –Rousseau, P. Hiccups. Southern Med J 1995; 2: –Lewis J. Hiccups: Causes and cures. J Clin Gastro 1985; 7: Mucositis –Dodd MJ, et al. Radiation-induced mucositis: a randomized clinical trial of micronized sucralfate versus salt & soda mouthwashes. Cancer Invest. 2003;21(1): –Shih A, Miaskowski C, Dodd MJ, Stotts NA, MacPhail L. A research review of the current treatments for radiation-induced oral mucositis in patients with head and neck cancer. Oncol Nurs Forum Aug;29(7): Links –Berger AM and Kilroy TJ. Oral Complications. in DeVita V et al (eds) Cancer: Principles and Practices of Oncology. 6 th edition. Lippincott Williams & Wilkins –Rubenstein, EB, Peterson, DE, Schubert, M, et al. Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis. Cancer 2004; 100: –Epstein, JB, Schubert, MM. Oropharyngeal mucositis in cancer therapy. Review of pathogenesis, diagnosis, and management. Oncology (Huntingt) 2003; 17:1767. Pruritus –Beuers U, Boberg KM, Chapman RW, et al. EASL clinical practice guidelines: management of cholestatic liver diseases. J Hepatol 2009;51: –Alan B. Fleisher, Jr and Jason R. Michaels. Pruritus. In: Principles & Practice of supportive Oncology. Eds: Ann Berger, Russell K. Portenoy, David E. Weissman. Lippincott-Raven Publishers Philadelphia 1998; –Krajnik M and Zylicz. Understanding pruritis in systemic disease. J Pain Symp Manage 2001; 21: –Mayo MJ, Handem I, Saldana S, et al. Sertraline as first line treatment for cholestatic pruritis. Hepatology 2007;45: –NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. V Available at NCCN.org. Secretions –Wilders H, Menten J. Death rattle: prevalence, prevention and treatment. J Pain Symptom Manage 2002; 23: –Cooke, C, Ahmedzai, S, Mayberry, J. Xerostomia--a review. Palliat Med 1996; 10:284. –Richardson, PS, Phipps, RJ. The anatomy, physiology, pharmacology and pathology of tracheobronchial mucus secretion and the use of expectorant drugs in human disease. Pharmacol Ther [B] 1978; 3:441. –LeVeque FG, Montogomery M, Potter D, et al. A multicenter, randomized, double ‐ blind, placebo ‐ controlled, dose ‐ titration study of oral pilocarpine for treatment of radiation ‐ induced xerostomia in head and neck cancer patients. J Clin Oncol 1993;11:1124 ‐ 31. –Johnson JT, Ferretti GA, Nethery WJ, et al. Oral pilocarpine for post ‐ irradiation xerostomia in patients with head and neck cancer. N Engl J Med 1993;329:390 ‐ 5. –NCCN Clinical Practice Guidelines in Oncology: Palliative Care. V Available at: NCCN.org. Seizures – Acute Management –DroneyJ, Hall E, Status Epilepticus in a Hospice Inpatient Setting. Journal of Pain and Symptom Management Vol36 No 1 July 2008 –Cereghino, J. Rectal Diazepam for threayment of Acute Repetitive Seizures in Adults. Archives of Neurology Vol 159 Decemver 2002 –Treiman, DM. Pharmacokinetics and clinical use of benzodiazepines in the management of status epilepticus. Epilepsia 1989; 30(suppl 2):s4. –Chapman, MG, Smith, M, Hirsch, NP. Status epilepticus. Anaesthesia 2001; 56:648. October Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.

24 Algorithm Evidence-Based References Sleep Disturbance –Carlos H. Schenck, Mark W. Mahowald, and Robert L. Sack.Assessment and Management of Insomnia JAMA : –NCCN Clinical Practice Guidelines in Oncology: Palliative Care. V Available at: NCCN.org. Wound Odor –Paul Walker. The pathophysiology and management of pressure ulcers. In: Topics in Palliative Care, Volume 3. Eds. Russell K. Portenoy and Eduardo Bruera. Oxford University Press Pp –Grocott P. The palliative management of fungating malignant wounds. J Wound Care. 2000; 9 (1):4-9. –Newman V, Allwood M, Oakes RA. The use of metronidazole gel to control the smell of malodorous lesions. Palliat Med. 1989; 3: –Bates-Jensen, B.M. (2006). Skin disorders: Pressure ulcers – assessment and management. In B.R. Ferrell, & N. Coyle (Eds.), Textbook of palliative nursing (2nd ed., pp ). New York, NY: Oxford University Press. –Bates-Jensen B.M., Seaman, S. & Early, L. (2006). Skin disorders: Tumor necrosis, fistules, and stoma. In B.R. Ferrell, & N. Coyle (Eds.), Textbook of palliative nursing (2nd ed., pp ). New York, NY: Oxford University Press –Grocott, P., & Dealey, C. (2004). Symptom management: Nursing aspects. In D. Doyle, G. Hanks, N. Cherney, & K. Calman (Eds.) Oxford textbook of palliative medicine (3rd ed., pp ). Oxford, UK: Oxford University Press. –Mamedio C, Anduciolo C, Nobre MRC. A systematic review of topical treatments to control odor of malignant fungating wounds. J Pain Symptom Manage 2010; 39: October Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always the initial route when possible.


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