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Mississauga Halton Adult Symptom Management Kit
Mississauga Halton
Adult Symptom Management Kit
Information package
Table of Content
Page
Definition……………………………………………………………………….………2
Background……………………………………………………………………….…...2
Why Order a SMK……………………………………………………………….…….3
When should a SMK be ordered…………………………………………………….3
Accessing the SMK…………………………………………………….……………..4
Disposal of the SMKT including unused medications……………….…………….4
Contraindications for a SMK…………………………………………………………4
Process for ordering a SMK for a client…………………………………………….5
Process for the administration of the medications from the SMK……….……….5
Content of the SMK ……………………………………………………….………….6
Cost of the SMK…………………………………………………………….…………7
Turnaround time to delivery or pick-up…………………………….………………..8
APPENDICES
1 – Palliative Performance Scale…………………………………………………….9
2 – MH Symptom Management Kit Prescription Form
3 – Expedited Access Individual Access Clinical Review Form &
4 - Memo re Expedited access Individual Access Clinical Review (ICR)
5 – Frequently Asked Questions (FAQ) Facilitated Access to Palliative Care
Drugs Mechanism
6 – Medications – quick reference guide
7 - SMK Clinical Evaluation Form
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Mississauga Halton Adult Symptom Management Kit
What is the Mississauga Halton (MH) Symptom Management Kit SMK?
The MH Symptom Management Kit (SMK) is a standardized package of
medications and related medical supplies provided to a client who is approaching
end-of-life for the purpose of relieving unanticipated or rapidly escalating
symptoms. It can be accessed by a community nurse authorized by a Community
Care Access Centre and/or a physician.
Background
SMKs have been available in several regions of Ontario as a system to support
people in their choice to remain at home and out of hospital. In Halton, a Crisis
Kit has been available for CCAC clients at end-of-life for several years now. It
was recognized that there have been differences in the processes of how SMKs
have been placed in the homes of clients across the Province and how they
would be accessed once there. A Ministry of Health and Long Term Care Task
Force was developed as an outworking of the Provincial End-of-Life Care
Advisory Committee, to attempt to develop some consistency across the
province and to support areas that do not have a SMK system.
The Task Force’s primary objective was to create a document that be could used
as a guide to assist areas of the province not having a SMK system in their
attempt to develop one. Initially, effort was made to develop a document that
would not be prescriptive about how to develop a SMK system. However, as the
Task Force continued its work, it was determined that effort should focus on
finding one best practice approach to the processes that need to be employed in
a SMK system. Within this approach would be flexibility to accommodate
regional differences in various non-process based issues, such as but not limited
to, physician prescribing practices, SMK contents etc.,
Although the draft guidelines produced by the Task Force were intended to be as
clear as possible, they are only guidelines. Their purpose is to support
communities as they work to develop their own local SMK system. These Task
Force Guidelines have been used as the foundation for the Mississauga Halton
Guidelines. The processes described in this document also take into
consideration that each of the health care providers involved (i.e. Registered
Nurses (RNs), Pharmacists and Medical Doctors (MDs)) must adhere to the
Standards of Practice of their respective College.
Each of the College of Nurses of Ontario, the College of Physicians and
Surgeons of Ontario and the Ontario College of Pharmacists has provided input
to the Task Force document and by consensus has provided their support to it.
However, that these organizations support this document does not necessarily
mean that it will answer all professional practice questions that could arise. If a
regulated health care provider has further professional practice questions that
are not addressed in this document, he/ she is advised to contact his/ her
respective college(s).
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Why order a SMK?
While it is predictable that clients facing end-of-life are likely to experience
increasing symptoms, sometimes the timing of those symptoms is not
predictable. Having an SMK on hand ensures that the community nurse has a
well thought out tool kit and instructions that make it possible for the nurse to
respond quickly and appropriately to ease a client’s unanticipated or rapidly
escalating symptoms. At this time, the SMK is the only available option for
emergency symptom management for in-home clients when the client’s physician
is not immediately available.
The SMK is not intended to replace the need for proper clinical assessment
leading to well defined care plans that properly identify potential issues.
Responsible care planning would include the service providers communicating
during the course of the care to ensure that appropriate PRN medications are in
place for the client.
When should the SMK be ordered?
The decision regarding when the SMK should go into the home should be part of
the development of the client’s overall plan of care. The development of the plan
should involve the client, the client’s family, the attending physician, the
community nurse, and any other members of the client’s care team.
Timing of placement of the SMK requires careful consideration. Placing the SMK
in the home prematurely may result in the expiry of the medication. Placing the
SMK in the home too late in the client’s disease process could cause delay in the
management of his/her symptoms and may result in Emergency Room or
hospital admission.
Clients who are identified by CCAC as MIS Service Recipient Code 95 (End-ofLife Care category) should have a kit in place. Clients who are approaching the
end-of-life phase of illness (Palliative Performance Scale (see Appendix 1 for
PPS information), have a PPS of 40 or less or are deteriorating rapidly should
have a kit in place.
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Accessing the SMK
It is appropriate to use the SMK in emergency situations when:
the client has sudden symptoms that cannot be managed at home by the
medication already available for the client or,
it is not possible to access the client’s physician and/or a pharmacy
quickly enough to relieve the client’s pain through additional prescriptions;
or,
the symptoms are of such intensity that, without the SMK, a visit to the
emergency room/hospital would be required.
Disposal of the Kit & of Unused Medications
The SMK is for the use of the designated client only. Contents may not be used
by anyone else. Both Legislation (The Pharmacy Act) and the Standards of
Practice for Pharmacists require that any medications and/or supplies remaining
in the kit, that have been ordered for a client as part of the SMK must be
disposed of to be destroyed after the designated client no longer needs it (i.e.
after the client has died). The nurse is to ensure that the family is aware of
where to return the kit. If the kit was obtained from Calea, it must be disposed of
by placing it in a biohazard waste container and requesting a pick-up from Calea.
If from a community pharmacy, the kit should be returned there for disposal.
Upon receiving the unused medications and/or supplies, the pharmacy must then
destroy them, in accordance with the Standards of Practice.
The reason that remaining medications and supplies cannot be used for another
client is to protect the safety of the consumer. Because the SMK is not under the
pharmacy control once it is in the home, neither the pharmacy nor the community
nurse can guarantee that the kit has been maintained in perfect condition; e.g. it
may have been stored at the wrong temperature, or in less than sterile
conditions. Ensuring client safety outweighs the relatively small financial loss
incurred by discarding unused medications.
Contraindications to ordering a SMK
A SMK is contraindicated for clients at home when:
the client’s death is imminent, and specific medications should be ordered
for end-of-life care;
the client is a child whose weight is such that medications and/or dosages
require special consideration;
___________________________________________________________________
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the client is incapable and there is no caregiver in the home who can be
responsible for the SMK;
there is evidence of substance use disorder by the client and/or family
and no effective plan can be implemented to prevent medication misuse;
there is evidence that the medications in the SMK could be used in ways
other than the intended purpose; and/or
the security of the SMK cannot be guaranteed in the home.
Process for Ordering an SMK for the Home:
1. The CCAC case manager, community nurse and physician, in
collaboration determine a client’s need for an SMK, based on the patient
PPS score and other indications that the client is nearing the end-of-life
stage of their illness or deteriorating rapidly.
2. The CCAC completes the top of the SMK prescription form (see
Appendix 2) with identifying information about the client (client name,
address, date of birth, etc.).
3. The CCAC case manager faxes “SMK Prescription Form” to the
physician requesting a SMK. The Case Manager also sends a “Request
for Palliative Care Medications” MOHLTC Form (see Appendix 3).
4. The physician completes the SMK form, which is actually the
prescription, and the Request for Palliative Care Medications MOHLTC
Form faxes it to the pharmacy selected from the ones listed on the form.
Physicians who are registered by the Ontario Medical Association to
participate in the Facilitated Access to Palliative Care Drugs
Mechanisms (see Appendix 4) do not need to complete the MOHLTC
Form as long as their special privilege is noted on the prescription form.
5. The Case Manager orders the SMK supplies kit CMIS – XSMK95
(Oakville, Milton, Georgetown, Acton) and PMI – IVKIT95 (Mississauga,
Etobicoke) for delivery with the SMK medications. If there is not a
hazardous waste container in the clients’ home a medium size biohazard
container is to be ordered.
6. The receiving pharmacist makes a copy of the completed SMK
prescription form, indicating “copy” on the form, and faxes it to the
CCAC.
7. The pharmacist prepares the SMK and delivers it to the client’s home,
preferably on the same day or call the family if the kit is to be picked up
when it is ready.
___________________________________________________________________
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Mississauga Halton Adult Symptom Management Kit
8. The SMK will be delivered in one bag, with a separate package for the
supplies and one for the medications. The nurse will combine all of the
elements into the box provided and instruct the family on where to store
the kit and record the location of the kit in her notes.
Process for the administration of the medications from the SMK
When the client displays symptoms that require use of the medications
contained in the SMK, the nurse in the home contacts the physician for
discussion. The medication is administered as per the physician’s order
and documented. As the SMK is not replenished, care planning to
ensure on-going symptom management is essential as the
medications in the kit will only provide coverage for 12-24 hours.
The nurse must contact the physician to discuss adequate on-going prn
medications.
If the nurse is unable to contact the physician when access to the kit is
required, the nurse administers the medications, based on the indication
provided with the medication. She can refer to the quick reference
medication information included in Appendix 6. The nurse informs the
physician and case manager as soon as possible.
The utilized medication is now part of the treatment plan for the client,
and is not returned into the SMK.
When the kit is no longer needed in the home, the nurse instructs the
family on how to dispose of the kit and completes the SMK evaluation
form (see Appendix 6) and returns the evaluation form to the CCAC Case
Manager.
Content
There are four physical components to the SMK:
Storage container
Drugs and Medications
Supplies and Other Kit Contents
Documents (medication quick reference guide and SMK evaluation form)
___________________________________________________________________
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1) Storage Container
The SMK will be contained in a “Tupperware” like container. The Patient’s name
and the date when the first medication in the kit will expire are posted on the
outside of the container.
2) Drugs and Medications
The SMK Prescription Form is a form listing a standardized set of pre-printed
orders (medications, dosages, routes and frequency) that when completed and
signed by the physician for a specific patient becomes a set of orders for that
patient.
On the list is a choice of three opioid concentrations. The decision by the
physician to order one or the other is made based on the patient’s previous
opioid dosing or lack thereof, i.e. the opioid-naïve patient (has not been
previously stabilized on an opioid). For unanticipated crisis pain management,
the physician will select the opioid and opioid concentration and will specify the
dose to be administered.
Each medication is stored in individual vials or zip lock bag with a prescription
label for the client appropriately attached.
3) Medication Quick Reference Guide
The Medication Quick Reference Guide included in this document (see Appendix
6) provides information the medications included in the kit, including indications
for which each medication can be administered.
If a community nurse is concerned about his/her ability to assess a symptom and
to evaluate the indication for a specific medication, he/she is recommended to
not administer the medication and to contact a supervisor for advice. All nurses
are accountable for their own decisions and actions and for maintaining
competence in their practice (College of Nurses of Ontario guiding principles).
4) SMK Evaluation Form
The SMK Evaluation Form (See Appendix 7) is to be completed by the visiting
nurse when the kit is no longer in use. The form is to be returned to the CCAC
by fax with the CCAC discharge report.
Cost of the SMK
The cost of the SMK is $25.00, inclusive of medications, supplies forms and
containers but not delivery cost.
___________________________________________________________________
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Turnaround time to delivery or pick-up
It is important to anticipate the needs of the client and to place the SMK in the
client’s home in a timely manner. All completed paperwork and prescriptions
must be received before the pharmacy can process a request for an SMK.
There should not be a substantial delay between ordering the kit and
providing the kit. Everywhere medications are available through the
Expedite Section 8 Drug List because Pharmacists have agreed to cover
the cost of Section 8 drugs initially and then obtain reimbursement from the
Ontario Drug Benefit Plan.
___________________________________________________________________
Mississauga Halton Symptom Management Kit
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Mississauga Halton Adult Symptom Management Kit
Appendix 1 – Palliative Performance Scale
(reproduced from Victoria Hospice, 2003)
___________________________________________________________________
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Appendix 2 - Mississauga Halton Symptom Management Kit
Prescription Form
Patient Name: ______________________________ HC#: ______________________
Address: ______________________________ Tel:___________________
Date of Birth:(year/month/day)______________________
Opioid Analgesic (choose one opioid option only and initial)
MD initial
Medication
Morphine 15 mg/ml
injectable
1 ml vial
Hydromorphone 2
mg/ml injectable
1 ml vial
Hydromorphone 10
mg/ml injectable
1 ml vial
Directions
Medication
Directions
Haloperidol 5 mg/ml
Injectable
1 ml vial
For nausea and vomiting:
0.5 – 1 mg. sc q8h prn
Prochlorperazine 10 mg
Suppository
Lorazepam 1 mg
Tablet
Midazolam 5mg/ml
Injectable
1 ml vial
Mitte
Coverage
3
ODB
3
ODB
3
ODB
III.
Mitte
Coverage
ODB
3
For Delirium/agitation:
1 - 2 mg. sc q1h prn until controlled then 2
mg. q 6 h sc prn
For nausea and vomiting:
1 supp pr q4h prn
For sedation:
1 – 2 mg. SL q2h prn (crush tablet and mix
with small amount of water)
For sedation:
2 mg. sc q1h prn
2
ODB
6
ODB
*
PCFA
2
Expedited Sect 8**
Scopolamine 0.4 mg/ml
Injectable
1 ml vial
For excess respiratory secretions:
0.4 mg. sc q4h prn
Acetaminophen 650 mg
Suppository
650 mg. pr q4h for temp > 38.5
6
*
PCFA
Expedited Sect 8**
o
2
ODB
Physician Name PRINT: ________________________________ CPSO #:__________
Physician Signature: _____________________________ Date:___________________
Phone#: (Daytime): ______________________ After hours/On-Call:________________
* PCFA (Palliative Care Facilitated Access) – Palliative Care physicians with provincial designation for this coverage
** Expedited Sect 8 – For Physicians without PCFA designation; “Request for palliative care medications - individual
Clinical Review (Section 8) form to be completed and sent to the pharmacy.
F AX TO:
CALEA (Order through CHRIS)
Halton Pharmacy, Oakville (905-842-1064)
Delivery
Pick-up
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Appendix 3 - ODB Form for Expedited End-of-Life Care
Request for Palliative Care Medications
Section 1 – Physician Information
Section 2 – Patient Information
First Name
First Name
Street it
Initial
Last Name
Street Name
Initial
Last Name
Ontario Health Insurance Number
City
Postal Code
Gender:
Male
Fax
Telephone
Date of Birth (YYYY/MM/DD)
Female
Section 3 – Patient Diagnosis
Primary Diagnosis: _______________________________________________________________________________
This patient has a terminal illness and has chosen outpatient palliative treatment. Life expectancy is less than six
months. The medications checked below are requested for symptom control for a maximum period of six months.
Section 4 – Requested Medication(s)
Diazepam injection or
Lorazepam injection – for seizure control, anxiety when other dosage forms cannot be
used
[DIN 00399728 (5mg/mL)]
[DIN 02243278 (4mg/mL)]
Dimenhydrinate injection – for nausea when other dosage forms cannot be used
[DIN 00392537 (50mg/mL)]
Furosemide injection for diuresis when oral route cannot be used
[DIN 00527033 (10mg/mL)]
Gabapentin - for neuropathic pain after failure of tricylic antidepressants and oploids if appropriate
[DINs 02243446 (100mg); 02243447 (300mg); 02243448 (400mg); plus all interchangeable DINs
Glycopyrrolate injection - for secretion control in the very terminal stage of care
[DIN 02039508 (0.2mg/mL)]
®
Hyoscine injection or
Hyoscine oral (Buscopan ) - for abdominal spasm, pain
[DIN 00363839 (2Omg/mL)] [DIN 00363812 (10mg)]
Methadone - if other opioids fail to control pain or lead to side effects
[DINs 02247698(1mg); 02247699 (5mg); 02247700 (10mg); 02247701 (25mg); 02247694(1mg/mL);
02241377(10mg/mL)]
Metoclopramide injection for nausea when oral route cannot be used
DIN 021 85431 (5mg/mL)]
Midazolam injection• for use in respiratory distress, anxiety
[DIN 02240286 (5mg/mL)]
®
Octreotide injection (Sandostatin ) - for bowel obstruction in palliative care
[DINs 00839205 (100mcg/mL); 02049392 (200mcg/mL, 5mL); 00839213 (500mcg/mL)]
®
Oxycodone (Supeudol ) - for use when combination oxycodone & acetaminophen cannot be used
[DINs 00789739 (5mg); 00443948 (10mg); 02262983 (20mg)]
Phenytoin injection for use in seizure control, when oral dosage forms cannot be used
[DIN 00780626 (50mg/mL)]
Scopolamine injection• for secretion control in the very terminal stage of care
[DINs 00541869 (0.4mg/mL); 00541877 (0.6mg/mL)]
Other (drug name, dose, dosage regimen and reason for use):_________________________________________
______________________________________________________________________________________________
Requests for ICR coverage of other medications may be considered on a case-by-case basis. Please attach a
separate written request, including the drug name, dosage regimen, rationale for use, and details of previous
medications tried, by following the procedures as outlined in Part VIII of the current 0DB Formulary. Requests
submitted this way may undergo a longer review process.
Physician Signature (Mandatory)
CPSO Number:
Date (YYYY/MM/DD):
___________________________________________________________________ 11
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Appendix 4 – Information about the Request for Palliative Care Medications
Individual Clinical Access Review Expedited Access Process
MEMO FROM THE MOHLTC DRUG PROGRAMS BRANCH
___________________________________________________________________ 12
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Appendix 5 - Frequently Asked Questions (FAQ)
Facilitated Access to Palliative Care Drugs Mechanism
1. When does the Facilitated Access to Palliative Care Drugs mechanism become
effective?
This funding mechanism becomes effective on March 23, 2007.
2. How will pharmacies know when to bill via this mechanism.
Physicians are requested to indicate either “palliative” or “PCFA” directly
on the prescription to signify to the pharmacist that the patient meets the
eligibility requirements for reimbursement under this mechanism: “The
patient has a terminal illness and has chosen outpatient palliative
treatment. Life expectancy is less than six months and the medications
are being requested for symptom control for a maximum period of six
months.”
Patients should also be ODB-eligible:
o Ontario residents aged 65 and over,
o Ontario residents receiving social assistance,
o Ontario residents receiving professional services under the
Home Care Program,
o residents of long-term care facilities, and
o people who have become eligible under the Trillium Drug
Program
3. Can the pharmacy bill using the drug product DIN?
Reimbursement of the Facilitated Access to Palliative Care drug products
under this mechanism is only allowed if the assigned PIN is used for
billing. Claims that are billed with the DIN may be rejected for payment.
A list of the PINs that are reimbursed under this mechanism was included
in a BBS bulletin (#7012) sent to pharmacies on March 5, 2007.
4. Are any of the Facilitated Access to Palliative Care drug products
interchangeable?
The drug products are only interchangeable if they are so listed in Part III
of the Comparative Drug Index (CDI) (e.g. various brands of gabapentin).
5. How can a pharmacy bill for the brand name Neurontin?
The same mechanism to reimburse for brand name products where there
are listed interchangeable products available is used {i.e. completion of
an Adverse Drug Reaction (ADR) by the prescriber must be kept on file in
the pharmacy}
6. Can any physician prescribe these medications for reimbursement?
Only the physicians who are registered by the Ontario Medical Association
(OMA) to participate in the Facilitated Access to Palliative Care Drugs
mechanism will be able to prescribe these medications to allow for the
pharmacy to claim for reimbursement under this FA mechanism. Physicians
wishing to participate in this program are asked to note that the following
criteria may be considered by OMA:
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Physicians who do more than 20 palliative care consults in a year;
Physicians who do more than 50 palliative care visits in a year;
Physicians who have been identified as a leader in palliative care by
a regional director for Cancer Care Ontario (CCO);
Physicians who have been identified as a
leader in palliative care by the executive of the section of palliative
medicine at the OMA;
Physicians who have been identified as a leader in palliative care by
an End of Life Network or Community Care Access Centre;
Physicians who have become members of a Palliative Alternate Funding
Plan (AFP).
For further information regarding the list of physicians and/or criteria for
physicians to be included on the list, please contact Dr. Howard Burke, c/o Ina
Nesbitt, Ontario Medical Association at (416) 340-2234 or via email at
[email protected]
Physicians who are not registered in this Facilitated Access to Palliative Care
Drugs mechanism may still submit a written request to the ICR/EA Unit for
consideration of coverage through the ICR/EA mechanism. The request should
include details of the patient’s diagnosis, current clinical status, and life
expectancy. These requests should also clearly specify that the requesting
physician is not registered in the Facilitated Access to Palliative Care
Drugs mechanism.
7. What is the total duration of approval allowed to be reimbursed?
The total duration of approval will be granted for a period of six months
from the initial billing/submission of a claim for a drug product under this
mechanism.
If the patient requires these medications beyond this six month period of
time, further billing under this mechanism will not be allowed.
Continuation of coverage will require the prescriber to submit a written
request via the ICR/EA mechanism. Renewal requests should clearly
specify that the patient requires continuing coverage.
Inappropriate billing with the DIN may be subject to recovery of funds by
the Ministry.
8. How can a physician request for coverage of drug products which are not
included on this list?
Requests for reimbursement of drugs not listed in this notice should be
submitted in writing to the ICR/EA Unit as usual. These requests should
provide details of the patient’s diagnosis, current clinical status, life
expectancy, previous therapies tried, and the rationale for selection of the
selected therapy.
9. What if there are other questions regarding this funding mechanism?
Physicians inquiring about participating in this mechanism should contact
Dr. Howard Burke, c/o Ina Nesbitt, Ontario Medical Association at (416)
340-2234 or via email at [email protected]
o On March 12, 2007, the initial list of participating physicians had
been forwarded to OPA, OMA, and pharmacies (BBS bulletin
#7014).
Pharmacists should contact the ODB Help Desk in Kingston toll free at
1(800) 668-6641.
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APPENDIX 6 – Medication Quick Reference Guide
MEDICATION
INDICATION
INFORMATION
SIDE EFFECTS AND CONTRAINDICATION
Morphine (s.c)
To manage pain
&/or dyspnea
when the oral
route is no longer
possible
For the opioid-naïve patient
– morphine 2.5 mg. q4h and
2.5 mg q1h prn; For patients
already on opioids – dosing
depends on the current
opioid dose.
Single dose is generally 5 –
10% of the total daily dose;
the parenteral dose is 50%of
the oral dose.
Nausea and vomiting
Constipation
Sedation
Delirium/agitation
Respiratory depression (unusual)
Opioid toxicity (delirium, myoclonus,
and increasing pain)
At end of life patients often will not
clear opioids normally and prn dosing
may suffice in the opioid-naïve patient
Hydromorphone
®
(s.c.) (Dilaudid )
To manage pain
&/or dyspnea
when the oral
route is no longer
possible
For the opioid-naïve patient
– hydromorphone 0.5 mg.
q4h and 0.5 mg. q4h prn
Nausea and vomiting
Constipation
Sedation
Delirium/agitation
Respiratory depression (unusual)
Opioid toxicity (delirium, myoclonus,
and increasing pain)
Haloperidol
®
(Haldol )
Prochlorperazine
®
(Stemetil )
For patients already on
opioids – dosing depends on
the current opioid dose.
Single dose is generally 5 –
10% of the total daily dose;
the parenteral dose is 50%of
the oral dose.
Nausea
The drug of first choice for
nausea and vomiting
Agitation/Delirium
The drug of first choice for
agitation/delirium. May need
multiple doses before control
achieved. For severe
delirium at the end of life
may need to add sedation
with lorazepam or
midazolam
Nausea and
vomiting
Alternative drug to
haloperidol for rectal
administration
At end of life patients often will not
clear opioids normally and prn dosing
may suffice in the opioid-naïve patient
Restlessness (akathesisia)
Stiffness and abnormal movements
(extrapyramidal effects/dystonic
reactions)
Fever - Neuroleptic malignant
syndrome (fever, rigidity and confusion)
– unusual
These side effects are uncommon with
the doses used in the palliative setting.
Contraindication:
Difficulty using the rectal route
Side effects – same as haloperidol
Lorazepam
®
(Ativan )
Anxiety
Sedation
May be useful for mild
sedation in combination with
Haloperidol
Sedation
Agitation – some patients will have a
paradoxical response that requires
discontinuation
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Midazolam
®
(Versed )
Sedation for
severe end-of-life
symptom distress
has not been
manageable by
other means –
most often severe
delirium or
dyspnea
Midazolam should only be
used if all other means to
manage the symptoms have
failed and the patient/family
is accepting of sedation. It
may produce deep sedation.
This medication has a rapid
onset of action but is shortacting (1-2 hours). If
symptoms remain severe a
continuous infusion may be
required
Sedation - should not be used if
patient/family strongly opposed to
intentional sedation.
Scopolamine
®
(Hyoscine )
Excess
respiratory
secretions at the
end of life
Will reduce respiratory
secretions in approximately
40 – 65% of patients. If not
responsive within 2-3 doses,
will likely not respond
May cause sedation or agitation in
patients who are still conscious
Acetaminophen
®
supp. (Tylenol )
Fever
Contraindication: difficulty using the
rectal route
References:
1. Symptom Management Guidelines, KFL&A Palliative Care Integration Project, Queen’s
Palliative Care Medicine Program, 2005
2. The Edmonton Palliative Care Program, www.palliative.org
3. Andree Neron et al. Pharmacy Specialty Group on Palliative Care.(2000) Care Beyond
Cure. A Pharmacotherapeutic Guide to Palliative Care. APES, and CSHP. Canada.
nd
4. Doyle, D. et al 1999.Oxford Textbook on Palliative Care 2 ed. Oxford University Press.
Great Britain.
___________________________________________________________________ 16
Mississauga Halton Symptom Management Kit
Mississauga Halton Adult Symptom Management Kit
Appendix 7 - SMK Evaluation Form
Name of Client: ________________________________________________________________
Address of Client: ______________________________________________________________
Optional: Name of person completing evaluation: ______________________________________
Phone Number: ________________________________________________________________
(Circle One)
1. Did you use the SMK?
Yes
No
2. Did the kit arrive within 24 hours of the initial request?
Yes
No
4. Did you reference or use the medication guidelines?
Yes
No
5. Did the client have a planned death at home?
Yes
No
6. Were you able to contact the physician: prior to the use of the kit or after
the use of the kit?
Prior
After
7. Did the use of this kit prevent/ delay/ avoid transfer of your client to an
emergency department or hospital admission?
Yes
No
Don’t
Know
8. What medications were used from the kit?
1.________________________________
3.______________________________
2.________________________________
4.______________________________
Strongly
Mildly
Disagree Disagree Disagree
Neutral
Mildly
Disagree
Agree
Strongly
Agree
Overall, even if the SMK was
unused, it was helpful to the family
to have it in the home.
1
2
3
4
5
6
7
If used, overall the SMK was
effective at managing the client’s
symptoms.
1
2
3
4
5
6
7
Overall the SMK was easy to use.
1
2
3
4
5
6
7
Comments:
______________________________________________________________________
_____________________________________________________________________
COMPLETED FORM TO BE FAXED TO CCAC WITH THE
DISCHARGE REPORT
___________________________________________________________________ 17
Mississauga Halton Symptom Management Kit