HOSPICE ATLANTA SYMPTOM MANAGEMENT PROTOCOLS

1. HOSPICE ATLANTASYMPTOM MANAGEMENTPROTOCOLS

2. TABLE OF CONTENTS

5. Assess For: • Duration of appetite suppression • Significant weight loss – (Over what period of time) • Difficulty with swallowing • Medication side effect • Mucositis, oral candidiasis • Depression • Nausea or constipation • Patient/family wishes regarding nutrition and hydration Anorexia ANOREXIA – REVERSIBLE CAUSES A: aches & pains N: nausea O: oral discomfort R: reactive depression E: evacuation X: xerostomia I: iatrogenic ( meds, chemo, etc.) A: acid-related problems Non-Pharmacologic Interventions ∙Assess and treat comorbid conditions ∙Educate and support patient and families that this is part of disease process and not under patient control ∙Offer favorite foods in small servings as well as nutritional supplements ∙Provide frequent mouth care as oral intake declines, as well as ice chips and cold beverages Trial Periactin 4 mg TID; may increase to 8 mg TID gradually over 3 week period. Reassess at 4 weeks for efficacy No relief • Trial prednisone 5mg daily with food; titrate up by 5mg at weekly intervals (MDD 20mg) • or • Trial Decadron 4mg BID to QID (MDD 16mg) • When using steroids, use in conjunction with proton pump inhibitor (omeprazole) • or • H2 antagonist (pepcid, zantac) • Consider blood glucose evaluation if patient remains on long-term steroids 1 Revised August, 2008

6. Assess For: • Pain level - differentiate acute exacerbation of chronic pain versus onset of new pain • Anxiety producing medications (i.e. corticosteroids) or withdrawal of opiates or barbiturates • Paradoxical effects of certain medications especially in geriatric population • Medications based upon the patient’s ability to take oral medications and based upon current weight (assess for weight loss) • And document history of tobacco, alcohol, or other substance abuse. Is there recent abstinence or evidence of withdrawal? • Fecal impaction- or urinary retention • Respiratory distress (See Dyspnea protocol) Anxiety/Agitation Non-Pharmacologic Interventions ∙Subdued environment/reduced stimulus ∙Softly lighted surroundings with familiar objects and familiar faces ∙Conversation with the patient and family should be calm and reassuring ∙Allow time for patient to talk freely about his/her concerns Anxiety without associated agitation Intolerance to Benzodiazepines Yes No Hydroxyzine HCL 10 to 25 mg PO Q 4 to 6 hours ATC or PRN (MDD 200mg) OR Hydroxyzine pamoate 25 mg PO Q4 to 6 hours ATC or PRN(MDD200mg) Lorazepam 1 mg PO/PR/SL/IV Q 4 to 6 hours ATC or PRN (MDD12mg) (Do not use more than 2 mg daily when initiating this drug in the elderly or debilitated – start dosing at .25mg) No relief No relief Increase dose of lorazepam, or change to alprazolam .25 to .5 mg Q4 to 6 hours ATC or PRN(MDD 4mg), or change to clonazepam .5 mg to 1 mg Q 8 to 12 hours ATC or PRN (MDD2mg) Add to regimen: Paxil 10 MG PO Q Day (MDD20mg), or Zoloft 25 MG PO Q Day for 7 days then 50 MG PO a day (MDD 150mg – call MD prior to increase) (Consider if depressive component) No relief Relief If symptoms persist Haldol 1 to 2 MG PO/PR/IV Q 6 hours PRN, maximum dose 20 MG per day (use with benadryl Q HS), or Trazadone 50 MG po QHS (MDD 200mg) (if insomnia more likely etiology) Continue therapy 2 Revised August, 2008

7. Anxiety/Agitation continued Agitation Altered mental status, hallucinations, hyper-mobility, anger Intolerant/contraindication to neuroleptics Yes No Lorazepam 1 mg PO/PR/SL/IV Q 4 to 6 hours ATC or PRN (do not use more than 2 mg daily when initiating this drug in the elderly or debilitated -start dosing at .25mg) Haldol 1 to 2 MG PO/PR/IV Q 6 hours PRN (MDD 20 MG) (use with benadryl 25mg Q bedtime) No relief No relief Add - Lorazepam 1 mg PO/PR/SL/IV Q 4 to 6 hours ATC or PRN (do not use more than 2 mg daily when initiating this drug in the elderly or debilitated- start dosing at .25mg) No relief Add - Phenobarbital 30 to 60 MG PO/PR/IV Q 6 hours PRN, titrate up by 30mg. (MDD 240mg) If inadequate symptom control, call Physician/Nurse Practitioner 3 Revised August, 2008

8. Assess For: • And document stage of disease and functional status • Medications based upon the patient’s ability to take oral medications and based upon current weight (assess for weight loss) • Presence of pain or discomfort (See Pain Algorithm) • Respiratory distress (See Dyspnea Algorithm) • Contributing causes such as diet and/or medications • Increasing abdominal girth (weigh patient if possible) • Extent of peripheral edema Ascites Non-Pharmacologic Interventions •Bed rest •Hospital bed •Patient will usually be more comfortable sitting up in chair with legs elevated or in bed with head of bed elevated and legs slightly elevated •Good skin care and hygiene are essential •Consider restricting sodium intake and fluids (frequent mouth care if fluid is restricted) Is patient more comfortable sitting up with head of bed elevated? Start diuretics: spironolactone (start at 50 mg QD) (This is most effective for nonmalignant ascites). If not effective after 5 days, increase to 100 mg PO QD; reassess frequently and titrate as necessary. If liver failure is present; consider lactulose 30-45 ml Q 6 hours; titrate dose to promote soft stools. Symptoms Controlled? No Continue treatment no yes Ascites should be reduced only to the extent necessary to relieve patient’s symptoms of dyspnea and /or discomfort. If pt needs further diuresis – trial of Lasix 40 mg/100 mg of spironolactone or Lasix alone for malignant ascites. (If prolonged diuretic therapy, consider checking electrolytes.) Consult Physician/Nurse Practitioner to consider paracentesis for comfort if above interventions are not effective 4 Revised August, 2008

9. Assess For: • UTI Symptoms • Fluid Intake • Indwelling catheter (assess function, catheter size and balloon – too large?) • Assess for neurologic problems (e.g. multiple sclerosis, spinal cord lesions, etc.) Bladder Spasms Non-Pharmacologic Interventions ∙Adjust fluid intake (cut fluids back; in some cases increasing fluids may stretch the bladder and decrease spasms) ∙Patient and family education for treatment options ∙Remove Foley catheter for a trial period (caution if patient has known urinary retention) Dipstick urine (if available) Consider urine culture and sensitivity if positive dipstick or history of complicated UTI Positive Dipstick or high index of clinical suspicion for UTI Negative dipstick or low index of clinical suspicion for UTI Start empiric antibiotics Consider pyridium 100-200 MG TID x 48 hours for transient dysuria (Educate pt/caregivers that pyridium can darken urine) Persistent Symptoms? Contact Physician/Nurse Practitioner If catheter in place, assess function; ( If decreased urine output, consider irrigation with 30 to 50 ML normal saline.) Relief? Yes No No further intervention Ditropan 5 MG BID to QID x 48 hours (MDD 20 mg), or Hycosamine .125 mg SL Q4 hours PRN(MDD .75 mg/day) Relief? Yes No Continue as indicated Contact physician/nurse practitioner, – consider B&O #15 or #16 rectal suppository 1 to 2 daily MDD – 4 suppositories. Relief? No Yes 5 Revised August, 2008

10. Assess For: • Dysphagia without observable signs of candidiasis • Changes in oral cavity (including tongue, gingiva, mucous • membranes, lips and saliva) • Voice quality and swallowing ability • Presence of creamy white curd-like patches in oral cavity • Oral hygiene practices • Oral intake • Use of steroid inhalers • AIDS • Current medications for the possibility of drug induced oral mucositis • that may resemble candidiasis (i.e. recent sulfa therapy) Candidiasis - Oral Non-Pharmacologic Interventions •Warm salt water rinses (swish, gargle) •Brush tongue as well as teeth with soft tooth brush •Rinse mouth with nonalcoholic mouth wash Q2 hours while awake •Soft diet for severe dysphagia •Rinse mouth with dilute hydrogen peroxide • Nystatin suspension 5 ml (500,000 U) swish and swallow/spit hold in mouth 2-5 minutes (swab if unable to cooperate) • For associated oral pain, see Mucositis Protocol Improved after 48 hours Not improved after 48 hours Continue nystatin 7-10 days or at least 48 hours after becoming asymptomatic Change to Clotrimazole (Mycelex) troches 10 mg five times daily Improved after 48 hours Not Improved Trial of oral antifungal: fluconazole (Diflucan) 200 mg loading dose then 100 mg QD for 5-7 days. Daily doses in excess of 400 mg are not recommended. Continue clotrimazole (Mycelex troches 10 mg five times daily for 14 days) Not Improved Consult Physician/Nurse Practitioner 6 Revised August, 2008

11. Assess For: • Recent antibiotic therapy • Recent chemotherapy or radiation treatments • Perineal discharge present (color, odor, consistency) • Perineal lesions and/or rash • Pruritus and/or pain • Dysuria • Personal hygiene practices • AIDS • Vaginitis • Diarrhea Candidiasis-Perineal Non- Pharmacologic Interventions ∙Apply powder or dry padding in potential problem areas of patients to prevent irritation and Candida growth ∙Check high risk patients frequently (obese, diabetics, chronic antibiotic or steroid therapy) ∙Cleanse 3-4 times per day minimum, especially after defecation or urination ∙Air dry involved area for brief times through the day Clotrimazole 1% cream (Gynelotrimin) applied to perineum BID. For intravaginal source of candidiasis, apply clotrimazole 1% cream intravaginally BID as well, or 100 mg vaginal tablet daily for 7 days. If diarrhea is present, Refer to Diarrhea protocol. Improved after 48 hours No improvement after 48 hours Continue clotrimazole 7-14 days For severe perineal candidiasis consider Mycolog ointment (nystatin/triamcinolone)-apply 2 to 4 times daily Not Improved Improved after 48 hours Consult Physician/Nurse Practitioner; consider Diflucan one time dose of 150 mg PO (may repeat x 1 in 4 days) Continue for 7 days 7 Revised August, 2008

12. Constipation • Assess For: • Opioid use • Other medications affecting bowel function • Bowel sounds-present-hypo/hyperactive • Abdominal tenderness or masses • Fecal impaction • Patient’s normal bowel pattern • Date of last bowel movement • What interventions have been tried • Nausea and vomiting • Fluid and dietary intake Non-Pharmacologic Intervention • ∙Increase dietary fiber (caution if patient unable to tolerate • adequate fluid intake) ∙Encourage increased mobility if possible ∙Increase fluid • intake if possible ∙See Yakima fruit paste / prune juice recipes page 9 Begin bowel regimen with a stool softener or stool softener with laxative such as: Docusate sodium 100 mg QD or BID (MDD 400 mg), or Senna –S 1 tablet BID to 4 tablets BID (Max 10 tablets/day (dosing guideline – 1 tablet per 15 mg of morphine) If no bowel movement in 48 hours, increase Senna –S by 1 tablet BID, or add Milk of Magnesia 30 ml PO QD until results, or add 30 ml of 70% Sorbital PO QD until results, or lactulose 30 ml QD until results; consider Miralax 17gm in 8 oz. fluid daily If no bowel movement within 72 hours, rule out fecal impaction with digital rectal examination and begin one of the following in addition to regular bowel program: Dulcolax suppository per rectum QD PRN, Magnesium citrate 8 oz QD PRN, Fleet enema QD PRN or mineral oil enema QD PRN until results, and intensify daily bowel program If rectal impaction present: Manually disimpact (consider premedication for pain/anxiety) Follow-up with tap water enema until clear and intensify daily bowel program If constipation complicated by hemorrhoids, consider Anusol HC suppositories 1 per rectum BID for 10 days 8 Revised August, 2008

13. CONSTIPATIONCont’d • Yakima Fruit Paste Recipe • 1 pound prunes • 1 pound raisins • 1 pound figs • 4 oz. senna tea • 1 cup brown sugar • 1 cup lemon juice • Dosing: • Children 2-5 years of age: 1 tsp. (5 ml) per day-titrate up if tolerated • Children 6-10 years of age: 1-2 tsp. ( 5-10 ml) per day-titrate up if tolerated • Children 11-15 years of age: 1 Tbsp. (15 ml) per day-titrate up if tolerated • Adult dosing: 1-2 Tbsp. (15-30 ml) per day • Prepare tea and steep 5 minutes • Strain tea to remove leaves and add only 1 pint tea to a large pot, then add fruit • Boil fruit and tea for 5 minutes • Remove from heat and add sugar & lemon juice. Allow to cool. • Use hand mixer or food processor to turn fruit mixture into smooth paste • Place in plastic container and place in freezer (Paste will not freeze but will keep forever in freezer) • Spoon out what you require each day • * Enjoy eating fruit paste straight off the spoon. • * Spread it on toast or add hot water and make a drink. • * Of the fruit paste is not working (no bowel movements) then increase the amount of fruit paste each day. • * If the fruit paste induces very loose stools, cut down on the amount of fruit paste intake. Consider taking it every other day in some cases. Prune Juice Warm prune juice with either 1 tsp. butter or 1 tsp. mineral oil 9 Revised August, 2008

14. Assess For: • Frequency and duration • Associated fever or chills • Sputum production • Pulmonary edema • Medications (is patient on an ACE inhibitor?) • Increased secretions • Allergy symptoms • Symptoms of reflux • Dyspnea Non-Pharmacologic Interventions ∙Elevate the head of the bed ∙Throat lozenges ∙Frequent sips of water ∙Humidify the room Determine whether cough Productive Non-Productive Yes Yes No Yes No Yes No Continue therapy No Yes Cough Yes No No Yes Continue therapy 10 Revised August, 2008

15. Assess For: • Insomnia, weight loss, appetite change, crying spells, suicidal ideation, lack of energy and inability to concentrate • Current medications • Unmet spiritual needs or unfinished business • Pain. • Any other unrelieved distressing symptoms • Anxiety or agitation • History of depression Depression Non-Pharmacologic Interventions • Encourage social work, chaplain and volunteer visits if no • other support systems in place •Help facilitate a safe environment • for the patient and caregiver, •Counsel on sleep hygiene If suicidal -see Policy and Procedure (page 62) Sleep disturbance is not a major component of depression Sleep disturbance is a significant component of depression • Initiate selective serotonin reuptake inhibitor: • Paroxetine (Paxil) 10 mg PO QD (MDD20mg) (consider if sleep disturbance is present) • Fluoxetine (Prozac) 20 mg PO QD (MDD 40 mg) • Sertraline (Zoloft) 25mg PO QD x 7 days, then 50mg QD(MDD 150 mg) • *For frail or elderly, consider initiating at 1/2 the dose and titrate to effect: Reassess at two and four weeks. • (Do not increase SSRI dose until after four week assessment) • Amitriptyline* (Elavil) 10mg PO Q HS. Titrate up every 3-5 days by 10 mg to 50 mg. Reassess at 4-6 weeks for efficacy. Advise patient of side effects, especially orthostatic hypotension, urinary retention; consult physician prior to initiating if any cardiac disease present. • Trazodone*(Desyrel) 50 mg PO Q HS. Titrate up every 3-5 days by 50 mg as needed. Average dosage range is 150 mg to 400 mg. (MDD 400 mg) • Ritalin 5mg am and noon (if psycho stimulant needed) • * For frail or elderly, consider initiating at 1/2 the dose and titrate to effect. Reassess at two and four weeks Consult Physician-Nurse Practitioner-Pharmacist 11 Revised August, 2008

16. Assess For: • Fecal impaction • Current or recent medications (side effect of medications?, • recent antibiotics?, antacid use?) • Disease process • Recent history of radiation treatments or chemotherapy • Overuse/abuse of laxatives • Tube feeding or use of liquid medications (sorbital may be present) Diarrhea Non-Pharmacologic Interventions • Clear liquids for 24 hours, advance to low residue diet (see pg 41 ) •Educate patient and family that some acute diarrheal episodes are self-limited and do not require specific therapy • •Consider modification of the diet (clear liquids for a day, avoid dairy products) • •Attend to perineal skin care (apply powder or dry padding to prevent irritation) If suspect candidiasis, refer to perineal candidiasis protocol •Avoid stimulants such as caffeine and nicotine. Relief No Relief Advance diet as tolerated; avoid spices, fats, rich foods, and stimulants such as caffeine or nicotine 1. Imodium 2 caps after each loose stool max 8 caps per days, or 2. Questran 1 packet daily, or 3. Metamucil 5-15 cc mixed with water PO BID No Relief Discontinue medication from above. Change to diphenoxylate HCI w/ atropine (Lomotil) 1 tab after each loose bowel movement (MDD 8 tabs). Adjust dose to patient’s response. Relief No Relief Consult Physician-Nurse-Pharmacist for further orders. Advance diet as tolerated 12 Revised August, 2008

17. Assess For: • Stage of disease process; other associated symptoms • And document respiratory rate, pulse and blood pressure • Anxiety component • Fluid status (congestive heart failure, renal disease, hepatic disease) • Tobacco use; educate patient regarding the risk of oxygen use while smoking • History of pulmonary disease • History of cardiac disease Dyspnea Non-Pharmacologic Interventions • Educate patient and family on positioning techniques to facilitate chest expansion • Cool room •Wet cloth on face • Elevate head of bed (pillows, bed support) • •Use fan in room to improve circulation of air •Rearrange home environment to minimize patient exertion If dyspnea is due to congestive heart failure (crackles/rales, peripheral edema), initiate therapy with diuretics, oxygen and consider nitrates. Monitor urine output, daily weights and presence of peripheral edema if feasible. If bronchospasm (audible wheezing) assess current medications and oxygen therapy Albuterol 2.5mg/3ml normal saline nebulized Q 4-6 hours PRN. If needed, add Atrovent 1 mg to nebulizer (order as Duonebs) • •Furosemide (Lasix 20-40 mg) PO for one dose. If effective, continue furosemide 20-40 mg PO daily or BID (obtain creatinine level if long-term treatment). • •Initiate supplemental potassium therapy, start with potassium chloride 20 mEq PO daily (must have baseline creatinine level before initiating potassium) • • If there is no diuresis with furosemide 40 mg PO BID, then Physician-Nurse-Pharmacist consultation • Oxygen: Consider supplemental oxygen 2-6 liters/min by nasal canula. Alternatively, use a ventimask (5 liters per min) • Nitrates: Nitropatch 0.2 - 0.4 mg/hr topically daily-apply Q am, remove Q bedtime; or NTG 1/150 Q5min PRN x 3 doses (monitor blood pressure when giving SL NTG) (Consider nitrates if etiology of CHF is ischemic) •Nebulized opioids should not be used for pain relief because of low systemic bio-availability (5%). If patient has history of asthma use albuterol with the nebulized morphine •Most patients prefer a mouthpiece rather than a mask •Start with morphine sulfate 4 mg diluted in 3mL saline (if mixing with albuterol, use morphine 4mg w/o saline to avoid large volume of saline to nebulize) •Repeat Q 4 h ATC and Q 1 h PRN continued next page 13 Revised August, 2008

18. DyspneaContinuation Symptomatic relief of dyspnea from a variety of etiologies may result from morphine sulfate (Roxanol 20:1) .25 to 1 ml PO/SL Q 1-6 hours PRN; monitor respiratory rate as appropriate. Consider nebulized morphine sulfate 4 mg/3 cc normal saline. Trial of oxygen 2-6 liters/min via nasal prongs. If the patient experiences symptomatic relief, continue oxygen. If further palliation is required, proceed to lorazepam therapy. No Relief Consider benzodiazepine for symptomatic relief of dyspnea. Lorazepam 0.5to 1 mg Q 4 hours PRN; monitor respiratory rate as appropriate. Consider increasing the dose of morphine (there is no upper limit); and consider benzodiazepine for symptomatic relief of dyspnea. Lorazepam 0.5 to 1mg Q 4 hours PRN; monitor respiratory rate as appropriate. Relief Relief No relief No relief Continue morphine and/or lorazepam ATC or PRN lorazepam (MDD 12mg) Consult Physician/Nurse Practitioner 14 Revised August, 2008

19. Assess For: • Presence of gastrointestinal reflux disease • Irritation of the diaphragm as etiology if disease state suggestive (i.e., abdominal distention, hepatomegaly, GI malignancy) • Metabolic abnormalities as etiology Hiccoughs Non-Pharmacologic Interventions •Rebreathing into a paper bag •Have patient drink liquids slowly •Offer patient a teaspoon of sugar to hold in the mouth and then swallow •Keep patient as comfortable as possible •Keep patient NPO for 24 hrs. •Distraction •Cool compresses to eyes • Lemon wedges with sugar • Drink water rapidly Chlorpromazine (Thorazine) 25-50 mg Q 6 hours PO/ PR. (MDD 200 mg) Reassess at 48 hours, or Baclofen 10 mg TID or QID. Relief? No Yes Change to: Metoclopramide (Reglan) 10-15 mg Q 6 hours PO/PR (MDD 60 mg). Relief? No Yes Change to: Prednisone 10-40 mg PO (MDD 40 mg) if hepatomegaly or tumor invasion. Reassess in 24-48 hours For efficacy. Taper over one week.. Relief? Yes No Change to: Haldol 1-2 mg Q 6 hours (MDD 20mg) Diazepam (Valium 2 mg PO/PR QID (MDD 40 mg/day) Relief? Yes No Consult Physician-Nurse Practitioner Continue as needed to control symptoms 15 Revised August, 2008

20. Hydration (Intravenous) • Assess For: • Patients with dehydration due to acute illness not for disease progression • Caregiver ability to manage IVF’s at home Questions for clinicians: What are goals/ expected outcomes? What is the symptom being alleviated? What affect will there be on co- morbid conditions? Questions for patient/caregiver: What are the goals? Do you believe IVF’s will improve the quality of your life? Is treatment related to terminal diagnosis? Is primary goal for comfort? YES NO Covered by hospice with medical approval Not covered by hospice 16 Revised August, 2008

21. Hydration in the Terminally Ill: A Review of the Evidence Journal of Hospice and PalliativeNursing May/June 2007 Edited by Darrell A. Owens, PhD, ACHPN, CNS The practice of providing parenteral hydration to patients at the end of life is an issue that continues to cause significant controversy and debate among providers (including those practicing palliative care), patients, and surrogates. (1-4) Practice patterns vary from almost 100% of patients in the acute care setting receiving primarily intravenous hydration at the end of life to almost none in the hospice setting receiving intravenous or subcutaneous hydration, with inpatients receiving palliative care consultation falling somewhere in between. (3,5) Despite this wide variation in practice patterns, the primary evidence found in the literature is anecdotal, and there is surprisingly little clinical evidence based on randomized, controlled trials on the subject. In fact, a review of the literature found only one randomized controlled, double-blind study exploring the effects of hydration. (5) Historically, hydration has been seen as a medical treatment that patients or their surrogates could accept or refuse based on the same principles that are applied to other medical decisions, including understanding the potential benefits, burdens, risks, associated discomfort, and cultural and religious beliefs of the patient or surrogate. (4) Like any medical decision making, the use of parenteral fluids must be an individualized one that takes into account an assessment of the current clinical situation, potential advantages and disadvantages, and the goals of care. The lack of randomized, controlled trials specific to the advantages and disadvantages of hydration adds to an already complex decision-making process. (5) Currently, a clinician’s decision regarding the use of hydration is based on perceived benefits of hydration or dehydration. Persons who support hydration report it as an ordinary treatment used for the relief of thirst and provision of nourishment. Family members and some providers believe that hydration demonstrates caring and is a way to honor the sanctity of human life. (2) Additional cited potential advantages include prevention of renal failure, which can contribute to accumulation of opioid metabolites and result in confusion, restlessness and neuromuscular excitability. (3,5) Another oft-cited reason includes lack of evidence that parenteral fluids prolong life and constitutes a minimum standard of care (3). The arguments cited against the use of hydration include less urine output and less need to void or use a catheter, less nausea and vomiting secondary to a decrease in gastrointestinal fluid and fewer respiratory problems, such as cough and pulmonary edema. Other arguments include the belief that dehydration may act as a natural anesthetic secondary to electrolyte imbalances, it does not cause discomfort and the actual hydration process may cause discomfort and limit patient mobility. (3) A consistent rationale found throughout the literature, although primarily through anecdotal reports, is that parental hydration causes burdensome and distressing symptoms. (2) Finally, there is no evidence that parenteral hydration for terminally ill patients prolongs life. One recent study found evidence supporting the benefits of parenteral hydration in terminally ill patients. (5)The study by Bruera and colleagues (5) suggested that the use of hydration was able to decrease overall symptom burden, myoclonus, and sedation in the treatment group compared with the placebo group. A second, multicenter prospective study found evidence that parenteral hydration may not be beneficial. The study explored the association between artificial hydration practice and laboratory findings and between fluid balance and clinical signs of dehydration and fluid retention in the last weeks of life. (6) The results of the study demonstrated that artificial hydration could result in hypoalbuminemia, with no clear beneficial effects on normalizing the blood urea nitrogen, creatinine, sodium, or potassium levels. The results also demonstrated that fluid balance does not strongly correlate with actual changes in clinical signs of dehydration or fluid reten- 17 Revised August, 2008

22. tion. Both studies included only patients with cancer, had very small sample sizes, and concluded that further randomized controlled trials were needed. What is clear after a review of the evidence is that there is a significant need for further research in this area, specifically multicenter studies with large sample sizes. Without further research, decisions related to hydration will continue to be made on individual preferences and experiences, data based on limited clinical trials, or both. It is important for all clinicians to know that the current research, albeit limited, does not support a strict practice pattern of always or never using parenteral hydration but rather one that considers the clinical presentation and goals of care. SUMMARY OF EVIDENCE * Use of parenteral hydration in terminally patients ranges from almost always in the acute care patient to almost never in hospice patients. * Evidence related to the use of parenteral hydration in terminally ill patients is limited and generally based on anecdotal evidence, not randomized, controlled trials. * Decisions regarding parental hydration in terminally ill patients should include an understanding of the potential benefits, burdens, risks, associated discomfort, and cultural and religious beliefs of the patient or surrogate. * Further research in this area is needed. Darrell A. Owens, PhD, ACHPN, CNS is Clinical Assistant Professor and Director of Palliative Care, University of Washington Harborview Medical Center, Seattle, WA. He is also an Associate Editor for the Journal of Hospice and Palliative Nursing and coordinates “Evidence for Practice” References Lanuke K. Hydration management in palliative care settings; a survey of experts. J Palliat Care. 2003;19(4):278-279 Smith S. controversies in hydrating the terminally ill patient. J Intraven Nurs. 1997;20(4):1993-200 Lanuke K, Fainsinder R, DeMoissac D. Hydration management at the end of life. J Palliat Med. 2004; 7(2): 257-263 Casarett D, Kapa J, Caplan A. Appropriate use of artificial nutrition and hydration: fundamentals, principles and recommendations, N Eng J Med. 2005;353(24):2607-2612 Bruera E, Sala R, Rico M, et al. Effects of parenteral hydration in terminally ill cancer patients: a preliminary study. J Clin Oncol. 2005;23(10):2366-2371 Morita T, Hyoida I, Yoshimi O, et al. Artificial hydration therapy, laboratory findings and fluid balance in terminally ill patients with abdominal malignancies. J Pain Symptom Manage. 2006;31(2):130-139 18 Revised August, 2008

23. Mucositis • Assess For: • Voice quality and swallowing ability • Oral hygiene practices (Is patient rinsing mouth frequently with plain water? • Is patient brushing teeth?) • Nutrition and fluid intake • Recent chemotherapy or radiation treatments • Medications (I.e. sulfa therapy that could lead to drug induced mucositis) • Dentition and fit of dentures • Pain- (See Pain protocols) • Oral candidiasis (See Oral Candidiasis protocol) • Oral cavity including tongue, gingiva, mucous membranes, lips, and saliva Non-Pharmacologic Interventions • •Artificial saliva• Lip balm• Brush teeth frequently using soft brush (> 3 times per day) •Encourage hydration •Recommend soft mechanical diet and cool, non-irritating foods • Rinse mouth frequently with non-irritating, nonalcoholic mouth wash •Avoid nicotine and alcohol intake • Isotonic saline or sodium bicarbonate rinses Q 1-2 hours while awake for 48 hours (1.5 teaspoons salt in 1 quart of water or 1.25 teaspoons of sodium bicarbonate in 1 pint of water). • For mucosal debris, consider trial of 1:4 ratio of water/peroxide rinses followed by saline rinse. • For oral candidiasis, see Oral Candidiasis protocol (pg 6) • Discontinue medications known to cause mucositis (i.e., sulfa drugs) • Sucralfate (Carafate) slurry swish and spit after meals as needed. Patient may hold in mouth 3-5 minutes or allow to dribble down throat if there are signs or symptoms of esophageal involvement, or • Lidocaine/diphenhydramine/nystatin/decadron (magic mouthwash) 5 ml swish and swallow Q3 to 4 hour ATC or PRN (Caution in patients with impaired gag reflex-swish and spit, or coat mouth with a swab). • Consider use of other topical anesthetics such as viscous Lidocaine 5 ml swish and spit Q 3 to 4 hours PRN • For discrete ulcers use: • Orabase- apply QID as needed (apply when aphthous ulcers begin, to achieve better results) • Viscous lidocaine 2% applied with cotton tip applicator to discrete oral ulcerations may also provide transient relief Relief No relief Consult Physician-Nurse Practitioner Continue as needed. Reassess at 7 days and prn 19 Revised August, 2008

24. Assess For: • Medication effect(Chemo / Opioids / NSAID’s) • Movement-related etiology • Metabolic etiology (Hypercalcemia / Hyponatremia / Hepatic or Renal Failure) • Metastatic disease( Brain / Liver) • Mentation (Anxiety) • GI (Mechanical Obst . Mucosal Irritation / Motility) • Myocardial ischemia Nausea and Vomiting Non-Pharmacological Interventions ∙Relieve constipation ∙Maintain oral hygiene ∙Avoid strong odors ∙Small portions, frequent meals, cold foods tolerated better Chemoreceptor Trigger Zone (CTZ) (Drugs, uremia, ketosis, carcinomatosis) Gastrointestinal (Mechanical obstruction, Motility, Mucosal irritation) Prilosec OTC 1 tablet daily, and/or Pepcid 20 mg daily to BID, and/or Reglan 5 to 10 mg QAC and HS (consider if symptoms occur 1 to 2 hours postprandially) Haldol 1 to 2 mg Q 4 to 6 hours PRN, (use with benadryl) and/or Reglan 5 to 10 mg QAC and HS, or Compazine 10 mg Q 2 to 6 hours PRN, and/or Compazine ER 10 to 15 mg po Q12 hours (MDD 30mg), or Phenergan 25 mg Q6 hours PRN (MDD200mg), and/or Ativan 1 mg Q 4 to 6 hours PRN (MDD12mg), and/or Decadron 4mg po QID(MDD16mg) Vestibular (Movement related) Cerebral (Metastases, meningeal irritation, mental anxiety) Meclizine 12.5 to 25 mg Q 8 hours PRN, and/or Scopolamine transdermal Q 72 hours Projectile Decadron 4 mg BID (use with prilosec or equivalent) Anxiety Ativan 1 mg Q4 to 6 hours PRN 20 Revised August, 2008

25. Assess For: • Location of pain • Quality of pain • Intensity of pain • Aggravating factors • Associated symptoms – nausea, anorexia, sleep disturbance, constipation • Liver or renal dysfunction • Past history of gastritis or recent GI bleeding • Progression of disease; Would patient benefit from initiation of steroids? Pain Management Non-Pharmacologic Interventions ∙Positioning patient for comfort/Hospital bed/Alternating pressure pad ∙Hot/cold applications ∙Relaxation techniques ∙Distraction/imagery techniques/music therapy NEUROPATHIC PAIN Stabbing, burning, shooting, tingling VISCERAL/SOMATIC/BONE PAIN Tenderness, aching, localized, cramping, squeezing Mild/Moderate (opioid naive) Mild/Moderate 1. Elavil* 10mg at bedtime; increase by 10mg Q 7 days to maximum 50mg at bedtime or 2. Neurontin 100 mg po TID, titrate by 100 mg TID q 48 hours for total 1800 mg daily. If no improvement, refer to moderate/ severe pain guidelines. *Elavil(amitriptyline) has several side effects and should be used with caution in the elderly. SE include dry mouth, constipation, dry eyes, urinary retention, orthostatic hypotension 1. Acetominophen 500-1000 mg po Q 6 hours ATC or PRN, (MDD 4 gm) (high does of acetominophen should not be used for prolonged periods), and/or 2. Ibuprofen 400-800 po Q8 hours ATC or PRN (MDD 2400mg) ( use with PPI or H2 blocker), or 3. Choline magnesium trisalcylate 500 mg (comes in liquid 500 mg/5 ml) po TID ATC or PRN (use with PPI or H2 blocker), and /or 4. Hydrocodone/APAP 5/500 1 to 2 Q 6 hours ATC or PRN (avoid concomitant use of acetominophen ), or 5. Oxycodone/APAP 5/325 1 to 2 Q 6 hours ATC or PRN (avoid concomitant use of acetominophen) If no improvement, refer to moderate/severe pain guidelines. Continued next page 21 Revised August, 2008

26. Pain(continued) NEUROPATHIC PAIN Stabbing, burning, shooting, tingling VISCERAL/SOMATIC/BONE PAIN Tenderness, aching, localized, cramping, squeezing Moderate/Severe Moderate/Severe 1. Morphine immediate release 5 to 10 mg po/sl Q 1 to 2 hours PRN (After 48 hours may convert total daily dose to Morphine ER if using great than or equal to 30mg daily ) 2. Methadone 2.5 mg po Q 8 hours and Q 2 to 4 hours PRN (After 72 hours may increase Q 8 hour dose by taking total number of mg over last 24 hours and convert to Q 8 hour dosing) The following medications require MD/NP approval 3. Oxycodone 5 to 10mg po Q 2 hours PRN (for morphine allergic patients) – (After 48 hours may convert total daily dose of oxycodone ER if total number mg greater or equal to 30 mg in 24 hours) 4. Fentanyl Patch 12 micrograms to skin Q 72 hours or appropriate conversion dose (if patient unable to take po) – (If dose greater than 200 micrograms, consider IV medication) 1. Start Methadone per protocol and/or 2. Consider Decadron 4mg daily to QID (particularly if brain or spinal cord involvement). 3. Wean Elavil/Neurontin once stable on Methadone. No relief No relief Consider the use of steroids for anti-inflammatory effect in bone pain, brain metastases, SVC syndrome, liver capsule pain, and cord compression No relief Consider Patient-Controlled Analgesia Consult Physician/Nurse Practitioner 22 Revised August, 2008

27. Opioid Equianalgesic Dosing Formula for converting to new drug or new route: Begin by converting all opioids to oral morphine using the following formulas: IV morphine x 3 = oral morphine Oral methadone x 10 = oral morphine IV dilaudid x 30 = oral morphine 1.5 Oral dilaudid x 30 = oral morphine 7.5 Oxycodone = oral morphine Hydrocodone = oral morphine Fentanyl patch x 2 = oral morphine To calculate breakthrough dose: Take ¼ to ½ of the regular scheduled dose, every 2 to 4 hours prn To convert to IV morphine: Divide the 24 hour dose of oral morphine by 3 and divide by 24 for the basal rate. Use one half of the hourly rate for the q 10 minute bolus dose. Exceptions: Converting to Methadone: Convert to 24 hour oral Morphine dose For oral Methadone take 10% of total 24-hour Morphine dose and divide by 3 (which is every 8 hours). Take half of that dose to get breakthrough and give every 2 hours as needed. For IV methadone take 3% of total 24-hour Morphine dose and divide by 24 (which is hourly rate). Take half that dose to get the bolus dose. Every 10-15 minutes. *Remember for opioid naïve patient you may want to consider half of usual starting methadone dose. Usual starting dose: 2.5 mg every 8 hours with 2.5 mg every 2 hours prn. Therefore, for the opioid naïve patient consider 1.25 mg twice daily to three times daily and 1.25 mg every 2 hours as needed. 23 Revised August, 2008

28. Pearls to Remember for • Methadone Dosing: • It takes 3-5 days for Methadone to reach steady state, therefore, watch for over sedation and allow for proper time before increasing scheduled doses. • For the patients that you are concerned about swallowing tabs, you may want to consider liquid methadone at a higher concentration to be given orally or sublingual. Methadone comes 2.5 mg, 5 mg, 7.5 mg, and 10 mg tabs or 5 mg/5 ml, 10mg/1ml or pharmacy can compound a concentrated elixir as consulted with MD/NP (40mg/1ml, 100 mg/1 ml). • For increasing Methadone, use only the last 24-hour breakthrough doses to calculate your increase in scheduled doses. 24 Revised August, 2008

29. PEARLS to Remember for • Basic Pain Management: • Don’t start with transdermal or extended release medications; always start with prn dosing in opioid naïve patients • Know the pain history well for most effective dosing; consider non-opioid or adjuvant medication where possible • Always counsel regarding side effects • Begin prophylactic bower regimen with use of opioids • Counsel regarding no driving, no alcohol 25 Revised August, 2008

30. Assess For: • Onset, frequency, duration, and intensity • Aggravating factors • Alleviating factors • Presence of scratch marks/rash • Presence of other skin conditions • Presence of liver or renal failure • Actual or potential causes of pruritus • Medications to rule out drug eruption Pruritus Non-Pharmacologic Interventions •Cool compresses •Hypoallergenic soaps (oatmeal) or aqueous moisturizers (Dove, Aveeno) •Lubricants if skin is dry •Loose fitting clothing and bedcovers •Pat skin (no rubbing or scratching) If possible, establish probable cause • Diphenhydramine (Benadryl) 25-50 mg Q 6 hours ATC or PRN (MDD200mg), • or • Hydroxyzine 10 to 25 mg TID or QID ATC or PRN (MDD 100mg), • or • Cyproheptadine (Periactin) 2-4 mg PO TID ATC or PRN (MDD24mg) • Improved? Yes No Triamcinolone .1 % ointment BID to affected area (for local irritation). Improved? Yes Continue PRN No Yes Try oral steroids. Begin with prednisone, 20-40 mg PO Q day; attempt to taper prednisone after 5-7 days. Improved? No Consult Physician/Nurse Practitioner 26 Revised August, 2008

31. Assess For: • Ability to swallow and chew • Presence of oral Candida or mucositis • Characteristics of secretions (purulent) • Oral hygiene practices • Oral intake of fluids • Medications that could lead to xerostomic- producing side effects • Recent radiation or chemotherapy? • Patient and family concerns regarding this symptom Secretions Algorithm Non-Pharmacologic Interventions • Non-Pharmacologic interventions for xerostomia: • Encourage frequent intake of oral fluids •Encourage good oral care •Avoid smoking, alcohol, caffeine and spicy foods Use artificial saliva •Chew sugarless gum •Suck sugarless candy, especially citrus • Non-Pharmacologic interventions for increased secretions: • Position patient to better deal with secretions •Suctioning • Absorbent towels to gather secretions For thick secretions: Guaifenesin 10-20 ml (100 mg/5mL) PO Q 4 hours • Assess: • Diminished secretions? • Increased secretions? • Thick secretions? • Presence of oral Candida or esophageal Candida • (See Oral Candidiasis protocol) If no relief, consult Physician/Nurse Practitioner Consider a trial of nebulized normal saline Q 4 hours PRN. Diminished saliva Xerostomia Increased secretions. Distressing to patient? No intervention necessary unless noisy breathing or gurgling is distressing to family. Distressing? No Yes Encourage good oral hygiene. Atropine drops 1% 1-2 drops po/sl Q 4 to 6 hours ATC/PRN Transderm scopolamine topically Q 72 hours Initiate non-pharmacologic interventions Yes No Atropine drops 1% 1-2 drops po/sl Q 4 to 6 hours ATC/PRN Transderm scopolamine topically Q 72 hours Begin artificial saliva with mucin; glycerol preparations Relief No Relief Consult Physician/Nurse Practitioner Supportive care only Continue PRN 27 Revised August, 2008

32. Assess For: • Hypoglycemia • Continued seizing without spontaneous termination, consider available routes of drug administration (intravenous, intramuscular, rectal administration) • Whether medications could be contributing to the seizure disorder (i.e. oral hypoglycemic agents) • Underlying medical condition causing the seizure or contributing to the seizure disorder (brain mets, hyponatremia, hypercalcemia, hypomagnesemia, hypotension, hypoxemia, withdrawal) • Current anti-seizure medications (What is the dosing of the current anti-seizure medications? Is the patient compliant with the dosing regimen: Is there a recent drug level -e.g.. Phenytoin, phenobarbital, valproate or tegretol level?) • Known or suspected cerebral lesions? • Headache? Visual changes? Tinnitus? • Focal neurologic findings. Is there a history of stroke? • Implementation of seizure precautions (padding and pillows, arm rails to help keep patient in bed, no driving discussion) Seizures Non-Pharmacologic Interventions • Initiate general seizure precautions (padding, safe environment no driving, calm soothing environment). • During seizure, if possible place patient on side. • Educate patient regarding avoidance of seizure stimulants (avoid alcohol and other substance abuse). • Do not put anything in patient’s oral cavity. • After seizure, consider suctioning patient if necessary to assist with oral secretions. • Educate patient and caregiver regarding the seizure disorder and the expected post-ictal phase. • If hypotensive, patient should be supine; legs elevated. • If patient is having a hypoglycemic seizure, administer oral glucose (juice, instant glucose, candy) if feasible. Proceed to Seizure Treatment for Actively Seizing Patient 28 Revised August, 2008

33. Actively seizing - immediate pharmacotherapy may not be necessary for a seizure of short duration. Protracted seizures, in excess of 5-10 minutes often require interventions * Patients currently taking anticonvulsants should not receive the full loading doses of medications described below. Seizure Treatment-Actively Seizing Patient Assess airway, breathing, circulation. Ensure adequate airway and oxygenation. Check blood pressure, pulse and temperature. Finger stick glucose to assess for hypoglycemia. If hypoglycemic, correct hypoglycemia Is intravenous access available No Yes Lorazepam 1 to 2 mg SL/PR Q5 to 10 minutes PRN; Seizure controlled after 15 minutes? Lorazepam (Ativan) 1-2 mg IV q 5 min PRN; maximum 30 mg. Seizure controlled after 15 minutes? Yes No No Yes Consult Physician/Nurse Practitioner. Continue lorazepam 1 mg Q 4 to 6 hours ATC/IV/SL/PR Phenytoin (Dilantin) loading dose is 18 mg/kg intravenously over 30 minutes; the maximum rate of infusion is 50 mg/min. Oral loading dose may be given 300 mg PO Q 3 hours for 3 doses Monitor heart rate (bradycardia) and blood pressure (hypotension). Continue lorazepam 1 mg Q 4 to 6 hours ATC/IV/SL/PR Consult Physician/Nurse Practitioner Consult Physician/Nurse Practitioner Phenobarbital loading dose - 20 mg/kg IV (maximum rate 100 mg/min); Divide oral maintenance dose 1-3mg/kg/day into TID dosing. 29 Revised August, 2008

34. Seizure TreatmentSeizure Control Therapies • Consult Physician-Nurse Practitioner prior to initiating chronic anticonvulsant therapy. Maintenance therapy with anti-seizure medications may be neuroprotective in patients with known causes. Address potential treatable etiologies • Cerebral metastases-dexamethasone • Hyponatremia-Fluid restriction, intravenous sodium chloride, medication adjustment (i.e. diuretics) • Hypercalcemia-Encourage fluids • Hypoglycemic reactions- Medication and dietary adjustments • Hypoxemia-Supplemental oxygen • Hypomagnesemia-Supplemental magnesium • Substance abuse-Eliminate substance abuse, support withdrawal • Infection etiologies (meningitis, cerebral abscess, encephalitis) 30 Revised August, 2008

35. Assess For: • Whether loss of sleep is accompanied by unrelieved distressing symptoms, especially pain • Medications side effects • Frequent napping during the day • Use of stimulants • Patient sleep ritual • Whether sleep disturbance could be a manifestation of depression • Recent changes in the patient’s home setting • Sundowner’s syndrome with increased restlessness in the evening • Possible sleep apnea Sleep Disorder Non-pharmacologic Interventions ∙Eliminate stimulant intake ∙Discourage daytime napping ∙Consult chaplain, social worker, volunteer coordinator to facilitate support for unmet emotional or spiritual needs Benadryl 25 mg at bedtime No relief Restoril 15mg at bedtime; may repeat one time (total of 30 mg at bedtime) or Trazadone 50mg at bedtime (up to 300mg at bedtime-titrate by 50 mg weekly if needed) No relief Ativan 1 to 2mg at bedtime (consider earlier if associated with anxiety disorder) Consult Physician/Nurse Practitioner 31 Revised August, 2008

36. Hospice Atlanta Formulary Medications are listed under their most common classification; however, each drug may be used for a variety of conditions and should be used in accordance with the symptom management protocols. Analgesics Aspirin Acetominophen Acetominophen with codeine (300/30mg) Propoxyphene/APAP (100/650mg) Hydrocodone with acetaminophen (5/500) Ibuprofen Methadone tablets Methadone Liquid 50:1, 10:1 Morphine Morphine ER Morphine IR Morphine liquid 20:1 Naproxen Tramadol Trisalicylate Oxycodone with acetaminophen (5/325) (Percocet) *Oxycodone *Oxycodone ER *Oxydose *Hydromorphone *Fentanyl patch Antibiotics To be determined on an as needed basis Anti-Convulsants Phenobarbital Phenytoin (Dilantin) Diazepam Clonazepam Carbamazepine (Tegretol) Lorazepam Valproic acid (Depakote) Gabapentin (Neurontin) *Levetiracetam (Keppra) Anti-Depressants(only covered if initiated while enrolled in hospice) Amitriptyline Trazadone Paroxetine (Paxil) Fluoxetine (Prozac) Sertraline (Zoloft) Methylphenidate (Ritalin) *Require Physician/Nurse Practitioner approval 32 Revised August, 2008

37. Anti-Diarrheals Loperamide (Imodium) Diphenoxylate/Atropine (Lomotil) Anti-Emetics Promethazine Prochlorperazine *BARPH PLO (25/1/10/25/5mg) *PRN PLO (Dramamine 25/Vistaril 25/Reglan 10) Anti-Fungal Agents Clotrimazole (Lotrimin) Clotrimazole troches (Mycelex) Nystatin Nystatin/Triamcinolone (Mycolog) *Fluconazole (Diflucan) Anti-Pruritic Hydroxyzine HCL (Atarax) Diphenhydramine (Benadryl) Hydroxyzine Pamoate (Vistaril) Cyproheptadine (Periactin) Anti-Psychotics ABH (1/25/1mg) Haloperidol Chlorpromazine *Quietapine (Seroquel) *Risperidone (Risperdal) Anti-Reflux/Antacids Famotadine (Pepcid) Prilosec OTC Aluminum Hydroxide/Magnesium Hydroxide/Simethicone (Maalox) Sucralfate (Carafate) Metaclopramide Anxiolytics Lorazepam (Ativan) Diazepam (Valium) Clonazepam (Klonopin) *Alprazolam (Xanax) Diuretics Furosemide (Lasix) Spironalactone (Aldactone) Metolazone (Zaroxolyn) Torsemide (Demedex) *Require Physician/Nurse Practitioner approval 33 Revised August, 2008

38. Heart/CVD/HTN Formulary Digoxin Amiodarone Metoprolol (Lopressor (use in place of Coreg) Diltiazem (Cardiazem) Lisinopril Atenolol (Tenormin) Terazosin (Hytrin) Clonidine tablets Nitroglycerin tablets, patch Isosorbide (Imdur) All diuretics previously listed Potassium (tablets or liquid) Verapamil Nifedipine (Procardia) Hydralazine Warfarin Aspirin Enalapril (Vasotec) Amlodipine (Norvasc) Laxatives/Stool Softeners Docusate sodium (Colace) Senna Senna-S Bisacodyl tabs/suppositories (Dulcolax) Sorbitol MOM Fleet’s Enema (Saline or Mineral Oil) Citrate of magnesia Lactulose Glycerin Suppositories *Polyethylene Glycol 3350 (Miralax) Muscle Relaxants Baclofen Carisoprodol (Soma) Cyclobenzaprine (Flexeril) Diazepam (Valium) Oral Agents Magic Mouthwash (equal parts Dexamethasone 0.5mg/5ml/Viscous Lidocaine /2% Nystatin suspension/Benadryl elixir) Nystatin swish and swallow Viscous Lidocaine 2% Parkinsons Formulary Levodopa/Carbidopa IR or ER (Sinemet) Amantadine (Symmetrel) Trihexyphrnidyl (Artane) Benztropine (Cogentin) *Require Physician/Nurse Practitioner approval 34 Revised August, 2008

39. Respiratory Formulary Albuterol MDI Nebulized Albuterol Nebulized Albuterol/Ipratropium (Duonebs) Nebulized Morphine Benzonatate (Tessalon Perles) Fluticasone (Flovent 110 or 220) Albuterol/Ipratropium (Combivent MDI) Theophylline Hydrocodone and Homatropine (Hycodan) Guaifenesin (Robitussin, Mucinex) Guaifenesin DM (Robitussin DM, Mucinex DM) Guafenesin with Codeine 100/10mg/5ml (Robitussin AC) Guaifenesin with Hydrocodone 100/5mg/5ml (Hycotuss) Urinary Tract Agents Oxybutynin (Ditropan) Phenazopyridine (Pyridium) * Belladonna and Opium (B&O suppositories) #15, #16 Steroids Prednisone Dexamethasone (Decadron) Methylprednisolone injection (Solu-Medrol) Secretion Control Atropine Hyoscyamine (Levsin) Scopolamine Sedative-Hypnotics Phenobarbital Diphenhydramine (Benadryl) Temazepam (Restoril) Trazadone Topical Medications Dakin’s solution Triple Antibiotic ointment (Neosporin) Mupirocin (Bactroban) Gentian Violet Silver Sulfadiazine (Silvadene) Metronidazole powder (Flagyl) *Require Physician/Nurse Practitioner approval 35 Revised August, 2008

41. General Tube Feeding Guidelines Check hospice formula substitution chart for correct formula to administer. For nasogastric tube, check position by auscultation with 10-15ml of air using a 60 ml syringe upon admission, before meds and before flushes. Elevate Head of Bed at least 30 degrees during and at least 30 minutes after feeding. Check residual before meds, before flushes and every shift. If greater than 100ml or twice the hourly rate, return residual, hold feeding and recheck residual in 2 hrs. If residual remains as above, hold tube feeding until MD evaluates. Flush feeding tube with 100ml water every 8 hrs. Change feeding bag every 72hrs; rinse bag every 24hrs with warm water. If patient is clinically improving with possible discharge from hospice, consult dietitian for tube feeding recommendations. 36 Revised August, 2008

42. 37 Revised August, 2008

43. 38 Revised August, 2008

44. BLAND DIET PURPOSE: The bland diet is used to aid in the initial treatment of the acute or inflammatory phases of gastrointestinal disease. Such conditions include severe peptic ulcer disease (PUD), esophagitis, and gastritis. DEFINITION/RATIONALE: Even though the rationale for the traditional bland diet is not supported by scientific evidence, some patients seem to experience comfort ingesting foods considered bland during acute phases of PUD and similar upper gastrointestinal disturbances. Grinding and pureeing of food should be necessary only when there are accompanying chewing or swallowing difficulties. Prolonged use of severely restricted bland diets may cause psychological dependence with associated unnecessary restrictions of food intake. As the patient improves, small amounts of the “Foods Not Allowed” may be tried gradually. Any of these foods that are tolerated may be added to diet. Known irritants not to be added back are: black and red pepper, chili powder, regular coffee and tea, cocoa, caffeine, caffeine-containing carbonated beverages and alcohol. NUTRITIONAL ADEQUACY: This diet meets the Recommended Dietary Allowance for all nutrients when the suggested meal plan is followed and a variety of foods are eaten. Careful planning is necessary to meet the iron recommendations for women under 51 years. RECOMMENDATIONS TO THE PATIENT: Eat slowly and chew food well Rest before and after meals Cheerful surroundings and freedom from emotional stress, particularly at mealtimes, is important Take medication only as the physician prescribes. Avoid extremes of temperature in foods. Eat cold foods, such as ice cream, slowly Best results are usually achieved by drinking juices at the end of the meal Drink 6-8 glasses of water daily. Eat frequent small feedings, 3 small meals plus snacks, evenly spaced throughout the day Avoid those foods and beverages that cause discomfort Avoid eating before going to sleep 39 Revised August, 2008

45. 40 Revised August, 2008

46. RESIDUE and FIBER RESTRICTED DIET The Residue and Fiber Restricted Diet is designed to minimize the frequency and volume of fecal output. Situations in which it may be necessary to limit fiber and residue include post-operative recovery from gastrointestinal surgery (GI), acute phases of inflammatory bowel disease, acute diverticulitis or the presence of esophageal or intestinal strictures and stenosis. Definitions Residue: unabsorbed dietary compounds and luminal contents (GI secretions, sloughed-off intestinal cells) post-digestion. Total Fiber: combination of Dietary Fiber and Functional Fiber. Dietary Fiber includes carbohydrates in foods that are not digested and lignin; Functional Fiber includes isolated, non-digestible carbohydrates synthesized or isolated from plants. Both fiber and residue contribute to increased fecal weight. Table 1 lists foods that may increase residue and Table 2 outlines foods that are low in fiber. Controversy exists over the use of milk on residue-restricted diets. If milk is restricted, the amount should be limited to 2 cups per day. A residue-fiber restricted diet contains approximately 10 grams of fiber. NUTRITIONAL ADEQUACY: This diet can provide adequate amounts of nutrients to meet the Dietary Reference Intakes except for fiber but careful planning is necessary to meet folate and iron requirements. 41 Revised August, 2008

47. Fiber Content Food Labels If a manufacturer places the terms “good source of fiber” or “contains fiber” on a label, the food must provide 2.5 to 4.9 grams of fiber per serving. “high” or “rich” fiber foods must provide at least 5 grams of fiber. 42 Revised August, 2008

48. Table 2: Foods with Low Fiber Content less than 1.5 g fiber/serving All beverages Candy without nuts or dried fruits Canned or cooked fruits without peel Cheese Crackers other than whole wheat Custards, pudding Eggs Fats Gelatin Ice cream Meats and poultry Milk products Most condiments Most cooked and canned vegetables (except peas, corn, spinach, Brussels sprouts, broccoli, and winter squash) Pastries without seeds, nuts, or dried fruits Potatoes without skin Refined breads Refined cooked and ready-to-eat cereals without seeds, nuts or dried fruits Refined pasta Sherbet Sorbet White rice Sample Menu Residue and Fiber Restricted Diet 43 Revised August, 2008

49. 44 Revised August, 2008