Agitation Excessive physical or mental restlessness. Increased activity that is generally not purposeful and associated with anxiety.

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1 October 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 possibl e. 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 as needed relief no relief Continue same dose Haloperidol every 12 scheduled Evaluate to continue, taper or dc Titrate up by 1 mg every 1 hour until desired effect achieved (1mg, 2 mg, 3 mg, etc); MDD 20 mg Lorazepam 0.5mg PO or IV every 1-2 as needed MDD* 12 mg no relief after MDD Haldol Consider Palliative Service consultation atypical antipsychotic meds starting doses for delirium Olanzapine 2.5mg q12 Risperidone 0.25mg q12 Quetiapine 12.5mg q12 relief no relief after 24 Benzodiazepines may increase agitation and delirium; consider chlorpromazine 25 mg IV every 8 Continue Lorazepam Evaluate regularly to taper or discontinue 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.

2 Antiemetic Medications Antiemetic Medications Butyrophenones Haloperidol (Haldol ) Droperidol (Inapsine ) Prokinetic agents Metoclopramide (Reglan ) (Metozolv ) Phenothiazines Prochlorperazine (Compazine ) Thiethylperazine (Torecan ) Trimethobenzamide (Tigan ) Etiology of Nausea and Vomiting Opioid induced nausea, chemical and mechanical nausea Post-op nausea and vomiting or CINV Gastric stasis Ileus in absences of complete obstruction Low level nausea and vomiting Low level nausea and vomiting Low level nausea and vomiting Dosage/Route Oral: mg every 4-6 SC: 1-5 mg/day via CSCI IV: 0.5 mg every 3-4 IV, IM: mg every 2-4 IV, IM: up to 2.5 mg mg, every 4-6 PO, ODT, IV Oral: 5-25 mg every 4-6 PR: 25 mg every 6-8 IM 5 mg/ml every 3-4 IV mg every 4-6 Oral: 10 mg every 4 IM: 10 mg/2 ml every 4 PR: 10 mg every 6-8 Oral: mg every 4 PR: 200 mg every 4 IM: 200 mg/2 ml every 34 Comments Dystonias Dyskinesia Akathisia Low side effects at lower dosage Black box warning Prolonged QTc interval and cardiac arrhythmia and sudden death Prolonged half-life in renal failure Dystonia Akathisia esophageal spasm Colic in GI tract obstruction Allergic reaction, EPS, headache, dry mouth, hypotension, drowsiness, irritation and anxiety May cause excessive drowsiness in elderly IM route is painful

3 Atypical Antipsychotic Olanzapine (Zyprexa, Zydis ) Dexamethasone Ondansetron (Zofran ) Granisetron (Kytril ) (Sancuso ) Aprepitant (Emend ) Dronabinol (Marinol ) Nabilone (Cesamet ) Hyoscine Scopolamine CNIV or patients with cancer Cerebral edema Intra-cranial tumors CINV Bowel obstruction CINV, abdominal radiation therapy, Post-op GI irritants CINV, abdominal radiation therapy, Post-op Acute and delayed CINV Only PO: mg QD-BID PO: 2-4 mg every 6 IV: 2-4 mg every 6 PO/ODT: 8 mg- 24 mg in divided doses depending on etiology IV: 0.15 mg/kg every 12 PO: 1 mg every 12 Transdermal patch: 3.1 mg/24 IV: 10 mcg/kg every 12 PO: 125 mg 1 hr prior to chemotherapy then 80 mg QD day 2 & 3 Second line antiemetic 2-10 mg every 2-4 PO Intestinal obstruction, peritoneal irritation, 1-2 mg BID-TID (max dose 6 mg/day) SL: mg every 4-8 Expensive. Sedation, hyperglycemia, reduced seizure threshold and increased serum lipids. Side effects profile helpful for palliative patients such as weight gain and improved appetite Insomnia, anxiety, euphoria and perirectal burning with IV administration GI upset Must taper to discontinue Constipation Headache Diarrhea Mild sedation Expensive. Constipation Headache Diarrhea Mild sedation Expensive Expensive. Sedation, dizziness, disorientation, concentration difficulties. Dysphoria, hypotension, dry mouth and tachycardia Caution in older adults Dry mouth, ileus, urinary retention, blurred vision,

4 Cyclizine (Meclizine ) Diphenhydramine (Benadryl ) Octreotide (Sandostatin; Sandostatin (LAR Depot) Lorazepam (Ativan ) increased intracranial pressure, excess secretions Motion sickness Motion sickness Increase intracranial pressure Intestinal obstruction Bowel obstruction SQ: mcg every 4-6 CSCI: mg/day Transdermal: mg every 72 Oral: mg every 8 Oral /IV mg every 6-8 SC: mg TID IVCI: mg/day IM Depot: mg every 3-4 wks agitation Sedation Dry mouth Blurred vision Expensive. Pain at injection site; worsening GI symptoms Reduces peristalsis and intestinal Secretions Dose reduce if renal or hepatic insufficiency Expensive for patient on outpatient basis. Anxiety mg QD-TID Not FDA approved as antiemetic Sedation Amnesia Delirium Depression

5 October 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, 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 For opioid induced constipation, consider methylnaltrexone SQ injection (<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.

6 Constipation Medication Laxative Classification Bulk-Producing Agents Polycarbophil Methylcellulose Psyllium Dietary Fiber Osmotic Agents Lactulose Sorbitol Saline laxatives Sodium bisphosphate Magnesium citrate Magnesium hydroxide Polyethylene glycol Glycerin suppository Surfactant Agents Docusate Sodium Stimulant Laxatives Bisacodyl tablet Senna Bisacodyl Mechanism of Action Potential Side Effects Increase stool bulk and by providing a substrate for bacterial growth and gas Works in 2-4 days Causes the intestines to draw in water, causing softening the stool and increased fecal weight. This promotes peristalsis by mechanical distention. Often effects seen in Increases water in intestinal lumen causing increased fecal weight Alters intestinal mucosal permeability and increases absorption of water into the intestine Distension Bloating Abdominal pain Lactulose: Flatulence Cramps Abdominal distention. Sorbitol: Less nauseating then lactulose Diarrhea Nausea Abdominal cramps Skin rash Watery diarrhea Abdominal cramping and discomfort Comments Need plenty of water ( ml) to be effective. Not effective in patients taking opioids Limited use in the seriously ill Lactulose: Monitor glycemic control in diabetic patients First line to use with stimulant laxative for opioid induced and other iatrogenic causes Not for use alone in management of opioid induced constipation First line for opioid induced or other iatrogenic causes. Use with stool softener recommended. Contraindicated in suspected intestinal obstruction or severe dehydration

7 Laxative Classification suppository Opioid-Receptor Antagonist Methylnaltrexone Lubricant Laxative Mineral oil Mechanism of Action Potential Side Effects Increases intestinal motility through direct stimulation of the nerve endings in the colonic mucosa. Work in 6-13 Displaces opioid binding in tissues in the gastrointestinal tract. Works in Coats the bowel and the stool mass with a waterproof film. This keeps moisture in the stool. The stool remains soft and its passage is made easier. Works in 6-8 Diarrhea Electrolytes imbalance Dermatitis Abdominal pain Flatulence Vomiting Nausea Fever Dizziness May interfere with the absorption of fat soluble vitamins like K, D, A, and E. Avoid mineral oil for patients taking blood thinners as it effects absorption of Vitamin K Comments Very expensive. Given as a subcutaneous injection Indicated for patients with opioid induced constipation not relived with other measures Do not take within 2 of other medications or vitamins to minimize issues of absorption Instruct patients not to lay down after taking mineral oil due to risk of pneumonia Do not give with docusate Mineral oil can cause pneumonia if aspirated by those with swallowing difficulties Diarrhea Cramps

8 Laxative Classification Enemas Phosphosoda Enema Mineral oil enema Mechanism of Action Potential Side Effects Overuse of phosphate enemas for constipation can lead to a condition called hyper-phosphatemia Salt called sodium phosphate keeps water in the intestines 2-10 minutes Lubricates the stool Retentions >30-60 min softens rectal stool Work in mins Dehydration Regular use can cause electrolyte imbalance Comments Should be used sparingly Should not be used in patients with low white blood cells or platelets Stool must be low in the colon to experience benefit to experience relief Saline Suppositories Glycerin Bisacodyl Softens stool & stimulate distal colon peristalsis Glycerin irritates the contractions of the muscles in the rectum to make expulsion of suppositories easier after the hardened fecal matter has been softened Bisacodyl acts by stimulating the nerve endings in the walls of May cause hypocalcemia and hypophosphatemia Stool must be low in the colon to experience benefit

9 Laxative Classification Mechanism of Action Potential Side Effects the large intestine (colon) and rectum Comments

10 October 2012 Complete respiratory assessment 12 If oxygen sats <90% give oxygen 2L/min. Check hemoglobin and transfuse if consistent with care goals established on signout. Dyspnea The sensation of air hunger. May be exhibited by gasping, accessory muscle involvement in breathing, tachypnea, discomfort. Complains of dyspnea Bronchospasm with audible wheeze If mild CHF(crackles on exam), with respiratory distress Fentanyl nebulizer 25 mcg in 2.5 ml of NS every 2 prn Albuterol 2 inhalations every 4 prn or 3ml nebulized every 2 prn Furosemide 40 mg PO/IV for one dose Monitor for improvement. Consider MD consult Trial of oxygen 2 liters/min Reassess every 2 If relief, continue If no relief, add oxygen 2 liters/min and ipratropium 1-2 inhalations every 4-6 prn or 2.5 ml nebulized every 4 prn For end stage, consider fentanyl nebulizer 25 mcg every 2 prn with 2.5 ml of NS If no relief, Consider Morphine 10 mg PO every 2 prn or 3 mg subcutaneous or IV hourly prn; monitor respirations If improvement, continue If no relief, add fentanyl nebulizer 25 mcg in 2.5 ml NS every 2 prn. Consider adding oxygen 2 liters/min If no relief, lorazepam 0.5 mg PO or IV every 4 prn. Monitor respirations 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.