Download Palliative Care Practice Guidelines:Thomas Palliative Care Services

Palliative Care Practice Guidelines
Thomas Palliative Care Services
VCU Massey Cancer Center
VCU Health System
Original May 2006
Revised 2008 2010 2012 2014
November 2014
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.
November 2014
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Table of Contents
Alternative Route for Opioid Administration
5
6
Bladder Spasms Treatment
Bowel treatment – stepped care program
7
Dyspnea
8
Fever
9
Hiccough
10
Mucositis
11
Pruritus
12
Secretions
13
Wound Odor
14
Name
Date
Medical Director, Thomas Palliative Care Unit
Name
Director, Nursing
Date
November 2014
4
Delirium
.
Delirium, or acute confusional state, is a syndrome that presents in two basic forms. In its hyperactive form, it is manifested as severe
confusion and disorientation, developing with relatively rapid onset and fluctuating in intensity. In its hypoactive form, it is manifested by
an equally sudden withdrawal from interaction with the outside world.
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
*consider QTc monitoring at higher doses
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
*consider QTc monitoring at higher
doses
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
November 2014
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.
*methadone not to be used due
to risk of tissue necrosis
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
November 2014
Bladder Spasms Treatment
An intermittent cramping sensation of the bladder resulting in discomfort
and/or pain.
Treat pain with prn
analgesic while
analyzing cause
Obtain urinalysis and
culture of clean catch
urine
If indwelling catheter is
present assess if
absolutely needs to be
left in
Negative
urinalysis
Assess catheter
function; irrigate
gently with NS
Consider replacing if
nonfunctioning or
present for daysweeks
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
Alternative to oxybutynins:
Tolterodine usual dose 1-2 mg
PO BID
Newer agents: solifenacin,
Trospium, darifenacin
Newer agents non-formulary
Positive urinalysis
Oxybutynin 5 mg PO
TID x 48 hours
MDD 20 mg
Treat UTI as
appropriate based on
rest of historical data
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
Use anticholinergic agents
carefully in patients who are
high risk for delirium;
monitor closely
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.
November 2014
Bowel treatment – stepped care
program
Treatment to alleviate hard stools and/or constipation associated with opioid administration.
Senokot 1-2 tab dayif 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
*consider KUB to r/o bowel obstruction
before adding laxatives
For opioid induced constipation, consider
methylnaltrexone SQ injection
(< 38kg: 0.15mg/kg (round up to nearest
0.1mL volume, 2mg/0.1mL
concentration), 38-62kg=8mg,
>62kg=12mg SQ every other day until
BM)
If not impacted, Magnesium
citrate 8 oz
OR
Fleets enema
Increase the prophylactic
regimen to 2 tab Senokot
twice/day
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.
7
November 2014
Complete respiratory assessment
If oxygen sats <90% give oxygen 2L/min.
Check hemoglobin and transfuse if
consistent with care goals established on
signout.
8
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 IF NO
BENEFIT consider lasix nebulizer
40 mg
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.
9
November 2014
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
May refer to Cerner "Neutropenic
Fever" care set for neutropenic
patients
Acetaminophen 650 mg PO/PR every
4 hours or 1,000 mg IV scheduled
every 6 hrs scheduled x 24 hours
(max 48 hrs, 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.
10
November 2014
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.
11
November 2014
Oral 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
PCA OPIOID, viscous lidocaine, topical cocaine.
Contact oral surgery re laser therapy
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.
12
November 2014
Pruritus
Severe itching.
Establish probable cause:
Consider medications**, liver injury,
renal failure, skin irritants, neoplasm
Hydroxyzine 10 mg every 6 hours
PO prn
Hydrocortisone/Pramoxine foam 4
times/day prn
OR
Diphenhydramine 25 mg PO/IV
every 6 hours
If opioid induced, trial another
opioid – hydromorphone if currently
on morphine or fentanyl if currently
on hydromorphone
Contact physician, consider
naloxone infusion (2.5 mg in 250
ml, start @ 4ml/hr & titrate to max.
rate of 12 ml/hr) or opioid rotation.
Also consider ondansetron 8mg po
q8 or iv qd
Improved after 24 hours, continue prn
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
-Consider ondansetron 8mg iv qd or po
q8h
- 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..
November 2014
Secretions
Oral or airway lubrication. Increased secretions may cause excessive, noisy
respirations. Decreased secretions may cause uncomfortable dry mouth.
Assess saliva
Diminished saliva
(xerostomia)
Encourage oral
fluid intake and
good oral care
Use saliva substitute 1
application swish and
spit prn dry mouth
Use sugarless
(xylitol-containing)
candy or gum
Increased secretions without trach
in an end-of-life (EOL) patient
(Note: with trach, evaluate risk of
obstruction from excessively dry
secretions)
If disturbing to pt/family, consider
trial of scopolamine patch 1.5mg
(onset in 12h) every 72 hours
AND
scopolamine 0.4 mg SQ/IV now
and every 4 hours prn
If relief, continue
treatment
If history of radiation to
head/neck
Pilocarpine 5 mg PO tid, up to 10
mg tid if necessary
No relief
Increased secretions without
trach in a non-EOL patient
Glycopyrrolate 0.2-0.4 mg
PO tid (does not cross
blood-brain barrier, lower
risk for CNS toxicity)
Thick secretions in
patients with good
cough
Guaifenesin 400 mg PO
every 4 hours prn
AND
Increase fluid intake
If patient unconscious, consider
suction for accessible secretions
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 every 2-4h prn
Consider Palliative service consultation
13
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.
November 2014
Wound Odor
A strong, noticeable, offensive smell emanating from a non-healing wound.
Consult Wound Care Team
In the meantime, cleanse with normal
saline or wound cleanser
For wound with drainage, apply absorptive dressing
with wound cover using:
•Calcium alginate
•Gauze packing
•Foam dressing or thick pads for heavy drainage
For dry wounds or bleeding risk, apply nonadherent (oil emulsion) gauze as first layer
Consider topical 0.75% metronidazole gel twice daily
(use systemic antibiotics only if evidence of deep wound
infection)
Use room deodorizer
Continue
14
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..
Evidence-Based References
November 2014
Delirium
–
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Alternative Route for Opioid Administration
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Bladder Spasms Treatment
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bladder: systematic review. BMJ 2003; 326:841.
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Bowel Treatment – stepped care program
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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
November 2014
Evidence-Based References
Dyspnea
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Oxygen Saturation in Dyspnea." Journal of Pain and Symptom Management. February, 23 (2), 2002, pp. 157-160.
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endurance during high-intensity constant work rate cycle exercise in chronic obstructive pulmonary disease. 2012 Apr;43(4):706-19. Epub 2011
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Fever
Zell JA, Chang JC. Neoplastic fever: a neglected paraneoplastic syndrome. Support Care Cancer. 2005 Nov;13(11):863-4.
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–
–
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
November 2014
•
•
•
Evidence-Based References
Hiccough
–
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Lewis J. Hiccups: Causes and cures. J Clin Gastro 1985; 7:539-552.
Mucositis
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Dodd MJ, et al. Radiation-induced mucositis: a randomized clinical trial of micronized sucralfate versus salt & soda mouthwashes. Cancer
Invest. 2003;21(1):21-33.
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Shih A, Miaskowski C, Dodd MJ, Stotts NA, MacPhail L. A research review of the current treatments for radiation-induced oral mucositis in
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(Huntingt) 2003; 17:1767.
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Sonis ST, Elad S; Mucositis Guidelines Leadership Group of the Multinational Association of Supportive Care in Cancer and International
Society of Oral Oncology (MASCC/ISOO). MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer
therapy. Cancer. 2014 May 15;120(10):1453-61. doi: 10.1002/cncr.28592. Epub 2014 Feb 25.
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for patients with cancer receiving treatment. 31 MAY 2010. DOI: 10.1002/14651858.CD001973.pub4
Pruritus
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Beuers U, Boberg KM, Chapman RW, et al. EASL clinical practice guidelines: management of cholestatic liver diseases. J Hepatol 2009;51:23767.
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David E. Weissman. Lippincott-Raven Publishers Philadelphia 1998; 245-250.
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Krajnik M and Zylicz. Understanding pruritis in systemic disease. J Pain Symp Manage 2001; 21:151-168.
–
Mayo MJ, Handem I, Saldana S, et al. Sertraline as first line treatment for cholestatic pruritis. Hepatology 2007;45:666-74.
–
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Tejesh Patel, Gil Yosipovitch: Therapy of Pruritis. Expert Opin Pharmacother. Author manuscript; available in PMC 2011 July 1. Published in
final edited form as: Expert Opin Pharmacother. 2010 July; 11(10): 1673–1682. doi: 10.1517/14656566.2010.484420 PMCID: PMC2885583
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Martin Steinhoff, Ferda Cevikbas, Akihiko Ikoma, Timothy G. Berger. Pruritis: Management Algorithms and Experimental Therapies. Semin
Cutan Med Surg. 2011 June; 30(2): 127–137. doi: 10.1016/j.sder.2011.05.001
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
November 2014
Evidence-Based References
•
Secretions
–
Wilders H, Menten J. Death rattle: prevalence, prevention and treatment. J Pain Symptom Manage 2002; 23:310-317.
–
Cooke, C, Ahmedzai, S, Mayberry, J. Xerostomia--a review. Palliat Med 1996; 10:284.
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Napenas JJ, Brennan MT, Fox PC. Diagnosis and treatment of xerostomia (dry mouth). Odontology 2009;97:76-83.
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Richardson, PS, Phipps, RJ. The anatomy, physiology, pharmacology and pathology of tracheobronchial mucus secretion and the use of
expectorant drugs in human disease. Pharmacol Ther [B] 1978; 3:441.
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LeVeque FG, Montogomery M, Potter D, et al. A multicenter, randomized, double‐blind, placebo‐controlled, dose‐titration study of oral
pilocarpine for treatment of radiation‐induced xerostomia in head and neck cancer patients. J Clin Oncol 1993;11:1124‐31.
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Johnson JT, Ferretti GA, Nethery WJ, et al. Oral pilocarpine for post‐irradiation xerostomia in patients with head and neck cancer. N Engl J Med
1993;329:390‐5.
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NCCN Clinical Practice Guidelines in Oncology: Palliative Care. V.2.2012. Available at: NCCN.org.
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Bennett M, Lucas V, Brennan M, et al. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative
care. Palliat Med 2002;16:369-74.
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Clark, K; Butler, M, Noisy respiratory secretions at the end of life. Current Opinion in Supportive & Palliative Care: June 2009 - Volume 3 Issue 2 - p 120–124
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Wound Odor
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Paul Walker. The pathophysiology and management of pressure ulcers. In: Topics in Palliative Care, Volume 3. Eds. Russell K. Portenoy and
Eduardo Bruera. Oxford University Press 1998. Pp 253-270.
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Grocott P. The palliative management of fungating malignant wounds. J Wound Care. 2000; 9 (1):4-9.
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Newman V, Allwood M, Oakes RA. The use of metronidazole gel to control the smell of malodorous lesions. Palliat Med. 1989; 3: 303-305.
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Bates-Jensen, B.M. (2006). Skin disorders: Pressure ulcers – assessment and management. In B.R. Ferrell, & N. Coyle (Eds.), Textbook of
palliative nursing (2nd ed., pp. 301-328.). New York, NY: Oxford University Press.
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Bates-Jensen B.M., Seaman, S. & Early, L. (2006). Skin disorders: Tumor necrosis, fistules, and stoma. In B.R. Ferrell, & N. Coyle (Eds.),
Textbook of palliative nursing (2nd ed., pp. 329-344.). New York, NY: Oxford University Press
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Grocott, P., & Dealey, C. (2004). Symptom management: Nursing aspects. In D. Doyle, G. Hanks, N. Cherney, & K. Calman (Eds.) Oxford
textbook of palliative medicine (3rd ed., pp. 628-640). Oxford, UK: Oxford University Press.
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Mamedio C, Anduciolo C, Nobre MRC. A systematic review of topical treatments to control odor of malignant fungating wounds. J Pain
Symptom Manage 2010; 39: 1065-76.
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Patel B, Cox-Hayley D. Managing wound odor #218. J Palliat Med 2010;13:1286-7.
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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