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Adult Palliative Care
Nurse Practitioner
Scope of Practice
For the management of adult palliative care patients registered with Southern Adelaide
Palliative Services
May 2012
Version 1.0 November 2006
Version 2.0 November 2010
Version 3.0 May 2012
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Table of Contents
Section Content Page
Number
1. Description of Health Service 3
2. Disclaimer 4
3. Plan for Dissemination, Implementation, Review and Evaluation of Health Management Protocol
4
4. Scope of Practice Statement 4
5. The Role of the Palliative Care Nurse Practitioner 5
6. Follow up, Monitoring and Evaluation 6
7. Referral 7
8. Expected Health Outcome 8
9. Drug Therapy Protocol 8
10. Auditing Nurse Practitioner Clinical Practice 19
11. References 20
12.
Appendices: 21
Appendix A *separate attachment
Opioid Equi-Analgesic Dose Guide
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1. Description of Health Service
Southern Adelaide Palliative Services (SAPS) is a specialist palliative care service operating across the Southern Adelaide Metropolitan area with partnering responsibilities with the South East Region of South Australia, the South Coast, Naracoorte and Kangaroo Island. The target population for the delivery of care by SAPS are people who have a life limiting illness, their primary carer and their family who have complex needs. The service is interdisciplinary and includes specialist palliative care doctors, registered nurses, allied health professionals and volunteers. SAPS has seven main areas of care activity: � Hospital consultancy services are provided to Flinders Medical Centre (FMC), Repatriation
General Hospital (RGH) and Noarlunga Health Service (NHS) and Private Hospitals in the Southern Adelaide region on request
� Outpatient Clinics, which operate at Flinders Cancer Clinic, Repatriation General Hospital and Noarlunga Health Service
� Consultative community palliative care services that operate in collaboration with General Practitioners (GP’s), Royal District Nursing Service (RDNS), Domiciliary Care (Dom Care) and other community support services. This is provided to patients and their families at their place of residence including Residential Aged Care Facilities
� A 15 bed palliative care inpatient unit located at Repatriation General Hospital – Daw House Hospice
� A 24 hour on-call consultancy service for Health Professionals/Service Providers and Patients/Families registered with the service
� Medical Specialist Outreach and Nursing Mentoring to the rural and peri-urban partners � Psychosocial, Volunteer, Bereavement, Pastoral Care and Complementary Therapy Services The Palliative Care Nurse Practitioner (PCNP) role was established at Southern Adelaide Palliative
Services (SAPS) in 2006. This was the first Palliative Care Nurse Practitioner role in Australia. The
purpose of the role was to address the identified gap in meeting the needs of patients and families
with highly complex needs:
• 30-40 families each year identified by SAPS whose needs were not adequately addressed
• 82 referrals in 2002 were under the age of 50
• These were deemed to be resource intensive
• They utilised Multiple Service Providers
• There were often complex psychosocial/psychological issues
• Primary service providers often had limited specialist palliative care skills
• There was a limited availability of institution based resources
As a result, specific triage criteria were identified. Patient’s need to meet 2 of the following criteria to
be referred to the Nurse Practitioner:
• Chronic complex mental health history - Patients who have a long term mental health history
who require ongoing assessment and treatment.
• Multiple service providers - Patients who have more than 3 community service providers (GP, RDNS, Dom Care etc).
• Complex symptom issues - Patients who have significant, complex symptoms (physical or psychological), that require advanced skills to assess and manage.
• Family dysfunction - Families who have demonstrated difficulty coming to terms with the diagnosis/prognosis of the patient and where there is significant ongoing conflict
• Complex individual caregiver issues - Carers who have significant ongoing personal (physical or psychological) and who demonstrate difficulties adapting to the role of carer.
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The PCNP case manages 15-20 clients in the community and also conducts Outpatient Clinics at GP
Plus Centres, seeing new patients referred to the service. On alternate Thursday afternoons the
PCNP coordinates and conducts clinics for people with Motor Neurone Disease. Apart from the
clinical role, the PCNP also participates in the provision of education, research and other projects and
representation on committees at a State and National level.
Following receiving a referral, the PCNP will carry out a comprehensive health assessment and identify any issues of concern. The NP will devise a management plan which may include ordering pathology and other investigations required for diagnostic purposes as well as initiating medication and other strategies for pain and symptom management. Formulation and implementation of the management plan occurs in collaboration with the patient, their family, the Palliative Medicine Consultant or Palliative Medicine Advanced Trainees, their General Medical Practitioner (GP) and other Health Professionals/Service Providers as required.
2. Disclaimer This document has been established to provide a frame work for the clinical practice of the Palliative Care Nurse Practitioner. This document should not be considered exhaustive or be used in exclusion of other relevant references, policies and clinical guidelines. It does not replace the need for professional and clinical judgement according to specific clinical requirements that may or may not be included in the document.
3. Plan for Dissemination, Implementation, Review and Evaluation of Scope of Practice
• The approved Palliative Care Nurse Practitioner Scope of Practice will be held in a repository
by the Director of Nursing Rehabilitation, Aged Care & Allied Health Division.
• This scope of practice will be reviewed and evaluated on a regular basis by the SAPS
interdisciplinary team to ensure that it meets the needs of the patients and the appointed
nurse practitioner
• Interim updates are required annually (or earlier if there is a population change or change in practice) to ensure they remain current with best practice.
4. Scope of Practice Statement The NP is responsible and accountable for making professional judgements about when the patient’s condition is beyond their scope of practice and for initiating consultation with a medical officer or other members of the health care team. All management initiated under this scope of practice will be in accord with the recommendations published in the Therapeutic Guidelines - Palliative Care, version 3, 2010 and the Australian Medicines Handbook (AMH) - except where specified in other resources and will be adapted to be in line with local practices and conditions.
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5. The Role of the Palliative Care Nurse Practitioner
Includes the following: 5.1 Clinical Assessment
The clinical assessment will include a thorough review of the patient’s health history as well as a
physical and psychosocial assessment tailored to the individuals need.
Investigations (may be initiated by NP within scope of practice or referred to treating Doctor/General
Practitioner (GP).
Pathology
MBA 20
Electrolytes and urea UEC
Liver function tests LFT’s
Thyroid function tests TFT’s
Serum calcium Ca++
Serum Glucose Glu
C-reactive protein CRP
Full Blood Examination FBE
Group and Save G&S
Group and X-Match GXM
Coagulation studies Coags
Monitoring of anti-epileptics
Serum phenytoin
Serum carbamazepine
Arterial Blood Gas ABG
Microbiology
Microscopy, culture and sensitivity (MC&S)
Urine
Sputum
Wound swab
Stool
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Radiology
Plain chest xray CXR
Plain abdominal xray AXR
Plain xray of limbs
Ultrasound Legs
Ulltrasound Abdomen and Pelvis
Other
Pulmonary Function Tests PFT’s
5.2 Palliative Care Treatment Plan
Non-pharmacological Management
� Counselling, psychosocial and family support
� Non drug symptom management strategies (e.g. in pain, dyspnoea, anxiety etc)
� End-of-life care planning including advanced health directives
� Co-ordination and provision of carer support
Pharmacological Management for symptoms experienced by patients who are in the palliative phase of an illness (may be initiated by NP within scope of practice or referred to GP or another Medical Consultant).
These symptoms include:
� Pain
� Constipation
� Nausea and vomiting
� Dyspnoea
� Delirium
� Fungal Infections
� Panic/Anxiety
� Seizures
� Sleep Disturbance
5.3 Patient and Family Support
� Facilitating / participating in case conferences as well as providing information and support to patients and families to assist in their decision making regarding their options for treatment and care.
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5.4 Management of Care in the Last Days of Life
• Review of medication requirements / converting oral opioids to subcutaneous opioids /writing
up subcutaneous medication orders / commencing a syringe driver if necessary (Refer
Appendix A – separate attachment)
� Provision of information and support to families who are coping with the loss of a close family
member.
5.5 Education / Mentoring / Research
� Provision of palliative care education as required
� Active involvement in initiating research and projects aimed at improving care � Mentoring of Nurse Practitioner Candidates as required
6. Follow-up, Monitoring and Evaluation
� The NP will consult with the appropriate Health Professionals/Service Providers at completion
of the initial assessment to discuss findings as well as care / treatment options as required
� A detailed letter and treatment recommendations is sent to the GP and other Health
Professionals/Service Providers involved in the care of the patient after each Outpatient
Consultation and as required
� The NP will continue to monitor and evaluate the patient’s response to therapeutic
interventions, particularly medications. This is achieved by face-to-face contact with the
patient/family or via telephone contact to the patient/family or other Health
Professionals/Service Providers.
7. Referral
The PCNP will work in a collaborative arrangement with General Practitioners, Palliative Medicine Consultants, Palliative Medicine Advance Trainees and Medical Consultants from other specialties. Referrals will be initiated by the PCNP to other Health Professionals/Service Providers, including Medical Consultants as required.
7.1 Referral to Acute Services or Palliative Medicine Consultant (Where specialist medical intervention may be required to treat /manage the cause. Consideration will be given to the appropriateness of further investigation / treatment depending on the clinical context and patient and family wishes.)
� Suspicion of spinal cord compression
� Severe agitated delirium
� Seizures
� Unexplained or uncontrolled pain
� Acute deterioration in respiratory status
� Uncontrolled nausea and vomiting
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� Cardiac Failure
� Urinary retention
� Abdominal distension requiring assessment
� Fracture
� Hypercalcaemia
� Chronic Obstructive Pulmonary Disease – infective exacerbation
� Adverse drug reactions
� New issues requiring timely investigation
7.2 Referral to GP
� Exacerbation of chronic disease outside the scope of practice of the nurse practitioner
7.3 Other Referrals
� Pharmacist
� Medical Specialists
� Allied Health Practitioners � Volunteers � Complimentary Therapy � Network Facilitator � Bereavement Services � Mental Health Services � Aged Care Services � Disability Services � Disease Specific Services ie. MND Association, Heart Failure Nurses, Respiratory Nurses � Hospital Avoidance Programmes
Currently in Australia Nurse Practitioners only have access to a Medicare provider number if they are working in private practice Consequently, until this situation changes, a referral from a nurse practitioner may cause financial disadvantage for the patient. To ensure the patients are not financially disadvantaged, all private referrals from the PCNP will be completed in collaboration with the patient’s GP or a senior medical officer with a provider number.
8. Expected Health Outcome
� Optimal symptom control in the context of patient and family goals of care in the appropriate care setting.
9. Drug Therapy Protocol
9.1 Nurse Practitioner prescribing of medication
The GP and the Palliative Medicine Consultant are the lead clinicians for the co-ordination of the
patient’s care and thus any new medications, titration of medication and recommended discontinuing
of medication must be communicated to him / her. In most situations the GP will then provide
subsequent scripts and medication orders for the patient. The PCNP is required to document any
medication changes on the appropriate forms.
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A patient who is on opioids to manage pain may experience a severe exacerbation of pain requiring
titration of the opioid medication. The PCNP after assessing the patient’s symptoms and calculating
the required increase can increase the opioid dose and inform the GP of the change(s) in
medication(s).
The PCNP will have a Prescriber Number allocated by Medicare Australia, which enables
medications to be prescribed in accordance with the current Department of Health and Ageing (SA)
Policy in relation to Nurse Practitioner Prescribing.
Choice of drug therapy is guided by the Therapeutic Guidelines – Palliative Care version 3 (2010) and
the Australian Medicines Handbook within the parameters of the Controlled Substances Act of South
Australia (1984).
The PCNP must verify that the choice of drug is suitable for the patient after carefully considering the
following individualised patient information, such as:
1. Age
2. Previous allergies
3. Adverse drug reactions
4. Co-morbidities such as renal and hepatic dysfunctions
5. Concomitant medication for potential drug interaction.
All care will be taken by the PCNP when selecting drug treatment to avoid adverse medication
events.
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9.2 Algorithm for PCNP pharmacological management of chronic non- malignant pain for patients requiring a palliative approach.
Abbreviations I.R - immediate release C.R - controlled release S.R – sustained release PPI - proton pump inhibitor B/T - breakthrough NSAID – non-steroidal anti-inflammatory drug
Partial or ineffective treatment response
Mild to moderate pain – assess for location, nature, severity of pain.
Consider non- pharmacological management eg. massage therapy, heat
packs, psychological intervention, referral to physiotherapist and
diversional therapist
Avoid NSAIDs in cardiac
disease, moderate to
severe renal failure,
history of peptic ulcer.
Mild to moderate pain – commence
paracetamol (do not exceed 4 gm / 24
hours). Consider non-selective NSAID
– may need to add PPI.
Assess efficacy of
analgesia and monitor
for side effects.
If neuropathic component to
pain add tricyclics
antidepressant (amitriptyline)
or anticonvulsant (sodium
valproate)
Add low dose prn opioid eg. I.R
oxycodone 2.5 - 5 mg or morphine
hydrochloride 2.5 - 5 mg 3rd hourly prn
for B/T pain or incident pain
Assess for efficacy of
medication. Monitor for side
effects / adverse reactions.
Commence concurrent prn
antiemetic and prn aperients.
Add C.R or S.R opioid – oxycontin or ms contin or kapanol or buprenorphine patch or fentanyl patch. Dose will depend on pain assessment and number of B/T opioid doses required over previous 24 – 48 hrs. If severe dysphagia or if malabsorption by oral route is suspected, then subcutaneous route should be used. Dose should be
1/3 of oral equivalent.
Assess for efficacy of
medication. Monitor for
side effects / adverse
reactions. Continue prn
antiemetic and prn
aperients
Consult with Palliative Medicine Consultant/GP
Pain persists
Partially effective / pain increases
Partially effective / pain increases
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9.3 Algorithm for NP pharmacological management of pain in advanced malignant disease
Partial or ineffective treatment response
Mild to moderate pain – assess for location, nature, severity of pain.
Consider non- pharmacological management eg. massage therapy, heat
packs, psychological intervention, referral to physiotherapist and
diversional therapy
Avoid NSAIDs in cardiac
disease, moderate to
severe renal failure,
history of peptic ulcer.
Mild to moderate pain – commence
paracetamol (do not exceed 4 gm / 24
hours). Consider non-selective NSAID
– may need to add PPI.
Assess efficacy of
analgesia and monitor
for side effects.
If neuropathic component to
pain add tricyclic
antidepressant (amitriptyline)
or anticonvulsant (sodium
valproate)
Add low dose prn opioid eg. I.R
oxycodone 2.5 - 5 mg or morphine
hydrochloride 2.5 - 5 mg 2nd hourly
prn for B/T pain or incident pain
Assess for efficacy of
medication. Monitor for side
effects / adverse reactions.
Commence concurrent prn
antiemetic and prn aperients.
Add C.R or S.R opioid – oxycontin or
ms contin or kapanol or fentanyl
patch. Dose will depend on pain
assessment and number of B/T opioid
doses required over previous 24 – 48
hrs.
Assess for efficacy of
medication. Monitor for
side effects / adverse
reactions. Continue prn
antiemetic and prn
aperients
Refer to Palliative Medicine Consultant / GP.
Abbreviations I.R - immediate release C.R - controlled release S.R – sustained release PPI - proton pump inhibitor B/T - breakthrough NSAID – non-steroidal anti-inflammatory drug
Pain persists
Partially effective / pain increases
Partially effective / pain increases
Consult with Palliative Medicine Consultant and/or GP. Titrate opioids based on assessment and prn B/T requirements Commence / continue neuropathic agent if neuropathic component to pain If severe dysphagia or if malabsorption by oral route is suspected, then
subcutaneous route should be used. Dose should be 1/3 of oral equivalent.
Partial or ineffective treatment response
Assess for efficacy of
medication. Monitor for
side effects / adverse
reactions. Continue prn
antiemetic and prn
aperients
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9.4 Preferred Prescribing List for Palliative Care Nurse Practitioner –
Choice of drug therapy and recommended doses guided by Therapeutic
Guidelines. Palliative Care. 2010
Paracetamol
Ibuprofen
Diclofenec
Naproxen
Dexamethasone
Morphine
Oxycodone
Fentanyl
Hydromorphone
Buprenorphine
Amitryptilline
Gabapentin
Metaclopramide
Haloperidol
Stemetil
Domperidone
Macrogol
Docusate with Senna
Omeprazole
Oxygen
Clonazepam
Nystatin
Amphotericin
Fluconazole
Carmellose Sodium
Hyoscine Hydrobromide
Oxazepam
Temazepam
Glycopyrolate
Midazolam
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9.5 Medically assisted hydration in the palliative context
Indications for administering subcutaneous fluid include
� Patient who is clinically dehydrated and it is expected that comfort will be improved by
hydration
� In the terminal phase of a palliative illness where families are having difficulty coming
to terms with the patient being no longer able to take food or fluids by natural means
Treatment
Normal saline can be administered at 1 litre over 24 hours. Fluids should be discontinued if no
improvement after 3 days.
Contraindications for medically assisted hydration in the palliative context
Subcutaneous fluids should not be administered when fluids need to be administered rapidly and in large amounts e.g. shock, severe dehydration, or when the patient is at high risk of developing pulmonary congestion or oedema, or with clotting disorders.
9.6 Blood Transfusions
The PCNP is able to request group and match and write written orders for Blood Transfusions when
required by patients managed under the Palliative Care Service and approved by a Doctor. The
transfusion will either be administered as a day patient in a Public Hospital where the patient is
admitted under a Palliative Medicine Consultant or in the patients own home under the care of
Hospital Avoidance Providers.
9.7 Replacement of Gastrostomy Tubes
The PCNP is permitted to change Balloon Gastrostomy Tubes for patients who have had their initial
tube replaced in a hospital setting. Training to perform this procedure has been provided by the
Gastroenterology Nurse at RGH.
9.8 Verification of Death
The PCNP may verify an expected death of a palliative care patient in the absence of a doctor. The
PCNP must notify the doctor nominated to complete the death certification as soon as possible after
the death has occurred. The PCNP should not verify the death in situations where the death is
suspicious and/or a report to the Coroner is required.
10. Auditing Nurse Practitioner Clinical Practice
� Weekly case conference meeting with the palliative care interdisciplinary team. The NP
presents a case / cases and discusses and seeks input and advice from the team into the
treatment plan.
� Clinical Support available from a Palliative Medicine Consultant or Advanced Trainee either in
person or via phone at all times.
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� Annual Performance Development Review and Plan to be conducted with the Director of
SAPS and the Director of Nursing Rehabilitation, Aged Care & Allied Health Division.
� PCNP participation in the fortnightly Radiology Review Meetings when possible
� Collaboration and Consultation with Palliative Care Advanced Practice Pharmacist on a
regular basis
Endorsements:
Karen Glaetzer Palliative Care Nurse Practitioner Southern Adelaide Palliative Services Justin Prendergast Director of Nursing Rehabilitation, Aged Care & Allied Health Division Repatriation General Hospital Kate Swetenham Service Director Southern Adelaide Palliative Services Dr Michael Briffa Palliative Medicine Consultant Medical Lead Southern Adelaide Palliative Services
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11. References
1. Therapeutic Clinical Guidelines. Palliative Care. Version 3, 2010
2. Primary and Clinical Care Manual (PCCM) Qld Health 2007
3. Health Management Protocol – Community Palliative Care Nurse Practitioner - For the management of palliative care patients in the adult population – Brisbane, Queensland
4. Health Management Protocol –Palliative Care Nurse Practitioner - For the management of palliative care patients living in Residential Aged Care Facilities in Metro South Health Service District – Brisbane, Queensland
5. Australian Medicines Handbook 2010
6. Eastern Metropolitan Palliative Care Consortium (Victoria), Clinical Working Party. Opioid Conversion Ratios - Guide to Practice, July 2008 (Appendix A – separate attachment)
7. Guidelines for the Handling of Medication in Community-Based Palliative Care Services (Appendix B – separate attachment)
8. MIMs electronic and hardcopy
9. Clinicians Knowledge Network – QHEPs intranet
10. Guidelines for Palliative Approach in Aged Care
11. Pain Management in Residential Aged Care Facilities
12. Palliative Care Australia Standards
13. CareSearch www.caresearch.com.au
14. Cochrane Data Base
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12. Appendices
Appendix A
Opioid Equi-Analgesic Dose Guide
Approximately equianalgesic doses of various opioids (Table 1.4) [NB1]
Opioid Oral Parenteral (SC/IV)
morphine 30 mg 10 mg
codeine 240 mg –
fentanyl [NB3] – 100 micrograms
hydromorphone 6mg 2 mg
methadone [NB4] [NB4]
oxycodone 20 mg 10 mg
tramadol [NB5] 150 mg 100 mg
NB1: These are average equivalent doses because of pharmacokinetic variation
between individuals. When changing from one opioid to another, commence with
one-third to one-half of the calculated equianalgesic dose and then titrate to
response.
NB2: See Table 1.6 for other routes of morphine administration.
NB3: For conversion of morphine to transdermal fentanyl patches, see fentanyl
product information.
NB4: Consultation with a pain clinic or a palliative care service is advised.
NB5: Tramadol may not be suitable for patients with moderate to severe pain.
Therapeutic Guidelines Version 3 2010