Allergies/Sensitivities: Last name: GP Practice:

Transcription

1 Chart No. of Community Palliative Care Drug Chart For authorisation of injectable (PRN) and syringe pump medication, and record of administration for adult patients. Section 1: Patient details, allergies/sensitivities, prescriber details, details of any person who administers medication, once only medicines (front page). Section 2: PRN subcutaneous medication for symptom control. Section 3: Syringe pump medication and cautions. Section 4: Community Palliative Care Prescribing Table (back page). PATIENT DETAILS: First name: Allergies/Sensitivities: Last name: DOB: GP Practice: No known allergies PRERIBER DETAILS: Must be completed by all prescribers. Name (printed) Signature Role Base DETAILS OF PERSON ADMINISTERING DRUGS: Must be completed by all administering drugs. Name (printed) Initials Base ONCE ONLY MEDICINES: Indication Drug (generic name) Date prescribed Route* Dose Date & Time to be given Prescriber signature Given by Date/time given * IM = Intramuscular; = Subcutaneous; BUC = Buccal

2 Patient Name: AS REQUIRED PRN DRUGS AS REQUIRED PRN DRUGS Max Frequency:

3 DRUGS TO BE MIXED TOGETHER IN SYRINGE PUMP FOR CONTINUOUS SUBCUTANEOUS INFUSION OVER 24 HOURS Patient Name: DRUGS TO BE MIXED TOGETHER IN SYRINGE PUMP FOR CONTINUOUS SUBCUTANEOUS INFUSION OVER 24 HOURS Diluent: Water for injection Normal saline (Tick as appropriate) **If more than one syringe pump in use, indicate A or B. Cautions re authorisation of syringe pump drugs with ranges Authorisation of syringe pump drugs in advance is appropriate if likely to be needed in a number of days and the patient s deterioration is not reversible OR occasionally for a patient who is at high risk of a specifi c symptom e.g. vomiting. Authorisation of ranges: for opioid or midazolam a conservative range in the syringe pump allows for incorporation of 2 PRN doses (e.g. morphine 30-40mg) and the usual maximum range allows for incorporation of 4 PRN doses (e.g morphine 30-50mg). Seek specialist advice if considering a wider range. It is not appropriate to authorise syringe pump drugs in advance or with dose ranges in settings where nursing staff do not have adequate syringe pump training e.g. some nursing homes. Cautions re administration of syringe pump drugs authorised as a dose range Start on the lowest dose in the range unless assessment of PRN requirements indicates the need for a higher dose. Rationale for the chosen dose should be documented. If the patient has ongoing symptoms or has already required 2/3 changes to a syringe pump consider GP review and advice from a hospice health care professional. See prescribing table for usual maximum dose of drug in 24 hours, which includes PRN and syringe pump doses.

4 DRUGS TO BE MIXED TOGETHER IN SYRINGE PUMP FOR CONTINUOUS SUBCUTANEOUS INFUSION OVER 24 HOURS Patient Name: DRUGS TO BE MIXED TOGETHER IN SYRINGE PUMP FOR CONTINUOUS SUBCUTANEOUS INFUSION OVER 24 HOURS Diluent: Water for injection Normal saline (Tick as appropriate) **If more than one syringe pump in use, indicate A or B. Cautions re authorisation of syringe pump drugs with ranges Authorisation of syringe pump drugs in advance is appropriate if likely to be needed in a number of days and the patient s deterioration is not reversible OR occasionally for a patient who is at high risk of a specifi c symptom e.g. vomiting. Authorisation of ranges: for opioid or midazolam a conservative range in the syringe pump allows for incorporation of 2 PRN doses (e.g. morphine 30-40mg) and the usual maximum range allows for incorporation of 4 PRN doses (e.g morphine 30-50mg). Seek specialist advice if considering a wider range. It is not appropriate to authorise syringe pump drugs in advance or with dose ranges in settings where nursing staff do not have adequate syringe pump training e.g. some nursing homes. Cautions re administration of syringe pump drugs authorised as a dose range Start on the lowest dose in the range unless assessment of PRN requirements indicates the need for a higher dose. Rationale for the chosen dose should be documented. If the patient has ongoing symptoms or has already required 2/3 changes to a syringe pump consider GP review and advice from a hospice health care professional. See prescribing table for usual maximum dose of drug in 24 hours, which includes PRN and syringe pump doses.

5 Community Palliative Care Prescribing Table: Injectable & Medication for Symptom Control (N.B. consider Just in Case (JiC) medication 1 PRN drug for each symptom 1-4) Just in Case (JiC) medication: supply at least 10 doses when authorising PRN drugs only. More doses will be needed if complex symptoms requiring frequent PRNs or if authorising syringe pump: e.g. at least 3 days supply. Symptom Drug Subcutaneous () as required (PRN) dose: Vial Strengths Starting dose range over 24 hours via subcutaneous syringe pump Usual total maximum dose/24 hours SYMPTOM 1: PAIN/DYSPNOEA If on oral opioids Morphine 1st Line see table for conversion If egfr <30 seek guidance Diamorphine 2.5-5mg 1 hourly PRN if opioid naïve OR 1/6th 24 hour subcutaneous dose 1 hourly PRN 2.5mg 1 hourly PRN if opioid naïve OR 1/6th 24 hour subcutaneous dose 1 hourly PRN 10, 15, 20 or 30mg/ml in 1ml or 2ml amps 5, 10, 30 or 100mg amps 10-15mg/24hr (if opioid naïve) 5-10mg/24hr (if opioid naïve) No upper limit but prescriber may indicate a max dose SYMPTOM 2: NAUSEA AND VOMITING Opioid or chemical Haloperidol 1.5mg BD PRN 5mg/ml 2.5-5mg/24hr 5mg Prokinetic Metoclopramide 10mg QDS PRN 10mg/2ml 30-60mg/24hr 80mg Centrally induced Cyclizine* 50mg TDS PRN: if not on regular cyclizine. (Not 1st line for JiC) 50mg/ml 150mg/24hr 150mg Broad Spectrum Levomepromazine 5mg TDS PRN 25mg/ml 5-25mg/24hr 25mg SYMPTOM 3: AGITATION IN LAST DAYS OF LIFE 1st line Midazolam 2.5-5mg 1 hourly PRN 10mg/2ml 10-20mg/24hr (5-15mg if lower dose indicated) 60mg + hallucinations or Haloperidol 1.5-3mg BD PRN 5mg/ml 2.5-5mg/24hr 10mg confusion 2nd line Levomepromazine mg QDS PRN 25mg/ml mg/24hr 100mg SYMPTOM 4: RESPIRATORY TRACT SECRETIONS IN LAST DAYS OF LIFE Noisy breathing Hyoscine Butylbromide 20mg 2 hourly PRN 20mg/ml mg/24hr 240mg Can also be used at the same doses for colic/reduce secretions in inoperable bowel obstruction Hyoscine Hydrobromide 400micrograms 4 hourly PRN 400 microgram/ml mg/24hr 2.4mg Conversion of oral to subcutaneous opioids via syringe pump/24hrs Oral morphine s/c morphine Divide oral total 24hr dose by 2 Oral morphine s/c diamorphine Divide oral total 24hr dose by 3 Oral oxycodone s/c oxycodone Divide oral total 24hr dose by 2 *Cyclizine is incompatible with hyoscine butylbromide and has dose related incompatibility with oxycodone in a syringe pump See guidance notes/seek advice for: Patients on opioid patches: do not discontinue, prescribe PRN opioid Opioids in renal failure (egfr <30ml/min/1.73m2): consider fentanyl or alfentanil Antiemetics in Parkinson s Disease: avoid haloperidol and metoclopramide For guidance notes and full guideline including anticipatory prescribing, plus pharmacies stocking palliative care drugs: 24 hour telephone advice: St Peter s Hospice: Weston Hospice: Dr C Cornish for Bristol Palliative Care Collaborative and Regional Anticipatory Prescribing Project. Jan Review Dec Version 3