Pocket Guide

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FORMULA FOR OPIOID CONVERSIONS

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.
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.

Multiply the equianalgesic unit by the equianalgesic dose of the new opioid (considering the new route).
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)

2. 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

3. 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)

4. 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

5. 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)

6. 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

7. 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