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POCKET GUIDE

Pocket Guide

Hospice Palliative Care Reference Tool

If you want to learn more about us, you’re in the right place. 

FORMULA FOR OPIOID CONVERSIONS

  1. Add up the total 24 hour dose requirement of each current opioid which is being given. If both parenteral and oral doses were used, calculate a separate total for each.
  2. Divide each 24 hour dose requirement by the equianalgesic dose listed in the equianalgesic dose chart for the current opioid and current route of administration.

The number obtained is called the equianalgesic unit.

  1. Multiply the equianalgesic unit by the equianalgesic dose of the new opioid (considering the new route).
  2. Divide by the appropriate dose interval or number of times you are giving the new opioid in 24 hours.

PEAK EFFECT OF OPIOIDS

 

  • IV 10-15 minutes
  • SC 20-30 minutes
  • PO 60-90 minutes

 

TITRATING OPIOID DOSE

  • 25% for mild pain (pain scale 1-3)
  • 50% for moderate pain (pain scale 4-6)
  • 75-100% for severe pain (pain scale 7-10)

DOSE ESCALATION FREQUENCY

  • Short-acting oral opioids every 2 hours
  • Sustained release oral opioids every 24 hours
  • Fentanyl transdermal every 72 hours
  • Methadone no more frequent than 96 hours

BREAKTHROUGH DOSING

(Except for Methadone)

  • PO: 10-20% of total daily dose every 2 hours as needed
  • PCA pump – hourly rate given every 15-30 minutes as needed

Make sure to have short acting opioid at home in case of pump failure

ORDERING OPIOIDS

  • Do not use large dosing ranges – limit to double dosing
  • No time interval
  • List both the dose and solution volume when ordering
  • Example: morphine conc 20mg/ml; take 0.25 ml to 0.5ml (5-10mg) orally every 2 hours as needed

Physician Role

  • DO NOT DELEGATE sharing bad news!

Sharing bad news is a physician’s role- in a meeting with a nurse and a team hopefully

  • Patients often accept bad news only from MD
  • MD best prepared to interpret news and to offer advice

Preparation

  • Confirm medical facts; plan presentation
  • Make only one or two main points; use simple, lay language

 Planning Care

  • Discuss agenda of patient/family first
  • Let physician priorities flow naturally after patient/family comments (eg: discussion of resuscitation and other directives)

 Discussion Items

Physical Care. What is best setting for level of care?

Social Care. What are the family and financial issues?

Emotional Care. What are the sources of support?

Spiritual Care. What are the sources of meaning?

  1. Setting the Stage
  • Choose appropriate, private environment (Neither hallway nor curtain provides privacy!)
  • Have tissues available
  • Allot enough time (20-30 minutes minimum with documentation)
  • Determine who should be present; invite SW, chaplain, and palliative care
  • Turn beeper to vibrate (Avoid interruptions, demonstrate full attention)
  • Shake hands with the patient first
  • Introduce yourself to everyone In the room
  • Always SIT at eye level with patient at a distance of 50-75cms
  • Ask permission before sitting on edge of bed
  • Arrange seating for everyone present if possible (Helps put patient at ease, prevent patient from hurrying)
  1. Starting the Conversation

ASK How do patient and family understand what is happening? What have others told them

WAIT 15-30 seconds to give opportunity for response

LISTEN Response may vary from “I think I am dying” to “I don’t understand what is happening.” How much does patient want to know? Ask patient is he/she wants to know prognosis

Patient may decline conversation and designate spokesperson

  1. When Family Wants to “Protect” Patient
  • Honour patient’s autonomy
  • Meet legal obligations for consent
  • Promote family alliance and support for the patient
  • Ask what family is afraid will happen
  • Offer to have family present when you speak to the patient (so they can hear patient’s wishes about knowing status/prognosis)
  1. Sharing Bad News
  • Give warning to allow people to prepare
  • Briefly state only one or two key points
  • Use simple language

STOP

  • Ask questions to assess understanding
  • Recommended statement for terminal illness: “This is an illness that humanity cannot cure,”

Humble statement, leaves open the possibility of the miraculous; helps change the focus from “cure” to palliation and support

Do not minimize severity of news

  1. Response to Emotions of Patient, Family and Staff
  • Be prepared for a range of emotions
  • Allow time for response
  • Communicate nonverbally as well as verbally (Usually acceptable to touch patients’s ARM)
  1. Suggest a Brief Plan

Medical Plan (eg: control dyspnea, home assistance to help deal with weakness)

Ancillary Support (eg: social work visits, pastoral care visits, palliative care visits)

Introduce Advance Care Planning (“Sometimes when people die, doctors try to bring them back to life…. Have you considered whether you would want this or not?”)

Discuss Timeline

  1. Offer Follow-up Meeting

When? Usually within 24 hours

Who? For current and additional family members

Why? To repeat portions of the news

How? Offer to contact absent family members, Get permission to share news if necessary

Next meeting, Upcoming discussions, Suggest flexible timelines

  1. Ending the Meeting

ASK “ DO you have any questions?”

WAIT

ANSWER

STAND An effective way to end the conversation

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