Managing Symptoms at the End of Life When the Oral route Fails

1. What is an RMAD? 2. Indications for the Use of the RMAD 3. Benefits of RMAD Placement 4. Making an RMAD 5. Placing an RMAD 6. Administering Medications via the RMAD 7. Documentation

A RMAD is a device which allows for easy and comfortable administration of fluids or medications that are in solution or suspension into the rectum.

The RMAD consists of: The RMAD consists of: A tube to carry the medication into the rectum Small holes at the end of the tube to disperse the medication onto the rectal mucosa A medication port A balloon inflation port which inflates a 10ml balloon inside the rectum

RMAD placement showing easy access to ports. Placement of the RMAD in the distal 1/3 of the rectum. Placement of the RMAD in the distal 1/3 of the rectum, showing Tube secured to patients thigh for easy access to the ports.

Indications The patient is in the last days to week of life, no longer able to swallow, and: Oral doses of liquid pain medications > 1.5ml Symptoms spiraling out of control Family is overwhelmed Patient is severely Agitated Multiple oral medications for comfort Copious oral secretions or vomiting Bowel obstruction Seizures

Benefits of RMAD placement 1.Quick control of severe symptoms (Pain, Agitation, SOB, Seizures < 1HR) 2.The patient no longer has to be repositioned for medications 3.Medication administration is painless 4.All current comfort medications can be continued

Benefits of RMAD placement 4.Highly cost effective 5.More reliable/quicker acting than transdermal gels 6.Families can give all medications easily by one route 7.Decreased chance of aspiration of medications

The RMAD Kit 1 Large Zip-lock bag 1 RMAD 1 Package water soluble lubricant 1 Mortar and Pestle 2 -10ml syringes 1-3ml syringe 1-specimen container 1- Catheter securing device 2-Clean barrier pads 1 pair- non-sterile gloves 2- Medication and Instruction Sheets 1- RMAD Quick Reference Sheet

Making an RMAD Step 1: Open one 14fr and one 16fr-5cc Foley catheter, but do not remove the 16fr catheter from its package.

Making an RMAD Step 2: Cut the valve off of the 14fr catheter

Making an RMAD Step 3: Place the cut valve (green) onto the drainage end of the16fr catheter.

Making an RMAD Step 4: Place tape (cloth-paper tape works well) around the drainage end and valve.

Making an RMAD Step 5: Leave the finished RMAD in the package.

Assessment Guidelines Prior to Placement Assess rectal opening for wounds, abscesses, or drainage Assess for diarrhea or hard stool Assess for allergy to latex, if present, use non- latex catheters to make RMAD.

Six general guidelines for administering medications via the RMAD. 1.Use cool tap water (not refrigerated). 2.Suspend solid medications as follows: For a small sized tablet (e.g., Valium) add 1ml water For a medium sized tablet (e.g., Phenobarbital) add 1.5ml water For a large sized tablet (e.g., Vicodin) add 2 ml water 3.Total amount should not exceed 13ml (including flush). 4.Instill over 5 to 10 seconds. 5.Tip syringe back and forth. 6.Always flush the RMAD with 3ml water after every dose.

Medications that can be given via RMAD Liquid Morphine Benzodiazepines (Ativan, Diazepam, etc.) Barbiturates (Nembutal, Phenobarbital) NSAID’s (excluding salicylates) Oral steroids Most anti-seizure Medications (not Dilantin) Anti-nausea Medications Resperidal and Haloperidol

Medications that cannot be given via RMAD. Dilantin Any “Do not Crush” Medications* Switch to short acting given ATC ASA and related Medication (Salicilates) Switch to Indocin

Sample Orders for RMAD Placement and Medications. Placement: “RN to place Rectal Medication Administration Device 3 inches into rectum. Inflate balloon to 10ml.” Medications: Phenobarbital Give Phenobarbital 400mg every 12 hours rectally via RMAD. Morphine (Scheduled) Give Liquid morphine (20mg/ml) -4ml every 4 hours rectally around the clock via RMAD.