McCulloch House

Health Care Professionals

• Combined Pain Medicine Clinic
• Protocols
  • Admission Policy & Procedure
  • Discharge Policy
  • Availability of Death Certificates
  • Legal issues
  • Drug administration (morphine) - intraventricular route - Ommaya reservoir injection
  • Instructions for CADD 1 pumps
  • Continuous medication via a Graseby MS26 syringe driver
    • Graseby MS26 syringe driver PDF Document
  • Intrathecal access and drug administration
  • Guidelines management of generalized seizures in a palliative care setting
  • Malignant hypercalcaemia
  • Hemibody radiation for palliation of bone pain
  • Mouthcare policy and procedure
  • Recommended drug combinations for continuous subcutaneous infusion
  • Anti-emetics commonly used in palliative care
  • Opioid conversion
  • Guidelines and Summary, Provision and Non-Provision of Medically-Assisted Nutrition and Hydration (MN&H), specifically Percutaneous Endoscopic Gastrostomy (PEG)
  • Assessment tools
    • Nursing pain assessment and intervention chart
    • Syringe driver medication chart for single or multiple drugs

  • 

    Combined Pain Medicine Clinic
    Anaesthesia, Pain Medicine and Palliative Care

    Telephone 03 9594 5361
    Facsimile 03 9594 6344
    
    Specialists
    Professor Colin Goodchild
    

    This clinic is held once a week to review patients with persistent acute/chronic pain of malignant and non-malignant origin. Patients are generally referred from within the Southern Health network. However, external referrals will be considered. All referrals should be accompanied by supporting medical history and test results.

    
    Referrals from palliative care agencies are welcome. It is recommended that you discuss the case with Professor Goodchild prior to making a referral.

    
    Access to this clinic may be made by contacting the Combined Pain Medicine Clinic office on 9594 5361. Please note that the Clinic office is only open on Wednesday. Callers at any other time may leave a message. Calls will be returned on Wednesday when the clinic is open.

    Appointment confirmations are sent to the patient. The patient is required to reconfirm the appointment at least seven (7) days prior to the appointment. Appointments not reconfirmed will be cancelled. Appointments are made on the understanding that if the patient is unable to attend, they will contact the Clinic administration office to advise of their inability to attend. Appointment cancellations must be advised three weeks prior to appointment date. If we are not advised of the patient's inability to attend, or insufficient notice has been given for cancellation of an appointment, no further appointments will be made for the patient without a new referral from either the general practitioner or specialist physician.

     

    

    Protocols

    Admission Policy & Procedure

    McCulloch House is an acute 16 bed academically orientated inpatient palliative care unit located at Monash Medical Centre, a teaching hospital campus of the Southern Health Care Network.  Ten of its sixteen beds opened on 5 February 1996.  This policy is intended to assist those who are considering making a referral.

    Purpose
    To ensure appropriate admissions in which the care needs and wishes of patients and families are suitably matched with the services available in the unit.

    Scope
    The policy is intended to act as a guide, it cannot cover all cases and situations and each referral will be considered on its own merits.  Flexibility in assessment and response is important.

    Role of Unit
    The unit will be focussed on the provision of specialised acute palliative care and should be regarded as an integral part of a seamless model which comprises care at the following locations –

    • Patient’s place of residence (own home, relative or friend’s home, nursing home or hostel)

    • Hospital

    • Specialist inpatient palliative care unit

    Patients move from one location to another according to their needs and wishes.  McCulloch House is seen primarily as supporting care at other locations in cooperation with general practitioners and primary care teams, other specialist palliative care services, RDNS, and other health care institutions.  We do not operate a separate home care service.  Admissions will be considered under the following category headings –

    • Assessment

    • Terminal care

    • Symptom control

    • Psychosocial support

    • Respite

    Patient Assessment
    This is at the discretion of the admitting medical officer.  All patients in Monash Medical Centre will be assessed by the Consultative Service prior to transfer.  Community referrals should be made directly to the unit by the general practitioner or by a specialist palliative care service with the agreement of the GP.  Patients requiring emergency hospitalisation will not normally be admitted directly to the unit at night.  Patients who are thought to require a palliative car bed should not be sent to the Accident & Emergency Department at Monash medical Centre unless there is no other reasonable option available and in all cases the duty palliative care medical officer or Registrar should be notified by telephone first (telephone Monash Medical Centre switchboard 9594 6666 and page).  The need for direct assessment for admission may be waived in the following circumstances –

    • Medical emergency

    • Urgent psychosocial needs

    • Patient already known to the palliative care consult service and suitable for admission

    • Referral is from another palliative care service and has been assessed by them and deemed suitable for admission

    • Readmission

  • The Nurse Unit Manager or designated deputy may approve admission in exceptional circumstances at her or his discretion.

    Prognosis
    Estimates of duration or remaining life are notoriously unreliable and should never constitute the sole reason for admission or non-admission.  All reasonable requests for admission will be considered and no specific prognosis limits have been set.

    The Limits of Admissions
    Reasonable limits to length of stay apply in view of bed numbers.  It is envisaged that most admissions to McCulloch House will last for between one and two weeks and its function should be clearly differentiated from the more residential focus of nursing homes and hostels.  No firm time limits will be set but patients, families, referring doctors, units and agencies will be advised that all admissions are reviewed after two weeks.  Discharge or transfer planning may be initiated prior to that time if necessary.  No such plans will be made without consultation and negotiation with all parties.  It is recognised that patients’ conditions often fluctuate and deteriorate unpredictably so all decisions will be reviewed and if the patient’s condition deteriorates no discharge or transfer will occur.

    Respite
    Pre-planned admissions in this category will be negotiated individually, are subject to bed availability and may require postponement or rearrangement if an emergency admission fills the bed.

    Unconscious Patients
    Where possible people who are unconscious and/or who appear to be moribund will not be transferred if they are already receiving inpatient care at another location, unless all parties are in agreement that such an admission is in the patient’s interests.

    Geographical Boundaries and Priorities
    There are no rigid geographical boundaries to admission and the service will be happy to discuss any potential admission.  However, priority will be given to the following –

    • Patients being cared for at home in the area covered by Southern Health and/or Southern Metropolitan Region

    • Readmission of patients known to Monash Medical Centre Palliative Care Consult Service

    • Inpatients of Monash Medical Centre and other hospitals who require access to specialist palliative care beds

    Aged Care/ACAT Assessment
    Close cooperation with the Geriatric assessment team will be maintained and all patients who are not considered suitable for admission to McCulloch House should be further considered, where appropriate, for ACAT assessment.

    Teaching and Research
    All potential patients should be advised of this function of McCulloch House but also equally of their rights to decline such involvement at any time and that this will not negatively influence their right to admission or continued stay in the unit.

    Shared Medical Care
    Although it is recognised that time and distance are significant limiting factors, general practitioners are warmly encouraged to visit their patients, attend team meetings and advise on their patient’s management.  It is our intention to work towards formal shared care arrangements in the future.

    Admission Procedure

    During normal working hours (Mon-Fri 9-5)
    The Palliative Care Registrar (Reg) (pager 809) will be the first point of contact except Tuesday afternoons when the Palliative Care Resident Medical Officer (RMO) (Pager 5056) will field the calls.

    The Reg or RMO will then discuss all proposed or potential admissions with the Nurse Unit Manager (NUM) or nurse in charge in her absence. Consultation with the senior medical staff member on duty for that day may also be required at the Reg or RMO’s discretion

    After hours
    All admission enquiries will be taken by the nurse in charge and referred to the medical staff member on call

    Phone enquiries
    The minimum information from a phone enquiry fielded by any team member is :-

    patient’s name
    referring person’s name, professional role (ie GP, palliative care nurse, RDNS) and contact phone number
    urgency in returning call
    purpose of call - ie phone advice, potential admission etc

    The details of the enquiry should be recorded on a Proposed Admission form kept at the Nurses Station and immediately made known to the nurse in charge who will advise the relevant medical officer.  The nurse in charge will be responsible for deciding the urgency with which this should be done.

    Admission decision-making

    General principles
    The final responsibility for the operation of the unit’s policies lies jointly with the Medical Director and the Nurse Unit Manager, or the person acting on their behalf in their absence.

    Individual admissions are evaluated on a case by case basis by the medical officer who receives the enquiry (see above), but no admission may be agreed to without the knowledge and agreement of the Nurse Unit Manager or the nurse in charge.  The nurse in charge will determine the timing and means of transport to the unit with the referring person or agency.

    Priority criteria for admission:

  • • Level of clinical (medical, nursing or allied health) care needs as determined by the person taking the referral

    • Care location (community emergency usually takes precedence over patient who is already in a bed)

    • Patient in MMC Clayton or other SH emergency department

    • Patient known to the unit or consult service

    • If respite or ‘slow’ terminal care are to be offered, then ease of geographical access for visitors may considered as a prioritising factor

  • All decisions are based on balancing the answers to the following questions concerning appropriateness and bed availability:

    • what does the patient need and want?

    • what do family/carers need?

    • can this patient’s needs be met at another location, and is such a location reasonably available to them?

    • is there a special clinical reason why admission has to be here (eg invasive procedure or intensive psychosocial support)?

    • what is the present bed state, and how does the case under consideration compare to other requests on the same day?

    Goals of Care

    Admissions are initially made under ONE of the following ‘goals of care’ categories, which must be documented in all cases:

    • assessment (goals unknown)

    • symptom control (list in order of severity)

    • psychosocial or care crisis intervention

    • terminal care (acute or ‘slow’) (the anticipated outcome of the admission is death of the patient)

    • respite (their is a negotiated time limit which will not exceed two weeks, with a clear and viable discharge plan and location in place at the time of accepting the referral)

    • Goals of care are to be reviewed at each ward round and revised as required by the patient’s condition and situation.

    • All admissions are routinely reviewed after two weeks and alternative care location plans are explored as indicated by the patient’s condition.

    • Patient and family communication and participation is of paramount importance in all care decisions.

    Bed Capacity and Management

    • The bed state will be reviewed at the beginning of each normal working day by the Nurse Unit Manager and the Registrar (or RMO), and the consult service will appraise themselves of this state prior to commencing rounds.

    • Each decision to exceed the unit’s bed capacity (which presently stands at sixteen) is at the discretion of the Nurse Unit Manager or nurse in charge in consultation with the medical officer who receives the enquiry.

    • If the number of beds occupied on any given day is ten or less, and no planned or anticipated admissions are known of, other services will be contacted and offered beds, particularly for respite purposes.

    • Any problems, especially dissatisfaction expressed by patients, families or other agencies should be communicated to the Medical Director or Nurse Unit Manager, and dealt with by them.  If policy needs review, this should occur at management team meetings.

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    Discharge Policy

    Purpose
    To ensure that all patients have an appropriate and planned discharge from the unit that meets the needs, wishes and circumstances of patient, family and carers, and involves all relevant community services.

    Scope
    This policy is intended to act as a guide only.  Every effort will be made to meet patient and family/carer needs and concerns.  Flexibility in each discharge is paramount to ensure all individual needs are met.

    Policy

    • Where clinically appropriate, discharge planning should be commenced on admission.

    • All patients on admission should be assessed for potential obstacles to discharge (eg, living arrangements, age/health of primary carer, cognitive state, mobility, etc) and referrals made to appropriate members of health care team.  All referrals should be documented in patients’ notes and on the whiteboard in nurses station.

    • Discharge Planning at McCulloch House adopts a team approach.  The focus is always on the seamless delivery of high quality, safe and effective care for patients and family.

    • Community services in place prior to admission should be notified of patient’s admission to McCulloch House and the expected length of stay.  For patients who do not have a nursing service in place the relevant service should be notified on admission of the possibility of a referral on discharge.

    • An opportunity should be organised for the primary carer(s) to speak to a member of the medical staff as soon as possible after admission in order to discuss goals of admission, and to allow the carer(s) to express their needs, wishes and concerns.

    • Changes in goals of care during the course of an admission need to be conveyed to patient and family and documented in the case notes.

    Procedure

    Discharge

    • When discharge date is decided (usually occurs at Monday or Thursday ward round) and case manager for discharge assigned, patient and family should be notified and this should be documented on Discharge Notification form.

    • A family meeting may be required for some patients to discuss discharge needs, education, placement issues, etc and these meetings should be organised by the assigned case manager and issues and outcomes from the meeting documented in patient notes.

    • When exact discharge date is decided family/carer and all relevant community services should be notified and notification documented on discharge notification form and in patient notes.

    • A written referral to the relevant community services should be completed and faxed as soon as possible after discharge date decided and documented on discharge notification form and in patient notes.

    • Mode of transport for discharge should be discussed with family and carer and if ambulance or a multi purpose taxi be required they are to be booked by ward clerk and time, etc, documented on discharge notification form and in patient notes.

    • On the day before discharge the community services must be telephoned to confirm discharge, and date of first visit.  If not already completed, a referral letter should be written and faxed to the relevant agencies and recorded on discharge notification form and in patient notes.

    • When patient discharged, RUG score should be recorded in discharge record book and in patient notes.

    Death

    • Special care should be taken to adhere to patient’s religious requirements.

    • After the death of a patient, if family are not present they should be notified and given time to spend with the patient.

    • Deceased patients should retain their name band (on) for identification by the funeral directors.

    • Death is confirmed by the unit RMO, or after hours, the duty RMO covering for palliative care.  The death certificate, and when applicable, cremation forms are subsequently completed (in working hours) by the medical practitioner who confirmed the death,  or one of the unit’s medical staff.

    • The name of the funeral director, if not already recorded in Admissions book, should be obtained from the family and recorded on discharge notification form and in admissions and discharge books.

    • The funeral director of choice is notified by staff and a time established to collect the deceased.

    • The patient is to remain in the room unless NUM or deputy decides the body should be moved to the holding room (the patient is moved on the bed).

    • McCulloch House patients do not go to the Monash Medical Centre morgue unless an autopsy is requested or required.

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    Procedure for Availability of Death Certificates

    • For clarification on how to complete a death certificate or cremation certificate, refer to  ‘Cause of Death Certification Australia’.

    • Death Certificates and Cremation Certificates are completed by the McCulloch House RMO at the time of certification of death or the next working day.

    • Patients who are admitted and die outside of McCulloch House RMO working hours, that is patients not seen by McCulloch House RMO, will have the death certificate completed by the covering RMO.

    • Certificate is checked by another member of the medical/nursing team for spelling and date details.

    • Ward clerk collects all notes and copy of death certificate.

    • File returned to medical records.

    • Death Certificates are given to or collected by the relevant funeral director, they are not given to the family.

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    Legal Issues in McCulloch House

    Introduction
    In an inpatient palliative care unit, it is not surprising that legal issues arise for patients and families, and that they seek help from the staff of the unit.  Whilst we must attempt to render reasonable assistance to them at all times, it is important for there to be a clear understanding by all parties about what  the law requires, and what role staff (and volunteers) may play in such circumstances.

    As a first general principle, nobody should sign anything that they do not fully understand, and

    All legal issues should be referred to the Nurse Unit Manager, Medical Director or Social Worker (or deputies).  This includes all requests to witness documents of any sort. 

    Testamentary Capacity
    The law requires that a person making a will, or giving power of attorney, should have testamentary capacity, which means that the person must have sound mind, memory and understanding.  All persons are considered to be of sound mind unless there is evidence to the contrary.[1]   A person is therefore assumed to be competent to make their own decisions, in other words, with respect to a will, to have testamentary capacity.  There are four requirements for capacity.  A person must:

    • understand what the purpose of a will is,

    • recollect the extent and character of his property, and dispose of it with “understanding and reason” (‘sound disposing mind’),

    • recall and understand the claims of potential heirs,

    • be free of delusions or hallucinations which would influence his decisions, and,

    • be free of undue influence. [2]

    It should be emphasised that the determination of testamentary capacity is a legal decision, which ultimately is made by a court, although any such decision requires detailed medical evidence, a medical practitioner cannot certify testamentary capacity.

    It should also be noted that there are no specific agreed tests of capacity, but that medical evidence consists of the full clinical history, physical findings and observations at the time in question, together with records of any drugs being administered.  More specific neuropsychiatric instruments may be used, but these usually require specialist psychiatric or clinical psychological input.

    If there is reason to doubt a person’s capacity, enquiries to staff concerning this may be received from family members, lawyers or their employees, friends, other service providers, or patients themselves.  Sometimes, medical staff will receive a request ‘out of the blue’ to give an affidavit (retrospectively) as to capacity for a will executed whilst a patient was in the unit, even if this was done without any knowledge of unit staff at the time. 

    It is incumbent upon medical practitioners to assist patients and their families, and on occasions, their legal representatives.  Clearly, courts may issue a sub-poena, which compels a practitioner to attend.  However, we feel that it is an important basic principle that clinicians (of all disciplines) should maintain a degree of detachment from patients’ private personal affairs (eg finances), and in particular,  from any disputes within families.

    Therefore, as a general rule, McCulloch House medical staff will not make assessments for the explicit purpose of assessing testamentary capacity.

    Any enquiries regarding a patient’s testamentary capacity should be referred to the social worker who will then liaise with the head of the unit.  In the absence of the social worker, enquiries should be directed to the nurse unit manager who will then liaise with the head of the unit.

    All such enquiries must be recorded in the clinical notes. 

    Any persons (other than patients) requesting assessment of testamentary capacity will be encouraged to seek an independent medical assessment, subject to the patient’s consent.

    If a patient requests such assistance, and it is felt that the matter requires speedy resolution, in the patient’s interests, (eg, for peace of mind when a person is dying and has not made adequate provision for a close relative, eg a child), the unit social worker will make an assessment of the situation jointly with the senior medical officer available (usually the unit head), and a medical assessment will be made.

    Witnessing Legal Documents
    From time to time, staff and volunteers may also be asked to witness a  patient’s signature on legal documents.  In most cases, this merely means that the witness is certifying the identity of the person whose signature is being witnessed.  However, there may be assumptions that this act of witnessing infers some kind of capacity assessment, or other endorsement by the unit, and hence the Network, of the document and its purpose or appropriateness.

    Staff and Volunteers at McCulloch House should not act as witnesses to legal documents for patients or families.

    Requests for the witnessing of legal documents should be directed to the social worker (or nurse unit  manager in the social worker’s absence). 

    Anyone needing witnesses to legal documents will be encouraged to seek independent assistance where possible.

    Powers Of Attorney - Appointment Of Agent/Guardian
    For legal purposes, these are all classes of people appointed to make decisions on behalf of a person who has become incompetent.  Powers of Attorney are legal instruments which allow competent persons to empower others to act on their behalf when they are unable to do so.

    A general Power of Attorney, or an Enduring Power of Attorney under the provisions of the Instruments Act does not give an Attorney power over medical matters.  A special Enduring Power of Attorney (Medical Treatment) is required for this whereby a patient may appoint an agent to make health decisions including the right to refuse medical treatment should he/she become incompetent.[3] 

    If a patient has not executed an Enduring Power of Attorney (Medical Treatment) or appointed an agent under the Medical Treatment Act, an approach to the Guardianship and Administration Board may be required in order that a Guardian be appointed for that person.  Social Work (and sometimes legal assistance) is required in making this application.  Note that the Guardianship Board is contactable 24 hours on 1800 136 829 (toll free).

    Letters By Medical Practitioners
    Medical staff are frequently asked to write letters, or sign forms by patients and their relatives.  Whilst many  of these requests are clear and legal, some are not, and may fail to achieve their objectives, or be of dubious validity or legality.

    Doctors should be absolutely clear about the status of the request, and should have had prior experience of the matter or form in question before proceeding.

    Consent should be obtained from the patient before any confidential material is divulged.

    A written request, including model format or form should be obtained before letters are written, and an addressee should be identified.

    If there is any doubt, a member of senior medical staff should be involved, before any reply is made.

    ---

    [1] British Medical Association and the Law Society.  Assessment of mental capacity: guidance for doctors and lawyers.  British Medical Association.  London, 1995.

    [2] Peisah C and Brodaty H.  Dementia and the will-making process: the role of the medical practitioner.  Med J Aus 1994; 161: 381-384.

    [3] In the state of Victoria, under the Medical Treatment Act 1988, a person can issue a  refusal of treatment certificate for a  “current condition”.  The Enduring Power of Attorney (Medical Treatment) Act 1990 (EPA) together with the Medical Treatment (Agents) Act 1992 (MTAA) enable an adult person of sound mind to appoint an agent (or alternate agent) who can refuse medical treatment for a “current condition” on behalf of the patient when he or she becomes incompetent.  See Danuta Mendelson, Bioethics News 1992; 12 (1)  34-39.

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    Continuous Subcutaneous Medication Via A Graseby MS26 Syringe Driver

    More information can be obtained by clicking on the PDF document link at the Index above. This link provides access to the most up-to-date documentation.

     Keywords
    Syringe Driver, Butterfly needle
    Actuator - (this is the sliding/mobile component of the  syringe driver that pushes the syringe plunger)

    Description
    To provide a continuous infusion of medication by use of portable battery operated pump for symptom control when the oral route is unsatisfactory or ineffective.

    Indications

  • Nausea or vomiting

  • Obstruction of digestive tract or impaired  absorption (eg, oesophagus occluded by tumour,  malignant small or large bowel obstruction, major GI surgery)

  • Poor symptom control or side effect profile  thought to be due to erratic fluctuating  concentrations of drug(s) in the blood.

  Desired Outcome
  To provide optimum patient comfort, together with mobility and independence while receiving medication

  Special Notes

  1. Syringe driver administers medication by gradual depression of the syringe plunger by the pump’s actuator.

  2. Multiple medications may be administered by continuous infusion via the syringe driver.

  3. The syringe drivers are not waterproof and must not be immersed in water.  They have even been affected by a steamy bathroom.  It is advisable to disconnect the syringe from the butterfly tubing for the short time it takes to shower.  The tubing may be capped by a bung or a 5ml syringe attached to form a cap.

  4. Breakthrough doses are not given by bolus button on syringe driver.

  Reasoning for this -

  • small dose administered by each depression of the boost button,

  • difficulty in calculating bolus dose administered;

  • presence of other drugs in the infusion.

  Butterfly needle insertion site should be checked 4 hourly and site changed if leaking, red, swollen, bleeding or tender.  Butterfly needle does not need to be changed routinely.  Infusion sites to be changes as required.

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  Intrathecal Access And Drug Administration

                          Intrathecal Route: Port-A-Cath System Injection

  Description
  To access a Port-A-Cath for injection of a prescribed drug into the cerebrospinal fluid.

  Desired Outcome
  To relieve pain and to maintain the patient in a pain free state.

  Explanation
  The Port-A-Cath intrathecal system is an implantable drug delivery system designed to permit repeated access to the subarachnoid space.  It consists of a self-sealing injection portal and catheter for the delivery of medications

  Equipment

  • Basic dressing pack

  • Sterile gloves

  • Mask

  • Betadine solution or swab sticks

  • Sterile needles

  • 19 gauge to draw up

  • 25 gauge for delivery

  • Ampoules of solution as prescribed and normal saline

  Procedure

  • Prepare equipment adhering to the principles of asepsis

  • Mask and wash hands

  • Draw up solution

  • Palpate and locate Port-A-Cath site, observing signs of inflammation, collection of blood or serous fluid, or tenderness

  • Swab the area with betadine using an outward spiral motion, allow to dry

  • Wash hands and put on gloves (gloves are only needed until wound has healed)

  • Insert the needle at a 90º angle firmly through the skin surface and septum until the needle reaches the base of the port

  • Do not twist or angle the needle once positioned as it may damage the self-sealing septum

  • Aspirate cerebrospinal fluid to confirm correct needle placement.  DO NOT inject unless the cerebrospinal fluid is clear.  If cloudy notify M.O. AT ONCE

  • Inject the solution slowly over 60 seconds

  • Withdraw needle from portal septum while pressing down on either side of the portal with two fingers.  Clean and check injection site

  • Document on pain chart and medication chart  BD P+T chart to be maintained

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  Guidelines Management Of Generalised Seizures In A Palliative Care Setting

  Prevention in known unstable epileptics/patients who have fitted recently
  Once patient is no longer able to swallow anticonvulsant medication, it should be ceased and the following considered -

  • Clonazepam 0.5mg 12hrly SL/SC, or

  • Midazolam 30mg/24hr SC infusion, or

  • Phenobarbitone 400-600mg/24hr SC infusion (do not mix with other drugs in syringe driver)

  NB : doses may need to be increased by 50-100% to prevent convulsions

  • Phenothiazines, haloperidol, antidepressants, antiemetics and ?opioids may predispose to fitting, and should be reviewed regularly.  It may be possible to reduce or cease some of them.

  • If appropriate, steroid therapy may improve seizure control in patients with cerebral tumours or  cerebral metastases

  General Principles

  • O₂ and suction to be available in patients room for at risk patients

  • During the fit, move the patient only if in physical danger.  Clear any harmful objects from the vicinity.  Do not try to restrain the patient or force anything into the patient’s mouth.  Give O₂ by mask if possible.

  • As the fit subsides, or when possible, place the patient in the coma position.  Maintain a clear airway and continue O₂  via mask.

  Single Seizure

  • Most seizures are self-limiting within 5-10 minutes.  The patient is then drowsy but rousable.  These require no  immediate drug therapy.

  Status Epilepticus

  • Status epilepticus occurs when seizure activity is prolonged and continuous, or recurs without recovery of consciousness.  This may result in irreversible brain damage if it is not adequately controlled within 20-30 minutes, and ultimately is life threatening.

  Management of Status Epilepticus
  Observe general principles above

  If there is no venous access and/or if doctor is not quickly available, a telephone or other order must be obtained for -

  • Clonazepam 0.5mg SC

  The following alternate regimens may be used -

  • Midazolam 5-10mg SC, or

  • Phenobarbitone 50-100mg SC

  If doctor is present -

  He/she may give IV Diazemuls 5-10mg slowly (rate <5mg/min).  Injection will be stopped once fitting is controlled.

  NB : Midazolam has a shorter half-life.  The effect of diazepam may be short-lived (20 mins) so, if the patient is not already taking anticonvulsants, preventative regimen should be considered (see 1a above)

  If fitting continues, the above doses may be repeated and further stabilisation treatment should be started.

  Further Stabilisation Therapy

  • IV phenytoin 250mg by slow IV injection over at least 5 minutes (rate<50mg/min and <25mg/min in patients with ischaemic heart disease).   Repeat dose after 30 minutes, and further 500mg over next 24 hours.    Hypotension and bradycardia may occur.   If patient already taking Phenytoin, IV Phenytoin 250mg only.

  • If Phenytoin alone unsuccessful, phenobarbitone, 50-200mg SC.  Phenobarbitone has a very long half-life and may cause considerable depression of consciousness and respiration.

  • Because of the risk of respiratory depression from anticonvulsants, some patients in status epilepticus cannot be controlled without ICU facilities.  At McCulloch House a decision to transfer a patient to the general hospital may, at times, be appropriate.

  Investigations
  For example - urea and electrolytes, calcium glucose, magnesium, or anti-convulsant levels may be appropriate.

  Consideration should be given to the possibility of alcohol or benzadiazepine withdrawal as the causal factor.

  Observations
  All patients, except those admitted for terminal care, will have baseline observations performed:

  • Pulse

  • Blood pressure

  • Respiratory rate

  • Temperature

  • O₂ Saturation on air +/- Oxygen

  During admission all symptom control/assessment patients will require B.D. observations each day.    Respite patients will have daily observations.    Please record on separate observation chart.

  Other specific observations include:

  • Lying / standing blood pressure twice per week for patients on:

    • Tricyclic antidepressants.

    • Anti-hypertensives.

  • Blood glucose monitoring:

    • B.D. for IDDM

    • Daily for NIDDM

    • Twice weekly for those on high dose steroids ( >12mgs Dexamethasone)

  • Fluid balance for all patients with naso-gastric drainage; esp pre and post octreotide.

  • Post Procedure observations are as per protocol.

  Any changes to the observations, for an individual patient, can be discussed at Monday or Thursday ward rounds.

  Between ward rounds changes to the observations will be determined jointly by the Registrar and Nurse Unit Manager.

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  Malignant Hypercalcaemia

  Hypercalcaemia should be suspected in any patient with unexplained nausea, vomiting, thirst, polyuria & polydipsia, anorexia, constipation & clouded conscious state, or may be asymptomatic.

  Treatment should be considered in all symptomatic patients providing that death is not imminent.

  Treatment

  • Intravenous rehydration with Normal Saline - minimum of 2-3 litres per 24hrs.
    Diuretic therapy not given routinely, only for pulmonary oedema.

  • Intravenous administration of Pamidronate to be initiated after review by medical staff, & not to be commenced after hours except in unusual circumstances.

  Corrected CalciumAPD DoseDilution & Rate

  <3.0 mmol/l30mg250ml over 2 hrs

  3.0-3.5mmol/l45-60mg500ml over 4 hrs

  3.5-4.0mmol/l60-90mg1000ml over 6-8hrs

  >4.0 mmol/l90mg1000ml over 6-8hrs

  To be given with hydration, and fluids to continue for at least another 24hrs.

  Possible side-effects include transient pyrexia, leucopaenia, bone pain & myalgias, hypocalcaemia 2-14 days post infusion.

  Calcium levels begin to fall within the first 2-3 days, although maximum benefit may take up to 2 weeks.

  Therapeutic response diminishes with repeated administration.

  • Calcitonin may be considered if corrected serum calcium above 3.4mmol/l
    Dose: 1-2mcg/kg, (usually rounded to 100mcg) sc twice daily for 2 days.

  • Steroids are only useful in hypercalcaemia related to haematologic malignancies, particularly multiple myeloma.

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  Hemibody Radiation For Palliation Of Bone Pain

  Selection of patients

  • Multiple sites of bony metastasis with at least one painful site

  • Judged to be likely to require further palliative radiotherapy for bone pain within three (3) months

  • Not suitable for strontium (funding)

  Admission and pre-medication

  • Admit the day prior to treatment

  • All - FBE, renal and liver function

  • Upper hemi-body only - chest X-ray, ECG

  • Transfuse if Hb less than 90

  • Do NOT treat if platelets less than 100, total white count less than 2

  • Change long-acting morphine preparation to 4-hourly equivalent for the morning of treatment

  • Light meals on day of treatment

  • Give pre-medication one hour prior to treatment

    • 8mg dexamethasone oral               )           repeat x 1 6 hours after

    • 8mg ondansetron oral                     )           HBI

    • IV infusion 1 litre normal saline over 8 hours

  Procedure

  • Transport to and from department on trolley

  • Radiation oncologist to define volume (upper, ‘middle’ or lower)

  • Dose prescription - 8Gy lower or middle, 6 Gy upper

  After-care

  • Hourly observations (TPR and BP) for 4 hours, 4-hourly overnight

  • Analgesia administered on prn basis, using previous 4-hourly requirement

  • Treat nausea symptomatically

  • Discharge at 24 hours unless otherwise indicated

  • Clinic appointment with FBE at 3 weeks (maximum)

  • If sequential hemibody is planned, book for second half no earlier than 6 weeks.

  Toxicity

  	Onset	Duration	LHBI	UHBI
  Nausea/vomiting	1-2 hrs	24 hrs max	++	++
  Pyrexia	1-2 hrs	6-12 hrs	+	+
  Diarrhoea	24 hrs	1 week	+	-
  Hypertension	1-2 hrs	Transient	+/-	+/-
  Platelet/wbc fall	2-3 weeks	2-3 weeks	+	+
  Parotitis	6 hrs	24-48 hrs	-	-
  Stomatitis etc	2-3 days	6 weeks	-	+
  Alopecia*	2-3 weeks	3 months	-	+

  *Avoid treating skull unless treating myeloma

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  Mouthcare Policy and Procedure

  Purpose
  To ensure all patients receive optimum mouthcare.

  Scope
  This is intended as a guide to the general principles employed within the unit and recognises that individual needs of patients will require clinical decisions appropriate to needs.

  Definition
  Mouthcare is the regular cleaning of patients teeth, gums and tongue ensuring the mouth remains free of infection, erythenia and ulcers.           

  Procedure

  • Patient’s mouth is to be inspected within 4 hours of admission.  A history of patient’s oral intake is also taken at this time.

  • Results of inspection and history are to be recorded on nursing care plan.

  • Decisions and appropriate mouthcare is documented on nursing care plan.

  • Condition of patient’s mouth to be recorded on nursing careplan each shift.

  • Changes in mouthcare regime to be documented on nursing care plan.

  • On discharge condition of patient’s mouth to be recorded on nursing care plan.

  Suggested Mouthcare Regimes

  Condition of Mouth	Suggested Regime
  Nil signs of problems but risk of breakdown	Clean teeth tds and  nocte with toothbrush and toothpaste.
  Mild soreness, ulcers present. No bleeding	Clean teeth tds and nocte with toothpaste and toothbrush.  Medyel to ulcers after teeth cleaning.
  Painful ulcers, coated tongue. Decreased oral intake.	Clean teeth tds and nocte with soft toothbrush and toothpaste. Or Broxyjet and swabs tds and nocte Medyel to ulcers Nilstat QID
  Painful mouth and throat, bleeding. Odeamatous coated tongue. Halitosis – little/no oral intake.	Incident analgesia may be needed. Broxyjet QID Nilstat QID Xylocaine viscous prior to cleaning Dentures out.
  If patient unconscious.	Mouthcare with swabs and mouthwash at least 2 hourly.
  Lanolin should be applied to dry lips. Salube QID if thrush a problem.

   

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  Procedure : Drug Administration (Morphine) -

  Intraventricular Route – Ommaya  Reservoir Injection

  Purpose
  To access an Ommaya Reservoir using a 25 gauge needle for injection of a prescribed opioid into the cerebrospinal fluid.

  To relieve pain that has been ineffectively treated by oral or parenteral opioids (or resulted in excessive side effects).

  NB:This procedure is performed only by RNs Division 1 who have satisfactorily completed the instructional program.

  Explanation
  The Ommaya Reservoir is a totally implantable drug delivery system designed to permit repeated access to the third ventricle of the brain.  It consists of a self-sealing silicone dome and a catheter for the delivery of medications.  Introduction of solutions into the reservoir is performed by percutaneous needle injection.

  Equipment required

  • Sterile “butterfly” 25 gauge (19mm) (for delivery)

  • Sterile 5ml syringe x 1 (for injection)

  • Sterile needle/s (19 gauge for drawing up)

  • Ampoules of morphine and sodium chloride 0.9% as prescribed

  • Masks 1

  • Sterile gloves

  • Basic dressing pack

  • Skin preparation of povidone iodine solution

  • Occlusive dressing

  • Ampoule of naloxone as prescribed (to be available at bedside)

  Nursing intervention

  • Provide the patient with a suitable explanation.  Check the patient’s identification label.   Check the dose on the medication chart.

  • Assist the patient to assume a position of comfort appropriate to the proposed procedure and site of the reservoir.

  • Inspect the area at the injection site for signs of inflammation, sepsis or collection of blood or serous fluid.  If the occlusive dressing does not require changing, the injection may be given through the dressing.  As the patient’s hair grows, the scalp may require shaving to permit clear access to reservoir.  An occlusive dressing may no longer be necessary.

  • Put on a mask, perform surgical handwash.

  • Open a dressing pack and add the required articles.

  • Break open the ampoules and draw up the appropriate morphine/sodium chloride solution.  For doses 2.5mg or less a double dilution is required (refer Pharmacy Department Protocol).

  • Disconnect the 19 gauge needles, expel excess air and place the syringe on the sterile field.

  • Locate the reservoir by palpating through the skin.

  • Perform a second surgical handwash and don gloves.

  • Swab the area with povidone iodine beginning in the centre and moving out to the periphery.  Allow the solution to air dry.

  • Prepare to insert the “butterfly” needle through the skin surface and silicone dome.  To avoid repeated injections through a single point the reservoir allows for puncturing over the surface of the dome between 45^° and 90^° angles to the skin surface.

  • Insert the needle firmly through the skin and confirm the correct position by the “feel” of the needle passing through the dome.  Continue gently until the resistance of the reservoir base is met.  Do not twist or angle the needle once positioned in the device as this may damage the self sealing dome.

  • Clamp the “Butterfly” tubing and remove the cap.

  • Attach the syringe of prescribed morphine/sodium chloride solution, release butterfly clamp and draw back 1 ml of cerebrospinal fluid into the solution.

  • Presence of cerebrospinal fluid verifies correct siting but procedure cannot continue unless CLEAR cerebrospinal is obtained.  Report stained fluid to medical officer.

  • Inject the solution slowly over sixty seconds.  Injection into the ventricle should not cause pain. No flush is required.

  • Observe the injection site for swelling throughout the procedure.  To avoid subcutaneous infiltration ensure the needle tip does not slide out of the reservoir during injection.  Stop injection and report to medical officer if swelling is noted.

  • Reclamp tubing and reconnect cap.  Unclamp.

  • Gently withdraw the butterfly from the reservoir while pressing down on either side of the portal with two fingers.  Maintain pressure over injection site with gauze square.

  • Check and cleanse the injection site with povidone iodine.  Dress the site with an occlusive dressing necessary.

  • Ensure the patient’s comfort.  There is no restriction to the patient’s usual activity, but for first day patient to remain in own room.

  • Record the administration of the medication.

  Complication
  All complications must be reported to the Registrar or Consultant.  The prescribed drug is not to be altered without prior consultation with the Registrar or a consultant.

  Infection
  The major risk is of meningitis.  Observe the implantation site for swelling, redness and tenderness.  If present DO NOT INJECT through the reservoir without consulting the Registrar or a consultant.

  Catheter Blockage
  Immediately notify the medical officer if resistance prevents instillation of solution.

  Withdrawal Symptoms
  A lower dose of opioid may result in withdrawal symptoms such as restlessness, runny eyes and nose, then later goose-pimples, sweating and nausea leading on to stomach cramps, vomiting, extreme restlessness, shivering and marked sweating.  These symptoms occur within the first 24 to 48 ours of opioid withdrawal.  (Oral methadone may be required until stabilisation and in high risk patients this medication may be ordered prophylactically).

  Nausea/Vomiting

  Drowsiness

  Respiratory depression
  NB: As all McCulloch House patients being treated with intraventricular morphine have already been exposed to high dose opioids, respiratory depression/apnoea is unlikely.

  Respiratory Depression/conscious state 3 or greater / SPO₂ falling or less than 90

  Action:

  • Give 0₂ 6L/min

  • Stimulate the patient by instruction to take a deep breath

  • Attempt to rouse the patient

  • Notify RMO/Summon assistance

  • Administer naloxone 0.2 mg IV stat or naxolone 0.2mg IM stat according to the Treatment order sheet.

  Apnoea

  Action:

  • Commence IPPV (intermittent positive pressure ventilation) via  an air-viva

  • Check for pulse (? Cardiac arrest)

  • Summon assistance

  • Administer naloxone 0.4 mg IV stat or naxolone 0.4mg IM stat according to the Treatment order sheet.

  • Notify RMO

  • When situation has stabilised, telephone Consultant (or Registrar) re site of ongoing care and frequency of observation.

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  Procedure : Instructions for use of CADD 1 Pumps

  • Insert 9-volt battery.  This turns pump on and off.

  • Allow pump approximately 15 seconds to flash up previous pump settings.

  • When this is completed

  • Press Lock key to display current lock level

  • Use Scroll key –Ø to display desired Lock level – 0, 1 or 2

  The Pump must be in LLO for Programming

  • Press Lock key.  Display screen will show – 000

  • Use Scroll key to enter security code ‘51’

  • Press Lock key to finish

  • Press Select Mode key

    • RATE             will appear in top left-hand corner

  • Scroll to the amount of mls per 24 hours to be delivered

  • To set value – press Set Clear key

  • Press Select Mode key

    • GIVEN            will appear in bottom left hand corner

  • Press Set Clear to clear amount.   000 should then appear

  • Press Select Mode key

    • RESIDUAL VOLUME            will appear in top left hand corner

  • Scroll the amount of millilitres in the cassette

  • To set value press Set Clear key

  • THE PUMP IS NOW SET

  Prime Pump

  • First attach new cassette to pump along with extension tubing

  • Prime tubing

  • Press Prime Key till PPP is displayed

  • Release the Prime key and the press Prime key again and hold.  The pump will continue to deliver while the Prime key is depressed or until 0.5mls has been delivered.  Repeat again if tubing not completely primed.

  Pump Must be Primed in LLO

  • Change Lock level to LL2

  • Press Lock

  • Scroll to LL2

  • Press Lock

    • Display screen will show 000

  • Use Scroll key to enter security code ‘51’

  • Press Lock key to finish

  • PUMP IS NOW READY FOR USE

  To Start Pump

  • Press Start until --- disappears from screen

  • Pump will flash through all settings to enable a check of all rates and amounts

  • Mls will flash in top right hand corner indicating pump is working

  • Res Vol in top left hand corner will be on display and the amount in the cassette will count backwards over 24 hours until cassette is empty

  • Remember to unlock all clamps or pump will beep

  NB      To remove cassette from pump or release a new one, use a 5c coin to unscrew button on side of pump

  NB      Pump requires a CADD extension set 152cm/60” 1.7ml Ref 21-7062-24

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  Recommended Drug Combinations for Continuous Subcutaneous Infusion

  INDICATION	MEDICATION	USUAL STARTING DOSE / 24Hrs	DOSE RANGE / 24 Hrs	COMMENTS
  Analgesic	Morphine Sulphate   10 mg / 1ml   15 mg / 1ml   30 mg / 1ml Morphine Tartrate   120 mg / 1.5ml	Same as total IM / IV dose for 24 hours   or one third total oral dose for 24 hours	Titrate according to response.  Usual starting dose for opioid naive patient is 10-30mg per 24 hours No upper limit	Local inflammation is rarely encountered. Use Morphine Tartrate when higher dose requirements would necessitate larger volume infusion
  Analgesic	Fentanyl *   100 mcg / 2 ml   500 mcg / 10ml	150-200 mcg Fentanyl approximately equivalent 10mg parenteral morphine	Titrate according to response	Indicated when proven intolerance to morphine (Consult Palliative Care Team)
  Anti-emetic	Metoclopramide   10mg / 2ml	20mg	20mg - 80mg	Risk of Parkinsonian side-effects Reconsider use if abdominal pain worsens in bowel obstruction.
  Anti-emetic Anti-spasmodic	Hyoscine Butylbromide * (Buscopan)   20mg / 1ml	20mg	10mg - 120mg	Excessively dry mouth, visual disturbance and tachycardia may occur at higher dose range
  Anti-emetic	Haloperidol   5mg / 1ml	5mg	2.5mg - 10mg	Risk of Parkinsonian side-effects Drowsiness at higher dose range
  Anxiolytic Anti-convulsant Sedative (for terminal restlessness)	Clonazepam   1mg / 2ml   (Use saline as diluent)	1mg	0.5mg - 5mg	Upper dose range is sedative, and it may be necessary to review and reduce dose in terminal phase Useful for “twitching” sometimes associated with high dose morphine In anti-convulsant indications, monitor for therapeutic levels
  Anxiolytic/sedative	Midazolam *   5mg / 1ml        15mg / 3ml	15mg	10mg - 120mg	Upper dose range is sedative

  *Indicated drug not available on Pharmaceutical Benefit Scheme

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  Whilst every effort has been made to ensure accuracy, the individual prescriber is not absolved from the responsibility to personally check that each medication is appropriate, not contraindicated, and in correct dosage.

  Any one of the opioids mixed with any combination of the other listed medications is understood to be compatible in the same syringe for up to 24 hours, provided no precipitation is observed on first mixing.  Hyoscine and Metoclopramide should not be used simultaneously, as their actions are antagonistic.  Chlorpromazine and Prochlorperazine must not be administered subcutaneously, as both are irritant.

  Modified  by Professor Michael Ashby, Professor/Director, McCulloch House, Palliative Care Centre, Monash Medical Centre, Clayton 3168  Telephone (03) 9594  5347

  From an original by Dr David Thorne, Director, Palliative Care Service, Queen Elizabeth Hospital, Woodville SA  Telephone (08) 243 6825   Facsimile (08) 8268 7855

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  Anti-emetics Commonly Used in Palliative Care

  Drug	Recommendations for use	Target area for action	Side effects
  Metoclopramide (Maxalon)	For vomiting due to gastric stasis, gastric irritation, chemotherapy and introduction of opioid-related vomiting	On the gut. By increasing lower oesophageal sphincter tone, it promotes gastric emptying and stimulates gastric motility.  May be given PO, IM, IV or S/C	Mild sedation, dystonia, akathisia, diarrhoea.  Contraindicated in patients with large bowel obstruction
  Haloperidol (Serenace)	For uraemia, hypercalcaemia, opioid-induced nausea and vomiting.	Very potent antagonist at the CTZ.  May be given PO, S/C	Extrapyramidal reactions
  Prochlorperazine (Stemetil)	For cerebral metastasis	Anitidopaminergic effect at the CTZ.  May be given PO, IM or rectal.  S/C injection can cause erythema or discomfort.	Extrapyramidal reactions
  Cyclizine (Valoid)	For raised intracranial pressure, motion sickness, vertigo, radiotherapy and chemotherapy effects	Action at the vomiting centre and vestibular afferents.  May be given PO, IV or S/C.  Cyclizine is compatible in syringe driver with morphine	Drowsiness, sedation, dry mouth
  Lorazepam (Ativan)	For chemotherapy-induced vomiting, anticipatory nausea and vomiting, anxiety states	Cerebral cortex.  Usually given sublingually	Drowsiness, confusion
  Dexamethasone	For vomiting caused by raised intracranial pressure, hepatic metastasis, intra—abdominal tumour	Precise mechanism unknown – reduces inflammation or oedema around tumour.  May be given PO, IV, or S/C	Restlessness if given at night.  Cushingoid symptoms if given long term
  Cisapride (Prepulsid)	For opioid-induced vomiting, pseudo-obstruction	Stimulates gut motility from stomach to colon.  Usually given PO	Colic, diarrhoea
  Ondansetron (Zofran)	Persistent vomiting, chemotherapy and radiotherapy-induced vomiting	Prevents vagal stimulation in the GIT.  May be given PO or IV	Headache, constipation, flushing
  Tropisetron (Navoban)	Persistent vomiting, chemotherapy and radiotherapy-induced vomiting	Prevents vagal stimulation in the GIT.  May be given PO or IV.	Headache and constipation

  Source : Collegian 2001;8(2):41 Nausea and vomiting in the patient with advanced cancer: an overview of pharmacological and non-pharmacological management 2 May 2001

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  Opioid Conversions

  Oral Morphine to Oral Oxycodone Morphine 10mg = Oxycodone (Endone) 10mg	1 : 1
  S/C Morphine to S/C Fentanyl Morphine 10mg = Fentanyl 150microg	70 : 1
  S/C Fentanyl to Transdermal Fentanyl Fentanyl 600mg/24hr CSCI = Transdermal/Fentanyl (Durogesic) 25mircog/hr	1 : 1
  S/C Fentanyl to S/C Sufentanil Fentanyl 100microg = Sufentanil 10microg	10-20 : 1
  S/C Morphine to I/T Morphine Morphine 100mg/24hrs CSCI = Morphine 1mg daily IT	100 : 1
  S/C Morphine to epidural Morphine Morphine 100mg/24hrs CSCI = Morphine 10mg daily epidural	10 : 1
  Oral Morphine to S/C Morphine Morphine 30mg bd (60mg) orally = Morphine 20mg CSCI/24hrs	3 : 1
  S/C Fentanyl to S/L Fentanyl	1 : 1
  S/C Sufentanil to S/L Sufentanil	1 : 1
  S/C Morphine to S/C Sufentanil Morphine 300mg/24hrs CSCI = Sufentanil 450microg CSCI/24hrs	700 : 1
  S/C Morphine to I/Ventricular Morphine Morphine 100mg CSCI/24hrs = Morphine I/V 0.1mg daily	1000 : 1
  Morphine to Methadone (Should liaise with Pain or Palliative Care staff due to incomplete cross tolerance issues)	?

  These ratios are approximate

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