Waterloo Wellington Hospice Palliative Care Network Symptom Response Kit Clinical Guidelines (Kit is for emergency purposes only) Notify the Physician if any of these symptoms develop. Obtain specific orders for each patient if possible. Symptom/ Medication Reference Indications Dyspnea & Call physician for opioid orders to relieve discomfort of breathlessness. Recommended Treatment for Dyspnea and related anxiety related to
If patient is on opioids, give regular breakthrough doses to treat dyspnea.
Starting doses for the opiate naïve patient may be:
Morphine 3-5 mg (0.2-0.33 ml) sc q1h prn
Open window, fan blowing air, quiet calm atmosphere
Consider oxygen therapy at low flow rate
COPD Considerations: Ensure bronchodilators and other concomitant therapies CHF Considerations: Current cardiac medications should be continued when
implementing dyspnea and other EOL clinical guidelines.
Identify possible cause: rectal impaction, urinary retention, an increase in pain,
medications (opioids, corticosteroids), metabolic derangements (diabetes,
hypercalcemia), dehydration, hypoxia, infection and brain metastases.
Treat the cause if appropriate. Identify goal of treatment: Haldol (haloperidol) is used to clear sensorium with minimal sedation Nozinan (methotrimeprazine) to clear sensorium with some sedation or Midazolam (versed) (Call physician for orders) if sedation is the primary goal and/or other treatments failed. Haldol (haloperidol) 0.5 -1.0 mg (0.1-0.2 ml) sc q4h prn Notify physician of current pain status and use of analgesics in past 24 hours, to obtain further orders.
Dilaudid (hydromorphone) is 5 times more potent than morphine. Dexamethasone may be added to manage escalating pain.
Midazolam (Versed) 5 mg sc to treat grand mal seizures (call physician for
orders). May repeat q 20 minutes x 3. Transfer to hospital if ineffective.
Keep calming environment for patient and family.
Scopolamine (hyoscine hydrobromide) 0.4 mg sc q4h prn
secretions (most frequently reported adverse effects are dry mouth and drowsiness - may cause or worsen delirium in conscious patients)
Periodic mouth care should be done for comfort. If secretions are in the airways and patient is too weak to clear them, try repositioning the patient on their side, with their head slightly lowered for positional drainage. Counsel family that the rattling is normal at this stage (obtunded terminal patients). Scopolamine reduces new secretions, but does not clear existing secretions.
Anxiety/ Lorazepam may be useful for mild anxiety but it can cause a worsening of Distress
symptoms in some patients if delirium is the cause (call physician for orders).
Revised: Jan 11, 2006 November 12, 2009
Cancer Care Ontario (CCO). (2009). Draft Delirium Technical Document. pp 5-6.
Doyle, D., Hanks, G., Cherny, N. & Calman, K. (2005). Oxford Textbook of Palliative Medicine. (3rd Ed.).
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Glare, P., Dunwoodie, D., et al. (2008). Treatment of Nausea and Vomiting in Terminally Ill Cancer
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Goodlin, S. J. (2009). Palliative Care in Congestive Heart Failure. Journal of the American College of
Jovey, R.D. (Ed.). (2002). Managing Pain: The Canadian Healthcare Professional’s Reference. Toronto,
Lanken, P. N., Terry, P.B., et al. (2008). An Official American Thoracic Society Clinical Policy
Statement: Palliative Care for Patients with Respiratory Diseases and Critical Illnesses. American Journal of Respiratory and Critical Care Medicine, 177, 912-927.
McCaffrey, M. & Passero, C. (1999). Pain: Clinical Manual. (2nd Ed.). St Louis, MO: Mosby.
Pereira, J.L. & Bruyere, E. (2008). The Pallium Palliative Pocketbook. Edmonton, AB: The Pallium
Project, Canadian Hospice Palliative Care Association.
Regional Palliative Care Program, Edmonton, Alberta. Capital Health, Caritas Health Group. (2003).
Acute Seizure (Status Epilepticus) Protocol for Pharmacological Management in Palliative Care Patients. Retrieved November 18, 2009 from:.
Rocker, G, Sinuff, T.,Horton, R. & Hernandez, P.(2007). Advanced Chronic Obstructive Pulmonary
Disease: Innovative Approaches to Palliation. Journal of Palliative Medicine.10, (3), pp 783-797.
Waterloo Region Palliative Care Pain & Symptom Management Program. (2004). Clinical Practice
Guidelines. Retrieved November 18, 2009 from: http://www.hpcconnection.ca/tools/pdf/clinical_practice_guidelines.pdf
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