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Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents
Residential Aged Care Palliative Approach Toolkit
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents
This document is licensed under a Creative Commons Attribution-NonCommercial-NonDerivs 3.0 Australia licence. To view a copy of this licence visit:
http://creativecommons.org/licenses/by-nc-nd/3.0/
© State of Queensland (Queensland Health) 2013
In essence you are free to copy, distribute and transmit the work in its current form for non-commercial purposes. You must attribute the work in the manner specified by the authors. You may not alter, transform or build upon this work.
Recommended CitationBrisbane South Palliative Care Collaborative (2013) Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents, Brisbane: State of Queensland (Queensland Health)
EnquiriesAll enquiries about this document should be directed to:
Brisbane South Palliative Care Collaborative (Queensland Health) Email: [email protected]
An electronic copy of this resource can be downloaded at: www.caresearch.com.au/PAToolkit
AcknowledgementsThis resource was developed as part of the National Rollout of the Palliative Approach Toolkit for Residential Aged Care Facilities Project. The Project was funded by the Australian Government Department of Social Services under the Encouraging Better Practice in Aged Care (EBPAC) Initiative.
Brisbane South Palliative Care Collaborative would like to thank the following for assistance in developing this resource:
• TheAustralianandNewZealandSocietyofPalliativeMedicine(ANZSPM) • SteeringCommitteefortheNationalRolloutofthePalliativeApproachToolkitforResidentialAgedCareFacilities • ClinicalEducationReferenceGroupfortheNationalRolloutofthePalliativeApproachToolkitforResidentialAgedCareFacilities • ClinicalstafffromMetroSouthPalliativeCareServices(QueenslandHealth)
Disclaimer This document was produced by the Brisbane South Palliative Care Collaborative as an educational resource and is intended for use by health professionals working in Australian residential aged care. The resource has been prepared to provide information on the use of medications in contributing to optimal symptom management during the terminal phase of a resident’s life.
Brisbane South Palliative Care Collaborative has exercised due care in ensuring that information and materials in this resource are based on the available best practice literature or, in the absence of this literature, expert opinion. The information and materials in this resource do not constitute professional advice and should not be relied on as such.
It is beyond the scope of this resource to examine and cover in detail all elements of clinical practice that need to be addressed prior to prescribing medication to manage end of life (terminal) symptoms. Clinical information and materials in this resource do not replace clinical judgement. Individual clinicians and other health professionals remain responsible for:
• Comprehensiveassessmentoftheresidentandensuringtheappropriatenessandsuitabilityofaparticularmedicationand dosage prior to prescribing or administering the medication. • Providingcarewithinscopeofpractice,meetingalllegislativerequirementsandmaintainingstandardsofprofessionalconduct.
Neither Brisbane South Palliative Care Collaborative nor any person associated with the preparation of this resource accepts liability for any injury, loss or damage incurred by use of or reliance upon the information and materials provided in this resource.
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents 1
ContentsAbout this Guide 2 Context 2 Focus 2 Key Features 3
Principles, Responsibilities and Strategies for the Pharmacological Management of End of Life (Terminal) Symptoms 4 Key Principles Guiding Quality Pharmacological Management of End of Life (Terminal) Symptoms 4 Roles and Responsibilities of Residential Aged Care Staff in the Provision of Optimal Symptom Control in the Terminal Phase
4
Strategies to Support Timely Access to Medications in the Terminal Phase 5
Symptom Management Flowcharts 10 Using the Flowcharts 10 Nausea and Vomiting 12 Pain 14 Respiratory Distress 16 Restlessness and Agitation 18
References 20
Glossary 22
Appendix A: Opioid Conversion Chart 23Appendix B: Additional Resources 24
List of Tables Table 1: Summary of Australian State and Territory Legislation on the Establishment of Medication Imprest Systems by RACFs
6
Table 2: End of Life (Terminal) Symptom Management Medications for RACFs 8Table 3: Palliative Care in RACFs: Medications Commonly Used to Manage Symptoms at End of Life 9
List of FiguresFlowchart 1: Pharmacological Management of Nausea and Vomiting for Residents on the RAC EoLCP 12Flowchart 2: Pharmacological Management of Pain for Residents on the RAC EoLCP 14Flowchart 3: Pharmacological Management of Respiratory Distress for Residents on the RAC EoLCP 16Flowchart 4: Pharmacological Management of Restlessness and Agitation for Residents on the RAC EoLCP 18
Good quality end of life (terminal) care can be delivered in a residential aged care facility if staff are adequately trained and resourced. This will mean that residents can remain in familiar surroundings, cared for by staff and with other residents they know, rather than move to the unfamiliar surroundings of an emergency department or hospital ward.1
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents2
About this Guide
ContextResidents who are dying commonly experience distressing symptoms in the last days and hours of life.2-4 High quality end of life (terminal) care requires ongoing assessment of the resident and timely use of pharmacological and non-pharmacological strategies to address emerging symptoms. Failure to do so can result in poor resident/family outcomes as well as poor health system outcomes if dying residents are inappropriately transferred to emergency departments/hospital wards.5,6
Residential aged care staff responsible for managing/administering medications to control end of life (terminal) symptoms require:
• Highlevelandup-to-dateknowledgeregardingendoflifesymptommanagementandtheappropriateusesofpalliative care medications. • Immediateaccesstothesemedicationsinordertorelievesymptomsastheyoccur.7 • Locallyspecificpoliciesandprocedures,linkedtothecontinuousqualityimprovementandriskmanagementprogramsof their residential aged care facility, to allow safe and effective medication management.1
The PA Toolkit includes a set of resources which, when used in combination, are designed to assist residential aged care providers to implement a comprehensive and evidence-based approach to care for residents.
Whereas palliative care may take place over a number months, end of life (terminal) care focuses on the final days or weeks of life.7
Symptoms commonly experienced during the terminal phase of life include:
• Pain • Breathlessness • Anxiety • Agitationandrestlessness • Hallucinations
• Dysphagia • Nausea • Vomiting • Respiratorysecretions
FocusThis guide has been developed as part of the Residential Aged Care Palliative Approach (PA) Toolkit. It is designed:
1. For use by clinical teams providing end of life (terminal) care in residential aged care settings. This includes residential aged care staff (e.g. clinical managers, registered and enrolled nurses) as well as medical officers and nurse practitioners.
2. To support the care of residents who have entered the terminal phase of their lives. It is expected that these residents will have been commenced on an end of life care pathway and that their prognosis is limited to days.
3. To supplement information contained in the following PA Toolkit resources:
• Module1:IntegratingaPalliativeApproach • Module2:KeyProcesses • Module3:ClinicalCare • WorkplaceImplementationGuide:SupportforManagers,LinkNursesandPalliativeApproachWorkingParties • EducationalDVD:HowtoUsetheResidentialAgedCareEndofLifeCarePathway(RACEoLCP)
4. To support the delivery of high quality and evidence-based end of life (terminal) care.
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents 3
Key FeaturesThis guide includes:
1. An overview of key principles guiding quality pharmacological management of end of life (terminal) symptoms.
2. An overview of the roles and responsibilities of residential aged care staff in the provision of optimal symptom control during the terminal phase:
(a) registered and enrolled nurses; and (b) residential aged care managers.
3. Aconsensus-basedlistofmedications,endorsedbyTheAustralianandNewZealandSocietyofPalliativeMedicine (ANZSPM),suitableforuseinresidentialagedcareforthemanagementofterminalsymptoms.
4. Atablesummarisingtheuses,dosesandroutesofadministrationofthemedicationsendorsedbyANZSPMthatcanbe used in the education and training of residential aged care staff.
5. Flowcharts summarising the pharmacological management of four common end of life symptoms within a quality use of medicine framework as set out in the Australian National Medicines Policy and inclusive of local jurisdictional legislative considerations.8 The four symptoms are:
• Nauseaandvomiting • Pain • Respiratorydistress • Restlessnessandagitation
Three Forms of Palliative CareIn considering a resident’s palliative care needs it is important to distinguish between a palliative approach, specialised palliative service provision, and end of life (terminal) care. Having a clear understanding of the differences between these three forms of palliative care is particularly important for care planning and in clarifying a resident’s treatment goals.
Palliative approachA palliative approach aims to improve quality of life for residents with life-limiting illnesses and their families by reducing their suffering through early identification, assessment and treatment of pain, physical, cultural, psychological, social and spiritual needs. Importantly, this form of palliative care is not restricted to the last days or weeks of a resident’s life.
Specialised palliative service provisionThis form of palliative care involves referral of a resident’s case to a specialist palliative care team. This, however, does not replace a palliative approach to care being provided by the RACF but rather augments it with focused, intermittent, specific input when required. Specialist palliative care teams do not usually take over the care of a resident but instead provide advice on complex issues and support to aged care staff and general practitioners.
End of life (terminal) careThis form of palliative care is appropriate when a resident is in the final days or weeks of life and care decisions may need to be reviewed more frequently. Goals are more sharply focused on a resident’s physical, emotional and spiritual comfort and support for the resident’s family.
Adapted from Guidelines for a Palliative Approach in Residential Aged Care (2006)7
Important:
Whereaspalliativecaremaybeappropriateoveralongerperiod,endoflife(terminal)carefocusesonthefinaldaysorweekoflife.7 This guide focuses on the medication management of end of life (terminal) symptoms commonly experienced by residents in the last days and hours of life.
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents4
Principles, Responsibilities and Strategies for the Pharmacological Management of End of Life (Terminal) Symptoms
Key Principles Guiding Quality Pharmacological Management of End of Life (Terminal) Symptoms
Residents who are in the terminal (or dying) phase are clinically unstable – symptoms can emerge at any time which may require pharmacological intervention. To ensure a good death, residents require proactive pharmacological management.
Key principles underlying this pharmacological management include:
• Medicationsareprescribed,obtained,chartedandadministeredaccordingtotheAustralianNationalMedicinesPolicyand in accordance with regional jurisdictional requirements and local facility policies and procedures.1,7,8 • Knowledgebytheresident,ortheirsubstitutedecisionmakerifappropriate,thatthedyingprocessisoccurringandthat medication administration may improve the quality of death.9 • Consentgivenbytheresident,ortheirsubstitutedecisionmakerifappropriate,toreceivemedicationsforthetreatmentof terminal symptoms.9 • Ifamedicationisconsiderednecessary,themostappropriatemedicineischosenandusedsafelyandeffectively.9,10 • Medicationsareimmediatelyavailabletoensureoptimalsymptomcontrol.1,7,9 • Chartedmedicationdosesarebasedonfrequentassessmentoftheresidentandareappropriatetotheseverityofthe symptom(s). Persistent symptoms are treated with regular doses of medication while as needed doses of medication are charted to cover ‘break through’ symptoms. Medications are administered by the most reliable route.9,10 • Responsestoadministeredmedicationsarechartedandadversereactionsnotedandnotified.9,10 The Therapeutic Goods Administration encourages reporting of all suspected adverse reactions to prescription, over-the-counter and complementary medicines. Information on how to lodge a report together with the ‘blue card’ adverse reaction reporting form are available online at www.tga.gov.au/safety/problem-medicines-forms-bluecard.htm • Actionistakenintheeventofamedicationerroroccurring-e.g.under-orover-dosingaccordingtolocalpolicyand procedure documentation.
Roles and Responsibilities of Residential Aged Care Staff in the Provision of Optimal Symptom Control in the Terminal Phase
a. Registered and enrolled nursesNursing staff responsibilities when caring for residents in the last days of life include:
• Recognisingwhenaresidentisapproachingtheterminalphaseandorganisingcarestrategiesincludingendoflife medications to facilitate a peaceful and dignified death. • Keepingresident/familyinformedofchangesintheresident’sconditionaswellaschangesintreatmentstrategies. • Requestingthatthemedicalofficerornursepractitionerpre-emptivelyprescribeandchartmedicationorderstomanage common end of life symptoms. • Monitoringswallowand,ifitdeteriorates,requestingoralmedicationordersbere-chartedusinganalternativerouteorceased if no longer required. • Regularreassessmentofsymptomsandtheefficacyofadministeredmedication. • Monitoringformedicationsideeffects. • Organisingmedicalofficer/nursepractitionerreviewifsymptomsarenotwellmanagedorifmedicationisnottolerated. • Initiatingappropriatenon-pharmacologicalstrategiestomanagesymptoms. • Contactingthemedicalofficer,nursepractitionerorlocalspecialistpalliativecareserviceforfurtheradviceifsymptomsare not responding to treatment.
For detailed information about the assessment of symptoms see Module 3: Clinical Care and the Self Directed Learning Packages in the PA Toolkit.
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents 5
Key Steps for Establishing a Medication Imprest System for Use in End of Life (Terminal) Care of Residents1. In consultation with the Medication Advisory Committee, develop an organisational policy and related procedures for managing a medication imprest/emergency stock of palliative care drugs.
Note that individual approvals may be required by RACFs from state regulatory authorities to purchase, store and supply controlled drugs.
2. Investigate and comply with relevant Australian State and Territory legislation regarding the establishment and maintenance of a Medication Imprest System in residential aged care (see Table 1). Each Australian State and Territory has specific legislation concerning obtaining a supply of controlled (Schedule 8) and restricted (Schedule 4) drugs that have not been prescribed for a particular resident.
Note that imprest supplies cannot be ordered or prescribed under the Pharmaceutical Benefits Scheme (PBS). Such stock must be purchased outside the PBS from a seller authorised under State legislation to supply the goods, including most community pharmacies.
3. Formulate a list of drugs to stock the Medication Imprest System that are commonly used to manage terminal symptoms (see Table 2).
4. Educate staff about the appropriate use of drugs to control common terminal symptoms (see Table 3 which is an educational resource that summarises key pharmacological information relating to each of the drugs listed in Table 2).
Important:
Safe and appropriate administration of medications to manage symptoms commonly experienced by residents at end of life requires a high level of nursing knowledge and skill. Residential aged care providers are responsible for ensuring that appropriately qualified staff are available onsite to administer these medications and evaluate their effectiveness.8
b. Residential aged care managersResidential aged care managers are responsible for providing systems, protocols and procedures that support staff in the safe and effective management of medications. This includes, but is not limited to:
• Developingpoliciesandproceduresinregardstothemanagementofmedicationsthatcomplywith,forexample, relevant Australian and State/Territory legislative requirements, clinical practice and other regulations for specific health professional groups, and Aged Care Accreditation Standards. • Ensuringthatup-to-dateevidence-basedinformationonallaspectsofmedicationmanagementiseasilyaccessiblewithin the facility for visiting medical officers and for nursing staff. • Providingandencouragingongoingeducationtoallregisteredandenrollednursestoensurethattheyhavetherequired level of knowledge and competence to appropriately manage medications. This is particularly important in palliative care where high risk medications such as opioids are commonly used. • Havingaqualityimprovementsysteminplacethatevaluatesthesafeandeffectiveuseofmedicationsatendoflife.1,9-11 • Establishingstrategiesandrelatedproceduresthatguaranteetimelyaccesstomedicationsintheterminalphase.11
This last responsibility is considered in more detail in the following section.
Strategies to Support Timely Access to Medications in the Terminal Phase Various strategies can be implemented to ensure timely access to medications for the terminal phase. Three examples are listed below:
• Prioritiseexcellentproactiveclinicalcareasthegoalofcare.Bestpracticeclinicalcareinvolvesearlyrecognitionofsigns and symptoms that indicate the dying process allowing residential aged care staff to pre-emptively organise the prescription, charting and delivery of necessary medications for subsequent administration. • Developmentofprofessionalrelationshipswithmedicalofficers,nursepractitionersandlocalspecialistpalliativecareservices that can act as prescribing resources in partnership with community pharmacists who agree to stock and deliver, in a timely fashion, commonly prescribed palliative care drugs for use in the terminal phase. This strategy requires particular consideration of how to ensure timely access to medications after hours, during weekends and over holiday periods. • Establishmentofanon-sitemedicationimprestoremergencystockofpalliativedrugsaccordingtorequirementssetout by the Medication Advisory Committee of the residential aged care facility and in accordance with national and jurisdictional regulatory legislation (see box below).
Consider using a combination of these three strategies.
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Legi
slat
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in V
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quire
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at R
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obt
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a H
ealth
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Info
rmat
ion
and
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ion
form
s fo
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f Hea
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VIC
300
1 T:
1300
364
545
E:
dpu
@hea
lth.vi
c.go
v.au
WesternAustralia
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liaallowsfortheclinicalm
anagerinaRAC
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lyfo
rapoisonspermit
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rmat
ion
and
appl
icat
ion
form
s fo
r a p
oiso
ns p
erm
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n be
obt
aine
d at
:
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MED
ICAT
ION
DOSE
STOC
K
Clon
azep
am d
rops
*2.
5 m
g/m
l1 b
ottle
(10
mls
)
Fent
anyl
Citr
ate
inje
ctio
n**
100
mcg
/2 m
l10
am
poul
es
Hal
oper
idol
inje
ctio
n5
mg/
ml
10 a
mpo
ules
Hyd
rom
orph
one
inje
ctio
n2
mg/
ml
5 am
poul
es
Hyo
scin
e Bu
tylb
rom
ide
(Bus
copa
n) in
ject
ion*
* 20
mg/
ml
5 am
poul
es
Met
oclo
pram
ide
inje
ctio
n10
mg/
2 m
l10
am
poul
es
Mid
azol
am in
ject
ion*
*5
mg/
ml
10 a
mpo
ules
Mor
phin
e Su
lpha
te in
ject
ion
10 m
g/m
l5
ampo
ules
Tabl
e 2:
End
of L
ife (T
erm
inal
) Sym
ptom
Man
agem
ent M
edic
atio
ns fo
r Res
iden
tial A
ged
Care
Fac
ilitie
s
A co
nsen
sus-
base
d lis
t of m
edic
atio
ns, e
ndor
sed
by T
he A
ustr
alia
n an
d Ne
w Z
eala
nd S
ocie
ty o
f Pal
liativ
e M
edic
ine
(ANZ
SPM
),
suita
ble
for u
se in
resi
dent
ial a
ged
care
for t
he m
anag
emen
t of t
erm
inal
sym
ptom
s
© S
tate
of Q
ueen
slan
d (Q
ueen
slan
d He
alth
) 201
3. D
evel
oped
by
Bris
bane
Sou
th P
allia
tive
Care
Col
labo
rativ
e (Q
ueen
slan
d He
alth
)
EndorsedbyT
heAustra
lianandNe
wZealandSocietyofP
alliativeMedicineInc(ANZ
SPM),July2013.
Not
es:
* N
on-P
BS u
nles
s fo
r sei
zure
con
trol
** N
ot o
n th
e PB
S
Tabl
e 3:
Pal
liativ
e Ca
re in
Res
iden
tial A
ged
Care
Fac
ilitie
s: M
edic
atio
ns C
omm
only
Use
d to
Man
age
Sym
ptom
s at
End
of L
ifeAn
edu
catio
nal r
esou
rce
sum
mar
isin
g th
e us
es, d
oses
and
rout
es o
f adm
inis
trat
ion
of th
e m
edic
atio
ns e
ndor
sed
by A
NZSP
MIM
PORT
ANT:
The
info
rmat
ion
pres
ente
d he
re is
for e
duca
tiona
l ben
efit o
nly.
It is
a g
ener
al g
uide
to a
ppro
pria
te p
ract
ice
and
is s
ubor
dina
te to
the
clin
ical
judg
emen
t of t
he tr
eatin
g cl
inic
ian.
Muc
hofth
eco
nten
tinthetablebe
lowwas
obtaine
dfrom
:Pallia
tiveCa
reExp
ertG
roup
.The
rape
uticGuide
lines
:Pallia
tiveCa
re.V
ersion
3.M
elbo
urne
:The
rape
uticGuide
lines
Lim
ited;2010
© S
tate
of Q
ueen
slan
d (Q
ueen
slan
d He
alth
) 201
3. D
evel
oped
by
Bris
bane
Sou
th P
allia
tive
Care
Col
labo
rativ
e (Q
ueen
slan
d He
alth
)En
dorsedbyT
heAustra
lianandNe
wZealandSocietyofP
alliativeMedicineInc(ANZ
SPM),July2013.
KEY:
CSC
I con
tinuo
us s
ubcu
tane
ous
infu
sion
| P
RN a
s ne
eded
by
pred
eter
min
ed ti
me
| S
ubcu
t sub
cuta
neou
s |
SOB
sho
rtnes
s of
bre
ath
| PVC
pol
yvin
yl c
hlor
ide
(pla
stic
)
DRUG
USUA
L DO
SE A
ND F
REQU
ENCY
OF
ADM
INIS
TRAT
ION
RANG
EUS
UAL
ROUT
E OF
AD
MIN
ISTR
ATIO
NRE
ASON
S FO
R US
ECO
MM
ENTS
Clon
azep
am0.
3 to
1 m
g, 4
hou
rly P
RN
0.25
to 1
mg,
4 h
ourly
PRN
1 to
4 m
g by
CSC
I ove
r 24
hour
s
Oral
liqu
id fo
rmul
atio
n
Subc
utan
eous
bol
us
CSCI
•An
xiet
y•
Prev
entio
n /
treat
men
t of s
eizu
res
•Te
rmin
al a
gita
tion
/ re
stle
ssne
ss•
Seda
tion
•Re
com
men
datio
n: lo
w in
itial
dos
ing
and
freq
uent
reas
sess
men
t•
Oral
adm
inis
trat
ion:
cou
nt o
ral d
rops
ont
o a
spoo
n pr
ior t
o pu
tting
into
m
outh
. Thr
ee d
rops
≈ 0
.3 m
g•
Oral
clo
naze
pam
is w
ell a
bsor
bed
by b
ucca
l muc
osa
•Su
bcut
aneo
us a
dmin
istr
atio
n: c
lona
zepa
m a
bsor
bs to
PVC
so
shou
ld
pref
erab
ly b
e gi
ven
usin
g PV
C-fr
ee e
quip
men
t
Fent
anyl
25 to
200
mcg
, 2 h
ourly
PRN
100
to 8
00 m
cg a
s CS
CI o
ver 2
4 ho
urs
Subc
utan
eous
bol
us
CSCI
•Pa
in•
SOB
•Sh
ort a
ctin
g (i.
e. e
ffec
tive
for 1
to 1.
5 ho
urs
so m
ay n
eed
to b
e gi
ven
mor
e fr
eque
ntly
than
oth
er n
arco
tics)
•Eq
uian
alge
sic
dose
: 15
0 m
cg fe
ntan
yl s
ubcu
t ≈ 10
mg
mor
phin
e su
bcut
Hal
oper
idol
0.5
to 1.
5 m
g, 12
hou
rly P
RNSu
bcut
aneo
us b
olus
•
Delir
ium
•Ps
ycho
sis
•Te
rmin
al a
gita
tion
/ re
stle
ssne
ss•
Nau
sea
•Vo
miti
ng
•Re
com
men
datio
n: lo
w in
itial
dos
ing
and
freq
uent
reas
sess
men
t•
Antie
met
ic d
oses
are
low
er th
an a
ntip
sych
otic
dos
es•
Cons
ult s
peci
alis
t pal
liativ
e ca
re s
ervi
ce fo
r mor
e de
taile
d in
form
atio
n re
gard
ing
dosa
ge•
Obse
rve
for e
xtra
pyra
mid
al s
ide
effe
cts
e.g.
aka
this
ia
1 to
5 m
g by
CSC
I ove
r 24
hour
sCS
CI
Hyd
rom
orph
one
Hyd
rom
orph
one
is 5
tim
es s
trong
er th
an
mor
phin
e; o
nly
to b
e us
ed in
con
sulta
tion
with
spe
cial
ist p
allia
tive
care
ser
vice
Subc
utan
eous
bol
us
CSCI
•Pa
in•
SOB
•Sy
nthe
tic fo
rm o
f mor
phin
e•
Pote
ntia
l for
med
icat
ion
erro
rs d
ue to
con
fusi
on w
ith m
orph
ine
•Eq
uian
alge
sic
dose
: 2
mg
hydr
omor
phon
e su
bcut
≈ 10
mg
mor
phin
e su
bcut
Hyo
scin
e Bu
tylb
rom
ide
20 m
g, 2
to 4
hou
rly P
RNSu
bcut
aneo
us b
olus
•
Resp
irato
ry s
ecre
tions
at e
nd o
f lif
e•
Colic
•M
ost f
requ
ently
use
d to
trea
t res
pira
tory
sec
retio
ns. M
ost e
ffec
tive
if gi
ven
early
(i.e
. as
soon
as
‘noi
sy re
spira
tions
’ beg
in)
20 to
60
mg
by C
SCI o
ver 2
4 ho
urs
CSCI
Met
oclo
pram
ide
10 to
20
mg,
6 h
ourly
PRN
10 to
80
mg
by C
SCI o
ver 2
4 ho
urs
Subc
utan
eous
bol
us
CSCI
•N
ause
a•
Vom
iting
•Ob
serv
e fo
r ext
rapy
ram
idal
sid
e ef
fect
s e.
g. a
kath
isia
Mid
azol
am2.
5 to
10 m
g, 2
to 4
hou
rly P
RNSu
bcut
aneo
us o
r su
blin
gual
bol
us•
Anxi
ety
•Se
izur
es•
Term
inal
agi
tatio
n /
rest
less
ness
•Se
datio
n
•Ra
pid
onse
t, sh
ort a
ctin
g be
nzod
iaze
pine
5 to
30
mgs
by
CSCI
ove
r 24
hour
s (o
ccas
iona
lly h
ighe
r dos
es u
sed)
CSCI
Mor
phin
e Su
lpha
te2.
5 to
20
mg,
2 to
4 h
ourly
PRN
5 to
200
mg
by C
SCI o
ver 2
4 ho
urs
(theo
retic
ally
no
ceili
ng d
ose)
Subc
utan
eous
bol
us
CSCI
•Pa
in•
SOB
•N
ot to
lera
ted
in re
side
nts
with
poo
r ren
al fu
nctio
n as
can
cau
se
conf
usio
n, m
yocl
onus
and
oth
er e
ffec
ts o
f nar
cotic
toxi
city
•
Equi
anal
gesi
c do
se:
5 m
g m
orph
ine
subc
ut ≈
15 m
g or
al m
orph
ine
Not
e: S
ubcu
tane
ous
infu
sion
s ar
e an
eff
ectiv
e w
ay to
giv
e a
com
bina
tion
of m
edic
atio
ns to
peo
ple
who
can
not s
wal
low,
are
nau
seat
ed a
nd/o
r hav
e co
mpl
ex s
ympt
oms.
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents10
Symptom Management Flowcharts
Using the FlowchartsThe following flowcharts present a stepwise approach to the use of medications in managing distressing symptoms that are commonly experienced by dying residents in the terminal phase:
• Flowchart1:NauseaandVomiting • Flowchart2:Pain • Flowchart3:RespiratoryDistress • Flowchart4:RestlessnessandAgitation
The flowcharts are intended to assist clinical staff in making best practice and, where possible, evidence-based decisions about the care of residents who are dying and who have been commenced on the Residential Aged Care End of Life Care Pathway (RAC EoLCP).
What is the Residential Aged Care End of Life Care Pathway (RAC EoLCP)?The RAC EoLCP is a clinical tool developed by the Brisbane South Palliative Care Collaborative (BSPCC) for use by Australian RACFs in documenting and delivering resident-centred end of life (terminal) care.
The RAC EoLCP form:
• Isaconsensus-based,bestpracticeguideforprovidingcareduringthelastdaysofaresident’slife. • Ismadeupoffivesectionswhichfacilitatethecomprehensivedocumentationanddeliveryofendoflife(terminal) care by RACFs. • Isabletobefreelydownloadedfrom:www.health.qld.gov.au/pahospital/services/raceolcp.asp
Whenimplementedinconjunctionwithapalliativeapproachframework,theRACEoLCPhasbeenshowntoimproveoutcomes for dying residents and enhance the quality of end of life (terminal) care provided by RACFs.6
Detailed information about the RAC EoLCP is provided in the following PA Toolkit resources:
• Module2:KeyProcesses • EducationalDVD:HowtoUsetheResidentialAgedCareEndofLifeCarePathway(RACEoLCP)
The flowcharts are a guide only and do not replace good clinical decision-making based on a detailed knowledge of the resident’s health history and a comprehensive assessment of the resident’s current condition and symptoms. Choice of drug(s) and specific dosage(s) remain the responsibility of the prescribing medical officer or nurse practitioner. Registered and enrolled nurses are responsible for:
(a) regularly assessing symptoms; (b) administering PRN medications when required; (c) regularly monitoring and documenting the effectiveness of prescribed drug(s); and (d) identifying and reporting side effects/adverse drug reactions caused by prescribed medication.
The flowcharts are a guide only and do not replace good clinical decision-making.
Careful monitoring, titration and frequent assessment of medication effectiveness, side effects and adverse reactions are essential.
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents 11
Each flowchart is accompanied by a brief summary of the current evidence used to inform the recommendations made about the pharmacological management of each symptom. The level of evidence currently available is identified in each summary. High level scientific evidence supporting the pharmacological management of end of life (terminal) symptoms in older people remains limited and, as a result, consensus-based expert opinion about best practice is often relied upon to guide clinical decision-making.
Key points to consider in the pharmacological management of end of life (terminal) symptoms experienced by residents in RACFs* include:
• Theresidentand/ortheirsubstitutedecisionmakershouldbeawarethattheresidentisdyingandsupporttheuseof medications to manage end of life (terminal) symptoms. • Medicationsanddosesprescribedshouldbebasedoncarefulassessmentofthedyingresident’sconditionandsymptoms. • Dosesshouldbeproportionatetotheseverityofsymptomsandresponsetotreatmentshouldberegularlyreassessed. • Medicationsthathaveminimaltherapeuticbenefitintheterminalphaseoflifeshouldbeceased. • Theburdenofhowmedicationsaregivenandofpotentialsideeffectsshouldbeminimised.Palliativecaremedicationsat the end of life are usually given via the subcutaneous route, which is generally the least invasive and most reliable route in the dying resident. • PersistentsymptomsrequireregularratherthanPRN(asneeded)orders. • Useofregularmedicationstomanagesymptomsdoesnotprecludetheneedforappropriatebreakthroughdoseorders. PRN orders should be written for intermittent symptoms and to cover possible breakthrough events for persistent symptoms. • AnticipatoryPRNprescribingforproblemswhichmayoccurduringthedyingprocessisimportantforgoodendoflife (terminal) care as it will ensure that medications are easily accessible when required.
[*Adapted from CareSearch: Symptom Management at the End of Life9]
These points have been used to inform recommendations made in the following set of four flowcharts.
Levels of EvidenceThe levels of evidence assigned in this document are those designed by the National Health and Medical Research Council of Australia with the addition of a Level V.12
I Systematic review of all relevant randomised control trials (RCTs) II At least one properly designed RCT III-1 Welldesignedpseudo-RCTs III-2 Comparative studies with concurrent non-randomised controls, case control studies or interrupted time series with a control group III-3 Comparative studies with historical control, two or more single arm studies, or interrupted time series without parallel control group IV Case series, either post-test or pre-test and post-test V Specialist expert opinion (the opinion of specialists with experience in the field of palliative medicine)
1. Re
view
cur
rent
ant
iem
etic
and
dos
e:•
Ifresidentusingregularoralantiemeticand
un
able
to s
wallo
w, c
onsi
der c
onve
rtin
g to
m
etoc
lopr
amid
e 20
to 3
0 m
g ad
min
iste
red
by
CSC
I usi
ng a
syr
inge
driv
er o
ver 2
4 ho
urs
•
Ensureorderwrittenform
etoclopram
ide
10
mg
subc
ut P
RN q
tds
Pre-
empt
ivel
y or
gani
se m
edic
atio
ns to
man
age
naus
ea a
nd v
omiti
ng.
Requ
est M
O/N
P to
revi
ew c
urre
nt d
rugs
, bot
h re
gula
r and
PRN
ord
ers
Is a
n an
tiem
etic
pre
scrib
ed?
1.Write/requ
esto
rderfo
rmetoclopram
ide
10 m
g su
bcut
PRN
q td
s
YES
NO
Even
if s
ympt
oms
abse
nt, c
ontin
ue to
revi
ew re
gula
rly fo
r nau
sea
and
vom
iting
. If
resi
dent
exp
erie
ncin
g na
usea
and
vom
iting
refe
r to
the
‘Sym
ptom
s pr
esen
t’ co
lum
n
YES
NO
If sy
mpt
om m
anag
emen
t rem
ains
inad
equa
te d
espi
te a
bove
inte
rven
tions
con
tact
MO/
NP o
r pal
liativ
e ca
re s
ervi
ce fo
r fur
ther
adv
ice
Flow
chart1:P
harm
acolog
icalMan
agem
ento
fNau
seaan
dVo
miting
forR
esiden
tsontheRe
side
ntialA
gedCa
reEnd
ofL
ifeCarePa
thwa
y(RAC
EoL
CP)
1.Write/requestm
edication
orde
r for
met
oclo
pram
ide
10 m
g su
bcut
PRN
q td
s 2.
Adm
inis
ter P
RN
met
oclo
pram
ide
3. O
bser
ve c
lose
ly fo
r
extra
pyra
mid
al s
ide
effe
cts
e.g.
aka
this
ia4.
Ass
ess
effe
ctiv
enes
s of
adm
inis
tere
d m
edic
atio
n
an
d co
ntin
ue a
dmin
iste
ring
as re
quire
d5.
If g
reat
er th
an 3
dos
es o
f
PRN
met
oclo
pram
ide
requ
ired
over
24
hour
s
co
nsid
er c
omm
ence
men
t
of a
ntie
met
ic u
sing
a
sy
ringe
driv
er
1. Re
view
cur
rent
ant
iem
etic
and
dos
e:•Ifnauseaandvo
mitingpersist,orifresidentusingregularoral
antie
met
ic a
nd u
nabl
e to
swa
llow,
con
side
r con
verti
ng to
m
etoc
lopr
amid
e 20
to 3
0 m
g ad
min
iste
red
by C
SCI u
sing
a sy
ringe
dr
iver o
ver 2
4 ho
urs
•En
sureorderwrittenform
etoclopram
ide10mgsubcutPRN
qtds
2. If
nau
sea
and
vom
iting
per
sist
con
side
r tria
l of h
alop
erid
ol 0
.5 to
1.5 m
g su
bcut
PRN
q b
d 3.
If h
alop
erid
ol a
ppea
rs to
be
mor
e ef
fect
ive
than
met
oclo
pram
ide
in m
anag
ing
naus
ea a
nd vo
miti
ng c
onsi
der c
hang
ing
to C
SCI o
f
halo
perid
ol u
sing
a s
yrin
ge d
river
ove
r 24
hour
s 4.
Reg
ular
ly re
asse
ss s
ympt
om m
anag
emen
t and
con
tinue
to
ad
min
iste
r PRN
met
oclo
pram
ide
or P
RN h
alop
erid
ol fo
r
br
eakt
hrou
gh n
ause
a an
d vo
miti
ng
5. O
bser
ve c
lose
ly fo
r ext
rapy
ram
idal
sid
e ef
fect
s of
met
oclo
pram
ide/
halo
perid
ol e
.g. a
kath
isia
Adm
inis
ter a
ppro
pria
te m
edic
atio
n as
cur
rent
ly c
hart
ed fo
r nau
sea
and
vom
iting
. Re
ques
t MO/
NP
to im
med
iate
ly re
view
cur
rent
dru
gs, b
oth
regu
lar a
nd P
RN o
rder
s
If gr
eate
r tha
n 3
dose
s of
PRN
met
oclo
pram
ide
10 m
g su
bcut
requ
ired
over
24
hour
per
iod,
or
if p
resc
ribed
hal
oper
idol
dos
e in
effe
ctiv
e ov
er 2
4 ho
ur p
erio
d, re
ques
t MO/
NP
revi
ew to
co
nsid
er c
hang
es in
med
icat
ion
and
syrin
ge d
river
ord
ers
Is a
n an
tiem
etic
pre
scrib
ed? ©
Sta
te o
f Que
ensl
and
(Que
ensl
and
Heal
th) 2
013.
Dev
elop
ed b
y Br
isba
ne S
outh
Pal
liativ
e Ca
re C
olla
bora
tive
(Que
ensl
and
Heal
th)
SYM
PTOM
S PR
ESEN
TSy
MPT
OMSAB
SENT
Revi
ew re
gula
rly fo
r sym
ptom
s of
nau
sea
and
vom
iting
(see
RAC
EoL
CP, C
omfo
rt C
are
Char
t, pa
ge 5
)
KEY:
bd
twic
e da
ily |
B/Tb
reak
thro
ugh
| C
SCI c
ontin
uous
sub
cuta
neou
s in
fusi
on |
MO
Med
ical
Offi
cer
| N
P Nu
rse
Prac
titio
ner
| P
RN a
s ne
eded
by
pred
eter
min
ed ti
me
| q
eve
ry |
Sub
cut
subc
utan
eous
| t
ds th
ree
times
per
day
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents 13
Pharmac
olog
icalMan
agem
ento
fNau
seaan
dVo
miting
forR
esiden
tsontheRe
side
ntialA
gedCa
reEnd
ofL
ifeCarePa
thwa
y(RAC
EoL
CP)
Key
mes
sage
s•
TheRA
CEo
LCPisacon
sensus-based
bestp
racticegu
idetoproviding
care
for r
esid
ents
in th
e la
st d
ays
of li
fe.
•Pre-em
ptiveprescribingwillensurethatinth
elastdaysan
dho
ursofa
re
side
nt’s
life
ther
e is
no
dela
y in
resp
ondi
ng to
a s
ympt
om if
it o
ccur
s.
•Re
side
ntson
theRA
CEo
LCPrequ
ire2hou
rlysym
ptom
assessm
ent.
Th
is a
llow
s fo
r em
erge
nt s
ympt
oms
to b
e de
tect
ed q
uick
ly a
nd tr
eate
d
ph
arm
acol
ogic
ally
if re
quire
d. E
ffica
cy o
f adm
inis
tere
d m
edic
atio
ns
sh
ould
be
eval
uate
d an
d do
cum
ente
d.
•Alwaysconsidernon
-pha
rmacolog
icalinterven
tionsinadd
ition
toth
e
ph
arm
acol
ogic
al m
anag
emen
t of e
nd o
f life
(ter
min
al) s
ympt
oms.
For f
urth
er in
form
atio
nCa
reSe
arch
: RAC
Hub
ht
tp:/
/ww
w.ca
rese
arch
.com
.au/
care
sear
ch/t
abid
/225
6/De
faul
t.asp
x
GlareP,MillerJ,N
ikolovaT&Tickoo
R(2011),Treatingna
useaand
vom
iting
in
pal
liativ
e ca
re: a
revi
ew. C
linic
al In
terv
entio
ns in
Agi
ng, 6
, 243
-259
.
Com
mon
wea
lth o
f Aus
tral
ia (2
006)
Gui
delin
es fo
r a P
allia
tive
Appr
oach
in
Resi
dent
ial A
ged
Care
– E
nhan
ced
Vers
ion,
Can
berr
a.
Palli
ativ
e Ca
re E
xper
t Gro
up (2
010)
The
rape
utic
Gui
delin
es: P
allia
tive
Care
(V
ersi
on 3
), M
elbo
urne
: The
rape
utic
Gui
delin
es L
imite
d.
Sum
mar
y of
clin
ical
evi
denc
e•
Factorscontrib
utingtonau
seaan
dvomiting
inare
side
ntwith
alife-limiting
illnessmayinclud
ebu
tarenot
lim
ited
to: d
rug
toxi
city
, urin
ary
trac
t inf
ectio
n, c
onst
ipat
ion,
dis
ease
s of
the
gast
roin
test
inal
trac
t, m
etab
olic
and
bioc
hem
ical
dis
turb
ance
and
org
an fa
ilure
. Cau
se(s
) of n
ause
a an
d vo
miti
ng in
the
last
day
s of
life
may
be
unid
entifi
able
and
mul
ti-fa
ctor
ial.13
(Lev
el V
)
•Nau
seaisoften
und
erre
cogn
ised
and
und
ertreated.
14 (L
evel
I)
•Th
ereislimite
deviden
ceto
guide
theuseofantiemeticth
erap
yinth
eelde
rly.13
(Lev
el V
)
•Op
ioidscommon
lycau
senau
seaan
dvomiting
.Metoclopram
ideha
sbe
ensho
wntobeeffectiveinth
e
man
agem
ent o
f nau
sea
and
vom
iting
in p
atie
nts
with
can
cer w
ho a
re o
n op
ioid
ther
apy.
13 (L
evel
V),
14 (L
evel
I), 1
5 (L
evel
V)
•Halop
eridolcan
betrialledtom
anag
ena
useaand
vom
iting
ifm
etoclopram
ideisineffective.
13 (L
evel
V),
14 (L
evel
I)
•Metoclopram
ideorhalop
eridolcan
cau
seextrapyramidalsideeffects.The
sedrugsneedtobeavoide
dorused
with
cau
tion
in re
side
nts
with
neu
rode
gene
rativ
e di
sord
ers
such
as
Park
inso
n’s
dise
ase.
10 (L
evel
V),
16 (L
evel
V)
•Su
bcutan
eousinfusion
ofa
ntiemeticsde
livered
viaasyringedriverhasbeenshow
ntobeeffectivein
m
anag
ing
pers
iste
nt s
ympt
oms
of n
ause
a an
d vo
miti
ng. 16
[Lev
el V
]
SYM
PTOM
S PR
ESEN
TSy
MPT
OMSAB
SENT
1.Write/requestopioid
orde
r for
pai
n m
anag
emen
t.
Co
nsid
er:
•M
orphine2.5to5mg
sub
cut P
RN q
2hr
ly
OR
•Fentanyl25to50mcg
sub
cut P
RN q
2hr
ly
OR
•Hydromorphone0
.5to1mg
s
ubcu
t PRN
q 2
hrly
2.
If pa
in p
rese
nt, a
dmin
iste
r
PR
N op
ioid
dos
e3.
As
sess
effe
ctiv
enes
s of
adm
inis
tere
d m
edic
atio
n
an
d co
ntin
ue a
dmin
iste
ring
opio
ids
as re
quire
d
1. Re
view
cur
rent
opi
oid
dose
:
•Ifresidentusing
regu
laro
ralopioidsand
unableto
swal
low,
con
side
r con
vert
ing
to a
ppro
pria
te s
ubcu
t
op
ioid
dos
e ad
min
iste
red
by C
SCI u
sing
syr
inge
dr
iver
ove
r 24
hour
s (s
ee O
pioi
d Co
nver
sion
Cha
rt)
•Ifop
ioidpatchinsitu
con
sider:
- co
ntin
uing
pat
ch a
t sam
e do
se
OR
- co
nver
ting
patc
h to
app
ropr
iate
sub
cut o
pioi
d
do
se a
dmin
iste
red
by C
SCI u
sing
a s
yrin
ge d
river
over
24
hour
s (s
ee O
pioi
d Co
nver
sion
Cha
rt)
•En
sureorderwrittenforo
pioidsubcutPRN
dose.
PRN
ord
er =
1/12
q 2
hrly
of t
otal
dai
ly o
pioi
d su
bcut
do
se
•IfresidentonlyhasoralPRN
opioiddo
sechang
e
to e
quiv
alen
t dos
e su
bcut
PRN
Pre-
empt
ivel
y or
gani
se m
edic
atio
ns to
man
age
pain
. Re
ques
t MO/
NP
to re
view
cur
rent
dru
gs, b
oth
regu
lar a
nd P
RN o
rder
s
Are
regu
lar o
r PRN
opi
oids
pre
scrib
ed fo
r pai
n?
1.Write/requ
esto
pioidorderforpain
man
agem
ent.
Cons
ider
:
•Morph
ine2.5to5m
gsubcutPRN
q2hrly
OR
•Fentanyl25to50mcgsubcutPRN
q2hrly
OR
•Hy
drom
orphone0.5to1mgsubcutPRN
q
2hrly
1. R
evie
w c
urre
nt o
pioi
d do
se:
•Ifresidentusingregularopioidsandunabletoswa
llowconsider:
- con
verti
ng re
gula
r ora
l opi
oids
to a
ppro
pria
te s
ubcu
t dos
e
adm
inis
tere
d by
CSC
I usi
ng a
syr
inge
driv
er o
ver 2
4 ho
urs
(
see
Opio
id C
onve
rsio
n Ch
art)
- If p
ain
caus
ing
dist
ress
and
/or i
f mul
tiple
PRN
opi
oids
a
dmin
iste
red
in p
revi
ous
24 h
ours
to m
anag
e pa
in, c
alcu
late
t
he to
tal d
ose
of B
/T o
pioi
ds o
ver p
revi
ous
24 h
ours
and
add
to
syr
inge
driv
er o
pioi
d do
se o
r titr
ate
up th
e op
ioid
dos
e
a
dministeredbysyringedriverinprevious24hoursby30
%
•Ifopioidpatchinsituconsider:
- c
ontin
uing
pat
ch a
t sam
e do
se a
nd g
ivin
g op
ioid
PRN
sub
cut
dos
e fo
r B/T
pai
n (m
ay re
quire
adv
ice
from
spe
cial
ist p
allia
tive
c
are
team
to c
alcu
late
app
ropr
iate
PRN
dos
e)
OR
- c
onve
rting
pat
ch to
app
ropr
iate
sub
cut o
pioi
d do
se
a
dmin
iste
red
by C
SCI u
sing
a s
yrin
ge d
river
ove
r 24
hour
s
(se
e Op
ioid
Con
vers
ion
Char
t)
•En
sureorderwrittenforP
RNdose.PRN
order=1/12q2hrlyof
tota
l dai
ly s
ubcu
t dos
e2.
If p
ain
pers
ists
, adm
inis
ter P
RN o
pioi
d do
se3.
Ass
ess
effe
ctiv
enes
s of
adm
inis
tere
d m
edic
atio
n an
d co
ntin
ue
ad
min
iste
ring
opio
ids
as re
quire
d
Adm
inis
ter a
ppro
pria
te m
edic
atio
n as
cur
rent
ly c
hart
ed fo
r pai
n.
Requ
est M
O/N
P to
revi
ew im
med
iate
ly c
urre
nt d
rugs
, bot
h re
gula
r and
PRN
ord
ers
Ifgrea
tertha
n3do
sesofPRN
opioids
requ
iredforB
/Tpainover24ho
urperiod,
requ
est M
O/NP
revi
ew to
con
side
r cha
nges
to m
edic
atio
n an
d sy
ringe
driv
er o
rder
sEv
en if
sym
ptom
s ab
sent
, con
tinue
to re
view
regu
larly
for p
ain.
If
resi
dent
exp
erie
ncin
g pa
in re
fer t
o th
e ‘S
ympt
oms
pres
ent’
colu
mn
Are
regu
lar o
r PRN
opi
oids
pre
scrib
ed fo
r pai
n?
Revi
ew re
gula
rly fo
r sym
ptom
s of
pai
n (s
ee R
AC E
oLCP
, Com
fort
Car
e Ch
art,
page
5)
Flow
char
t 2: P
harm
acol
ogic
al M
anag
emen
t of P
ain
for R
esid
ents
on
the
Resi
dent
ial A
ged
Care
End
of L
ife C
are
Path
way
(RAC
EoL
CP)
YES
NOYE
SNO
If sy
mpt
om m
anag
emen
t rem
ains
inad
equa
te d
espi
te a
bove
inte
rven
tions
con
tact
MO/
NP o
r pal
liativ
e ca
re s
ervi
ce fo
r fur
ther
adv
ice
© S
tate
of Q
ueen
slan
d (Q
ueen
slan
d He
alth
) 201
3. D
evel
oped
by
Bris
bane
Sou
th P
allia
tive
Care
Col
labo
rativ
e (Q
ueen
slan
d He
alth
)
KEY:
bd
twic
e da
ily |
B/Tb
reak
thro
ugh
| C
SCI c
ontin
uous
sub
cuta
neou
s in
fusi
on |
MO
Med
ical
Offi
cer
| N
P Nu
rse
Prac
titio
ner
| P
RN a
s ne
eded
by
pred
eter
min
ed ti
me
| q
eve
ry |
Sub
cut
subc
utan
eous
| t
ds th
ree
times
per
day
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents 15
Phar
mac
olog
ical
Man
agem
ent o
f Pai
n fo
r Res
iden
ts o
n th
e Re
side
ntia
l Age
d Ca
re E
nd o
f Life
Car
e Pa
thwa
y (R
AC E
oLCP
)
Key
mes
sage
s•
TheRA
CEo
LCPisacon
sensus-based
bestp
racticegu
idetoproviding
care
for r
esid
ents
in th
e la
st d
ays
of li
fe.
•Pre-em
ptiveprescribingwillensurethatinth
elastdaysan
dho
ursofa
re
side
nt’s
life
ther
e is
no
dela
y in
resp
ondi
ng to
a s
ympt
om if
it o
ccur
s.
•Re
side
ntson
theRA
CEo
LCPrequ
ire2hou
rlysym
ptom
assessm
ent.
This
allo
ws
for e
mer
gent
sym
ptom
s to
be
dete
cted
qui
ckly
and
trea
ted
phar
mac
olog
ical
ly if
requ
ired.
Effi
cacy
of a
dmin
iste
red
med
icat
ions
shou
ld b
e ev
alua
ted
and
docu
men
ted.
•Alwaysconsidernon
-pha
rmacolog
icalinterven
tionsinadd
ition
toth
e
ph
arm
acol
ogic
al m
anag
emen
t of e
nd o
f life
(ter
min
al) s
ympt
oms.
For f
urth
er in
form
atio
nCa
reSe
arch
: RAC
Hub
ht
tp:/
/ww
w.ca
rese
arch
.com
.au/
care
sear
ch/t
abid
/225
6/De
faul
t.asp
x
Guid
elin
es fo
r LCP
Dru
g Pr
escr
ibin
g in
Adv
ance
d Ki
dney
Dis
ease
ht
tp:/
/ww
w.liv
.ac.
uk/m
edia
/liv
acuk
/mcp
cil/m
igra
ted-
files
/liv
erpo
ol-c
are-
pathway/pdfs/Nationa
l,LCP,Ren
al,sym
ptom
,con
trol,guide
lines,%
28Ju
ne,20
08%29
,%28
p.pd
f
Pain
in R
esid
entia
l Age
d Ca
re F
acili
ties:
Man
agem
ent S
trat
egie
s
ww
w.ap
soc.
org.
au/o
wne
r/fil
es/9
e2c2
n.pd
f
Resi
dent
ial A
ged
Care
Pal
liativ
e Ap
proa
ch T
oolk
it: M
odul
e 3
– Cl
inic
al C
are
Nat
iona
l Col
labo
rativ
e Gu
idel
ines
for C
ance
r: Op
ioid
s in
Pal
liativ
e Ca
re -
Safe
an
d Ef
fect
ive
Pres
crib
ing
of S
trong
Opi
oids
for P
ain
in P
allia
tive
Care
of
Adul
ts
http
://w
ww.
ncbi
.nlm
.nih
.gov
/pub
med
heal
th/P
MH
0050
722/
Sum
mar
y of
clin
ical
evi
denc
e•
Stud
iesindicateth
atpainisacom
mon
problem
experienc
edbyelde
rlypeo
plelivinginRAC
Fs.The
prevalenc
e
ofpersisten
tpaininth
ispop
ulationisestim
ated
tobebe
tween49
%and
80%
.17 [L
evel
III-
2], 1
8 [L
evel
V]
•Op
ioidsareeffectivean
dgene
rallywelltolerated
inth
eelde
rly.19
[Lev
el V
]
•Op
ioidnaïvere
side
ntsrequ
iring
opioidsto
man
agepa
insho
uldbe
com
men
cedon
thelowesto
pioiddo
se
po
ssib
le. C
aref
ul u
pwar
d tit
ratio
n m
inim
ises
the
risk
of to
xici
ty.19
[Lev
el I]
, 20
[Lev
el V
]
•Co
mmon
sideeffectsofopioidad
ministrationinclud
econstip
ation,nau
seaan
dvomiting
,dizzine
ssand
seda
tion.
Mos
t sid
e ef
fect
s di
min
ish
with
con
tinue
d us
e ex
cept
for c
onst
ipat
ion
whi
ch w
ill p
ersi
st. A
laxa
tive
orde
r sho
uld
be in
pla
ce to
min
imis
e th
is p
robl
em.10
(Lev
el V
)
•Morph
ineshou
ldbeavoide
dinre
side
ntswith
severerena
lfailure(eGF
R<30
)due
toth
ebu
ildupofto
xic
met
abol
ites.
Fen
tany
l has
no
activ
e m
etab
olite
s of
rele
vanc
e an
d ha
s be
en id
entifi
ed a
s th
e op
ioid
that
is le
ast
lik
ely
to c
ause
har
m in
resi
dent
s w
ith s
ever
e re
nal i
mpa
irmen
t whe
n us
ed a
ppro
pria
tely.
21 [L
evel
I]
•Tooptim
isereliefo
fpersisten
tpain,opioidssho
uldbe
adm
inisteredon
an‘aroun
d-the-clock’basisaccording
to th
e du
ratio
n of
act
ion
of th
e pr
escr
ibed
opi
oid.
10 (L
evel
V)
•Breakthrou
ghpainoccu
rscom
mon
lyinpeo
plewho
arere
ceivingop
ioidsforp
ersisten
tpain.
22 [L
evel
III-
2] In
addi
tion
to th
e re
gula
r opi
oid
dose
, a P
RN b
reak
thro
ugh
opio
id d
ose
shou
ld b
e pr
escr
ibed
at 1
/12t
h to
1/6t
h of
the
24 h
our d
ose.
10 (L
evel
V)
•Tran
sdermalopioidpa
tche
s(bup
reno
rphine
and
fentan
yl)arenotsuitabletocom
men
ceinth
elastdaysof
lif
e. T
rans
derm
al o
pioi
d pa
tche
s ha
ve a
pro
long
ed o
nset
tim
e an
d th
eref
ore
rapi
d, s
afe
dose
titr
atio
n to
man
age
es
cala
ting
sym
ptom
s is
not
pos
sibl
e.23
[Lev
el I]
•Whe
ninitiatingop
ioidsinth
elastdaysoflifeorw
henoralro
uteisnolong
erviable,acon
tinuo
ussub
cutane
ous
in
fusi
on u
sing
a s
yrin
ge d
river
is th
e pr
efer
red
rout
e of
adm
inis
trat
ion.
10 (L
evel
V),
24 (L
evel
V)
© S
tate
of Q
ueen
slan
d (Q
ueen
slan
d He
alth
) 201
3. D
evel
oped
by
Bris
bane
Sou
th P
allia
tive
Care
Col
labo
rativ
e (Q
ueen
slan
d He
alth
)
SYM
PTOM
S PR
ESEN
TSy
MPT
OMSAB
SENT
1.Write/requestopioidorderfor
sh
ortn
ess
of b
reat
h. C
onsi
der:
•Morphine1.5
to2.5mgsubcut
PRN
q 2h
rly
OR
•Fentanyl25to50mcgsubcut
PRN
q 2h
rly
OR
•Hy
drom
orphone0.25
to0.5mg
su
bcut
PRN
q 2
hrly
2. I
f sho
rtnes
s of
bre
ath
pres
ent
ad
min
iste
r opi
oid
PRN
dose
3. A
sses
s ef
fect
iven
ess
of
ad
min
iste
red
med
icat
ion
and
cont
inue
adm
inis
terin
g op
ioid
s
as
requ
ired
1. R
evie
w c
urre
nt o
pioi
d do
se:
•Ifresidentusingregularoralopioidsandunabletoswa
llow,
cons
ider
con
verti
ng to
CSC
I usi
ng s
yrin
ge d
river
ove
r 24
hour
s
•En
surewrittenorderforopioiddosePRN
forshortn
essof
brea
th. P
RN o
rder
= 1
/12
q 2h
rly o
f tot
al d
aily
subc
ut d
ose
•IfresidentonlyhasPR
NoralopioidchangetosubcutPRN
Pre-
empt
ivel
y or
gani
se m
edic
atio
ns to
man
age
resp
irato
ry d
istre
ss.
Requ
est M
O/NP
to re
view
cur
rent
dru
gs, b
oth
regu
lar a
nd P
RN o
rder
s
A. S
hort
ness
of b
reat
h: A
re o
pioi
ds p
resc
ribed
for a
ny re
ason
?
1.Write/requestopioidorderfor
shor
tnes
s of
bre
ath.
Con
side
r:•Morphine1.5to2.5mgsubcutPRN
q2hrly
OR
•Fentanyl25to50mcgsubcutPRN
q2hrly
OR
•Hy
drom
orphone0.25
to0.5mgsubcut
PRN
q 2h
rly
1. Re
view
cur
rent
opi
oid
dose
: •Ifresidentusingregularopioidsandunabletoswa
llowconsiderconverting
regu
lar o
ral o
pioi
ds to
app
ropr
iate
sub
cut d
ose
adm
inis
tere
d by
CSC
I
us
ing
syrin
ge d
river
ove
r 24
hour
s•Ifresidentve
rydistre
ssedand/orrequiringmultiplePRN
opioidsto
man
age
brea
thle
ssne
ss, m
ay n
eed
high
er d
ose
in s
yrin
ge d
river
but
generallyadvisednottotitra
teabove30%
ofpreviousdailyrequirements
•Ifopioidpatchinsitucontinueatsam
edoseandadm
inisterP
RN
med
icat
ion
for B
/T s
ympt
oms
OR
•Co
nvertpatchtoappropriatesubcutopioiddoseadm
inisteredbyCSC
I
us
ing
a sy
ringe
driv
er (s
ee O
pioi
d Co
nver
sion
Cha
rt)•En
sureorderwrittenforP
RNdose.PRN
order=1/12q2hrlyoftotaldaily
subc
ut d
ose
2. If
sho
rtnes
s of
bre
ath
pres
ent a
dmin
iste
r opi
oid
PRN
dose
3. A
sses
s ef
fect
iven
ess
of a
dmin
iste
red
med
icat
ion
and
cont
inue
ad
min
iste
ring
opio
ids
as re
quire
d
Adm
inis
ter a
ppro
pria
te m
edic
atio
n(s)
as
curre
ntly
cha
rted
for r
espi
rato
ry d
istre
ss.
Requ
est M
O/NP
to re
view
imm
edia
tely
cur
rent
dru
gs, b
oth
regu
lar a
nd P
RN o
rder
s
YES
NO
C. E
xces
sive
sec
retio
ns: W
rite/requestorderforhyoscinebutylbromide(Buscopan)20mg
subc
ut P
RN q
2 to
4hr
ly a
nd a
dmin
iste
r if e
xces
sive
resp
irato
ry s
ecre
tions
pre
sent
B.Associatedan
xiety:Areben
zodiazep
inesalre
adyp
rescrib
edto
man
agean
xiety?
YES
NOA.
Sho
rtne
ss o
f bre
ath:
Are
opi
oids
pre
scrib
ed fo
r any
reas
on?
Revi
ew re
gula
rly fo
r sym
ptom
s of
resp
irato
ry d
istr
ess
(see
RAC
EoL
CP, C
omfo
rt C
are
Char
t, pa
ge 5
)
Flow
char
t 3: P
harm
acol
ogic
al M
anag
emen
t of R
espi
rato
ry D
istr
ess
for R
esid
ents
on
the
Resi
dent
ial A
ged
Care
End
of L
ife C
are
Path
way
(RAC
EoL
CP)
Resp
irato
ry d
istre
ss in
clud
es th
e sy
mpt
oms
of A
. sho
rtne
ss o
f bre
ath
(obs
erve
d or
repo
rted
),B.assoc
iatedan
xiety
and/
or C
. exc
essi
ve s
ecre
tions
1. R
evie
w c
urre
nt b
enzo
diaz
epin
e do
se:
•Ifresidentusingregularoralbenzodiazepinetabletsandunabletoswa
llow,
cons
ider
con
verti
ng to
sub
cut r
oute
via
CSCI
usi
ng sy
ringe
driv
er o
ver 2
4 ho
urs
•En
sureorderforP
RNdoseforanxiety
•IfresidentonlyhasPR
Noralbenzodiazepinetabletchangetomidazolam
su
bcut
or c
lona
zepa
m s
ubcu
t/or
al d
rops
1. R
evie
w n
eed
for b
enzo
diaz
epin
e
or
der.
If re
quire
d co
nsid
er:
•Midazolam
2.5to5mgsubcut
PRN
q 2h
rly
OR
•Clonazepam
0.25to0.5mgoral
drop
s/su
bcut
PRN
4hr
ly
C. E
xces
sive
sec
retio
ns: P
re-e
mpt
ivel
y w
rite/
requ
est o
rder
for h
yosc
ine
buty
lbro
mid
e (B
usco
pan)
20
mg
subc
ut P
RN q
2 to
4hr
ly to
man
age
exce
ssiv
e re
spira
tory
sec
retio
ns
B.Associatedan
xiety:Areben
zodiazep
inesalre
adyp
rescrib
edto
man
agean
xiety?
1. Re
view
cur
rent
ben
zodi
azep
ine
dose
:
•Ifresidentusingregularbenzodiazepinetabletsandunableto
swal
low,
con
side
r con
verti
ng to
sub
cut r
oute
via
CSC
I usi
ng s
yrin
ge
dr
iver
ove
r 24
hour
s
•En
sureorderforP
RNdoseforanxiety
•Ifresidentonlyh
asPRN
oralbenzodiazepinetabletchangeto
m
idaz
olam
sub
cut o
r clo
naze
pam
sub
cut/
oral
dro
ps
2. I
f anx
iety
pre
sent
adm
inis
ter P
RN d
ose
of b
enzo
diaz
epin
e3.
Ass
ess
effe
ctiv
enes
s of
adm
inis
tere
d m
edic
atio
n an
d co
ntin
ue
adm
inis
terin
g be
nzod
iaze
pine
s as
requ
ired
1.Write/requestbenzodiazepineorderfor
an
xiet
y an
d if
requ
ired
adm
inis
ter a
s
so
on a
s po
ssib
le. C
onsi
der:
•
Midazolam
2.5to5mgsubcutPRN
q2hrly
OR
•Clonazepam
0.25to0.5mgs
ubcutororal
drop
s PRN
4hrly
2. A
sses
s ef
fect
iven
ess
of a
dmin
iste
red
med
icat
ion
and
cont
inue
adm
inis
terin
g
be
nzod
iaze
pine
s as
requ
ired
If gr
eate
r tha
n 3
dose
s of
any
PRN
med
icat
ion
requ
ired
over
24
hour
per
iod,
requ
est M
O/NP
revi
ew
to c
onsi
der c
hang
es to
med
icat
ions
and
syr
inge
driv
er o
rder
sEv
en if
sym
ptom
s ab
sent
, con
tinue
to re
view
regu
larly
for a
ny e
mer
ging
sym
ptom
s of
resp
irato
ry d
istre
ss.
If sy
mpt
oms
appe
ar re
fer t
o th
e ‘S
ympt
oms
pres
ent’
colu
mn
YES
NOYE
SNO
If sy
mpt
om m
anag
emen
t rem
ains
inad
equa
te d
espi
te a
bove
inte
rven
tions
con
tact
MO/
NP o
r pal
liativ
e ca
re s
ervi
ce fo
r fur
ther
adv
ice
KEY:
bd
twic
e da
ily |
B/Tb
reak
thro
ugh
| C
SCI c
ontin
uous
sub
cuta
neou
s in
fusi
on |
MO
Med
ical
Offi
cer
| N
P Nu
rse
Prac
titio
ner
| P
RN a
s ne
eded
by
pred
eter
min
ed ti
me
| q
eve
ry |
Sub
cut
sub
cuta
neou
s |
tds
thre
e tim
es p
er d
ay
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents 17
Key
mes
sage
s•
TheRA
CEo
LCPisacon
sensus-based
bestp
racticegu
idetoproviding
care
for r
esid
ents
in th
e la
st d
ays
of li
fe.
•Pre-em
ptiveprescribingwillensurethatinth
elastdaysan
dho
ursoflife
th
ere
is n
o de
lay
in re
spon
ding
to a
sym
ptom
whe
n it
occu
rs.
•Oraland
sub
cutane
ousop
ioidsad
ministeredinapp
ropriatedosesaresafe
an
d ef
fect
ive
in m
anag
ing
shor
tnes
s of
bre
ath.
•Re
side
ntson
theRA
CEo
LCPrequ
ire2hou
rlysym
ptom
assessm
ent.
Th
is a
llow
s fo
r em
erge
nt s
ympt
oms
to b
e de
tect
ed q
uick
ly a
nd tr
eate
d
ph
arm
acol
ogic
ally
if re
quire
d. E
ffica
cy o
f med
icat
ion
adm
inis
tere
d sh
ould
be e
valu
ated
and
doc
umen
ted.
•Alwaysconsidernon
-pha
rmacolog
icalinterven
tionsinadd
ition
toth
e
ph
arm
acol
ogic
al m
anag
emen
t of e
nd o
f life
(ter
min
al) s
ympt
oms.
For f
urth
er in
form
atio
nCa
reSe
arch
: RAC
Hub
ht
tp:/
/ww
w.ca
rese
arch
.com
.au/
care
sear
ch/t
abid
/225
6/De
faul
t.asp
x
Com
mon
wea
lth o
f Aus
tral
ia (2
006)
Gui
delin
es fo
r a P
allia
tive
Appr
oach
in
Resi
dent
ial A
ged
Care
– E
nhan
ced
Vers
ion,
Can
berr
a.
Resi
dent
ial A
ged
Care
Pal
liativ
e Ap
proa
ch T
oolk
it: M
odul
e 3
– Cl
inic
al C
are
Sum
mar
y of
clin
ical
evi
denc
e•
Dyspno
eaisacom
mon
sym
ptom
experienc
edinadvan
ceddiseaseirrespe
ctiveofdiagn
osis.The
prevalenc
e
an
d se
verit
y ca
n in
crea
se o
ver t
ime
part
icul
arly
in th
e la
st d
ays
of li
fe.25
[Lev
el I]
, 26
[Lev
el II
I-2]
•Initiatesimplemeasurestore
ducedyspn
oeasuch
asrepo
sitio
ning
thereside
nt,tep
idspo
ngeiffebrileand
air
flow
acr
oss
the
face
usi
ng ro
tatin
g fa
n or
ope
n w
indo
w.10
(Lev
el V
)
•Th
ereislimite
deviden
ceto
sup
portth
euseofoxygentom
anag
edyspno
eaate
ndoflife
.Oxygenha
sno
tbeen
show
n to
relie
ve d
yspn
oea
in n
on-h
ypox
ic p
atie
nts.
25 [L
evel
I] If
a re
side
nt is
hyp
oxic
, oxy
gen
is re
com
men
ded
for p
rovi
sion
of s
hort
term
relie
f. Ox
ygen
sho
uld
be c
ontin
ued
for r
esid
ents
who
hav
e re
quire
d lo
ng te
rm u
se fo
r
the
man
agem
ent o
f bre
athl
essn
ess
in c
hron
ic re
spira
tory
illn
esse
s.27
[Lev
el 1]
•System
icopioidsadm
inisteredinapp
ropriatedosesaresafean
deffectiveinm
anag
ingdyspno
ea.28
[Lev
el I]
•Op
ioidnaïvere
side
ntsrequ
iring
opioidsto
man
agesymptom
sshou
ldbecommen
cedon
thelowesto
pioiddo
se
po
ssib
le. C
aref
ul u
pwar
d tit
ratio
n m
inim
ises
the
risk
of to
xici
ty.19
[Lev
el I]
, 20
[Lev
el V
]
•Morph
ineshou
ldbeavoide
dinre
side
ntswith
severerena
lfailure(eGF
R<30
)due
toth
ebu
ildupofto
xic
met
abol
ites.
Fen
tany
l has
no
activ
e m
etab
olite
s of
rele
vanc
e an
d ha
s be
en id
entifi
ed a
s an
opi
oid
that
is le
ast
lik
ely
to c
ause
har
m in
resi
dent
s w
ith s
ever
e re
nal i
mpa
irmen
t whe
n us
ed a
ppro
pria
tely.
21 [L
evel
I]
•An
xietyisoften
associatedwith
sho
rtne
ssofb
reathan
dbe
nzod
iazepine
sareeffectiveinm
anag
ingthis
sy
mpt
om.25
(Lev
el V
), 29
[Lev
el II
]
•Excessiverespira
torysecretio
nscan
beverydistre
ssingforthe
reside
ntand
theirfam
ily.H
yoscine
butly
brom
ide
(Bus
copa
n) re
duce
s re
spira
tory
sec
retio
ns. I
t doe
s no
t cro
ss th
e bl
ood-
brai
n ba
rrie
r and
ther
efor
e
do
es n
ot c
ontr
ibut
e to
dro
wsi
ness
or d
eliri
um.30
[Lev
el II
]
Phar
mac
olog
ical
Man
agem
ent o
f Res
pira
tory
Dis
tres
s fo
r Res
iden
ts o
n th
e Re
side
ntia
l Age
d Ca
re E
nd o
f Life
Car
e Pa
thwa
y (R
AC E
oLCP
)Re
spira
tory
dis
tress
incl
udes
the
sym
ptom
s of
A. s
hort
ness
of b
reat
h (o
bser
ved
or re
port
ed),B.assoc
iatedan
xiety
and/
or C
. exc
essi
ve s
ecre
tions
If sy
mpt
om m
anag
emen
t rem
ains
inad
equa
te d
espi
te a
bove
inte
rven
tions
con
tact
MO/
NP o
r pal
liativ
e ca
re s
ervi
ce fo
r fur
ther
adv
ice
KEY:
bd
twic
e da
ily |
B/Tb
reak
thro
ugh
| C
SCI c
ontin
uous
sub
cuta
neou
s in
fusi
on |
MO
Med
ical
Offi
cer
| N
P Nu
rse
Prac
titio
ner
| P
RN a
s ne
eded
by
pred
eter
min
ed ti
me
| q
eve
ry |
Sub
cut s
ubcu
tane
ous
| t
ds th
ree
times
per
day
© S
tate
of Q
ueen
slan
d (Q
ueen
slan
d He
alth
) 201
3. D
evel
oped
by
Bris
bane
Sou
th P
allia
tive
Care
Col
labo
rativ
e (Q
ueen
slan
d He
alth
)
SYM
PTOM
S PR
ESEN
TSy
MPT
OMSAB
SENT
1.Write/requestorderfor
be
nzod
iaze
pine
to m
anag
e
rest
less
ness
and
agi
tatio
n.
Cons
ider
:
•Midazolam
2.5to5mgsubcut
PRN
q 2h
rly
OR
•Clonazepam
0.25to0.5mgoral
dr
ops
or s
ubcu
t PRN
q 4
hrly
2. A
dmin
iste
r PRN
ben
zodi
azep
ine
dose
3. A
sses
s ef
fect
iven
ess
of
ad
min
iste
red
med
icat
ion
and
cont
inue
adm
inis
terin
g
be
nzod
iaze
pine
s as
requ
ired
4. I
f sym
ptom
s pe
rsis
t con
side
r use
of a
ntip
sych
otic
med
icat
ion
1. Re
view
cur
rent
ben
zodi
azep
ine
dose
:•Ifresidentonlongterm
regularbenzodiazepineandunabletoswa
llow,
may
requ
ire c
onve
rsio
n to
CSC
I usi
ng s
yrin
ge d
river
ove
r 24
hour
s.
Cons
ider
:
-
Mid
azol
am -
usua
l com
men
cem
ent d
ose
5 to
10 m
g ov
er 2
4 ho
urs
but
m
ay n
eed
high
er d
ose
depe
ndin
g on
pre
viou
s 24
hou
r dos
e
OR
-
Clon
azep
am –
usu
al c
omm
ence
men
t dos
e 1 t
o 2
mg
over
24
hour
s bu
t
may
nee
d hi
gher
dos
e de
pend
ing
on p
revi
ous
24 h
our d
ose
•En
surewrittenorderforbenzodiazepinedosePRN
.Consider:subcut
m
idaz
olam
or o
ral o
r sub
cut c
lona
zepa
m•IfresidentonlyhasPR
Noralbenzodiazepinetabletorderconverttooral
drop
s or
sub
cut d
ose
Pre-
empt
ivel
y or
gani
se m
edic
atio
ns to
man
age
rest
less
ness
and
agi
tatio
n.
Requ
est M
O/NP
to re
view
cur
rent
dru
gs, b
oth
regu
lar a
nd P
RN o
rder
s
A.Anxiety/emotiona
ldistre
ss.Isaregu
laro
rPRN
ben
zodiazep
ineprescribed
fora
nyre
ason
?
1.Write/requestorderfor
benz
odia
zepi
ne to
man
age
rest
less
ness
and
agi
tatio
n.
Co
nsid
er:
•Midazolam
2.5to5mg
subc
ut P
RN q
2hr
ly
OR
•Clonazepam
0.25to0.5mg
oral
dro
ps o
r sub
cut P
RN q
4hr
ly
1. Re
view
cur
rent
ben
zodi
azep
ine
dose
:•Ifresidentonlongterm
regularbenzodiazepineandunabletoswa
llow,
requ
ires
conv
ersi
on to
CSC
I usi
ng s
yrin
ge d
river
ove
r 24
hour
s. C
onsi
der:
- M
idaz
olam
- us
ual c
omm
ence
men
t dos
e 5
to 10
mg
over
24
hour
s
but m
ay n
eed
high
er d
ose
depe
ndin
g on
pre
viou
s 24
hou
r dos
e
OR
-
Clon
azep
am –
usu
al c
omm
ence
men
t dos
e 1 t
o 2
mg
over
24
hour
s but
may
nee
d hi
gher
dos
e de
pend
ing
on p
revi
ous
24 h
our d
ose
•En
surewrittenorderforbenzodiazepinedosePRN
.Considersubcut
mid
azol
am o
r ora
l or s
ubcu
t clo
naze
pam
2. A
dmin
iste
r PRN
ben
zodi
azep
ine
dose
3. A
sses
s ef
fect
iven
ess
of a
dmin
iste
red
med
icat
ion
and
cont
inue
ad
min
iste
ring
benz
odia
zepi
nes
as re
quire
d4.
If s
ympt
oms
pers
ist c
onsi
der u
se o
f ant
ipsy
chot
ic m
edic
atio
n
Adm
inis
ter a
ppro
pria
te m
edic
atio
n as
cur
rent
ly c
harte
d fo
r res
tless
ness
and
agi
tatio
n.
Requ
est M
O/NP
to re
view
imm
edia
tely
cur
rent
dru
gs, b
oth
regu
lar a
nd P
RN o
rder
s
Ifgreatertha
n3do
sesofanyPRN
med
icationrequ
iredforB
/Tre
stlessne
ss/agitatio
nover24ho
ur
perio
d, re
ques
t MO/
NP re
view
to c
onsi
der c
hang
es to
med
icat
ion
and
syrin
ge d
river
ord
ers
YES
NO
1. Re
view
cur
rent
ant
ipsy
chot
ic d
ose
•Ifresidentonlongterm
antipsychoticandunabletoswa
llow,requires
co
nver
sion
to C
SCI u
sing
syr
inge
driv
er o
ver 2
4 ho
urs.
Con
side
r:
-
Halo
perid
ol a
t dos
e eq
uiva
lent
to p
revio
us a
ntip
sych
otic
dos
e ov
er 2
4 ho
urs
•En
surewrittenorderforantipsychoticdosePR
N.Consider:
- Ha
lope
ridol
0.5
to 1
mg
subc
ut P
RN u
p to
twic
e da
ily•IfresidentonlyhasaPR
Noralorw
aferantipsychoticconverttosubcutdose
1.Write/requestm
edication
orde
r for
:
•Ha
loperidol0.5to1mg
subc
ut u
p to
twic
e da
ily
to m
anag
e re
stle
ss a
nd
agita
tion
if it
aris
es
Even
if s
ympt
oms
abse
nt, c
ontin
ue to
revi
ew re
gula
rly fo
r res
tless
ness
and
agi
tatio
n.
If re
side
nt e
xper
ienc
ing
rest
less
ness
and
agi
tatio
n re
fer t
o th
e ‘S
ympt
oms
pres
ent’
colu
mn
B.Delirium
.Isan
antipsychotic(e.g.rispe
ridon
e)prescrib
edfo
ranyre
ason
?
1. Re
view
cur
rent
ant
ipsy
chot
ic d
ose:
•Ifresidentonlongterm
antipsychoticandunabletoswa
llow,requires
co
nver
sion
to C
SCI u
sing
syr
inge
driv
er o
ver 2
4 ho
urs.
Con
side
r:
-
Halo
perid
ol –
com
men
cem
ent d
ose
depe
nds
upon
pre
viou
s do
se a
nd
se
verit
y of
sym
ptom
s•Ifresidentonlyh
asaPRN
oralorw
aferantipsychoticconverttosu
bcutdose
2. A
dmin
iste
r PRN
ant
ipsy
chot
ic d
ose
3. A
sses
s ef
fect
iven
ess
of a
dmin
iste
red
med
icat
ion
and
cont
inue
adm
inis
terin
g
a
s re
quire
d4.
Obs
erve
for e
xtra
pyra
mid
al s
ide
effe
cts
1.Write/requestantipsychotic
or
der f
or p
ersi
sten
t res
tless
ness
and
agita
tion.
Con
side
r:
•Ha
loperidol0.5to1mgsubcut
PRN
q bd
2. A
sses
s ef
fect
iven
ess
of
m
edic
atio
n an
d co
ntin
ue
ad
min
iste
ring
antip
sych
otic
as re
quire
d3.
Obs
erve
for e
xtra
pyra
mid
al
si
de e
ffect
s
Revi
ew re
gula
rly fo
r sym
ptom
s of
rest
less
ness
and
agi
tatio
n (s
ee R
AC E
oLCP
, Com
fort
Car
e Ch
art,
page
5)
Flow
chart4
:Pha
rmac
olog
icalMan
agem
ento
fRestle
ssne
ssand
Agitatio
nforR
esiden
tsontheRe
side
ntialA
gedCa
reEnd
ofL
ifeCarePa
thwa
y(RAC
EoL
CP)
YES
NO
YES
NOYE
SNO
B.Delirium
.Isan
antipsychotic(e.g.rispe
ridon
e)prescrib
edfo
ranyre
ason
?
A.Anxiety/emotiona
ldistre
ss.Isare
gularo
rPRN
ben
zodiazep
ineprescribed
fora
nyre
ason
?
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents 19
Key
mes
sage
s•
TheRA
CEo
LCPisacon
sensus-based
bestp
racticegu
idetoproviding
care
for r
esid
ents
in th
e la
st d
ays
of li
fe.
•Pre-em
ptiveprescribingwillensurethatinth
elastdaysan
dho
ursoflife
th
ere
is n
o de
lay
in re
spon
ding
to a
sym
ptom
whe
n it
occu
rs.
•Re
stlessne
ssand
agitatio
natend
oflife
isdistre
ssingno
tonlyforthe
resi
dent
but
als
o fo
r the
fam
ily a
nd c
are
staf
f. If
the
cond
ition
is n
ot
w
ell m
anag
ed th
ere
is th
e po
tent
ial f
or fa
mili
es/s
taff
to re
tain
dis
tress
ing
mem
orie
s of
the
last
day
s of
a re
side
nt’s
life.
•Re
side
ntson
theRA
CEo
LCPrequ
ire2hou
rlysym
ptom
assessm
ent.
This
allo
ws
for e
mer
gent
sym
ptom
s to
be
dete
cted
qui
ckly
and
trea
ted
phar
mac
olog
ical
ly if
requ
ired.
Effi
cacy
of m
edic
atio
n ad
min
iste
red
shou
ld
be
eva
luat
ed a
nd d
ocum
ente
d.
•Alwaysconsidernon
-pha
rmacolog
icalinterven
tionsinadd
ition
toth
e
ph
arm
acol
ogic
al m
anag
emen
t of e
nd o
f life
(ter
min
al) s
ympt
oms.
For f
urth
er in
form
atio
nCa
reSe
arch
. RAC
Hub
ht
tp:/
/ww
w.ca
rese
arch
.com
.au/
care
sear
ch/t
abid
/231
7/De
faul
t.asp
x
Clin
ical
Pra
ctic
e Gu
idel
ines
for t
he M
anag
emen
t of D
eliri
um in
Old
er P
eopl
e (2
006)
, Mel
bour
ne: V
icto
rian
Gove
rnm
ent D
epar
tmen
t of H
uman
Ser
vice
s w
ww.
heal
th.g
ov.a
u/in
tern
et/m
ain/
.../D
eliri
um_C
PGfo
rMOD
IOP_
web
Com
mon
wea
lth o
f Aus
tral
ia (2
006)
Gui
delin
es fo
r a P
allia
tive
Appr
oach
in
Resi
dent
ial A
ged
Care
– E
nhan
ced
Vers
ion,
Can
berr
a.
Resi
dent
ial A
ged
Care
Pal
liativ
e Ap
proa
ch T
oolk
it: M
odul
e 3
– Cl
inic
al C
are
Sum
mar
y of
clin
ical
evi
denc
e•
Restlessne
ssand
agitatio
noccu
rcom
mon
lyate
ndoflife
and
can
often
beattributed
tom
ultip
lecau
ses.
In
vest
igat
ing
the
unde
rlyin
g ca
use
may
not
be
appr
opria
te in
the
last
day
s of
life
.10 (L
evel
V)
•Itisim
portan
ttoassessand
man
agefactorswhich
con
tributetore
stlessne
ssand
agitatio
nsuch
aspa
in,
ur
inar
y re
tent
ion,
rect
al im
pact
ion,
hyp
oxia
, env
ironm
enta
l fac
tors
, psy
chol
ogic
al a
nd s
pirit
ual d
istre
ss.10
(Lev
el V
)
•Non
-pha
rmacolog
icalinterven
tionshavebe
ensho
wntobeeffectiveinth
epreven
tionan
dman
agem
ento
f
delir
ium
. The
se in
clud
e a
peac
eful
, fam
iliar
env
ironm
ent,
the
pres
ence
of a
fam
iliar
per
son(
s), a
void
ance
of t
he
da
rk a
nd o
f brig
ht li
ghts
and
re-o
rient
atio
n of
the
resi
dent
.7 [L
evel
V],
31 [L
evel
I]
•Re
stlessne
ssand
agitatio
natend
oflife
can
becaused
byan
xietyan
ddistress.The
add
ition
ofa
lowdose
benz
odia
zepi
ne c
an b
e ef
fect
ive
in m
anag
ing
thes
e sy
mpt
oms.
32 (L
evel
I), 3
3 (L
evel
V)
•Lowdoseha
lope
ridoliseffectiveinm
anag
ingrestlessne
ssand
agitatio
nassociated
with
delirium
.34 (L
evel
I)
•Ex
trap
yram
idalsideeffects(dystoniaan
dakathisia)occurm
orecommon
lyindosesofh
alop
eridolabo
ve
4.
5 m
g pe
r day
.34 (L
evel
I)
Phar
mac
olog
ical
Man
agem
ent o
f Res
tless
ness
and
Agi
tatio
n fo
r Res
iden
ts o
n th
e Re
side
ntia
l Age
d Ca
re E
nd o
f Life
Car
e Pa
thwa
y (R
AC E
oLCP
)
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents20
References
1 Commonwealth of Australia (2012) Guiding Principles for Medication Management in Residential Aged Care Facilities, Canberra. 2 HansonLC,EckertJK,DobbsD,WilliamsCS,CaprioAJ,SloanePD&ZimmermanS(2008)Symptomexperienceofdyinglong-termcareresidents.JournaloftheAmericanGeriatricSociety,56(1),91-98.3CaprioAJ,HansonLC,MunnJC,WilliamsCS,DobbsD,SloanePD&ZimmermanS(2008)Pain,dyspnoeaandthequalityofdyinginlong-termcare.JournaloftheAmericanGeriatricSociety,56(4),683-688.4VandervoortA,VandenBlockL,vanderSteenJT,VolicerL,VanderSticheleR,HouttekierD,DeliensL(2013)NursingHomeResidents Dying with Dementia in Flanders, Belgium: A Nationwide Postmortem Study on Clinical Characteristics and Quality ofDying.JAMDA14485-492.5KonetzkaRT,SchlackWS,LimcangcoMR(2008)Reducinghospitalizationsfromlong-termcaresettings.MedicalCareResearch and Review. 65, 40-66.6ReymondL,IsraelF&CharlesM(2011)Aresidentialagedcareend-of-lifecarepathway(RACEoLCP)forAustralianagedcarefacilities. Australian Health Review, 35, 350-356. 7 Commonwealth of Australia (2006) Guidelines for a Palliative Approach in Residential Aged Care – Enhanced Version, Canberra8 Commonwealth of Australia (1999) National Medicines Policy 2000. Canberra. Viewed 7 Oct 2013 http://www.health.gov.au/internet/publications/publishing.nsf/Content/CA25774C001857CACA2574FC0079DC1A/$File/nmp2000.pdf9 CareSearch (2013) Symptom Management at the End of Life. Viewed 24 May 2013 http://www.caresearch.com.au/caresearch/tabid/741/Default.aspx10 Palliative Care Expert Group (2010) Therapeutic Guidelines: Palliative Care (Version 3), Melbourne: Therapeutic Guidelines Limited. 11 Commonwealth of Australia (2002) National Strategy for Quality Use of Medicines. Canberra12WACancerandPalliativeCareNetwork(2011)EvidenceBasedClinicalGuidelinesforAdultsintheTerminalPhase(2ndedition),Perth:WADepartmentofHealth.13GlareP,MillerJ,NikolovaT&TickooR(2011)Treatingnauseaandvomitinginpalliativecare:areview.ClinicalInterventionsinAging, 6, 243-259.14 HardyJ,DalyS,McQuadeB,AlbertsonM,Chimontsi-KyprioV,StathopoulosP&CurtinP(2002)Adouble-blind,randomised,parallel group, multinational, multicentre study comparing a single dose of ondansetron 24 mg p.o. with placebo and metoclopramide 10 mg t.d.s. p.o. in the treatment of opioid-induced nausea and emesis in cancer patients. Supportive Care in Cancer, 10(3), 231-236.15PorrecaF&OssipovM(2009)Nauseaandvomitingsideeffectswithopioidanalgesicsduringtreatmentofchronicpain:mechanisms, implications and management options. Pain Medicine, 10(4), 654-662. 16 CareSearch 2013. Antiemetics. Viewed 24 May 2013 http://www.caresearch.com.au/caresearch/tabid/305/Default.aspx17WonAB,LapaneKL,VallowS,ScheinJ,MorrisJN&LipsitzLA(2004)Persistentnon-malignantpainandanalgesicprescribingpatternsinelderlynursinghomeresidents.JournaloftheAmericanGeriatricSociety,52,867-74.18MercadanteS&AcuriE(2007)Pharmacologicalmanagementofcancerpainintheelderly.DrugsandAgeing,24,761-776.19PergolizziJetal(2008)Opioidsandthemanagementofchronicseverepainintheelderly:consensusstatementofaninternationalexpertpanelwithfocusonthesixclinicallymostoftenusedWorldHealthOrganizationstepIIIopioids(buprenorphone, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Practice, 8(4), 287-313.20ElliotRA(2006)Problemswithmedicationuseintheelderly:anAustralianperspective.JournalofPharmacyPracticeandResearch, 36, 58-66.21 KingS,HanksGW,FerroCJ&ChambersEJ(2011)Asystematicreviewofopioidmedicationforthosewithmoderatetosevere cancer pain and renal impairment: a European palliative care research collaborative opioid guidelines project. Palliative Medicine, 25, 525-552.22PortenoyRK,BennettDS,RauckR,SimonS,TaylorD,BrennanM&ShoemakerS(2006)Prevalenceandcharacteristicsofbreakthroughpaininopioid-treatedpatientswithchronicnoncancerpain.TheJournalofPain,7,583-591.
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents 21
23 Rossi S (ed) (2013) Australian Medicines Handbook 2013, Adelaide: Australian Medicines Handbook Pty Ltd.24AbrahmJ,SavareseD&PortenoyRK(2012)Painassessmentandmanagementinthelastweeksoflife.InDSBasow(ed),UpToDate, Massachusetts: UpToDate. 25 DudgeonD&ShaddJ(2012)Assessmentandmanagementofdyspnoeaatendoflife.InDSBasow(ed),UpToDate,Massachusetts: UpToDate. 26 Currow DC et al (2010) Do the trajectories of dyspnoea differ in prevalence and intensity by diagnosis at end of life? A consecutivecohortstudy.JournalofPainandSymptomManagement,39,680-90.27BoothS,AndersonH,SwannickM,WadedR,KiteeS&JohnsonM(2004)Theuseofoxygeninthepalliationofbreathlessness: a report of the expert working group of the scientific committee of the association of palliative medicine. Respiratory Medicine, 98, 66–77.28 JenningAL,DaviesAN,HigginsJP,Anzures-CabreraJ&BroadlyK(2001)Opioidsforpalliationofbreathlessnessinterminalillness. Cochrane Data Base Systematic Review (CD002066): www.cochrane.org/reviews/en/ab004769.html Accessed online: 16thJanuary2013.29 NaviganteAH,CerchiettiLC,CastroMA,LutteralMA&CabalarME(2006)Midazolamasanadjuncttherapytomorphineinthealleviationofseveredyspnoeaperceptioninpatientswithadvancedcancer.JournalofPainandSymptomManagement,31, 38-47.30 WildiersHetal(2009)Atropine,HyoscineButylbromide,orScopolamineareequallyeffectiveforthetreatmentofdeathrattleinterminalcare.JournalofPainandSymptomManagement,38,124-133.31TabetN&HowardR(2009)Non-pharmacologicalinterventionsinthepreventionofdelirium.AgeandAging,38,374-379.32KehlKA(2004)Treatmentofterminalrestlessness:areviewoftheevidence.JournalofPainandPalliativeCarePharmacotherapy, 18, 5-30.33BreuraE,BillingsJA,SavareseDM&DevR(2012)Palliativecare:overviewtomanagingcommonnon-painsymptoms.InDSBasow (ed), Up to Date, Massachusetts: Up to Date. 34LonerganE,BrittonAM,LuxenbergJ&WyllerT(2007)Antipsychoticsfordelirium.CochraneDataBaseofSystematicReviews(CD005594):www.cochrane.org/reviews/en/ab005594.htmlAccessedonline:16thJanuary2013.
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents22
Glossary
Analgesic: Drugs that provide symptomatic relief of pain but do not affect the underlying cause(s). Examples of analgesics include opioids, paracetamol and non-steroidal anti-inflammatory drugs.
Antiemetic: A drug used for preventing or alleviating nausea and vomiting.
Blood-brainbarrier:A network of blood vessels with closely spaced cells that make it difficult for potentially toxic substances to penetrate the blood vessel walls and enter the brain.
Breakthroughdose: Administration of an additional dose of opioid medication in response to pain that occurs between regular doses of an analgesic. This may be due to an increase in pain beyond the control of the baseline analgesia or it may reflect an occasional natural fluctuation in pain.
Consensus-based: An opinion or position reached by a group as a whole.
Delirium: A fluctuating state of confusion and rapid changes in brain function sometimes associated with hallucinations and restlessness. Symptoms may include inability to concentrate and disorganised thinking evidenced by rambling irrelevant and incoherent speech.
Dyspnoea: An awareness of uncomfortable breathing that can seriously affect quality of life.
Evidence-based practice: The integration of clinical expertise, patient values, and the best research evidence into the decision-making process for patient care.
Extrapyramidal side effects: Symptoms (including tremor, slurred speech, akathisia, dystonia, anxiety, distress, and paranoia) that are primarily associated with or are unusual reactions to neuroleptic (antipsychotic) medications.
Hypoxia: Inadequate oxygen supply to the cells and tissues of the body.
Imprest drugs/emergency stock of medicines: Restricted (Schedule 4) and controlled (Schedule 8) medications that are not supplied on prescription for a specific person but are instead obtained by an establishment (e.g. RACF) to be used as emergency stock.
Levels of evidence: A system to stratify evidence based on its quality.
Non-pharmacological interventions: Treatments that do not use drugs to alleviate symptoms. Examples include massage, music therapy and aromatherapy.
Opioid (or narcotic): A group of substances that resemble morphine in their physiological and/or pharmacological effects (especially in their pain-relieving properties).
Opioid naïve: Refers to an individual who has either never had an opioid or who has not received repeated opioid dosing for a two to three week period.
Opioid rotation: Switching one opioid for another. This is required for patients with inadequate pain relief and/or intolerable opioid-related toxicities or adverse effects.
Opioid titration: Increasing or decreasing the dosage of an opioid. This requires regular assessment of the patient’s pain and monitoring for possible side effects.
Pharmacological interventions: Treatments that involve the administration of drugs to alleviate symptoms.
Randomised control trial: Trial conducted using participants selected in such a way as all known selective biasing factors have been eliminated. The trial involves the comparison of an experimental group with another group of participants, equal in all respects, who do not undergo the treatment being trialled.
Substitute decision maker: As people become less able to manage their affairs they may appoint a Power of Attorney or an Enduring Power of Attorney to assist them in future planning or decision-making.
Terminal restlessness: A common symptom appearing in the last hours to days of life. The person may show symptoms of being unable to relax, picking at clothing or sheets, confusion and agitation, and trying to climb out of bed.
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents 23
Appendix A: Opioid Conversion Chart
• Theseconversionsareaguideonly.ResidentsinRACFsmayvaryintheirresponsetodifferentopioids.
• Whenrotatingopioidsforintolerablesideeffects,inadequateanalgesiaortochangethedeliveryroute,itisadvisabletoreducethedose by25-50%duetoincompletecross-tolerance.
• Dosereductionisparticularlyimportantwherepainescalationisnot the reason for rotation to a different opioid.
• Followingopioidrotation,closeassessmentoftheresidentisrequiredtoensurethedrug,thedoseandthedeliverymethodaretolerated and effective.
• Conversionsinvolvingmethadonearecomplicatedandprescribingshouldberestrictedtomedicalspecialistswithexperiencein methadone prescribing.
References:PalliativeCareExpertGroup(2010)TherapeuticGuidelines:PalliativeCare(Version3),Melbourne:TherapeuticGuidelinesLimited.
PergolizziJetal(2008)Opioidsandthemanagementofchronicseverepainintheelderly:consensusstatementofaninternationalexpertpanelwithfocusonthesixclinicallymostoftenusedWorldHealthOrganizationstepIIIopioids(buprenorphine,fentanyl,hydromorphone,methadone,morphine,oxycodone).PainPractice,8(4),287-313.
Oral Morphine to Other Oral Analgesics
Oral to Oral Conversion ratio
Example
morphine to codeine 1 : 8 oral morphine 7.5 mg ≈ codeine 60 mg
morphinetohydromorphone(DilaudidIR&JurnistaCR) 5 : 1 oral morphine 5 mg ≈ oral hydromorphone 1 mg
morphinetooxycodone(EndoneIR/OxynormIR&Oxycontin CR)
1.5 : 1 oral morphine 15 mg ≈ oral oxycodone 10 mg
morphine to oxycodone – naloxone (Targin CR) 1.5 : 1 oral morphine 15 mg ≈ oral oxycodone 10 mg naloxone 5 mg
morphine to tramadol* 1 : 5 oral morphine 10 mg ≈ oral tramadol 50 mg
CR = Controlled Release IR = Immediate Release
Oral Opioid to Parenteral Opioid (Subcut) – same drug to same drug
Oral to Oral Parenteral Conversion ratio
Example
hydromorphone hydromorphone 3 : 1 oral hydromorphone 60 mg ≈ subcutaneous hydromorphone 20 mg
morphine morphine 3 : 1 oral morphine 30 mg ≈ subcutaneous morphine 10 mg
Parenteral (Subcut) Morphine to Other Parenteral (Subcut) Opioid
From subcutaneous
To subcutaneous Conversion ratio
Example
morphine fentanyl 100-150 : 1 morphine 10 mg ≈ fentanyl 150 mcg
morphine hyrdromorphone 5 : 1 morphine 10 mg ≈ hydromorphone 2 mg
morphine tramadol* 1 : 10 morphine 10 mg ≈ tramadol 100 mg
TransdermalBuprenorphinetoOralMorphine
Buprenorphinepatchstrength Daily oral morphine dose Breakthroughoralmorphinedose5 micrograms per hour 12 mg daily 1 to 2 mg 2hrly PRN
10 micrograms per hour 24 mg daily 2 to 4 mg 2hrly PRN
Transdermal Fentanyl to Oral Morphine
Fentanyl patch strength Daily oral morphine dose Breakthroughoralmorphinedose12 micrograms per hour 30 to 60 mg 2 to 4 mg 2hrly PRN
25 micrograms per hour 60 to 100 mg 5 to 10 mg 2hrly PRN
50 micrograms per hour 120 to 200 mg 10 to 20 mg 2hrly PRN
* Tramadol has a limited role in managing moderate to severe pain in palliative care.
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents24
AppendixB:AdditionalResources
CareSearch (2013) Symptom Management at the End of Life http://www.caresearch.com.au/caresearch/tabid/741/Default.aspx
Commonwealth of Australia (2012) Guiding Principles for Medication Management in Residential Aged Care Facilities, Canberra http://www.health.gov.au/internet/main/publishing.nsf/content/nmp-pdf-resguide-cnt.htm
National Prescribing Service (NPS) http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-prescribers-nps.htm
Medicine enquiries Medicines Line (for expert medicines information for the cost of a local call): 1300 MEDICINE (1300 633 424), Monday to Friday 9am–5pm AEST
Adverse Medicine Events (AME) Line Report a problem or side effect with your medicine for the cost of a local call: 1300 134 237, Monday to Friday 9am–5pm AEST
PharmaceuticalBenefitsScheme http://www.pbs.gov.au/pbs/home
PalliativeCareExpertGroup(2010)TherapeuticGuidelines:PalliativeCare(Version3),Melbourne:TherapeuticGuidelinesLimited http://www.tg.org.au/index.php?sectionid=47
Therapeutic Goods Administration The Therapeutic Goods Administration encourages reporting of all suspected adverse reactions to prescription, over-the-counter and complementary medicines. Information on reporting adverse drug reactions is available online at http://www.tga.gov.au/safety/problem-medicines-forms-bluecard.htm or telephone: 1800 044 114.
About the Residential Aged Care Palliative Approach Toolkit
The Residential Aged Care Palliative Approach Toolkit (PA Toolkit) includes a set of resources which, when used in combination, are designed to assist residential aged care providers to implement a comprehensive and evidence-based approach to care for residents.
The PA Toolkit includes the following resources:
• Module1:IntegratingaPalliativeApproach
• Module2:KeyProcesses
- Advance Care Planning
- Palliative Care Case Conferencing
- End of Life Care Pathway
• Module3:ClinicalCare
- Pain
- Dyspnoea
- Nutrition and Hydration
- Oral Care
- Delirium
• 3Self-DirectedLearningPackages(NurseIntroduction,NurseAdvance,Careworker)
• WorkplaceImplementationGuide:SupportforManagers,LinkNursesandPalliativeApproachWorkingParties
• TrainingSupportGuide:HowtoDevelopaStaffEducationandTrainingStrategytoHelpImplementaPalliative Approach in Residential Aged Care
• GuidetothePharmacologicalManagementofEndofLife(Terminal)SymptomsinResidentialAgedCareResidents
• 3EducationalDVDs:
- Suiting the Needs: A Palliative Approach in Residential Aged Care
- All on the Same Page: Palliative Care Case Conferences in Residential Aged Care
- How to Use the Residential Aged Care End of Life Care Pathway (RAC EoLCP)
• 2EducationalFlipchartSets:
- Introduction to a Palliative Approach
- Clinical Care Domains
• BereavementSupportBookletforResidentialAgedCareStaff
• TherapeuticGuidelines:PalliativeCare,Version3,2010
• UnderstandingtheDyingProcessbrochure
• NowWhat?UnderstandingGriefPalliativeCareAustraliabrochure
• InvitationandFamilyQuestionnaire-PalliativeCareCaseConferences
• GuidelinesforaPalliativeApproachinResidentialAgedCareorderform
For further information and to download PA Toolkit resources visit: www.caresearch.com.au/PAToolkit
Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care ResidentsA