1. Top Tips in Palliative Care Dr Claire Curtis (in collaboration with the Worcestershire Specialist Palliative Care Teams) Nov 2012 Click to continue

2. Top Tips Transdermal Fentanyl use at the EOL LCP use Just in case boxes Convulsions in the community Spinal cord compression Hypercalcaemia Acute confusion Click to continue

3. Transdermal Fentanyl - 1 78 year old man with recurrent laryngeal carcinoma Pain from throat – Fentanyl 100 mcg/hr patch – Oramorph 20-30mg prn – approx 3-4 times a day Nausea – Cyclizine liquid 50mg tds Deteriorating rapidly – expected prognosis: few days Plan to remain at home for EOL care. Struggling to take oral medication and complaining of pain without oramorph What do you do? Click to continue

5. Transdermal Fentanyl - 1 No increase Remember: Steady state reached 36-48h after patch applied (but can take longer) If thought near to EOL – may not be time to reach optimal analgesia At home – no easy way to give breakthrough analgesia while waiting for steady state Click to continue

7. Transdermal fentanyl - 1 Start a syringe driver Difficulty swallowing Profound weakness Comatose/moribund (expected soon) (Also need to give anti-emetic) NB: other indications for syringe driver: – Persistent nausea/vomiting – Poor alimentary absorption – Intestinal obstruction – Administration of drugs that cannot be given enterally) Click to continue

9. Transdermal fentanyl - 1 DO NOT remove the fentanyl patch Risk making pain worse ADD an appropriate dose of morphine/diamorphine to the driver – Eg morphine 40mg/24hrs NB – check reason for fentanyl is not renal impairment Click to continue

10. Transdermal fentanyl - 1 Don’t forget fentanyl patch when prescribing breakthrough analgesia Breakthrough dose for morphine 40mg/24hrs alone = 5mg morphine sc Breakthrough dose for morphine 40mg/24hrs PLUS fentanyl 100mcg/hr patch = 25mg morphine sc Click to continue

11. Transdermal fentanyl - 2 45 year old lady with metastatic breast cancer Condition deteriorating over a number of weeks – felt to be dying You are called on a Friday because she has been bedbound all week, still opening her eyes and saying a few words, but has been unable to take her morning dose of MST Usual dose is MST 30mg bd, only very occasionally needs oramorph, pain well controlled Click to continue

12. Transdermal fentanyl - 2 Do you change her MST to a fentanyl patch, to provide analgesia that she doesn’t need to take orally (given that her pain is well controlled)? NO Remember: Steady state reached 36-48h after patch applied Will be in pain for the next 2days Will have to call OOH doctors Click to continue

13. Transdermal fentanyl - 2 Do you stop her MST and start a syringe driver?driver? YES Convert equivalent dose to morphine or diamorphine Ensure breakthrough analgesia prescribed (Plus anti-emetic, antisecretory agent, anxiolytic and DNACPR form) Click to continue

16. When to start the LCP? Too soon: – Feel foolish if still alive 1 week later when family prepared for imminent death – Patient improves and appears no longer to be dying – Denying patient food/fluids/treatment? Too late: – No time to benefit from sensible review of interventions/medication – No time to prepare family for death Click to continue

17. When to start the LCP? Deterioration - You think they are dying and could be in the last few days of life Potentially reversible causes have been considered Discussion with patient, relative, carer – Understanding that patient is dying – Explain use of LCP “a tool that supports doctors and nurses to provide a high quality of care to patients and their families in the last days of life ” Click to continue

18. They’re on the LCP and they’ve not died yet It’s OK – the LCP can be stopped if needed! – It can be continued as long as it’s needed Should be reviewed: – Every 3 days – Patient improves – Concerns expressed by patient, relative, carer or team member Click to continue

20. When do you arrange a “just in case” box? All red patients Consider yellow patients Maybe green patients If you think of it, do it Click to continue

21. Just in case box Drugs to include: – Analgesic, Anti-emetic, Anxiolytic, Anti-secretory If green/yellow – may not want to include all – Eg if analgesic requirements expected to change Anti-emetic Most useful Drug most wanted OOH Click to continue

23. Convulsions in the community 48 year old man with primary brain tumour Has had RT and chemo No plans for further active treatment Remain on moderate dose of dexamethasone 12mg daily Also on anti-epileptic Click to continue

24. Convulsions in the community Has had grand mal or petit mal seizures in recent weeks Admitted after each grand mal – Anti-epileptic meds reviewed – CT – no oedema Dislikes being in hospital Lives with wife – feels able to manage at home End of Part 1