Palliative Care: Pain and Symptom Card
by: Drs P Critchley, M Grantham, E Latimer, N Plach, J Sproat, A Woods
Copyright 1998
Used with permission

Table of Contents

• Opioid Equivalency Table
• Opioids
• Respiratory Depression
• Pain
• Symptoms
• Respiratory
• Neurological
• Mouth Care
• Other Symptoms
• Skin Care
• Subcutaneous Injections
• Steroid Equivalency Chart

Opioid Equivalency Table

• Morphine dose increments (oral): 5, 10, 15, 20, 25, 30, 40, 60, 80, 100, 120 mg. Increments of 30 - 50 mg until 400 mg, then by 100 mg.
• Avoid IM injections: SC route less painful, more reliable.
• Breakthrough analgesia - 50% of regular dose given q 2 hr prn.
• Slow release preparations of morphine, hydromorphone, codeine and oxycodone: calculate total 24 hour dose (oral equivalent), divide by 2 and administer q 12 hr regulary. If pain repeatedly recurs before 12 hrs, increase dose rather than shorten interval.
• Transdermal fentanyl (Duragesic) - continuous release for 72 h. Calculate oral morphine (mg/day) equivalency and apply appropriate dose of patch (mcg/hr)

Example:

See CPS for higher doses.

Opioids

Types:

1. Natural
   • codeine
   • morphine
2. Semisynthetic
   • hydromorphone (Dalaudid)
   • heroin
   • oxycodone (Percocet/Percodan)
3. Synthetic
   • levorphanol (Levodromoran)
   • pentazocine (Talwin)
   • meperidine (Demerol)
   • fentanyl (Duragesic)
   • anileridine (Leritine)

Respiratory Depression

Goal: to reverse respiratory depression without reversal of analgesia. To avoid PAIN CRISIS and WITHDRAWAL REACTION: If respiratory rate is < 8 per minute: naloxone (Narcan) 0.1 mg SC or IV q 10 min. prn. See CPS for doses of naloxone to reverse opioid completely.

Pain

1. Bone Pain
   • aching, localized
   Medications:
   • opioid
   • ± NSAID (naproxen, ibuprofen) + cytoprotective agent (misoprostol 200 mcg po bid - qid)
   or
   • steroid (if unable to tolerate NSAID or prior to radiotheraphy)
   Consider:
   • radiotheraphy
   • splinting
   • surgical fixation
2. Neuropathic Pain
   1. Dysesthetic, burning
      Medications:
      • TCA
        eg. imipramine
        nortriptyline
        amitriptyline
        start at 10 - 25 mg po qhs. Increase dose q 3 - 5 days by 10 - 25 mg as tolerated (max 75 - 150 mg od)
      • capsaicin 0.025% - 0.075% cream applied topically qid requires 6 weeks for benefit
   2. Lancinating, shooting pain Medications:
      • carbamazepine 100 mg - 200 mg po q 12 hrs
        • max 100 - 400 mg tid - qid
        • monitor plasma levels
      or
      • clonazepam 0.25 mg po q 12 hr
        • increase to 0.5 mg - 3 mg po q 8 h as needed
   3. Consider for either of the above:
      • TENS
      • Anaesthesia Consultation
        • nerve block
        • epidural
      • dexamethasone 4 mg po/sc/iv od - qid
3. Visceral Pain
   • deep, poorly localized
   Medications:
   • opoid
   • ± steroid or NSAID

Symptoms

1. Constipation
   • optimize diet, fluids, exercise, privacy...
   • REASSESS DAILY and adjust laxatives as necessary.
   Medications:
   • docusate sodium (Colace) 1 - 2 caps bid-tid
     plus senna (Senokot) 2 - 4 tabs OD-tid
   or
   • pericolace (combination laxative) 1 - 2 caps OD-tid
   or
   • lactulose (Chronulac, Cephlac) 30 - 60 cc OD-tid
2. Nausea and Vomiting
   • rule out NON-OPIOID causes eg. metabolic, BI (reflux, obstruction, constipation), raised intracranial pressure, other drugs...
   • often may discontinue antiemetics in a few days
   Medications:
   • prochlorperazine (Stemetil) 5 - 10 mg q 4 - 8 hr po/pr/im/iv
   or
   • haloperidol (Haldol) 1 - 2 mg bid-tid po/sc
   If gut motility impaired:
   • metoclopramide (Maxeran) 10 mg q 4 - 6 hr iv/sc/po
   or
   • domperidone (Motilium) 10 - 20 mg ac & qhs po
   or
   • cisapride (Prepulsid) 5 - 10 mg ac & qhs po
   If nausea in association with vestibular disturbance
   • dimenhydrinate (Gravol) 50 - 100 mg po/pr/iv/im, q 4 hrs prn

Respiratory

1. Dyspnea
   • treat underlying cause if able
   • cool air, increase air circulation (open window, bedside fan)
   Medications:
   • oxygen if O2 saturation < 90% Caution: COPD Patients)
   • opioid eg. oral or sc low dose morphine (2.5 - 5 mg sc) - if currently on opioid increase dose by 25% - 50%
   • anxiolytic
     • lorazepam 0.5 - 1 mg sl/sc q 4 - 6 hrs prn or regularly
     or
     • midazolam 0.5 - 2 mg sc q 4 - 6 hrs prn or regularly
   • steroid eg dexamethasone 4 mg po/sc/iv bid - qid
   • nebulized opioid (especially for CHF, pulmonary fibrosis) ie. morphine 5 - 10 mg (preservative-free injectable) or injectable hydromorphone 1 - 2 mg in 3 ml normal saline q 4 hrs prn [titrate (increase) to effect].
   • bronchodilators and diuretics as indicated
   Consider:
   • radiotheraphy
   • thoracentesis / pleuradesis
2. Terminal Airway Secretions - "Death Rattle"
   • due to weakness, patient unable to clear secretions
   • suction if required and effective
   Medications:
   • scopolamine (hyoscine) 0.4 mg - 0.6 mg sc q 4 hrs prn (can be given regularly)

Neurological

1. Delirium
   • R/O underlying causes and treat if appropriate eg. hypercalcemia, electrolyte imbalance, dehydration, constipation, cerebral metastases, infection, hypoxia, urinary retention, medications (opioids, anti-cholinergic, sedatives)
   Medications:
   • treat symptoms eg hallucinations, agitation
   • haloperidol 0.5 - 2 mg po/sc q6 - 12 hrs
   or
   • chlorpromazine 12.5 mg - 50 mg im/po/pr/iv q 8 - 12 hrs (regular dose initially)
   If opioid induced
   • rotate to another opioid
   • reduce dose of opioid if possible
2. Restlessness - endstage
   • D/C non-essential meds
   • R/O urinary retention, fecal impaction
   Medications:
   haloperidol 1 - 2 mg sc/po bid - tid (may increase if required)
   or
   • chlorpromazine 12.5 mg - 50 mg im/po/pr/iv q 8 - 12 hrs (may be more sedating)
   or
   • lorazepam 0.5 - 1 mg po/sl/sc q 4 hrs prn
   For severe restlessness consider:
   • medazolam 1 -2 mg sc q 2 h prn (may increase if required)

Mouth Care

1. Dry Mouth
   AVOID:
   • mouthwash containing alcohol
   • glycerine mouth swabs
   Consider:
   • sour candies
   • ice chips, popsicles
   • moisten iwth water or normal saline (spray bottle, syringe, red rubber catheter)
   • K-Y Jelly to inside of mouth
   • humidifier or humidified air / oxygen
   • artificial saliva
   • intravenous hydration or hypodermoclysis if patient is thirsty and above not sufficient
2. Oral Candidiasis
   • due to antibiotics, steroids ...
   Medications:
   • nystatin 500,000 units S & S qid x 7 days
   • ketoconazole 200 mg po od x 5 - 7 days
   • fluconazole 100 mg po od
3. Ulceration and Stomatitis
   Medications:
   • normal saline rinses q 2 hrs
   • benzydamine HCl (Tantum oral rinse - 1/2 or full strength 15 ml qid)
   • penicillin (if severe - po/iv)
   • nystatin 500,000 units S & S qid (prophylactic)
   • xylocaine viscous 2% to paint mouth, -15 ml q 3 h (maximum 120 ml / 24 h)
   • Maalox swish and swallow
4. Oral Crust / Debris
   • rinse with water and hydrogen peroxide (50/50) qid until clear

Other Symptoms

1. Hiccups
   • 1 tsp. white granulated sugar - swallowed dry
   Medications:
   • chlorpromazine 10 - 25 mg po/pr/iv bid - tid x 5 - 10 days and reassess
2. Myclonic Jerks
   • R/O and treat reversible cause where possible eg. uremia, hepatic failure, electrolyte imbalances (Na, K, Ca, Mg), medications eg. opioids (especially when dose increased rapidly)
   • if opioid related - attempt to reduce dose
   Medications:
   • haloperidol 0.5 - 2 mg po/sc q 6 - 12 hrs
   or
   • diazepam 2.5 - 5 mg po/im q 8 - 12 hrs
   or
   • lorazepam 0.5 - 1 mg sc/po/sl q 8 - 12 hrs
   or
   • clonazepam 0.25 - 0.5 mg po bid - tid
   or
   • midazolam 0.5 - 1 mg sc q 4 hrs prn
3. Anorexia
   • R/O underlying nausea, mouth lesions, oral thrush, constipation, depression
   • attempt small portions, increase frequency of meals, offer supplements, serve food cold or room temperature, avoid foods with strong odours.

Skin Care

1. Pruritis
   Topically
   • consider non-allergenic sheets
   • mild soaps
   • moisturizer
   • menthol / camphor
   • topical steroids
   • doxepin topical cream
   Medications:
   • doxepin 10 mg po od - tid
   • cholestyramine if jaundiced
   • oral antihistamines eg. diphenhydramine (Benadryl)
2. Odour Problems - due to necrotic tumour
   Medications:
   • topical metronidazole gel, cream or opened capsules directly on wounds
   • dressing soaked in metronidazole injectable solution
   • metronidazole 250 - 500 mg po/iv q 8 hrs
3. Skin Breakdown
   • prevention: turn q 2 h, pressure relief mattress (Therarest, Advance 2000)
   • protect normal skin with barrier cream or moisturizer
   Stage 1: non blanchable erythema - intact skin. RX - cleanse with normal saline; apply Tegaderm or Opsite to protect from shearing forces
   Stage 2: partial thickness skin loss involving epidermins and/or dermis. RX - cleanse with normal saline; apply Duoderm & check daily
   Stage 3: full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to fascia. RX - saline gel (Normagel or Intrasite gel) and absorptive dressing ie. gauze or Mesalt to absorb exudates. If mucky, 2" Kling soak in proviodine.
   Stage 4: full thickness skin loss iwth extensive destruction of tissue, necrosis or damage to muscle, bone or supporting structures. RX: Irrigate with saline; if mucky, 2" Kling soaked in proviodine, packed into cavity

Subcutaneous Injections

• may be used with some medications where po/pr/iv not practical
• use a 25 gauge short butterly needle when repeated subcutaneous injections anticipated
• cover site with Opsite or Tegaderm
• maximum volume tolerated with injection 1 - 2 cc.
• change site if red, bleeding, swollen, leaking or sore

Steroid Equivalency Chart