Download Palliative Care Algorithms

October 2012
Palliative Care Practice Guidelines
Thomas Palliative Care Services
VCU Massey Cancer Center
VCU Health System
October 2012
Development and Verification
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The practice guidelines were developed by an interdisciplinary group of
palliative care clinicians based on the best available research for each
symptom addressed. If two medications seemed equally beneficial,
medications were then selected based on cost, side effect profile,
nursing time, and availability on our formulary.
The practice guidelines are reviewed annually by our group of fellows,
attending physicians, pharmacists, and nurses to determine if changes
need to occur. The impact on symptoms are evaluated annually to
determine if we have improved symptom burden within our population
of patients. These practice guidelines have been reviewed by outside
experts in the past.
Nurses and fellows are educated on the use of the practice guidelines
which also help instruct residents who are doing their palliative training
on consistent research-based symptom management practice.
We believe this has improved symptom management throughout the
institution for those patients who do not receive or require a palliative
care consult.
October 2012
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Table of Contents
Agitation
3
Alternative Route for Opioid Administration
4
Anorexia
5
Anuria
6
Bladder Spasms Treatment
7
Bowel treatment – stepped care program
8
Candidiasis – Oral
9
Candidiasis – Perineal
10
Dyspnea
11
Fever
12
Hiccough
13
Mucositis
14
Pruritus
15
Secretions
16
Seizures – Acute Management
17
Sleep Disturbance
18
Wound Odor
19
Name
Date
Medical Director, Thomas Palliative Care Unit
Name
Director, Nursing
Date
October 2012
4
Agitation
Excessive physical or mental restlessness. Increased activity that is generally not
purposeful and associated with anxiety.
Depending on appropriateness, evaluate for reversible causes, including delirium and treat the underlying etiology if possible.
Symptom control may begin concurrently with diagnostic work-up.
Nonpharmacological interventions: reorientation, maintaining sleep wake schedule
Avoid restraints, minimize immobilizing treatments, maintain communication, med reconciliation
Haloperidol 0.5 mg PO/IV/SC every 4 hours as needed
relief
Continue same dose
Haloperidol every 12 hrs scheduled
no relief
Titrate up by 1 mg every 1 hour until desired effect
achieved (1mg, 2 mg, 3 mg, etc); MDD 20 mg
no relief after MDD Haldol
Evaluate to continue, taper or dc
Lorazepam 0.5mg PO or IV
every 1-2 hours as needed
MDD* 12 mg
relief
Benzodiazepines may
increase agitation and
delirium; consider
chlorpromazine 25 mg IV
every 8 hrs
Continue Lorazepam
Evaluate regularly to taper or
discontinue
Consider Palliative Service
consultation
atypical antipsychotic meds
starting doses for delirium
Olanzapine 2.5mg q12hrs
Risperidone 0.25mg q12hrs
Quetiapine 12.5mg q12hrs
no relief after 24 hours
Consider Palliative Service
consultation
* MDD = Maximum Daily Dose
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
5
October 2012
Alternative Route for Opioid Administration
If IV access is no longer available
AND
Patient is able to take PO medications, select
appropriate long and short acting opioids and
convert dosage requirements using equianalgesic
conversion card
If patient is unable to take PO analgesic
AND
IV access is not available
Convert 24-hour opioid
requirement of continuous
infusion of Basal Opioid via PCA
pump. May add PCA dose of
atleast 50% of basal rate every 6
min w/ bolus 3 times basal rate
of every1 hr
Example: 360 mg of PO MSO4
every day divided by 3 = 120
divided by 24 hrs = basal rate of 5
mg/hr IV MsO4
PCA dose would be 2.5 mg q 6 min
Bolus = 3 times basal dose = 15 mg
q 1hr
OPTIONS
Convert to Fentanyl patch using
equianalgesic coversion card,
continue to give Fentanyl
sublingual at dose of 25 mcg
every ½ hour prn
(Note: no benefit from patch for
8-14 hours)
Convert to subcutaneous
infusion of PCA using 27 gauge
needle (PCA dose remains the
same, change lock out to every
15 min). Infusion volume not to
exceed 2 ml/hr so may need
higher concentration.
Remember can call pharmacy
for assistance in how to order
SQ PCA.
Convert to rectal, vaginal or
stoma route for long acting
opioid (same dose) using
Fentanyl injection sublingual 25
mcg every 30 min prn.
Can give Roxanol(morphine
20mg/ml) sublingual and it can
be given to patients that aren’t
awake.
Document patient ability to
maintain internally.
May also place subcutaneous needle for use if
only intermittent opioids required, convert PO
dose to parenteral dose using equianalgesic
conversion card. Continue prn schedule.
** Physicians NOTE: Please consider incomplete cross tolerance in your conversions.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
6
October 2012
Anorexia
A loss of appetite with noted weight loss which is bothersome to the patient.
Supportive counseling for patient and family:
anorexia as a natural symptom of disease,
validation of normalcy, dietary and nutritional
changes and counseling
Appetite Suppression
IF BOTHERSOME TO PATIENT
Trial of megestrol acetate (Megace)
400 mg liquid PO daily
Reassess at 1 week for efficacy
no relief
relief
Continue megestrol at
current dose
Recommend increase dose of
megestrol to 800 mg liquid PO
daily
Reassess at 1 week for efficacy
(consider risk for DVT)
relief
Continue megestrol
at current dose
no relief
Prednisone 20mg daily
(considered most useful if estimated
prognosis less than 6 weeks)
HIV Patients: Dronabinol starting
dose 2.5mg bid MDD 20mg daily
(NOTE: Dronabinol is nonformulary)
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
7
October 2012
Anuria
Minimal to no urine output.
Anuria can be part of dying process, enact algorithm if unexpected or patient symptomatic, eg pain, agitation.
Catheterize for residual urine or perform bedside
bladder scan if available
Over 250 mls
Less than 250 mls
Leave catheter in place
Evaluate volume status
Review medications:
Anticholinergic, antidepressants,
antihistamines, opioids as
cause
Management for BPH
Re-asses catheter need periodically
If catheter becomes plugged irrigate with
normal saline prn
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
8
October 2012
Bladder Spasms Treatment
An intermittent cramping sensation of the bladder resulting in discomfort
Alternative to oxybutynins:
and/or pain.
Tolterodine
Treat pain with prn
analgesic while
analysing cause
Obtain urinalysis and
culture of clean catch
urine
If indwelling catheter is
present would do this
first
Negative
urinalysis
Assess catheter
function; irrigate
gently with NS
Consider replacing if
catheter present
greater than 5 days
Oxybutynin 5 mg PO
TID x 48 hoursMDD 20 mg. If PO
difficult, available in
patch 3.9mg/day twice a
No further
intervention is
needed
Oxybutynin 5 mg
TID x 48 hours
MDD 20 mg
OR
Scopolamine
0.4mg IV or sub
cutaneously every
4 hours prn
Newer agents: solifenacin,
Trospium, darifenacin
Newer agents are non-formulary
Positive urinalysis
Contact MD
Anticipate TMP/SMX
Oxybutynin 5 mg PO
TID x 48 hours
MDD 20 mg
Start TMP/SMX DS PO
twice/day; if sulfa
allergic, ceftriaxone 1g
IV daily
week (patch not in
formulary)
Continue
Oxybutynin
MD/RN/Rx consult
Scopolamine patch
every 72 hours
OR
scopolamine 0.4mg IV
every 4 hours prn
Promote increased
fluid intake as
appropriate
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
October 2012
Bowel treatment – stepped care
program
Treatment to alleviate hard stools and/or constipation associated with opioid administration.
Stool softener and/or gentle laxative
Docusate 100 mg twice/day (taking no
opioids)
Senokot 1 tab twice/day (taking opioids)
If no bowel movement in next
12 hours, perform rectal exam
to rule out impaction
If no bowel movement for 48
hour period add one of these:
Milk of magnesia concentrate 10 ml po
every day
OR
Bisacodyl 10 mg PO/PR every day if po
not tolerated or refused
If not impacted, Magnesium
citrate 8 oz
OR
Fleets enema
Increase the prophylactic
regimen to 2 tab Senokot
twice/day
For opioid induced constipation, consider
methylnaltrexone SQ injection
(<62kg=8mg, >62kg=12mg SQ every
other day until BM)
Consider Palliative Service consultation
If impacted,
Fleets enema
Soften with glycerin suppository
then manually disimpact
Follow up with tap
water enema until clear
Increase the prophylactic
regimen to 2 tab Senokot
twice/day
Consider Palliative Service consultation
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
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10
October 2012
Candidiasis – Oral
Whitish patches on the inner oral cavity, tongue or throat, which may or may
not cause discomfort.
Remember someone who is immunocompromised may need to get
fluconazole from the beginning.
Nystatin susp 400,000-600,000 swish
and swallow four times/day; hold in
mouth 2-5 minutes
OR
Clotrimazole troche 10 mg five times a
day
Improved after 48 hours
Not improved and patient using
appropriately, or not able to
swallow
Continue 7 days
Mucocutaneous candidiasis:
Fluconazole 200 mg Loading Dose
then 100 mg every day x 14 days.
Esophageal candidiasis:
Fluconazole 400 mg Loading Dose
then 200 mg every day x 14 days.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
11
October 2012
Candidiasis – Perineal
Reddened areas between skin folds in the genital area, which may or may
not cause discomfort.
Clotrimazole cream 1% applied twice/day
or nystatin powder tid & area kept dry
Improved after 48 hours
No improvement
after 48 hours
Continue
clotrimazole
or nystatin
powder 7-14
days
Fluconazole 150 mg one time dose.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
October 2012
Complete respiratory assessment
If oxygen sats <90% give oxygen 2L/min.
Check hemoglobin and transfuse if
consistent with care goals established on
signout.
12
Dyspnea
Complains of dyspnea
Bronchospasm with
audible wheeze
Fentanyl nebulizer 25 mcg
in 2.5 ml of NS every 2
hours prn
Albuterol 2 inhalations every 4
hours prn or 3ml nebulized every
2 hours prn
Trial of oxygen 2
liters/min
Reassess every 2
hours
If relief, continue
If no relief, Consider Morphine
10 mg PO every 2 hours prn or 3
mg subcutaneous or IV hourly
prn; monitor respirations
If mild CHF(crackles on
exam), with respiratory
distress
Furosemide 40 mg PO/IV for
one dose
Monitor for improvement.
Consider MD consult
If no relief, add oxygen 2 liters/min
and ipratropium 1-2 inhalations
every 4-6 hours prn or 2.5 ml
nebulized every 4 hours prn
If improvement,
continue
If no relief, lorazepam
0.5 mg PO or IV every
4 hours prn.
Monitor respirations
The sensation of air hunger. May be exhibited by gasping,
accessory muscle involvement in breathing, tachypnea,
discomfort.
For end stage, consider fentanyl
nebulizer 25 mcg every 2 hours
prn with 2.5 ml of NS
Consider adding oxygen 2
liters/min
If no relief, add fentanyl nebulizer 25
mcg in 2.5 ml NS every 2 hours prn.
If relief, continue
lorazepam prn
MDD 10 mg/day
Consider non-pharmacologic
options (e.g. fans, relaxation,
CPAP or BiPAP, physical
comfort measures, relaxation)
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
13
October 2012
Fever
A temperature of over 101.4 (orally), 100.4 (axillary), or 100.4 (for patients
with known neutropenia.
Symptomatic Fever or Rigors
Refer to signout to see goals of care.
Workup needed?
yes
no
Source of infection is suspected by
history or exam
Treat symptomatically, especially end
stage disease
Consider workup and possible
antibiotic therapy
Acetaminophen 650 mg PO/PR every
4 hours scheduled x 24 hours (avoid
other tylenol containing products) if
symptomatic or temp > 101 PO
Reassess after 24 hours
If no relief, try Ibuprofen 400 mg PO
or aspirin 650 mg PO or aspirin
suppository 600 mg every 6 hours or
ketorolac IV (15 mg)
every 6 hrs x 24 hrs
If no relief, consider Palliative Service
consultation
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
14
October 2012
Hiccough
A spasmodic intermittent closure of the glottis following lowering of the
diaphragm causing a short, sharp, inspiratory cough.
Non-pharmacological treatment:
Holding breath, mild irritation of nasopharynx
Valsalva, sipping liquids slowly, 5th vertebrae rubbing
Baclofen 5mg po
every 6 hours prn,
can increase to
10mg every 6hrs if
CrCl >30
If no effect or unable to take PO
If GERD: maalox 30ml PO
every 4 hours prn, can
Start PPI on formulary
Eg: esomeprazole 40mg daily
Continue as needed
Consider scheduling
Can continue baclofen. Haloperidol
2 mg PO/Subcutaneous/IV
Maintenance 2 mg PO three
times/day
No effect
Consider Gabapentin
300mg PO 3 times/day
OR
Chlorpromazine 25 mg
PO 3 times/day
Effect
Effect
Metoclopramide 10 mg PO/IV every 6
hours prn
Maintenance 10-20 mg po 4 times/day
If no relief, consider anesthesia
consult for block
Continue as needed
Continue as needed
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
15
October 2012
Mucositis
(without obvious infection)
Inflammation of the mucus membranes. Generally causes pain in the oral cavity and
throat and exhibited by excessive drooling, spitting and mucus production.
Evaluate for and treat thrush if present (see oral
candidiasis algorithm); consider evaluating for oral HSV
Sodium bicarbonate rinses
OR
1:1 Isotonic saline/sodium bicarbonate rinses every 2
hours while awake
If relief, continue rinses as needed.
Reassess in 7 days.
Consider non-pharmacologic
measures (e.g. removal of
dentures; avoiding salty, acidic or
dry foods; change PO to IV
formulation as appropriate/able)
If no relief, start trivalent mouth wash (Benadryl,
maalox, lidocaine mixture)5 ml swish/spit every
hour
OR
swish/swallow every 4 hours
No relief after 24 hours
Consider other analgesic interventions such as PCA,
viscous lidocaine, topical cocaine.
Consider Palliative Service consultation
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
16
October 2012
Pruritus
Severe itching.
Establish probable cause:
Consider medications, high bilirubin, skin
irritants
Hydroxyzine 10 mg every 6 hours
PO prn
Hydrocortisone/Pramoxine foam 4
times/day prn
OR
Diphenhydramine 25 mg PO/IV
every 6 hours
Improved after 24 hours, continue prn
If opioid induced, trial another
opioid – hydromorphone if currently
on morphine or fentanyl if currently
on hydromorphone
Contact physician, consider narcan
infusion (2.5 mg in 250 ml, start @
4ml/hr & titrate to max. rate of 12
ml/hr) or opioid rotation
If obstructive jaundicecholestyramine 4gm PO every day
before breakfast.
No improvement after 48 hours
Increase cholestyramine to 4gm PO
ac breakfast & dinner
-Consider PO Rifampicin 150 mg daily &
possible titration with monitoring of liver
function & CYP450 drug interactions
- If not on SSRI or SNRI anti-depressant,
consider PO Sertraline 50 mg daily & titrate
up to 100 mg after a week
Consider Palliative Service consultation
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible..
17
October 2012
Secretions
Oral or airway lubrication. May be noted by excessive, noisy respirations
Assess saliva
Diminished saliva
(xerostomia)
Increased secretions without trach
(Note: with trach evaluate risk of
excessively drying up secretions)
Encourage oral
fluid intake and
good oral care
Use artificial saliva
Suck on sugarless
candy, chew
sugarless gum
If history of radiation to
head/neck Pilocarpine 5 mg PO
tid, up to 10 mg tid if necessary
If disturbing to pt/family, consider a
trial of scopolamine patch every 72
hours and scopolamine 0.4 mg
subcutaneous/IV now and every 4
hours prn
If relief, continue
treatment
Thick secretions
Guaifenesin 200 mg PO
every 4 hours prn
Increase fluid intake
If patient unconscious, consider
suction
No relief
Add a second scopolamine patch every 72 hours
OR
Increase scopolamine to 0.6mg subcutaneous/IV
every 4 hours prn
OR
Glycopyrrolate 0.2-0.4 mg IV/SQ q4-6h prn
Consider Palliative service consultation
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
18
October 2012
Seizures – Acute Management
Sudden, non-purposeful, rhythmic movement of any part of the body or
facial muscles lasting from less to a minute to more that several minutes.
Seizure
Lorazepam 2 mg IV/Sublingual/Subcutaneous stat
Notify physician
May repeat in 15 min prn
MAXIMUM 8 mg
(Consider 2 mg IV midazolam or 5mg IV diazepam if
lorazepam not available)
Is it appropriate to escalate care for this patient?
Yes
Further work-up, monitoring and medication load for
chronic suppression therapy
No
Notify family, consider chronic suppression with
lorazepam
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
19
October 2012
Sleep Disturbance
(consider etiology and r/o delirium, treat cause)
An inability to fall asleep and or stay asleep causing discomfort or fatigue.
Is this daytime sedation?
Considerations include:
Caffeine 100 mg PO every 6 hours
until 4 PM
OR
Methylphenidate 2.5-5 mg 2 times
per day (2nd dose no later than
noon, max. 10 mg bid)
OR
Modafinil 100 mg every morning
Consider cause including
pain, anxiety, agitation,
caffeine, medications
Zolpidem 5 mg PO at bedtime, may
repeat in one hour if no delirium
If relief, continue as
needed
Control environmental factors: minimize
nighttime interruptions, lights, television, late
meals, caffeine encourage daytime OOB,
and lights
If sleep loss related to depression,
consider treatment options accordingly
If no relief after 2 nights, notify physician
Consider a trial of temazepam 15 mg PO qhs
Use with caution in > 60 yr old & consider trazodone
25-50 mg PO qhs instead
If relief, continue as
needed
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
20
October 2012
Wound Odor
A strong, noticeable, offensive smell emanating from a wound.
Cleanse with normal saline or wound
cleanser
Apply non-adherent (oil emulsion) gauze as first
layer on wounds that are dry, when dressings stick,
or bleeding is a factor
Apply absorptive dressing with wound cover using:
•Calcium alginate
•Gauze packing
•4x4s or kerlix roll gauze with NS
•Foam dressing, or
•Baby diapers for heavy drainage
Consider topical 0.75% metronidazole gel (in a heavily
draining wound this may increase drainage and not help
odor)
Lightly spray outer dressing with Enzymatic Rain with
each change
Use room deodorizer
Continue
Consult Wound Care Team
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible..
October 2012
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Algorithm Evidence-Based References
Agitation
–
Jackson, KC, Lipman, AG. Drug therapy for delirium in terminally ill patients. In: The Cochrane Library, Issue 2, Chichester, UK: John Wiley
Sons, 2004.
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Breitbart W, Marotta R, Platt MM, Weisman H, Derevenco M, Grau C, Corbera K, Raymond S, Lund S, Jacobson P. A double-blind trial of
haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J.Psych1996 ;153:231-7.
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Stahl, S. Essential Psychopharmacology: Neuroscientific Basis and Practical Applications 2nd ed. Cambridge University Press 2000.
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Pasacreta, J., Minarik, P., & Nield-Anderson, L. (2006). Anxiety and depression. In B. R. Ferrell, & N. Coyle. (Eds.), Textbook of palliative
nursing (2nd ed., pp. 375-400). New York, NY: Oxford University Press.
Alternative Route for Opioid Administration
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Bruera E, Brenneis C, Michaud M, et al. Use of the subcutaneous route for the administration of narcotics in patients with cancer pain. Cancer
1988; 62: 407-411.
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Principles of analgesic use in the treatment of acute pain and cancer pain. American Pain Society, 5 th Edition, 2003 www.ampainsoc.org
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Pereira J et al. Equianalgesic dose rations for opioids: a critical review and proposals for long-term dosing. J Pain Sym Manage 2001;22:672687.
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Gourlay GK. Treatment of cancer pain with transdermal fentanyl. The Lancet Oncology 2001; 2:165-172.
Anorexia
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Jatoi A, Windschitl HE, et al. Dronabinol Versus Megestrol Acetate Versus Combination Therapy for Cancer-Associated Anorexia: A North
Central Cancer Treatment Group Study. Journal of Clinical Oncology, Volume 20, Number 2, 2002; 567-573.
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Inui, A., Cancer Anorexia-Cachexia Syndrome: Current issues in research and management, CA Cancer J Clin 2002; 52: 72-91.
–
Jatoi, A. On appetite and its loss, Classic Papers, Supplement to JCO, Vol 21, No 9 (May 1), 2003: pp 79s-81s.
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Bistrian, B. (1999). Clinical trials for the treatment of secondary wasting and cachexia. Journal of Nutrition, 129(1S Suppl), 290 S-294 S
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Fainsinger, R. L., & Periera, J. (2004). Clinical assessment and decision-making in cachexia and anorexia. In D. Doyle, G.W.C. Hanks, N.
Cherney, & K. Calman. Oxford textbook of palliative medicine (3rd ed., pp. 533-560). Oxford, UK: Oxford University Press
Anuria
–
Cravens (2000) Am Fam Physician 61(2): 369-76
–
Walsh (1998) Campbell's Urology, Saunders, p. 159-62
Bladder Spasms Treatment
–
Herbison, P, Hay-Smith, J, Ellis, G, Moore, K. Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive
bladder: systematic review. BMJ 2003; 326:841.
–
Nicolle, LE, Bradley, S, Colgan, R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic
bacteriuria in adults. Clin Infect Dis 2005; 40:643.
–
Howe, RA, Spencer, RC. Cotrimoxazole. Rationale for re-examining its indications for use. Drug Saf 1996; 14:213.
Bowel Treatment – stepped care program
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Klaschik E, Nauck F, Ostgathe C. Constipation--modern laxative therapy. Support Care Cancer. 2003;11(11):679-685. Epub 2003 Sep 2020.
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Mancini I, Bruera E. Constipation in advanced cancer patients. Support Care Cancer. 1998; 6(4):356-364.
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Locke, GR III, Pemberton, JH, Phillips, SF. AGA technical review on constipation. Gastroenterology 2000; 119:1766.
Palliative Care practice guidelines: These are to be used as general guidelines. Please review carefully before using. Please note the PO route is always
the initial route when possible.
21
Algorithm Evidence-Based References
October 2012
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Candidiasis – Oral
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Candidiasis – Perineal
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Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis 2004; 38:161-89.
Sweeney MP, Bagg J. The mouth and palliative care. Am J Hosp & Pall Care 2000; 17(2):118-124.
Sobel JD, Brooker D, Stein GE, Thomason JL, Wermeling DP, Bradley B, Weinstein L. Single oral dose fluconazole
compared with conventional clotrimazole topical therapy of Candida vaginitis. Fluconazole Vaginitis Study Group. Am
J Obstet Gynecol. 1995 Apr;172(4 Pt 1):1263-8.
National guideline for the management of vulvovaginal candidiasis. Clinical Effectiveness Group (Association of
Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999; 75
Suppl 1:S19.
Rex, JH, Walsh, TJ, Sobel, JD, et al. Practice guidelines for treatment of candidiasis. Clin Infect Dis 2000; 30:662.
Dyspnea
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Bruera E, Sweeny C and Ripamonti C. Dyspnea in patients with advanced cancer. In: Principles and Practice of
Palliative Care and Supportive Oncology. 2 nd Ed Berger A, Portenoy R and Weissman DE (eds). Lippincott-Raven,
2002.
Chan KS et al. Palliative Medicine in malignant respiratory diseases. In Oxford Textbook of Palliative Medicine 3 rd
Ed. Doyle D, Hanks G, Cherney N and Calman N. Oxford, 2005
Fohr SA. The double effect of pain medication: separating myth from reality. J Pall Med 1998; 1:315-328.
Coyne, P. J., Lyne, M.E., & Watson, A. C. (2002). Symptom management in people with AIDS. American Journal of
Nursing, 102(9), 48-56.
Coyne, P., J., Viswanathan, R., and Smith, T., "Nebulized Fentanyl Citrate Improves Patients Perception of Breathing,
Respiratory Rate, and Oxygen Saturation in Dyspnea." Journal of Pain and Symptom Management. February, 23 (2),
2002, pp. 157-160.
NCCN Clinical Practice Guidelines in Oncology: Palliative Care. V.2.2012. Available at NCCN.org
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Jensen Jensen D, Alsuhail A, Viola R, Dudgeon DJ, Webb KA, O'Donnell DE J Pain Symptom Manage.
Inhaled fentanyl citrate improves exercise endurance during high-intensity constant work rate cycle
exercise in chronic obstructive pulmonary disease.
2012 Apr;43(4):706-19. Epub 2011 Dec 14.
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Fever
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Zell JA, Chang JC. Neoplastic fever: a neglected paraneoplastic syndrome. Support Care Cancer. 2005
Nov;13(11):863-4.
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the initial route when possible.
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