Clinical Practice Guidelines: Nurse Practitioner, Palliative Care Service

Clinical Practice Guidelines: Nurse Practitioner, Palliative Care Service Purpose of Role The Nurse Practitioner (NP) will provide comprehensive palliative care management and advanced nursing care in an expanded nursing role to adults at St John of God Subiaco Hospital (SJGSH), Western Australia. Scope of Practice The role of Nurse Practitioner (NP), Palliative Care Service (PCS) is to optimize the care of patients with palliative care needs. The role will allow the Nurse Practitioner to act independently and also be a member of a team comprising medical staff and other health professionals. The NP will provide comprehensive palliative care assessment, management and advanced nursing care in an expanded nursing role to adults with both malignant and non malignant illnesses, at SJGSH. The patients within this cohort would include: Patients with progressive, life limiting or life threatening disease (malignant and/or non malignant) The patient has symptoms that require specialist assessment/management and which are beyond the capacity of the primary care team to manage optimally The patient and/or their family has psychological, social or spiritual needs that require specialist assessment. The patient is dying and the primary care team requires additional support and/or advice Note: Patients who are having life prolonging treatment are not excluded from palliative care nurse practitioner review. Recurrent presentations to hospital for complications relating to their progressive disease Progressive disease despite life prolonging therapy 1

Low probability of success from available therapeutic options Withdrawal or consideration of withdrawal, of life prolonging treatment (e.g. haemodialysis, ventilation) Patient or family concern about end of life issues Recent marked decline in physical function Patients requiring outpatient follow up for ongoing symptom management and supportive care. Patients and families who require facilitation of Advanced Health Directive discussions. The NP will work within the PCS under the supervision of the Palliative Care Consultants and the Oncology Head of Department and report to the Director of Nursing and Midwifery. Clinical Assessment The Palliative Care NP will: Adopt a holistic approach to patient assessment to include the physical, psychological, emotional and social aspects of care which will inform pharmacological and non pharmacological intervention Undertake a comprehensive patient history and examination with specific reference to physical, emotional, psychological and social aspects of patient care. Employ current subjective and objective symptom assessment scoring techniques to help assess symptom distress. Evaluate the efficacy and adverse effects of pharmacotherapeutic regimes on patient outcomes. Review investigation results to ensure management plan is appropriate. Communicate planned interventions with primary care team. Main palliative care considerations Malignant or non malignant diagnosis Primary diagnosis and spread of disease. 2

Treatment response and options for future anticancer therapies or lifeprolonging interventions Patient and family treatment goals Patient Advanced Health Directive Patient social circumstance Involvement of multidisciplinary team Presentation of symptoms, current management (pharmacological and nonpharmacological), implications of intervention to manage symptoms. Treatment decisions and management plan reflects patient and family choice/wishes and decisions are made in consultation with patient and family. Diagnosis There is an acknowledgement that there will be occasions when the patient s symptoms are reflecting the expected deterioration associated with the progressive nature of the terminal disease and the treatment decisions in such circumstances will be made in consultation with the primary care team, patient and family. Acute situations that would require urgent medical review would include: Spinal cord compression Bowel Obstruction Superior vena cava obstruction Hyperalgesia or pain crisis Haemorrhage Sepsis Treatment of such conditions would be managed in consultation with the primary medical consultant. Drug therapy protocol Principles: Therapeutic Guidelines and Australian Medicine Handbook guide choice of pharmacological therapy within the parameters of the Prescribing Schedule approved by relevant Legislative Authorities, Medical Consultant Palliative Care and Medical Oncologist in practice at St John of God, Subiaco Hospital. The NP will ascertain that the choice of drug is suitable for the patient after considering the following individual information such as: Age 3

Co morbidities such as renal, respiratory and hepatic dysfunction Concomitant medications and potential drug interactions. High risk patient groups Impaired renal function Cardiac disease Cachexia Liver disease Obesity Organ transplantation Mental health problems Cancer Elderly patients Pregnancy / Lactation. Prescription drug therapy protocol Prescriptions written by a NP will be signed by the NP and must identify them as a NP including their name, and their position in a handwritten format below their signature. Prescriptions written by a NP maybe for in hospital use and or for discharge purposes. Follow up Patient will be reviewed at least daily by the PCS if the NP has commenced a pharmacotherapeutic intervention. Ongoing assessment and documentation should focus on the response to treatment such as symptom severity and side effects. Major changes in patient condition will require further comprehensive assessment and medical consultation to form appropriate treatment plan which is aligned with patient and family wishes. A detailed discharge plan will be documented for patients regarding continuation of new medications and other supportive treatments or referrals.. Referral / Consultation Surgical or Medical specialist referral may be required if symptoms are unexpected and physical examination warrants further investigation or intervention. The NP will collaborate with the Medical Consultant prior to referral of patients to other medical practitioners. 4

Use of allied health providers such as physiotherapy and psychology as indicated and collaboration with ward clinical pharmacists is essential for effective symptom management holistic supportive care. The NP will order investigations in accordance with the Medicare items list. Results for pathology and radiology tests must be reviewed as soon as available and if necessary results reported to relevant medical practitioner. The NP will promptly consult with Medical Consultant in the following situations: Persistent signs of distress despite treatment. Previously unidentified, decreased or decreasing function of any vital organ or system. Signs of recurrent or persistent infection. Atypical presentation of a common illness or unusual response to treatment. Further clinical input is required to safely manage the patient. Referral to another health facility is required. In the case of a patient being assessed as being in a potentially life threatening situation or if the patient s condition deteriorates unexpectedly the NP will act in accordance with SJHSH Nursing and Clinical Services Policy 060. Expected Outcomes Improved patient access to palliative care services. Minimization of adverse events. The NP will positively contribute to patient outcomes. Service Evaluation Prescription data and use of approved medications. Number of patient contacts, and type of consultations. Patient and family satisfaction with the NP service. Medical Practitioner satisfaction with the NP service. Joint review of the service by the Palliative Care Consultants and the Oncology Head of Department the Director of Nursing and Midwifery. 5

CLINICAL PROTOCOL: NURSE PRACTITIONER PALLIATIVE CARE This clinical protocol will guide the palliative care nurse practitioner (NP) and will be used in conjunction with Clinical Practice Guidelines: Nurse Practitioner, Palliative Care. The attached formulary of drugs is an extensive list and covers a broad range of drug classes. This is essential to manage palliative care patients from both malignant and non malignant populations who require specialist care at some point along the end of life trajectory. This protocol may be prescribed for palliative care conditions. The list of drugs includes some Off Label (OL) items, which may be indicated in accordance with evidence for best practice for certain conditions. It is acknowledged that the NP has undertaken the intensive pharmacological education at a tertiary level and is registered with the Australian Health Practitioners Registration Authority. It is expected that the NP will apply evidence based approaches to his or her advanced nursing practice through ongoing consultation and collaboration. The NP will work within his/her scope of practice and this decision making framework will guide clinical care planning. The NP takes full professional responsibility for all prescriptions they write under this protocol. Comprehensive health assessments may lead to further diagnostic testing by the NP. Consultation with the patient s medical consultant may lead to changes in the patient s pharmacotherapeutic regime, including drug or dose changes, cessation of particular drug therapies, and/or introduction of new drug therapies. The NP and medical practitioner(s) will manage ongoing diagnostic testing and pharmacotherapy collaboratively. This protocol is based on current national and international evidence for best practice and includes the following websites: DYSPNOEA; AGITATION/TERMINAL RESTLESSNESS; NAUSEA/VOMITING; PAIN; CONSTIPATION http://www.healthnetworks.health.wa.gov.au/cancer/docs/evidence_based_guidelines_201 1.pdf PAIN http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf CONSTIPATION http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf MUCOSITIS http://www.mascc.org/assets/guidelines Tools/mascc%20isoo%20mucositis%20guidelines%20summary%201feb2014.pdf 6

NAUSEA AND VOMITING http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf BLOOD PRODUCT ADMINISTRATION http://www.anzsbt.org.au/publications/documents/anzsbt_guidelines_administration_blo od_products_2nded_dec_2011_hyperlinks.pdf FLUID and ELCTROLYTE REPLACEMENT http://www.nice.org.uk/nicemedia/live/13298/63879/63879.pdf The following drug formulary may be used for each of the palliative care scenarios listed below. Pain Management Paracetamol PO, IV See AMH section 3.1.1 Ibuprofen PO See AMH 15.1.1 Naproxen PO See AMH 15.1.1 Paracetamol 500mg & Codeine 8mg Paracetamol 500mgs & Codeine 30mgs PO See AMH 3.1.2 S3 PO See AMH 3.1.2 R Hydromorphone PO, Subcut, IV See AMH 3.1.2 S8 Morphine PO, Subcut, IV See AMH 3.1.2 S8 Oxycodone PO See AMH 3.1.2 S8 Oxycodone/Naloxone PO See AMH 3.1.2 S8 Fentanyl Subcut (OL), IV, Buccal, TD See AMH 3.1.2 (SCM for Buccal) S8 Methadone PO, Subcut See AMH 3.1.2 S8 7

Buprenorphine PO, SL, TD See AMH 3.1.2 S8 Amitriptyline PO OL/ etg Nortriptyline PO OL/ etg Pregabalin PO See AMH 16.1.3 Sodium Valproate PO OL/ etg Ketamine PO, Subcut, IV See AMH 2.1.1 S8 Midazolam PO, Subcut, IV* See AMH 18.4.1 S8 Clonazepam PO, SL, Subcut OL/eTG Celecoxib PO See AMH 15.1.1 Dexamethasone PO, Subcut (OL), IV See AMH 14.5.2 Hyoscine Butylbromide PO, Subcut See AMH 12.2/ etg (bladder pain) Duloxetine PO OL/eTG S2 8

Nausea Dexamethasone PO, Subcut (OL), IV See AMH 14.5.2 Metoclopramide PO, Subcut (OL), IV See AMH 12.3.1 Haloperidol PO, Subcut See AMH 18.2 Domperidone PO See AMH 12.3.1 Promethazine PO, Subcut, IV See AMH 1.2.1 S3 Hyoscine Hydrobromide PO, Subcut See AMH 12.3.4 S2 Ondansetron PO, SL, IV See AMH 12.3.2 Prochlorperazine PO, Subcut (OL) See AMH 12.3.2 Lorazepam PO, SL (OL) See AMH 18.4.1 Clonazepam PO, SL, Subcut (OL) See AMH 18.4.1 Olanzapine PO, SL OL/ BNF Palliative Formulary Oesophageal Reflux Esomeprazole PO See AMH 12.1.4 Omeprazole IV See AMH 12.1.4 Dyspnoea 9

Morphine PO, Subcut, IV OL/eTG S8 Hydromorphone PO, Subcut, IV OL/eTG S8 Oxycodone PO OL/eTG S8 Methadone PO, Subcut OL/eTG S8 Salbutamol neb See AMH 19.1.1 Ipratropium neb See AMH 19.1.2 Anxiety Lorazepam SL, PO See AMH 18.4.1 Midazolam Subcut (OL), IV See AMH 18.4.1 R Clonazepam PO, SL, Subcut (OL) See AMH 18.4.1 Triazolam PO See AMH 18.4.1 Alprazolam PO See AMH 18.4.1 S8 Constipation Bisacodyl PO, PR See AMH 12.4.2 Unscheduled Senna PO See AMH 12.4.2 Unscheduled Docusate PO See AMH 12.4.1 Unscheduled Sorbitol PO See AMH 12.4.4 Unscheduled Polyethylene glycol macrogol (Movicol) PO See AMH 12.4.3 Unscheduled Glycerol PR See AMH 12.4.3 Unscheduled Pyridostigmine PO OL/ BNF palliative Guidelines 10

Neostigmine Subcut OL/ BNF palliative Guidelines Methylnaltrexone Subcut See AMH 12.4.4 Sodium picosulphate PO See AMH 12.4.3 S3 Lactulose PO See AMH 12.4.3 Unscheduled Psyllium PO See AMH 12.4.4 Unscheduled Docusate and Senna PO See AMH 12.4.2 Unscheduled Diarrhoea Generic Name Route Evidence Codeine PO OL/ etg S8 Loperamide PO See AMH 12.5.1 S2 Psyllium PO See AMH 12.4.4 Unscheduled Delirium Risperidone PO OL/ etg Olanzapine PO, SL OL/ etg Haloperidol PO, Subcut See AMH 18.2 Midazolam Subcut, IV* OL/eTG R Lorazepam PO, SL OL/eTG Quetiapine PO OL/eTG 11

Terminal Agitation Clonazepam PO, SL, Subcut See AMH 18.4.1 Midazolam Subcut, IV* See AMH 18.4.1 R Phenobarbitone Subcut BNF Palliative Care Formulary, OL/ etg Antimicrobials Ciprofloxacin PO Quinolone antibiotic See AMH 5.1.9 Fluconazole PO Antifungal agents See AMH 5.2.1 Amoxycillin and clavulanic PO Penicillin antibiotic acid See AMH 5.1.8 Ticarcillin with clavulanic IV See AMH 5.1.9 acid Mouth Care Lignocaine Viscous 2% PO See AMH 2.4.1 S2 Gelclair Topical _ Unscheduled Mood Mirtazapine PO See AMH 18.1.4 12

Desvenlafaxine PO See AMH 18.1.4 Intravenous Fluid Generic Name Route Schedule Sodium Chloride 0.9% IV Unscheduled Potassium Chloride (premixed bags ONLY) IV Unscheduled Itch Promethazine PO See AMH 1.2.1 S3 Loratadine PO See AMH 1.2.2 S3 Doxepin PO OL/eTG Ondansetron PO OL/eTG *=IV midazolam, for emergency use only up to 10mg OL = Off Label, CTO = Continuing Therapy Only, SCM = Shared Care Model Sources of evidence used for this clinical protocol include: http://www.amh.net.au/ (2013) AMH Online, Australians Medicines Handbook http://aah.hcn.com.au, Australian Anti infection Handbook http://www.tga.gov.au/ Therapeutic Goods Administration, Australian Government; Department of Health and Ageing Australian Medicines Handbook (Current edition). AMH. Adelaide: South Australia. Australian Medicines Handbook (Current edition). Aged Care Drug Choice Companion. AMH Adelaide: South Australia Electronic Therapeutic Guidelines (Palliative Care) complete (Current edition). Therapeutic Guidelines Complete: Melbourne. 13

BNF Palliative Care Formulary (Fourth Edition). Palliativecaredrugs.com. United Kingdom: 2012 Multidisciplinary Advisory Group The multidisciplinary Advisory Group agrees that this scope of practice and formulary has been developed collaboratively and is supported practice for the named oncology nurse practitioner at St John of God Subiaco Hospital. Name and Designation Signature Date Ms Laura Colvin Director of Nursing and Midwifery St John of God Subiaco Hospital Dr Derek Eng Medical Consultant Palliative Care St John of God Subiaco Hospital Dr Han Wei Chiew Medical Consultant Palliative Care St John of God Subiaco Hospital Dr Andrew Dean Head of Department Medical Oncology St John of God Subiaco Hospital Dr Joe Pracilio Medical Director/Head of Anaesthetics St John of God Subiaco Hospital Peter Custance Chief Pharmacist St John of God Subiaco Hospital AUTHORISATION Name and Designation Signature Date Dr Lachlan Henderson Chief Executive Officer St John of God Subiaco Hospital NURSE PRACTITIONER Louise Angus Signature: Date: 14