Adult Palliative Care Nurse Practitioner Scope of Practice For the management of adult palliative care patients registered with Southern Adelaide Palliative Services Version 1.0 November 2006 Version 2.0 November 2010 Version 3.0 May 2012 May 2012
Table of Contents Section Content Page Number 1. Description of Health Service 3 2. Disclaimer 4 3. Plan for Dissemination, Implementation, Review and Evaluation of Health Management Protocol 4. Scope of Practice Statement 4 5. The Role of the Palliative Care Nurse Practitioner 5 6. Follow up, Monitoring and Evaluation 6 7. Referral 7 8. Expected Health Outcome 8 9. Drug Therapy Protocol 8 10. Auditing Nurse Practitioner Clinical Practice 19 11. References 20 4 12. Appendices: 21 Appendix A *separate attachment Opioid Equi-Analgesic Dose Guide Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 2 of 16
1. Description of Health Service Southern Adelaide Palliative Services (SAPS) is a specialist palliative care service operating across the Southern Adelaide Metropolitan area with partnering responsibilities with the South East Region of South Australia, the South Coast, Naracoorte and Kangaroo Island. The target population for the delivery of care by SAPS are people who have a life limiting illness, their primary carer and their family who have complex needs. The service is interdisciplinary and includes specialist palliative care doctors, registered nurses, allied health professionals and volunteers. SAPS has seven main areas of care activity: Hospital consultancy services are provided to Flinders Medical Centre (FMC), Repatriation General Hospital (RGH) and Noarlunga Health Service (NHS) and Private Hospitals in the Southern Adelaide region on request Outpatient Clinics, which operate at Flinders Cancer Clinic, Repatriation General Hospital and Noarlunga Health Service Consultative community palliative care services that operate in collaboration with General Practitioners (GP s), Royal District Nursing Service (RDNS), Domiciliary Care (Dom Care) and other community support services. This is provided to patients and their families at their place of residence including Residential Aged Care Facilities A 15 bed palliative care inpatient unit located at Repatriation General Hospital Daw House Hospice A 24 hour on-call consultancy service for Health Professionals/Service Providers and Patients/Families registered with the service Medical Specialist Outreach and Nursing Mentoring to the rural and peri-urban partners Psychosocial, Volunteer, Bereavement, Pastoral Care and Complementary Therapy Services The Palliative Care Nurse Practitioner (PCNP) role was established at Southern Adelaide Palliative Services (SAPS) in 2006. This was the first Palliative Care Nurse Practitioner role in Australia. The purpose of the role was to address the identified gap in meeting the needs of patients and families with highly complex needs: 30-40 families each year identified by SAPS whose needs were not adequately addressed 82 referrals in 2002 were under the age of 50 These were deemed to be resource intensive They utilised Multiple Service Providers There were often complex psychosocial/psychological issues Primary service providers often had limited specialist palliative care skills There was a limited availability of institution based resources As a result, specific triage criteria were identified. Patient s need to meet 2 of the following criteria to be referred to the Nurse Practitioner: Chronic complex mental health history - Patients who have a long term mental health history who require ongoing assessment and treatment. Multiple service providers - Patients who have more than 3 community service providers (GP, RDNS, Dom Care etc). Complex symptom issues - Patients who have significant, complex symptoms (physical or psychological), that require advanced skills to assess and manage. Family dysfunction - Families who have demonstrated difficulty coming to terms with the diagnosis/prognosis of the patient and where there is significant ongoing conflict Complex individual caregiver issues - Carers who have significant ongoing personal (physical or psychological) and who demonstrate difficulties adapting to the role of carer. Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 3 of 16
The PCNP case manages 15-20 clients in the community and also conducts Outpatient Clinics at GP Plus Centres, seeing new patients referred to the service. On alternate Thursday afternoons the PCNP coordinates and conducts clinics for people with Motor Neurone Disease. Apart from the clinical role, the PCNP also participates in the provision of education, research and other projects and representation on committees at a State and National level. Following receiving a referral, the PCNP will carry out a comprehensive health assessment and identify any issues of concern. The NP will devise a management plan which may include ordering pathology and other investigations required for diagnostic purposes as well as initiating medication and other strategies for pain and symptom management. Formulation and implementation of the management plan occurs in collaboration with the patient, their family, the Palliative Medicine Consultant or Palliative Medicine Advanced Trainees, their General Medical Practitioner (GP) and other Health Professionals/Service Providers as required. 2. Disclaimer This document has been established to provide a frame work for the clinical practice of the Palliative Care Nurse Practitioner. This document should not be considered exhaustive or be used in exclusion of other relevant references, policies and clinical guidelines. It does not replace the need for professional and clinical judgement according to specific clinical requirements that may or may not be included in the document. 3. Plan for Dissemination, Implementation, Review and Evaluation of Scope of Practice The approved Palliative Care Nurse Practitioner Scope of Practice will be held in a repository by the Director of Nursing Rehabilitation, Aged Care & Allied Health Division. This scope of practice will be reviewed and evaluated on a regular basis by the SAPS interdisciplinary team to ensure that it meets the needs of the patients and the appointed nurse practitioner Interim updates are required annually (or earlier if there is a population change or change in practice) to ensure they remain current with best practice. 4. Scope of Practice Statement The NP is responsible and accountable for making professional judgements about when the patient s condition is beyond their scope of practice and for initiating consultation with a medical officer or other members of the health care team. All management initiated under this scope of practice will be in accord with the recommendations published in the Therapeutic Guidelines - Palliative Care, version 3, 2010 and the Australian Medicines Handbook (AMH) - except where specified in other resources and will be adapted to be in line with local practices and conditions. Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 4 of 16
5. The Role of the Palliative Care Nurse Practitioner Includes the following: 5.1 Clinical Assessment The clinical assessment will include a thorough review of the patient s health history as well as a physical and psychosocial assessment tailored to the individuals need. Investigations (may be initiated by NP within scope of practice or referred to treating Doctor/General Practitioner (GP). Pathology MBA 20 Electrolytes and urea Liver function tests Thyroid function tests Serum calcium Serum Glucose C-reactive protein Full Blood Examination Group and Save Group and X-Match Coagulation studies UEC LFT s TFT s Ca++ Glu CRP FBE G&S GXM Coags Monitoring of anti-epileptics Serum phenytoin Serum carbamazepine Arterial Blood Gas ABG Microbiology Microscopy, culture and sensitivity (MC&S) Urine Sputum Wound swab Stool Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 5 of 16
Radiology Plain chest xray Plain abdominal xray CXR AXR Plain xray of limbs Ultrasound Legs Ulltrasound Abdomen and Pelvis Other Pulmonary Function Tests PFT s 5.2 Palliative Care Treatment Plan Non-pharmacological Management Counselling, psychosocial and family support Non drug symptom management strategies (e.g. in pain, dyspnoea, anxiety etc) End-of-life care planning including advanced health directives Co-ordination and provision of carer support Pharmacological Management for symptoms experienced by patients who are in the palliative phase of an illness (may be initiated by NP within scope of practice or referred to GP or another Medical Consultant). These symptoms include: Pain Constipation Nausea and vomiting Dyspnoea Delirium Fungal Infections Panic/Anxiety Seizures Sleep Disturbance 5.3 Patient and Family Support Facilitating / participating in case conferences as well as providing information and support to patients and families to assist in their decision making regarding their options for treatment and care. Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 6 of 16
5.4 Management of Care in the Last Days of Life Review of medication requirements / converting oral opioids to subcutaneous opioids /writing up subcutaneous medication orders / commencing a syringe driver if necessary (Refer Appendix A separate attachment) Provision of information and support to families who are coping with the loss of a close family member. 5.5 Education / Mentoring / Research Provision of palliative care education as required Active involvement in initiating research and projects aimed at improving care Mentoring of Nurse Practitioner Candidates as required 6. Follow-up, Monitoring and Evaluation The NP will consult with the appropriate Health Professionals/Service Providers at completion of the initial assessment to discuss findings as well as care / treatment options as required A detailed letter and treatment recommendations is sent to the GP and other Health Professionals/Service Providers involved in the care of the patient after each Outpatient Consultation and as required The NP will continue to monitor and evaluate the patient s response to therapeutic interventions, particularly medications. This is achieved by face-to-face contact with the patient/family or via telephone contact to the patient/family or other Health Professionals/Service Providers. 7. Referral The PCNP will work in a collaborative arrangement with General Practitioners, Palliative Medicine Consultants, Palliative Medicine Advance Trainees and Medical Consultants from other specialties. Referrals will be initiated by the PCNP to other Health Professionals/Service Providers, including Medical Consultants as required. 7.1 Referral to Acute Services or Palliative Medicine Consultant (Where specialist medical intervention may be required to treat /manage the cause. Consideration will be given to the appropriateness of further investigation / treatment depending on the clinical context and patient and family wishes.) Suspicion of spinal cord compression Severe agitated delirium Seizures Unexplained or uncontrolled pain Acute deterioration in respiratory status Uncontrolled nausea and vomiting Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 7 of 16
Cardiac Failure Urinary retention Abdominal distension requiring assessment Fracture Hypercalcaemia Chronic Obstructive Pulmonary Disease infective exacerbation Adverse drug reactions New issues requiring timely investigation 7.2 Referral to GP Exacerbation of chronic disease outside the scope of practice of the nurse practitioner 7.3 Other Referrals Pharmacist Medical Specialists Allied Health Practitioners Volunteers Complimentary Therapy Network Facilitator Bereavement Services Mental Health Services Aged Care Services Disability Services Disease Specific Services ie. MND Association, Heart Failure Nurses, Respiratory Nurses Hospital Avoidance Programmes Currently in Australia Nurse Practitioners only have access to a Medicare provider number if they are working in private practice Consequently, until this situation changes, a referral from a nurse practitioner may cause financial disadvantage for the patient. To ensure the patients are not financially disadvantaged, all private referrals from the PCNP will be completed in collaboration with the patient s GP or a senior medical officer with a provider number. 8. Expected Health Outcome Optimal symptom control in the context of patient and family goals of care in the appropriate care setting. 9. Drug Therapy Protocol 9.1 Nurse Practitioner prescribing of medication The GP and the Palliative Medicine Consultant are the lead clinicians for the co-ordination of the patient s care and thus any new medications, titration of medication and recommended discontinuing of medication must be communicated to him / her. In most situations the GP will then provide subsequent scripts and medication orders for the patient. The PCNP is required to document any medication changes on the appropriate forms. Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 8 of 16
A patient who is on opioids to manage pain may experience a severe exacerbation of pain requiring titration of the opioid medication. The PCNP after assessing the patient s symptoms and calculating the required increase can increase the opioid dose and inform the GP of the change(s) in medication(s). The PCNP will have a Prescriber Number allocated by Medicare Australia, which enables medications to be prescribed in accordance with the current Department of Health and Ageing (SA) Policy in relation to Nurse Practitioner Prescribing. Choice of drug therapy is guided by the Therapeutic Guidelines Palliative Care version 3 (2010) and the Australian Medicines Handbook within the parameters of the Controlled Substances Act of South Australia (1984). The PCNP must verify that the choice of drug is suitable for the patient after carefully considering the following individualised patient information, such as: 1. Age 2. Previous allergies 3. Adverse drug reactions 4. Co-morbidities such as renal and hepatic dysfunctions 5. Concomitant medication for potential drug interaction. All care will be taken by the PCNP when selecting drug treatment to avoid adverse medication events. Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 9 of 16
9.2 Algorithm for PCNP pharmacological management of chronic nonmalignant pain for patients requiring a palliative approach. Mild to moderate pain assess for location, nature, severity of pain. Consider non- pharmacological management eg. massage therapy, heat packs, psychological intervention, referral to physiotherapist and diversional therapist Pain persists Avoid NSAIDs in cardiac disease, moderate to severe renal failure, history of peptic ulcer. Mild to moderate pain commence paracetamol (do not exceed 4 gm / 24 hours). Consider non-selective NSAID may need to add PPI. Assess efficacy of analgesia and monitor for side effects. Partially effective / pain increases If neuropathic component to pain add tricyclics antidepressant (amitriptyline) or anticonvulsant (sodium valproate) Add low dose prn opioid eg. I.R oxycodone 2.5-5 mg or morphine hydrochloride 2.5-5 mg 3 rd hourly prn for B/T pain or incident pain Assess for efficacy of medication. Monitor for side effects / adverse reactions. Commence concurrent prn antiemetic and prn aperients. Partially effective / pain increases Add C.R or S.R opioid oxycontin or ms contin or kapanol or buprenorphine patch or fentanyl patch. Dose will depend on pain assessment and number of B/T opioid doses required over previous 24 48 hrs. If severe dysphagia or if malabsorption by oral route is suspected, then subcutaneous route should be used. Dose should be 1/3 of oral equivalent. Assess for efficacy of medication. Monitor for side effects / adverse reactions. Continue prn antiemetic and prn aperients Partial or ineffective treatment response Consult with Palliative Medicine Consultant/GP Abbreviations I.R - immediate release C.R - controlled release S.R sustained release PPI - proton pump inhibitor B/T - breakthrough NSAID non-steroidal anti-inflammatory drug Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 10 of 16
9.3 Algorithm for NP pharmacological management of pain in advanced malignant disease Mild to moderate pain assess for location, nature, severity of pain. Consider non- pharmacological management eg. massage therapy, heat packs, psychological intervention, referral to physiotherapist and diversional therapy Pain persists Avoid NSAIDs in cardiac disease, moderate to severe renal failure, history of peptic ulcer. If neuropathic component to pain add tricyclic antidepressant (amitriptyline) or anticonvulsant (sodium valproate) Mild to moderate pain commence paracetamol (do not exceed 4 gm / 24 hours). Consider non-selective NSAID may need to add PPI. Partially effective / pain increases Add low dose prn opioid eg. I.R oxycodone 2.5-5 mg or morphine hydrochloride 2.5-5 mg 2 nd hourly prn for B/T pain or incident pain Assess efficacy of analgesia and monitor for side effects. Assess for efficacy of medication. Monitor for side effects / adverse reactions. Commence concurrent prn antiemetic and prn aperients. Partially effective / pain increases Add C.R or S.R opioid oxycontin or ms contin or kapanol or fentanyl patch. Dose will depend on pain assessment and number of B/T opioid doses required over previous 24 48 hrs. Assess for efficacy of medication. Monitor for side effects / adverse reactions. Continue prn antiemetic and prn aperients Partial or ineffective treatment response Consult with Palliative Medicine Consultant and/or GP. Titrate opioids based on assessment and prn B/T requirements Commence / continue neuropathic agent if neuropathic component to pain If severe dysphagia or if malabsorption by oral route is suspected, then subcutaneous route should be used. Dose should be 1/3 of oral equivalent. Assess for efficacy of medication. Monitor for side effects / adverse reactions. Continue prn antiemetic and prn aperients Partial or ineffective treatment response Abbreviations I.R - immediate release C.R - controlled release Refer to Palliative Medicine Consultant / GP. S.R sustained release PPI - proton pump inhibitor B/T - breakthrough Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 11 of 16 NSAID non-steroidal anti-inflammatory drug
9.4 Preferred Prescribing List for Palliative Care Nurse Practitioner Choice of drug therapy and recommended doses guided by Therapeutic Guidelines. Palliative Care. 2010 Paracetamol Ibuprofen Diclofenec Naproxen Dexamethasone Morphine Oxycodone Fentanyl Hydromorphone Buprenorphine Amitryptilline Gabapentin Metaclopramide Haloperidol Glycopyrolate Midazolam Stemetil Domperidone Macrogol Docusate with Senna Omeprazole Oxygen Clonazepam Nystatin Amphotericin Fluconazole Carmellose Sodium Hyoscine Hydrobromide Oxazepam Temazepam Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 12 of 16
9.5 Medically assisted hydration in the palliative context Indications for administering subcutaneous fluid include Patient who is clinically dehydrated and it is expected that comfort will be improved by hydration In the terminal phase of a palliative illness where families are having difficulty coming to terms with the patient being no longer able to take food or fluids by natural means Treatment Normal saline can be administered at 1 litre over 24 hours. Fluids should be discontinued if no improvement after 3 days. Contraindications for medically assisted hydration in the palliative context Subcutaneous fluids should not be administered when fluids need to be administered rapidly and in large amounts e.g. shock, severe dehydration, or when the patient is at high risk of developing pulmonary congestion or oedema, or with clotting disorders. 9.6 Blood Transfusions The PCNP is able to request group and match and write written orders for Blood Transfusions when required by patients managed under the Palliative Care Service and approved by a Doctor. The transfusion will either be administered as a day patient in a Public Hospital where the patient is admitted under a Palliative Medicine Consultant or in the patients own home under the care of Hospital Avoidance Providers. 9.7 Replacement of Gastrostomy Tubes The PCNP is permitted to change Balloon Gastrostomy Tubes for patients who have had their initial tube replaced in a hospital setting. Training to perform this procedure has been provided by the Gastroenterology Nurse at RGH. 9.8 Verification of Death The PCNP may verify an expected death of a palliative care patient in the absence of a doctor. The PCNP must notify the doctor nominated to complete the death certification as soon as possible after the death has occurred. The PCNP should not verify the death in situations where the death is suspicious and/or a report to the Coroner is required. 10. Auditing Nurse Practitioner Clinical Practice Weekly case conference meeting with the palliative care interdisciplinary team. The NP presents a case / cases and discusses and seeks input and advice from the team into the treatment plan. Clinical Support available from a Palliative Medicine Consultant or Advanced Trainee either in person or via phone at all times. Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 13 of 16
Annual Performance Development Review and Plan to be conducted with the Director of SAPS and the Director of Nursing Rehabilitation, Aged Care & Allied Health Division. PCNP participation in the fortnightly Radiology Review Meetings when possible Collaboration and Consultation with Palliative Care Advanced Practice Pharmacist on a regular basis Endorsements: Karen Glaetzer Palliative Care Nurse Practitioner Southern Adelaide Palliative Services Justin Prendergast Director of Nursing Rehabilitation, Aged Care & Allied Health Division Repatriation General Hospital Kate Swetenham Service Director Southern Adelaide Palliative Services Dr Michael Briffa Palliative Medicine Consultant Medical Lead Southern Adelaide Palliative Services Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 14 of 16
11. References 1. Therapeutic Clinical Guidelines. Palliative Care. Version 3, 2010 2. Primary and Clinical Care Manual (PCCM) Qld Health 2007 3. 4. Health Management Protocol Community Palliative Care Nurse Practitioner - For the management of palliative care patients in the adult population Brisbane, Queensland Health Management Protocol Palliative Care Nurse Practitioner - For the management of palliative care patients living in Residential Aged Care Facilities in Metro South Health Service District Brisbane, Queensland 5. Australian Medicines Handbook 2010 6. Eastern Metropolitan Palliative Care Consortium (Victoria), Clinical Working Party. Opioid Conversion Ratios - Guide to Practice, July 2008 (Appendix A separate attachment) 7. Guidelines for the Handling of Medication in Community-Based Palliative Care Services (Appendix B separate attachment) 8. MIMs electronic and hardcopy 9. Clinicians Knowledge Network QHEPs intranet 10. Guidelines for Palliative Approach in Aged Care 11. Pain Management in Residential Aged Care Facilities 12. Palliative Care Australia Standards 13. CareSearch www.caresearch.com.au 14. Cochrane Data Base Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 15 of 16
12. Appendices Appendix A Opioid Equi-Analgesic Dose Guide Approximately equianalgesic doses of various opioids (Table 1.4) [NB1] Opioid Oral Parenteral (SC/IV) morphine 30 mg 10 mg codeine 240 mg fentanyl [NB3] 100 micrograms hydromorphone 6mg 2 mg methadone [NB4] [NB4] oxycodone 20 mg 10 mg tramadol [NB5] 150 mg 100 mg NB1: These are average equivalent doses because of pharmacokinetic variation between individuals. When changing from one opioid to another, commence with one-third to one-half of the calculated equianalgesic dose and then titrate to response. NB2: See Table 1.6 for other routes of morphine administration. NB3: For conversion of morphine to transdermal fentanyl patches, see fentanyl product information. NB4: Consultation with a pain clinic or a palliative care service is advised. NB5: Tramadol may not be suitable for patients with moderate to severe pain. Therapeutic Guidelines Version 3 2010 Palliative Care Nurse Practitioner - Southern Adelaide Palliative Services Version 3.0 May 2012 Page 16 of 16