Download Appendix 2 – HPC Teams for Central LHIN Symptom Relief Kit

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Appendix 2 – HPC Teams for Central LHIN Symptom Relief Kit
PALLIATIVE SYMPTOM RELIEF KIT (SRK) PRESCRIPTION
Hospice Palliative Care Teams for Central LHIN
POLICY
1.
This is a physician’s order to be implemented by a Registered Nurse when symptoms require urgent intervention to facilitate a comfortable
home death.
2.
The attending physician is to be notified as soon as possible regarding change in patient’s condition and need for ongoing
prescription(s).
3.
EDITH (Expected Death in the Home) protocol should be in place.
4.
Completed prescription to be FAXED to CCAC 416-222-6517 (South) / 905-952-2404 (North) AND the pharmacy; Calea 905- 629-0123 or
Bayshore 1-888-287-8577 (Applicable pharmacy determined by CCAC)
URGENT DELIVERY
RN TO VISIT ASAP TO INITIATE KIT
Date:
Patient Name:
(Last Name, First Name)
dd/mm/yy
DOB:
HIN:
dd/mm/yy
Address for Delivery:
ANXIETY or SEIZURE:
Lorazepam tab 1mg
Dispense: 10 tabs
PO (not SL formulation) 1-2 tabs PO/SL q2h PRN. May
crush or dissolve in water to put under tongue.
DELIRIUM OR NAUSEA:
Haloperidol Inj 5mg/ml
Dispense: 3 amps of 5mg
2mg SC q1h until settled, then 2mg q3-4h PRN
(2 mg = 0.4 ml)
Midazolam 5 mg/ml injectable 1 ml amp
Dispense: 5 amps
1 mg-2 mg SC q1h PRN
(1 mg = 0.2 ml)
Palliative Care Facilitated Access license required for
coverage under ODB
(Nurse must contact physician before initiating)
Olanzapine Sublingual (Zyprexa Zydis) 5mg Rapid Dissolve Tab
Dispense: 5 tabs
5mg PO once daily, placed on tongue
EXCESS PULMONARY SECRETIONS:
Atropine 1% Eye Drops
Dispense: 5ml
2 drops SL or buccal q3h PRN
Methotrimeprazine (Nozinan) 25 mg/ml
Dispense: 5 amps
12.5 mg- 25 mg SC q3h PRN
(12.5 mg = 0.5 ml)
(Nurse must contact physician before initiating)
Scopolamine 0.4 mg/ml injectable 1 ml
Dispense: 5 amps
0.4 mg SC q3h PRN
Palliative Care Facilitated Access license required for
coverage under ODB
PAIN and/or SHORTNESS OF BREATH: CHOOSE ONLY ONE OPIOID
Hydromorphone (Dilaudid) Inj 10mg/ml
Morphine Inj 15mg/ml
Dispense: 4 amps
Dispense: 10 amps
Opioid naïve patients with moderate to severe pain or dyspnea require 1mg
SC q1h PRN. (Contact the physician for increased dosing if symptoms
are unmanaged)
Opioid naïve patients with moderate to severe pain or dyspnea require 3mg
SC q1h PRN. (Contact the physician for increased dosing if symptoms
are unmanaged)
(1 mg = 0.1ml) use 1cc syringe with needle
(3mg = 0.2ml) use 1cc syringe with needle
For Physician information: If patient is already on oral Hydromorphone / Morphine, to convert from patient’s usual dose, take total daily dose and
calculate half to give total parenteral daily dose. Parenteral daily dose should be divided up over 24 hours to calculate an hourly dosage.
ADDITIONAL MEDICATIONS
Note: Nurse to use a separate butterfly for each medication and label.
Nurse to begin with lowest dose first.
INSERT INDWELLING FOLEY CATHETER PRN
CCAC TO USE ESTABLISHED PROCESSES TO ORDER THE FOLLOWING SUPPLIES:
FOLEY CATHETER KIT: Yes
No
PRN adaptor (4), Gloves (2 pairs),Transpore tape
Size: 14 and 16
SUPPLIES: Alcohol swabs (20), TB syringes (10), Butterfly (4),Tegaderm (4),
Physician Contact Information:
Office
Pager
Physician Signature
Cell
Print Physician Name
Palliative Symptom Relief Kit Prescription – CCAC 159 April 2014
Fax
OPSC#