Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Key References NHS Lanarkshire Palliative Care Guidelines 3

rd Edition

NICE CG140. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. May 2012 The British Pain Society. Opioids for persistent pain:Good practice January 2010 Page 1 of 12

Palliative Care for Adults - Guidance for Primary Care

These principles are intended for guidance and do not cover all aspects of an individual patients care. They reflect commonly accepted practice in palliative medicine. The use of some medicines may be off-label –

this may relate to dose, route or indication.

Contents

Pain Control p 1-5 McKinley T34 Syringe Pump p 10 Management of Toxicity to Opioids p 6 Symptom Control in the last days of life

Shortness of Breath

Bronchial Secretions

Agitation

p 11 Nausea and Vomiting p 7

Constipation p 8 Use of A Syringe Driver p 9

Useful Contacts p 12

Effective Communication Is Imperative For Effective Symptom Control

PRINCIPLES OF PAIN CONTROL Assess: Prior to treatment an accurate assessment should be made to determine the cause

(consider if reversible), type and severity of the pain and its affect on the patient.

Assess All Pains and treat accordingly. Patients with cancer still develop other pains, which could be related to the treatment, debility or unrelated causes.

Consider Total Pain: The physical, emotional, social, and spiritual dimensions of distress all affect a patient’s perception of pain.

Consider any Factors That Lower Or Raise Pain Tolerance (see page 2).

Discuss and Explain symptoms and treatments (pharmacological and non-pharmacological) to patient and carer.

With Continuous Pain Prescribe Continous Analgesia, never just PRN.

Use the WHO Pain Ladder in choosing appropriate analgesia.

If Strong Opioids are required discuss and resolve any concerns about strong opioids, including concerns about addiction and overdose. All patients/carers should be provided with a patient information leaflet.

Start with immediate release oral morphine every 4 hours. If higher frequency use is anticipated in an individual case, contact specialist palliative care for advice.

The patient does not need to be specifically woken to take a dose during the night.

In some cases, it may be appropriate to start with a 12 hour release oral morphine preparation. This should be started at low dose and titrated accordingly.

Use low doses and titrate the dose slowly if the patient is frail, elderly or has renal impairment.

Breakthrough Pain: If only prescribed immediate release morphine, give additional PRN doses for breakthrough pain at the same dose as the regular 4-hourly dose.

If on sustained release opioids prescribe additional immediate release opioid for episodes of breakthrough pain. This is given 4-hourly PRN at a dose of one sixth of the total daily dose of opioid (ask the patient to keep a record of usage). Use this record of all morphine administered to calculate dose increases in the sustained release opioid.

Constipation occurs with all opioids. Laxatives are usually needed (see page 9)

Nausea should be treated with an appropriate anti-emetic (see page 10).

Review frequently to optimise analgesia as soon as possible. Pain can be managed in the majority of patients. If pain is not controlled, review assessment.

Specialist Advice should be sought ASAP especially if pain has not responded to treatment, dose of opioid has increased rapidly but patient is still in pain, there are episodes of severe acute pain or pain is worse on movement.

Consider renal and hepatic function. Dose adjustment or alternative medicine choices may be required. Seek specialist advice if required.

IF UNCERTAIN PLEASE CONTACT A SPECIALIST TEAM FOR ADVICE. see useful contact numbers on page 12

Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Key References SIGN Guideline 106: Control of pain in patients with Cancer 2008 Turk DC and Okifuji A. Assessment of patients’ reporting of pain: an integrated perspective Lancet 1999;353:17848 Gold Standards Frameork for Palliative care. http://www.goldstandardsframework.org.uk/ Page 2 of 12

MEASUREMENT AND ASSESSMENT AND OF PAIN Factors affecting pain tolerance*

* SIGN Guideline 106: Control of pain in patients with Cancer 2008

Measuring pain The patient should be the prime assessor of his or her pain. Measuring using the scales below* creates some objectivity between one review and the next.

* Turk DC and Okifuji A. Lancet 1999;353:17848

In addition to, or as a minimum, grade pain as per the Gold Standards Framework PACA tool (Patient and Carer assessment tool SCR3):

GSF PACA score Pain level

0 Pain absent

1 Pain present, not affecting daily life.

2 Pain present, moderate effect on daily life

3 Pain present, daily life dominated by symptom

Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Key References NHS Lanarkshire Palliative Care Guidelines 3

rd Edition

NICE CG140. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. May 2012 The British Pain Society. Opioids for persistent pain:Good practiceJanuary 2010 Page 3 of 12

TREATMENT GUIDANCE FOR PAIN

NON-OPIOIDS Paracetamol or NSAIDs (e.g.

ibuprofen or naproxen)

WEAK OPIOIDS e.g.Codeine

Max dose in 24h – 60mg qds Ensure dose is titrated and optimised

before considering strong opioid

STRONG OPIOIDS (Immediate release Morphine)

e.g. Morphine sulphate oral solution 10mg/5ml 5-10mg 4 hourly.

Increase dose by 30-50% each day if necessary to achieve pain control.

Use a record of all immediate release morphine used to inform increases.

If pain remains uncontrolled consult with specialist. Lower doses should be used in elderly/renally

impaired.

ANTICIPATE CONSTIPATION a stimulant and faecal softener

laxative is recommended (see

table on page 8)

1st LINE SLOW RELEASE MORPHINE Use 12 hour release preparation ONLY

Calculate 12 hourly dose by adding up total amount of immediate release morphine taken over the last 24

hours and divide by 2. New breakthrough dose (4 hourly immediate release dose) will be 1/6

th of the dose of the total daily dose.

For all patients on regular strong opioids, always prescribe an opioid for breakthrough pain – to be used when required. A maximum total daily dose of 120mg morphine (or equivalent) should not be exceeded without specialist advice.

The dose of opioid for breakthrough pain is equivalent to one sixth of the 24 hour dose (i.e 4 hourly dose).

Ask the patient to keep a record of how much breakthrough medication they have needed.

All patients on opioids should be prescribed a regular laxative and a prn anti-emetic.

Refer to page 5 for approximate equivalent doses when converting between opioids

For management of opioid toxicity see guidance on page 6.

Pain controlled on regular dose. Convert to equivalent dose of slow release

opioid if not already prescribed.

Start with slow release morphine preparation (12 hour release) instead of immediate release if appropriate

Continue laxative

Consider anti-emetic PRN (may only be necessary for the first 4-5 days)

Ensure patient/carer is counselled on regular and breakthrough medication to avoid confusion

If pain remains uncontrolled refer to specialist

Refer to page 5 for approximate conversion doses between opioids

Co-prescribing of weak and strong opioids is NOT recommended – stop any weak opioid

before initiating a strong opioid

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significant renal impairment, then use of 2nd

line opioid may need to be considered.

Second line choices - Fentanyl patches or oral oxycodone HCl – refer to guidance overleaf re choice.

SEEK SPECIALIST ADVICE FIRST

WHO Step 1 Mild pain Non-opioid

analgesics +/- adjuvant

WHO Step 2 Moderate

pain Weak opioids + non-opioid +/- adjuvant

WHO Step 3

Moderate to severe pain

Strong opioids + non-opioid

+/- adjuvant

Steps on the WHO Pain

Ladder

Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Key References NHS Quality and Productivitybulletin. Appropriate prescribing of fentanyl patches December 2011 and Appropriate prescribing of oxycodone December 2011 NHS Lanarkshire Palliative Care Guidelines 3

rd Edition

British National Formulary Ed66 September 2013-March2014 Page 4 of 12

COMMON TYPES OF PAIN

VISCERAL / SOFT TISSUE

Constant dull pain poorly localised.

Usually opioid responsive

BONE PAIN

Usually well localised worse on movement

local tenderness.

Partly opioid responsive Generally NSAID and paracetamol

responsive Radiotherapy may help if metastases are

present at the site of pain

NEUROPATHIC PAIN

Often described as burning, stabbing, shooting or ‘pins and needles’

May be partially opioid responsive Likely to require an adjunctive analgesic e.g. tricyclic

antidepressant or anticonvulsant e.g. gabapentin

USE OF SECOND LINE STRONG OPIOIDS Oral morphine is the first line choice where a strong opioid is required. A second line choice should be used for moderate to severe opioid responsive pain where oral morphine is not suitable. Specialist advice should be sought before changing treatment and to discuss alternatives. The table below outlines the place in treatment for oral oxycodone and fentanyl patches:

ORAL OXYCODONE FENTANYL PATCHES Consider if

Analgesia is inadequate with morphine despite dose optimisation (this may include circumstances in which opioid rotation is being considered); or

Dose optimisation of morphine is limited by persistent adverse effects.

Consider if:

There is an established swallowing difficulty, persistent nausea and vomiting, GI blockage or severe renal impairment where dose adjustment with morphine is not feasible.

There are unacceptable side effects from morphine

The patient is not tolerating oral medication. Not suitable for patients with unstable or rapidly changing pain.

Can be prescribed generically. Should be prescribed by brand name to ensure patients remain on the same preparation.

Oxycodone is available as both modified release formulation (12 hour) preparation and immediate release preparation.

Patches are changed every 72 hours (3 days). If more than one patch is needed apply them at the same time to avoid confusion.

Patients should be counselled appropriately on the differences between the preparations to avoid confusion regarding which is for regular dosing and which for breakthrough pain.

Patients should be counselled to use a new area of (hairless) skin and remove old patches. Heat/pyrexia increases the rate of fentanyl absorption and can cause toxicity – ensure pyrexic patients are monitored for adverse events and counsel all patients to avoid exposing the application site to external heat e.g radiators, hot water bottles.

There should be a clear reason for changing to oxycodone and for ongoing prescribing. If, after an adequate trial of oxycodone, no benefit has been achieved, consider changing back to morphine or alternative analgesia.

If dose needs to be increased, increase patch dose by 12 – 25 micrograms/hr (unless dose >100-150 micrograms/hr, in which case increase by 50 micrograms/hr). Frail or elderly patients may need lower doses and slower titration. Improved analgesic effect may take up to 12 hours. Leave a minimum interval of 48 hours between dose increases.

Reduced clearance in mild to moderate renal impairment so titrate slowly and monitor. Consider dose reduction and increased dosage and time between doses if required. Avoid in stage 4-5 chronic kidney disease Avoid in moderate to severe liver impairment as clearance is reduced.

No initial dose reduction is needed in renal impairment but monitor for signs of accumulation. Dose reduction may be needed in severe liver impairment.

Immediate release oxycodone can be used for breakthrough pain. Ensure the patient/carer is aware of when and at what dose to use the immediate release and modified release preparations.

Ensure immediate release morphine i.e. morphine sulphate oral solution 10mg/5ml is available for breakthrough pain at an appropriate dose The 12mcg/hr strength patch is licensed for dose titration but may be used for patients requiring a lower starting dose (unlicensed) It can take 22 hours or longer for the plasma fentanyl concentration to decrease by 50%. Therefore if replacing fentanyl with another strong opioid seek specialist advice.

Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Page 5 of 12

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Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Page 6 of 12

MANAGEMENT OF TOXICITY TO OPIOIDS There is a wide variation in the dose of opioid that causes symptoms of toxicity. Be aware this can also occur if the level of pain has reduced significantly e.g. after radiotherapy used to manage bone metastases as opioid requirements may decrease post treatment. Common warning signs of opioid toxicity or overdose

Increasing/persistent drowsiness (exclude other causes)

New onset or worsening confusion

Muscle twitching/myoclonus/jerking

Vivid dreams/hallucinations

Agitation

Respiratory depression (overdose/severe toxicity)

Coma (overdose/severe toxicity) Management of toxicity Mild toxicity:

Consider decreasing the opioid dose by a third and closely monitor the patient.

Ensure patient is well hydrated

Contact specialist palliative care team for advice regarding ongoing management

Consider advance care plan and admitting patient

Change syringe driver medications/dose on specialist advice Moderate to severe toxicitiy:

Seek specialist advice immediately

Call an ambulance if medical emergency

Be careful not to confuse a dying patient with someone who is experiencing opioid toxicity, be clear

on the diagnosis. If in doubt, seek specialist advice.

Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Key References British National Formulary Ed 66 September2013-March 2014 NHS Lanarkshire Palliative Care Guidelines 3

rd Edition

NHS Wales Adult Palliative Care General Guidelines. October 2011 Palliative Care Formulary 4, September 2012 Page 7 of 12

NAUSEA AND VOMITING 1.GENERAL MEASURES Consider potentially reversible factors and treat these if possible and appropriate (correction may not be indicated for some of these if the patient is imminently dying). Causes include:

Medicines Cough Severe pain

Uraemia Anxiety Infection

Hypercalcaemia Bowel obstruction Raised intracranial pressure

Constipation Ascites

2. MANAGEMENT Choice of medication is based on likely cause, side effect profile and route of administration as well as patients condition/prognosis.

Cause First Line Second Line

For gastritis or gastric stasis use a prokinetic anti-emetic (provided the patient is not in bowel obstruction).

Metoclopramide 10mg orally

tds (caution in those at risk of extrapyramidal side effects e.g. Parkinson’s disease) or

Domperidone 10mg orally or rectally

tds

(note MHRA advice re cardiac risk). Extrapyramidal side-effects rare with domperidone

Levomepromazine

6.25-12.5mg orally ON (avoid when at risk of seizure e.g. brain metastases, epilepsy).

For most chemical causes of vomiting (e.g. opioids, hypercalaemia, uraemia) use a centrally acting anti-emetic

Haloperidol 1.5-3mg orally once daily or 2.5-5mg continuous subcutaneous infusion (both unlicensed) / 24hrs

Levomepromazine 6.25-12.5mg (i.e. ¼ - ½ 25mg tablet) orally nocte

or 6.25-25mg continuous subcutaneous infusion /24hrs (avoid when at risk of seizure).

Raised intra-cranial pressure, motion sickness

Cyclizine 50mg orally tds or

50-150mg continuous subcutaneous infusion / 24hrs

OTHER CONSIDERATIONS

Syringe driver for continuous subcutaneous infusion or IM Injections

Also consider use of an antacid or proton pump inhibitor

Use metoclopramide with caution in those at risk of/from extrapyramidal side-effects e.g. Parkinson’s

disease. Extrapyramidal side-effects are rare with domperidone.

Review efficacy of anti-emetic medication every 24 hours until control achieved

If underlying cause is resolved, review and discontinue antiemetic medication

Avoid combining medications with similar mode of action or side-effect profile

Do not combine prokinetics with anticholinergics

If nausea and vomiting are not controlled with oral antiemetics, review the patient’s regular oral medications and consider conversion to alternative route in order to maintain absorption e.g to fentanyl patches or syringe driver

Advise patient/carer on good mouth care and on avoiding any nausea triggers e.g. strong smells

Refer to local specialist palliative care team if causes such as bowel obstruction or raised intracranial pressure are suspected.

Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Key References British National Formulary Ed 66 September2013-March 2014 NHS Lanarkshire Palliative Care Guidelines 3

rd Edition

NHS Wales Adult Palliative Care General Guidelines. October 2011 Palliative Care Formulary 4, September 2012 Page 8 of 12

CONSTIPATION

Regularly enquire about constipation.

Clarify the cause before starting treatment.

Beware, chronic constipation can mislead and be misdiagnosed . Signs include:

abdominal pain

anorexia

malaise

colic

tenesmus

spurious diarrhoea

urinary retention

intestinal obstruction

mental confusion

Patients should be advised to maintain an adequate fluid intake

A stepwise approach to laxative therapy should be adopted – prescribe regular laxative treatment and optimise before adding or changing treatment.

Daily laxatives are necessary for almost all patients on strong opioids (unless already liable to diarrhoea).

Most patients will need a softener and a stimulant.

Increase doses as necessary every 1-2 days. Rectal measures may still be required e.g. glycerol suppositiories or sodium citrate enema

Stimulant laxatives act within 6-12 hours

Osmotic laxatives may take 1-3 days to have an effect

Stool softeners take 24-36 hours to act

For patients experiencing abdominal pain, do not titrate opioid dose to treat this – investigate and treat cause.

ROUTINE LAXATIVES

Softener

Docusate sodium

100mg capsules

Initially 100mg BD Max 200mg TDS

Softener at lower doses and mild stimulant at higher doses. Mostly a faecal softener.

Osmotic laxative

Lactulose 10-20mls OD-BD Can be unpalitable, and can cause wind and distension, but some patients may prefer.

Macrogol oral powder

Initially 1-3 sachets a day. Max 8 sachets daily for 1-3 days for faceal impaction

1 sachet administered with 125ml water is isotonic. It is important to ensure sachet is administered in the correct volume of liquid. For use in faecal impaction refer to current edition of the BNF Large volume of liquid may be difficult to take for some patients e.g. frail.

Stimulant – avoid in intestinal obstruction

Senna tablets or liquid

1-2 tabs OD-BD or 7.5mg/5ml syrup 10–20mls ON

Can cause abdominal cramps.

Bisacodyl 5mg tablets or 10mg suppositories

5-10mg ON (oral) 10mg ON (PR)

Mostly acts on large bowel.

Docusate sodium

100mg capsules Initially 100mg BD Max 200mg TDS

Softener at lower doses & mild stimulant at higher doses. Mostly a softener.

Co-danthramer and co-danthrusate are options for severe constipation in palliaitive care patients ONLY. Seek advice from a specialist before initiating and refer to full prescribing information for dosage information.

Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Key References British National Formulary Ed 66 September2013-March 2014 NHS Lanarkshire Palliative Care Guidelines 3

rd Edition Page 9 of 12

USE OF A SYRINGE DRIVER

A syringe driver is an alternative administration route where other routes of administration are not viable or continuous infusion is needed.

Medication is delivered by continuous subcutaneous infusion (CSCI).

Indications for its use include: persistant nausea and vomiting, dysphagia, intestinal obstruction, coma, or too weak to take oral medications.

Take advice from the local specialist palliative care team regarding the need for a syringe driver, medications, doses etc. If there is no specialist palliative care support available a GP could initiate and write a prescription for treatment including completing a syringe driver prescription sheet.

Try to anticipate the need for a syringe driver and prescribe in advance so that drugs and paperwork are all correct and present when the drugs are needed and can be sourced within working hours. Most pharmacies can obtain palliative care drugs within 24 hours and should be able to inform you if there is any likely delay.

Engage district nurse service to set up and monitor syringe driver

A syringe driver prescription/authorisation sheet will need to be completed and given to the DN or left with the patient for the DN to action.

A maximum of three medications can be administered via a syringe driver. On rare occasions four drugs can be given – ONLY on specialist palliative care team advice.

Water for injection is the usual diluent

The use of most opioids for continuous subcutaneous infusion is unlicensed.

Before setting up a syringe driver, it is important to explain its use to the patient and their family. It is important that the syringe driver is not seen just as the last resort but as an effective method of relieving certain symptoms by injection.

Ensure compatibilities of medications in the syringe driver have been checked prior to prescribing – check with the specialist palliative care team if required.

Refer to table on page 5 for approximate dose conversions between opioids

Note: Morphine injection is available in different strengths (e.g. 10mg/ml, 30mg/ml). Care needs to be taken when prescribing, preparing and administering, to ensure patient receives the correct dose. Seek specialist advice

SYMPTOM DRUGS GUIDELINES TO DOSAGE

Pain Morphine sulphate

If opioid naïve start at 10-15mg/24hrs.

For both medications:No ceiling limit. Titrate cautiously. Do not titrate above 120mg morphine daily (or equivalent) without specialist advice

Diamorphine hydrochloride If opioid naïve start at 5- 10mg/24hrs.

Colic Hyoscine butylbromide 20-160mg in 24 hours

Bronchial secretions Hyoscine Hydrobromide

Glycopyrronium bromide

1200-2400 micrograms in 24 hours. Confusion limits use. 200-400 micrograms, 6-8 hourly as required

Nausea and vomiting Metoclopramide 30-100mg in 24 hours

Cyclizine (do not dilute with

sodium chloride 0.9%) 50-150mg in 24 hours

Nausea and vomiting/ restlessness

Levomepromazine

(avoid if risk of fitting.) 6.25-25mg in 24 hours (for anti-emetic) 12.5-150mg in 24 hours (for restlessness/sedation) Higher doses for sedation only

Nausea and vomiting Haloperidol 2.5-5mg in 24 hours Doses >8mg/day risk extrapyramidal effects Above 2mg/ml can precipitate in diamorphine

Terminal agitation, anti-convulsant

Midazolam 10-60mg in 24 hours (ensure flumazenil available)

LESS COMMONLY USED DRUGS – SPECIALIST INITIATED

Dexamethasone (If possible, should be administered as sole drug in syringe driver. Seek specialist advice if site

irritation occurs)

Ketorolac (Bone pain)

Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Key References British National Formulary Ed 66 September2013-March 2014 NHS Lanarkshire Palliative Care Guidelines 3

rd Edition

NHS Cumbria and Lancashire North Palliative Care guidance 2008 Page 10 of 12

McKinley T34 Syringe Pump

There is only one type of syringe driver in use across North Central London – this is the McKinley T34

The volume in the syringe will infuse over 24 hours

Refer to local guidance (community nursing policy) or consult with specialist palliative care team or district nurses for advice on equipment, setting up and administration of syringe pump.

The infusion line should be checked each visit/regularly for signs of redness, induration, crystallisation of the infusing solution, leakage.

For advice on managing injection site reactions, seek advice from the palliative care team.

A Syringe driver prescription/authorisation chart should be completed for medicines to be administered via the pump. This can be accessed via community nurses or palliative care team or local GP website.

Compatibility of medications to be mixed in a syringe driver should be checked. Seek advice from the palliative care team.

Syringe driver drug compatibility chart

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Key

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Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Key References British National Formulary Ed 66 September2013-March 2014 NHS Lanarkshire Palliative Care Guidelines 3

rd Edition Page 11 of 12

SYMPTOM CONTROL IN LAST DAYS OF LIFE

SHORTNESS OF BREATH KEY POINTS

Very frightening for patient– empathy important.

Is it appropriate to treat underlying cause? e.g. CCF - Seek specialist advice if in doubt

Are there reversible causes that can be treated? e.g. pulmonary embolism, infection, pleural effusion etc.

Check oxygen saturation

SYMPTOM CONTROL

Visualised reminder charts can be used to remind patient in crisis

Physical measures e.g. open windows, fan, keep face cool

Refer to physio for relaxation techniques

Where appropriate - bronchodilators (via spacer/nebuliser), antibiotics, steroids, diuretics, oxygen (only if hypoxic). Oxygen must be specialist intiated.

Consider low dose oral morphine to help manage e.g. 1- 2.5mg oral morphine liquid regularly 4 hourly or PRN. Patient will require an oral syringe to measure small volumes/doses of morphine liquid

BRONCHIAL SECRETIONS IN LAST 48 HOURS KEY POINTS

Consider if these are due to treatable underlying cause e.g. heart failure

General management measures include repositioning to lateral position, avoiding over hydration, addressing family distress

SYMPTOM CONTROL Conscious Patient

hyoscine butylbromide 20mg sc/orally stat or 60 – 120mg over 24 hrs in syringe driver OR

glycopyrronium bromide 200-400mcg SC, 6-8 hourly as required Unconscious Patient or where sedation may be of benefit

hyoscine hydrobromide 400-600 micrograms sc stat PRN or 1200-2400 micrograms over 24 hrs in syringe driver

For other measures available – consult local specialist palliative care team.

AGITATION KEY POINTS

Ensure calm and comfortable environment

Treat reversible causes - Pain - Urinary retention - Constipation

May still be appropriate to use sedation even if reversible causes are present.

SYMPTOM CONTROL

Subcutaneous stat administration or CSCI (continuous subcutaneous infusion) via a syringe driver over 24hrs may be needed.

1

st line

LORAZEPAM (if patient conscious) 500microgram to 1mg orally or sublingually 4-6 hourly PRN (max 4mg daily)

MIDAZOLAM - useful in patients who are at risk of seizure

Use 2.5-5mg SC hourly PRN or 10-60mg over 24 hours in syringe driver

2nd

line LEVOMEPROMAZINE - avoid if risk of seizure.

Is both sedative and anti-emetic.

Use 6.25-25mg SC OD-BD (antiemetic) or 25-100mg (restlessness) over 24 hours in syringe driver

Higher doses should only be used for restlessness A combination of both sedatives may be needed, but ONLY on specialist advice.

Palliative Care for Adults – Guidance for Primary Care v 2 (Updated June 2014 – next review date May 2017)

Page 12 of 12

USEFUL CONTACTS - LOCAL SPECIALIST PALLIATIVE CARE TEAMS If you wish to discuss how you manage the palliative care needs of a patient with a specialist palliative care service the following are the options. This may enable the patient to be managed in their own home and avoid a hospital admission.

Local community specialist palliative care teams

Area

Team base Office hours Out of hours

Islington ELiPse team, Well House, Benwell Road

Mon-Fri: 09:00-17:00

Tel: 020 3317 5777 Fax: (for referrals) 020 7607 3995

Tel: 0845 155 5000 (UCLH Trust Switchboard) and ask to air-call

the palliative care team. Provides telephone advice and visiting where needed. South

Camden UCLH Mon-Fri: 08:30-17:00

Tel: 020 3447 7140 Fax: (for referrals) 020 3447 7677

North Camden

Royal Free Hospital Mon-Fri: 09:00-17:00

Tel: 020 7830 2905

Sat-Sun: 9.00-5.00 Tel: 020 7794 0500 and ask to

air-call the palliative care team

Haringey

Whittington Health Community Palliative Care Team

Mon-Fri: 09:00-17:00

Tel: 020 3224 4340 Fax: 020 3224 4304

No direct OOH service.

Contact St. Josephs Hospice or Marie Curie Hampstead

City and Hackney

St Joseph’s Hospice Mon-Fri: 09:00-17:00

Tel: 020 8525 6060 First Contact Team

Tel: 0300 303 0400

Mon-Sun: 18:00-08:00 Tel: 020 8525 6000

DISTRICT NURSES

24hr District Nurse (DN) Message Service Telephone No.

Camden (DN Available 24h - 7 days a week)

Tel: 020 3317 5916 Fax: 020 7813 8719 OOH referrals: Tel: 0207 391 6360 (from 17:00–08:30)

Islington (Whittington Health) (DN Available 08:30-24:00 - 7 days a week)

Tel: 020 3316 1111 Fax: 0844 774 6419 OOH referrals: Tel: 020 7527 4250

City and Hackney (DN available 08:30-23:30 - 7 days a week)

Tel: 020 7683 4144 Fax: 020 7014 7274

Haringey (DN available 09:00–17:00 & 18:00–24:00 7 days a week)

Tel: 020 8442 6296 Fax: 020 8442 6849

Local Hospices contact details

Marie Curie Hospice Hampstead St John’s Hospice St Joseph’s Hospice North London Hospice

Tel: 020 7853 3400 Tel: 020 7806 4065 Tel: 020 8525 6000 Tel: 020 8343 8841

Pharmacy services

Islington Pharmacies (Palliative care medicines scheme) for Islington patients only:

Clan Pharmacy. 150 Upper Street. N1 1RA Tel:020 7359 7595

Dev’s Chemist (Atchem Ltd). 110 Seven Sisters Road. N7 6AE Tel:020 7607 3081 Camden 100 hour pharmacies

Boots the Chemists, Unit 19, St Pancras Station, N1C 4QL. Tel: 020 7833 0216

Boots the Chemists, Western Ticket Hall, Kings Cross Station. N1C 4AP Tel: 020 7278 5861

Baban Pharmacy, 42 Chalton St, NW1 1JB. Tel: 020 7388 9989

IPSA Pharmacy, 7 Harben Parade, Finchley Road. NW3 6JP. Tel: 020 7449 9490

Sainsburys Pharmacy, 17-21 Camden Road, London NW1 9LJ. Tel 020 7482 3828 Haringey Pharmacies providing on demand medicines for end of life care and other specialist medicines

Boots the Chemist Unit A2, Tottenham Hale Retail Park, N15 4QD. Tel: 0208 801 7243 Monday – Saturday 09:00 – 19:00, Sunday 11:00 – 17:00

Hornsey Central Pharmacy 151 Park Rd, Crouch End N8 8JD Tel: 020 3074 2700 Monday – Saturday 07:00 – 22:00, Sunday 09:00 – 19:00

Philips Chemist 193 Lordship Lane, Tottenham, London, N17 6XF Tel: 020 8808 4040 Monday – Friday 09:00 – 18:30, Saturday 09:00 – 17:30

Pharmacy Express 214 High Road, London, N22 8HH. Tel: 020 8888 1669

Monday – Friday 09:00 – 18:30, Saturday 09:00 – 13:00

This guideline is an update of the 2010 guideline and was reviewed with input from CCG representatives and local specialists from Camden, Islington and Haringey teams – March 2014 Adapted from the original The Pocket Guide for Palliative Care 2004. For clinical queries relating to this guideline please contact the local CCG borough medicines management team or local specialist team