1. Innovation and excellence in health and care Addenbrooke’s Hospital I Rosie Hospital FY1 Introduction to Palliative Care 7 th August 2015 Clinical Nurse Specialist Sue Sharpe and Dr Yvonne Cartwright,

2. Innovation and excellence in health and care Managing Symptoms in the Last Days of Life Keep thinking! Pain Nausea Breathlessness Agitation Respiratory Secretions

3. Chocolate biscuits and Fentanyl patches? Innovation and excellence in health and care

4. Opioid Conversions - Codeine Patient admitted on 60mg qds Codeine Phosphate which is working for him. He occasionally thinks he needs a bit extra. There are no contraindications to Oramorph (Morphine Sulphate Immediate Release Liquid 10mg/5ml). How much do you write up as a prn? 1 st Calculate the 24hour Morphine equivalent 240mg of Codeine = 24mg Oral morphine Divide by 6 to get the 4hourly prn dose= approximately 5mg four hourly prn (Prescribe as mg)

5. Innovation and excellence in health and care Opioid Conversions - Tramadol Patient admitted on 100mg qds Tramadol, nurses ask you to write something up in case she gets pain. Again no contra-indication to Oramorph (Morphine Sulphate Immediate Release Liquid 10mg/5ml). 1 st Calculate the 24hour Morphine equivalent 400mg of Tramadol = 80mg of Oral Morphine Divide by 6 to get the 4hourly prn dose= approximately 10-15mg four hourly prn

6. Innovation and excellence in health and care Opioid Conversions MST Gentleman admitted on 30mg MST (Morphine Sulphate Modified-Release tablets). He takes 1 or 2 doses of the liquid Oramorph if he gets pain and it works well. He says he takes a “spoonful”. What would an appropriate prn dose for him? 1 st Calculate the 24hour Morphine equivalent 30mg bd of MST = 60mg Oral morphine Divide by 6 to get the 4hourly prn dose= 10mg (Prescribe as mg)

7. Innovation and excellence in health and care Opioid Conversions MST to Diamorphine Patient previously well controlled on Morphine Sulphate Modified- Release (MST) 30mg bd. Now dying and unable to swallow. No reason to change opioids. What dose of Diamorphine would you put in a syringe driver? 1 st Calculate the 24hour Morphine equivalent 30mg bd of MST = 60mg Oral morphine Divide by 3 to convert the 24hourly Oral Morphine dose to get the 24hourly Diamorphine dose= 20mg Prescribe 20mg Diamorphine/24hours via subcutaneous injection. The prn dose is still 1/6 th of the 24hour dose= 2.5mg-5mg Diamorphine 2-4hourly as required for pain.

8. Nausea Think of a cause before you decide on management Sensible first decision and a sensible method of administration Innovation and excellence in health and care

9. Breathlessness Why is this patient breathless now? Remember that new onset breathlessness at rest is significant in cancer patients Positioning, air, oxygen, management of anxiety, opioids and benzodiazepines may have a role Innovation and excellence in health and care

10. Agitation Why has this patient become agitated? Medication is a last resort but important to use it when it is needed effectively Innovation and excellence in health and care

11. Respiratory Secretions Good nursing, medical care and explanation to the family are as important as getting the medications right Treat symptoms not sounds! Innovation and excellence in health and care

12. Remember Our pages on Connect are full of info Phone if you think we might be able to help - 4404 for a referral or non-urgent/non-immediate advice --Out of Hours Consultant advice via switchboard ask for the on-call Consultant in Palliative Medicine EPIC – Order In-Patient Pall Care Team End of life meds order