Top tips for prescribing in palliative care. Dr Stephanie Lippett

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1 Top tips for prescribing in palliative care Dr Stephanie Lippett

2 contents Tips Pain management Anticipatory prescribing DNACPR 3 things that primary care can do to improve things for patients/themselves Hospice services

3 pain Remember pain is what the patient says it is But some patients are really bad at describing pain

4 Pain management Think- what is the likely cause of pain? Character- description of pain Site Disease itself-? More likely to cause neuropathic pain/ dx spread What is helping? Anxiety-total pain Co-morbidities/CI to medications- CCF and amitriptyline/ renal failure

5 Pain management Who analgesic ladder- 3 step vs 2 step approach

6 Pain management No point titrating up opiates if they are not working for the painconsider adjuvants Fentanyl for stable pain not for chasing pain (exceptional circumstances) New pain-do they need investigation? Bone mets/mscc/brain mets

7 Pain management Drugs commonly used in pain management Opiates-start with short acting Paracetamol NSAIDs Amitriptyline Duloxetine Gabapentin/ Pregabalin Steroids Buscopan Last resort Sodium valproate BDZ Radiotherapy/chemotherapy bisphosphonates Ketamine Interventional procedures- nerve blocks

8 Pain management Patient/Dr. anxieties and fears-addiction Coroner- high dose opiates/ serotonin syndrome Ask for help high dose opiates (HMR- conversion charts go up to 200mg Bd morphine/100mcg fentanyl) If gabapentin/amitript not helping think about asking for help

9 Any questions?

10 Anticipatory prescribing Prescribe in anticipation of decline- amber GSF (green if potential to decline rapidly) Patients decline rapidly and there are more out of hours than in hours Part of advanced care planning discussions- take opportunities to discuss (patient cues/ dx progression/ PPD)

11 Anticipatory prescribing Remember prescribing advice so drugs can be administered Consider DNACPR/ special notes Consider quantity- needs to last out of hours (Friday-Monday) Take into account Single use vials/ampules and wastage, doses of oral meds and conversion to subcut meds/ PRN and syringe driver doses with ranges

12 Anticipatory prescribing Midazolam 10mg/2ml amps x10 Glycopyrronium 600mcg/3ml amps x10 (200mcg/1ml ok for PRN) (some areas use hyoscine hydrobromide) Levomepromazine 25mg/1ml amps x10 (some areas use haloperidol) Water for injection 10ml amps x10 Opiates What opiate are they on and why? How much are they on? Renal impairment? What is the opiate of choice in your area (HMR = diamorphine)

13 Anticipatory prescribing Oxycodone (difficult) alfentanil/ fentanyl (impossible) to get out of hours Don t discontinue fentanyl patch-continue same dose and take it into account with PRN doses Write up syringe driver and PRN doses-write a range for changes needed out of hours. PRN 1/6 th syringe driver dose Starting syringe driver dose = sub cut equivalent for oral opiates the patient is on or 2 PRN doses if opiate naïve.

14 Anticipatory prescribing NICE guidelines advise individualised anticipatory prescribing-how do we achieve and teach this? What are the likely symptoms for THIS patient and prescribe accordingly What is working for this patient?

15 Any questions?

16 DNACPR Difficult conversation to broach-use opportunities (dx progression/ PPD discussions/ patient cues) Phrase the discussion appropriately- asking do you want resuscitation? Implies a choice ( the doctor asked me if I wanted to die, of course I don t want to die ) Not patient choice = medical decision but advised to discuss it (disease making the decision) Is patient choice to accept DNACPR form in their house. udnacpr lilac form for patient- ambulance crew can refuse to accept a copy.

17 DNACPR udnacpr form about to change to ReSPECT form To be valid Form needs to be discussed with patients/carer (or good reason why not-your distress not a good enough reason) Signed and dated with GMC/NMC no. (countersigned by senior clinician) Review date indicated if on the form- indefinite box ticked if present

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20 Any questions?

21 Improving end of life care

22 3 things to improve things for the patient Easier/priority access to GP/medications- perceived difficulty getting into GP/ difficulty obtaining medications when drugs changed Stressful situation without the difficulty of navigating the system See own palliative patients where possible-decreases unnecessary admissions Ensure special notes in place- very frightening for families when police turn up after death, can undo all the good that has been done leading up to the death Open and honest discussions about wishes/ppd/prognosis-?if someone needs admission-stage of disease/potential for dying in hospital etc.

23 3 things to improve things for you Prescribe anticipatories in advance of decline- less stressful Carry documentation in your bag-prescribing advice/dnacpr formssave having to go back and forth Refer to community specialist palliative care team, where appropriate, and listen to advice they give. Different referral criteria in different areas

24 Hospice services

25 Hospice services Differ from hospice to hospice- charity run in the main therefore can set their own priorities Have referral criteria- usually includes life limiting illness/specialist palliative care needs CCG can negotiate payments for additional services (pain clinic for non terminal patients-need to consider is this the best place for them?) If you are uncertain as to whether a patient meets the criteria but would benefit from the services-worth a discussion. Patient will probably be discussed at an MDT

26 Hospice services HMR community services/springhill hospice set up Hospice services-life limiting illness, usually in last 12 months of life requiring Specialist palliative care Day hospice IPU OPD Lymphoedema Bereavement/ counselling Pastoral/spiritual support

27 Hospice services Community services- patients on GSF register SPCN (not Macmillan)-caseload/ rapid response nurses Community doctor Hospice at home Counselling Complementary therapies Physio Pastoral/spiritual support Social worker education

28 Hospice services Need to consider why you feel the patient would benefit from the hospice- Specialist unit/ not a nursing home/ expensive discharge lounge/priorities. EOLC Symptom control Crisis intervention Respite (not all hospices do this) Hospital discharges/ deflections- if appropriate No investigation facilities/ limited antibiotic access Bed blocking- difficult to discharge inappropriate patients Lack of OOH doctor cover

29 Hospice services Not a useful stepping stone to a nursing home Patient just gets settled in and has to move again Setting up to fail at the nursing home as hospice nursing/doctor ratio is greater (patients often describe it as a 5 star hotel) Referral form information is crucial How admissions/visits are prioritised Make sure what is in your head comes across in the form

30 More information Greater Manchester and Cheshire SCN symptom control guidelines PCF5 On the website you will have access to other more detailed presentations of mine on pain management Difficult conversations complicated pain Anticipatory prescribing and symptom control in end of life care Fentanyl conversion Nice guideline summary

31 Any questions?