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Download Management of Medication for Symptom Control in the Dying 2014
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Cheshire & Merseyside Palliative & End of Life Care Network Audit Group: Management of Medication for Symptom Control in the Dying 2014 Please complete this form for any patient who has died between 1 st July 2014 and 31st August 2014. If you have any questions about how this form should be completed please contact Demographics – Patient’s Specialist Palliative Care Service Group Area Aintree Western Cheshire Central Cheshire East Cheshire Halton Isle of Man Liverpool North Lancashire South Cumbria St Helens and Knowsley Warrington Southport, Formby and West Lancashire Wirral Demographics – Patient Age: _________ Sex: Female Male Primary diagnosis causing death Heart Disease Cerebrovascular Disease Infectious Disease Other (please specify) Patient’s Place of Death: Community: Home Hospice: Hospital: Respiratory Disease Dementia Renal Disease Nursing Home Cancer Other Neurological Other (please specify) Was a member of a Specialist Palliative Care Team involved in the patient’s management in the last hours to days of life?: Yes No Unknown 1. Review of Medication Were all medications reviewed when the patient was recognised to be dying and considered to be in the last hours to days of life? Yes No Unknown Were all non-essential drugs discontinued when the patient was recognised to be dying and considered to be in the last hours to days of life? Yes No Unknown Who conducted this review? Clinical Nurse Specialist in Palliative Care Doctor (Consultant & Associate Specialist Palliative Medicine) Doctor (General Practitioner) Doctor (General Practitioner – out of hours) Doctor (Medical Officer/Clinical Assistant, Palliative Medicine) Doctor (Specialty Registrar) Doctor (Core Trainee) Doctor (Foundation Year 2) Doctor (Foundation Year 1) Unclear/Unknown Other (Please Specify) 2. Anticipatory Prescribing Please indicate which drugs were PRESCRIBED “as required” for each indication when the patient was recognised to be dying and considered to be in the last hours to days of life (tick all that apply) Cheshire & Merseyside Palliative & End of Life Care Network Audit Group: Management of Medication for Symptom Control in the Dying 2014 Pain None Paracetamol oral Paracetamol IV Ketorolac subcut Opioid oral Opioid subcut Other (please specify e.g. Abstral, Pecfent) Paracetamol PR Shortness of Breath None Opioid oral Opioid subcut Lorazepam subling Midazolam subcut Other (please specify with route) Agitation None Lorazepam subling Midazolam subcut Levomepromazine oral Levomepromazine subcut Haloperidol oral Haloperidol subcut Phenobarbitone IM Olanzapine oral Other (please specify with route) Nausea/Vomiting None Cyclizine oral Metoclopramide oral Levomepromazine oral Haloperidol oral Ondansetron oral Domperidone oral Cyclizine subcut Metoclopramide subcut Levomepromazine subcut Haloperidol subcut Ondansetron subcut Other (please specify with route) Secretions None Glycopyronium subcut Hyoscine hydrobromide subcut Hyoscine butylbromide (buscopan) subcut Octreotide subcut Other (please specify with route) Pyrexia None Paracetamol oral Paracetamol IV Ibuprofen oral Ketorolac subcut Other (please specify with route) Paracetamol PR 3. Use of anticipatory prescribing Please indicate which drugs were GIVEN “as required” for each indication at any time when the patient was recognised to be dying and considered to be in the last hours to days of life (tick all that apply) Pain None Paracetamol oral Ketorolac subcut Paracetamol IV Paracetamol PR Cheshire & Merseyside Palliative & End of Life Care Network Audit Group: Management of Medication for Symptom Control in the Dying 2014 Opioid oral Opioid subcut Other (please specify e.g. Abstral, Pecfent) Shortness of Breath None Opioid oral Opioid subcut Lorazepam subling Midazolam subcut Other (please specify with route) Agitation None Lorazepam subling Midazolam subcut Levomepromazine oral Levomepromazine subcut Haloperidol oral Haloperidol subcut Phenobarbitone IM Olanzapine oral Other (please specify with route) Nausea/Vomiting None Cyclizine oral Metoclopramide oral Levomepromazine oral Haloperidol oral Ondansetron oral Domperidone oral Cyclizine subcut Metoclopramide subcut Levomepromazine subcut Haloperidol subcut Ondansetron subcut Other (please specify with route) Secretions None Glycopyronium subcut Hyoscine hydrobromide subcut Hyoscine butylbromide (buscopan) subcut Octreotide subcut Other (please specify with route) Pyrexia None Paracetamol oral Paracetamol IV Ibuprofen oral Ketorolac subcut Other (please specify with route) Paracetamol PR 4. Routes of administration At the point of time when dying was recognised: Was there a functional PEG in situ? Yes Was there a working IV cannula? Yes Was there a working PICC? Yes No No No Unknown Unknown Unknown At the time of death: Was there a functional PEG in situ? Was there a working IV cannula? Was there a working PICC? No No No Unknown Unknown Unknown Yes Yes Yes 5. Use of a continuous subcutaneous infusion Was a continuous subcutaneous infusion via a syringe driver prescribed when the patient was recognised to be dying and considered to be in the last hours to days of life? Cheshire & Merseyside Palliative & End of Life Care Network Audit Group: Management of Medication for Symptom Control in the Dying 2014 Yes – as an anticipatory prescription Yes – for immediate use No – not needed No – already in use If a continuous subcutaneous infusion via a syringe driver was needed for symptom control, was it available at the time of request within your health setting? Yes No Not Applicable If not, why? If a syringe driver was not available, by which route was regular medication administered? Oral Subcutaneous injection Intravenous injection Intravenous infusion Intramuscular injection Sublingual Intranasal Transdermal Rectal Via PEG/RIG/NG Other (please state) At the time of death was a continuous subcutaneous infusion via a syringe driver in use? Yes No Unknown Please list the medication and the last administered dosage in the CSCI prior to the patient’s death (e.g morphine sulphate 10mg, levomepromazine 6.25mg) or if slow acting medication was administered by other means (e.g. intravenously or via a PEG/PEJ/NG/NJ) 6. Management Review How often was the patient’s medication reviewed? Daily More often than daily Less often than daily
