Many drugs used in Palliative Care are used outside of the Product Licence or recommendations of the Datasheets. There is wide experience of their use in Palliative Care however, the responsibility for prescribing is taken by the Doctor. Practitioners should be aware when using drugs in a manner which falls outside of the product licence specification and should be able to support their actions eg with literature references. Further advice can be obtained from your local Hospital Drug Information Service. All drugs included in the factsheets have been agreed for use in Palliative Care by the CHHA Palliative Care Group.
We have endeavoured to ensure that the information and drug doseages included in the Factsheets are accurate, but cannot accept responsibility for any errors or omissions, which may have occurred. When in doubt, information should be checked against published literature or other specialist sources.
To keep the guidance succinct individual references have not been included, however a major source of reference is:
'Palliative Care Formulary', Fourth Edition (PCF4)
Editors: Robert Twycross, Andrew Wilcock
For syringe driver information, the recommended resource is:
'The syringe driver: continuous subcutaneous infusions in palliative care'
Editors: Dickman, A; Schneider, J.
Oxford University Press
Useful website information can be obtained at:
Other relevant resources are noted within the Factsheets.
It has been decided by the Cambridgeshire Clinical Guidelines Group to adopt the free guidelines available at http://book.pallcare.info which are both peer reviewed and regularly updated.
Click a title below to view more information about the chosen factsheet and to download...
This factsheet applies to the use of McKinley T34 syringe drivers. To download this factsheet, please click on the blue text below.
FACTSHEET_01_-_for_review_March_2017 (372 KB) 24/03/2015 17:41
Where patients are able to take regular oral opioid medication, and there is thought to be no problem with absorption, there is no theoretical benefit (ie no greater potency or efficacy) in administering opioids parenterally.
Factsheet 3 - for review July 2017
Factsheet 4 - for review July 2017
Transdermal administration is an alternative (not necessarily 'better') method of drug administration. After application of a 'patch' there is a delay of many hours before therapeutic levels of the drug are achieved. Similiarly, after removing a patch, there is a delay of many hours before circulating levels of drug drop to sub-therapeutic level.ie. there is a SLOW ONSET and SLOW OFFSET of analgesia and there is a SLOW ONSET and SLOW OFFSET of side effects. Consider using patches only when:
- non-opioid and weak opioids have proved ineffective
- pain is stable therefore analgesic requirement is stable
- opioid requirement has been determined by previous titration with Morphine (oral or parenteral).
Factsheet 5 - for review July 2017
- Many patients will have more than one type of pain - each pain should be assessed seperately
- Active involvement of both patient and family in treatment decisions will improve pain management
- A multidisciplinary approach has been shown to provide better symptom control for patients with advanced disease.
This factsheet should be used in addition with Factsheet 6. The topics covered are:
- Non-steroidal anti-inflammatory drugs (NSAIDS)
- Anti Convulsants Tricyclic Anti-depressants
- Incident Pain
- Additional pharmacological measures
- Anxiety and depression
- Specific Treatments:
- Specific Neural Blockade
- Transcutaneous Nerve Stimulation (TENS)
- Psychosocial Interventions
- Support for carers
Confusion is a state in which there is cognitive impairment - leading to disturbance of comprehension and poor concentration. Characteristically onset is acute (unlike dementia). The course may be fluctuant, with diurnal variation, and the patient may retain insight. Where a cause or factor can be identified and treated, the confusion may be partially or fully reversible, but may recur.
The factsheet goes on to explain the possible causes of confusion and the treatments that can be used.
Factsheet 8 - for review October 2015
This factsheet does not include obstruction - you should refer to Factsheet 11 for this.
Any advancing disease may be accompanied by nausea and vomiting. Often metabolic disturbance (electrolyte imbalance/organ failure) will cause nausea - the resultant anorexia and poor intake can cause dehydration and result in increased nausea, sometimes accompanied by vomiting.
Nausea and vomiting are frequent symptoms in patients with cancer. In the earlier stages of disease, this is often related to chemotherapy and/or radiotherapy; it is well documented that the anxiety patients experience at this stage can lead to anticipatory nausea and vomiting while waiting for treatment. This anxiety may well recur if, at a later stage, a patient experiences nausea/vomiting due to other causes.
The factsheet goes on to recommend assessment methods and possible treatments.
Obstruction occurs when there is occlusion of the bowel, due to either extrinsic or intrinsic cause, which prevents or delays the contents from passing through.
The factsheet guides you through causes, assessment, examination, management, treatment and re-assessment.
Constipation can be defined as the infrequent passage of hard stool, often accompanied by straining and tenesmoid pain.
In the Palliative Care setting, reports of distress due to constipation exceed those for pain. Fifty percent of patients admitted to UK hospice beds are constipated. It is necessary to prescribe prophylactic laxative therapy to accompany all regular analgesics.
Covered further in the factsheet are causes, assessment and suggested treatments.
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Oral problems greatly impact on the quality of life of patients.
Impaired oral function may result in malnutrition, anorexia and cachexia. Oral integrity plays a role in communication and social interactions: problems may result in psychological disturbances. Good oral hygiene is fundamental for oral integrity. In general, teeth should be cleaned twice daily with a fluoride toothpaste and soft brush.
The factsheet contains information on factors affecting oral integrity, assessment and suggested management techniques of a number of symptoms.
FACTSHEET_13_-_for_review_Sept_2016 (65 KB) 02/09/2014 15:02
"A breathless patient is an anxious patient..."
Dyspnoea is an unpleasant awareness of the process of breathing: The awareness may be of the frequency or the effort of breathing.
This factsheet covers the causes behind the symptoms, how to carry out an assessment and potential treatments.
Anxiety and depression both remain under diagnosed and under treated in Palliative Care patients. Estimates of the incidence of depression in Palliative Care vary but are of the order of 20-40%. Often the symptoms will be accepted by the patient, family or physician as a "normal" reaction to incurable illness:-
30% of patients will experience "adjustment reactions" at the time of diagnosis or of relapse, but these will usually resolve within a few weeks, with appropriate support.
20% of patients will develop psychiatric disorders that require specific management and treatment in addition to support.
This factsheet covers the importance of a 'correct' assessment, how to manage the symptoms and the use of psychotropic drugs.
Palliative care emergencies encompass not only situations that are imminently life threatening, but also those that could result in impaired quality of life for the remainder of the patient's life, or for the family in their bereavement.
When planning the care of your patient:
- be aware of potential "emergencies" eg patient with vertebral metastases likely to develop spinal cord compression
- be aware of patients wishes in the event of emergency eg preferred place of care, living wills, resuscitative measures
- be aware of family/carer wishes eg to be with patient whatever happens
- focus on anticipating emergency and planning appropriately in advance eg green towels and sedation for haemorrhage: emergency contact number
'Emergencies' considered in this factsheet are:
- psychiatric emergency
- spinal cord compression
- superior vena cava obstruction
- raised intra cranial pressure
FACTSHEET_16_-_for_review_Sept_2016 (123 KB) 02/09/2014 15:03
The terminal phase can be distressing for patient, family and health professionals. As with all Palliative Care, careful assessment, an individualised treatment plan and detailed explanation are essential.
Appropriate communication with the patient and family, and changes to the patient's care, can only be achieved if there is recognition of the fact that the patient is dying. A knowledge of the patient's disease progression and observation of their changing physicl and mental condition should enable the multi-disciplinary team to determine when death is approaching: increasing weakness or drowsiness, becoming bed-bound, difficulty taking oral medication or only taking sips of fluid are common signs.
The factsheet goes on to cover symptom control in the following areas:
- Terminal Agitation
- Nausea and Vomiting
- Excess Bronchial Sereations
- Mouth care
Corticosteroids are useful drugs, but they are not without their side-effects. Evidence for their efficacy is variable.
- Clinician and patient need to be clear as to the reasons for commencement of corticosteroid therapy, and the symptoms that will be assessed as indicators of response.
- If symptoms do not respond, stop responding, or recur, steroids should be withdrawn.
- Therapy should be guided by the clinical picture and discussion with the patient.
- As corticosteroids can have considerable side-effects, the lowest effective dose should be used. The clinician should try and reduce the medication until this dosage is found.
- Side effects, or long-term sequele, may be less important with patients who might benefit for the last weeks of life.
- Monitoring of treatment is essential for patiens with longer prognosis.
The factsheet contains further information on side-effects, routes and doses and discontinuing steroids.
FACTSHEET_18_-_for_review_Sept_2016 (141 KB) 02/09/2014 15:03
Anorexia or loss of appetite is a very common symptom in palliative care patients and can be distressing for both patients and carers. It denies the carer one of the main aspects of care they can provide ie to nourish. This is a frequent cause of tension between patient and carer.
The factsheet contains information on:
- Suppor for patient and family
- Nutritional advice
FACTSHEET_19_-_for_review_Sept_2016 (53 KB) 02/09/2014 15:03
Cancer and end-stage organ failure can cause a number of problematic symptoms, due to various underlying causes that can be difficult to identify. These symptoms can cause great distress to patients, sometimes more than more common symptoms such as pain and nausea/vomiting.