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End of Life Care Symptom Management (Specific to Heart Failure) Appropriate Prescribing

Anorexia Cachexia

Dyspnea

Edema Ascites

Fatigue

Nausea Vomiting

Pain

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Anorexia/Cachexia Heart Failure Symptom Management Guideline For adults, age 19 and older in British Columbia

What is anorexia? Anorexia is a syndrome characterized by some or all of the following symptoms: loss of appetite, nausea, early satiety, weakness, fatigue, food aversion, and significant physical and/or psychological symptoms. Causes of anorexia are multifactorial and include fatigue, dyspnea, medication side-effects, nausea, depression, anxiety and sodium restricted diets which may all be found in patients with heart failure. What is cachexia? Cachexia is a syndrome characterized by severe body weight, fat and muscle loss and increased protein catabolism due to underlying disease. The prevalence of cachexia is 16–42% in the heart failure population and is associated with a 50%, 18 month mortality risk independent of variables such as ejection fraction, age and functional ability. How is cachexia diagnosed? Chronic condition with 2  >5% weight loss in <12 months; or body mass index (BMI) <20kg/m ; and  3 out of 5 additional criteria: 1) Fatigue, 2) Decreased muscle strength, 3) Anorexia, 4) Low muscle mass, 5) Abnormal biochemistry *Blood testing to diagnose cachexia in advanced stages of disease is not advocated. Reminder: Malnutrition also affects prognosis in patients with heart failure and is often found in early transitions of the disease. However this symptom management guideline will focus on the assessment and treatment of anorexia and cachexia.

Approach to Managing Anorexia/Cachexia Assessment  History: When did weight loss begin? How much weight was lost? Obtain baseline (dry) weight. How is appetite? What do you eat or drink on a typical day ?  How has weight loss affected mood?  Ask about: nausea, early satiety, dyspnea, poor oral hygiene, dysphagia, malabsorption, bowel habits.  Ask about other factors causing anorexia/cachexia, e.g. cancer, hypothyroidism, severe liver disease, infections, depression.  Use Edmonton Symptom Assessment System (ESAS) to rate appetite, nausea, fatigue, depression.  Review medications known to contribute to anorexia/cachexia. eg. amiodarone, digoxin.  Assess functional capacity for effects of early fatigue and muscle weakness

Tips

Anorexia Cachexia

Reversibility Reversible Irreversible

Malnutrition

Reversible

Comparing Malnutrition and Cachexia Treatment Options Other Therapies Preventative Nutritional support/ Preventative stratigies Supportive symptom management as Focus on symptom management and psychological support there is no cure Increase nutrient intake Nutrition support may help

 Focus interventions on treatment of symptoms and reduction of psychological burden for patient and family.  Cachexia is not the same as starvation in that catabolism and subsequent weight loss can occur even if caloric intake is maintained or increased.  Educate patient/family re difference between weight loss related to cachexia versus related to diuresis.  Artificial nutrition in the setting of advanced cachexia is ineffective and will not improve quality of life.  If patient is able, gentle physical exercise is recommended as it is in known to improve peripheral blood flow, metabolism and neurohormonal abnormalities associated with cachexia.

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Anorexia/Cachexia Management Guidelines | Page 2 Non-Pharmacological approach Cachexia treatment options:  Emphasis should be placed on maintaining/improving quality of life. Anorexia treatment resources:  Refer to a registered dietitian (RD); ensure dietitian aware of goals of care and focus of symptom management.  Consider focus on maintenance of food and fluid intake for social and psychological benefits; liberalize dietary choices as much as possible (eg. low fat diet unnecessary).

Pharmacological Approach  Standard heart failure therapies are known to improve quality of life and reduce symptoms and may reduce symptoms even at advanced stages of disease.  Although many guidelines will refer to the use of appetite stimulants and steroids in the treatment of anorexia and cachexia, there is insufficient evidence of the benefit of these therapies. They are not recommended at the current time.  Early satiety/nausea: Metoclopramide 10 mg PO or subcutaneous, 30-45 minutes prior to meals and at bedtime (hs) (reduce dosage in renal impairment).  Where concomitant depression/anxiety/insomnia is present, the antidepressant Mirtazapine may have the added benefit of increased appetite and weight gain. Starting dose of 7.5 mg may be up titrated to 30 mg at hs with consideration to sedative effects.

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Heart Failure End of Life Appropriate Prescribing Guideline For adults, age 19 and older in British Columbia The management of heart failure (HF) involves numerous pharmacological (beta blockers, ACE-I inhibitors) and non-pharmacological (device therapy) treatments. As end of life (EOL) approaches, the focus of care shifts from active disease management, towards palliation of symptoms. However, some HF therapies remain important and reduce symptoms (Goodlin, 2009). This module is intended to assist with de-prescribing medications, and guide the safe reduction of medications at the end of life. Communication early in the trajectory of HF will facilitate decision making between the clinician, patients and family members, with the aim of hoping for the best but preparing for the worst (Gadoud, Jenkins & Hogg, 2013).

Guiding Principles for Appropriate Prescribing Medications

     

 

Review meds regularly considering survival and symptom management and the goals of the patient. Discuss all medication changes with patient and family Focus on symptom management Eliminate unnecessary medications, especially those that may be causing more adverse effects than benefits. Avoid medications that cause hypotension or syncope Maintenance of some HF meds will provide positive benefit, ease symptoms, potentially avoid re-admissions to hospital as well as improve quality of life: o Beta Blockers protect against tachycardia and anxiety o Diuretics ease pulmonary congestion and shortness of breath. o ACE-I or ARBs provide positive left ventricular support Dose reductions may be preferred over discontinuation When the patient can no longer take oral meds, DO NOT change to IV or SC route (except possibly diuretics if required) Gadoud et al, 2013.

January 2015

Return to Page 1 Heart Failure End of Life Appropriate Prescribing Guideline| Page 2 Appendix 1: Gadoud et al. 2013 Table 1. Conventional medical HF management in advanced HF and last days of life. Drug

HF survival improved?

Common side effects

Advanced HF

Last days of life

Yes

HF symptoms improved? Yes

ACE Inhibitor

Cough, ↓BP, ↑K+, renal impairment

Discontinue

Amiodarone

No

Yes

Nausea, liver and thyroid dysfunction, QT prolongation

Angiotensin receptor blocker

Yes

Yes

↓BP, ↑K+, renal impairment

Aspirin

No

GI irritation and hemorrhage

Beta blocker

No (unless recent infarct) Yes

Yes

Digoxin

No

Yes

↓HR, ↓BP, cold peripheries, nightmares, fatigue ↓HR, nausea and GI disturbance, agitation, drowsiness

Continue if tolerated (except during hypovolaemic illness *) Continue if required for arrhythmia control unless significant adverse effects Continue if tolerated (except during hypovolaemic illness) Discontinue unless significant vascular disease/recent infarct Continue if tolerated Continue if tolerated but vigilance required to avoid toxicity

Diuretic

Possibly

Yes

↓K+, dehydration, gout

Continue with dose titration as required

Ivabradine

Yes

Yes

Continue if tolerated

Hydralazine

Yes (with nitrate) Yes

No

↓HR, visual disturbance, headache GI disturbance, headache, flushing ↑K+, renal impairment, GI disturbance, gynaecomastia (spironolactone only)

Discontinue but may still provide symptom relief so could continue Discontinue but may still provide symptom relief so could continue Discontinue

Continue if tolerated

Discontinue

Continue if tolerated (except during hypovolemic illness)

Discontinue

Yes (with hydralazine) No

Yes

Headache, GI and sleep disturbance Liver dysfunction, myalgia, myositis

Continue if tolerated

Discontinue

Discontinue

Discontinue

Mineralcorticoid receptor antagonist (eplerenone/ spironolactone) Nitrate Statin

Yes

No

Discontinue

Discontinue Discontinue Discontinue

* Dosing may need to be adjusted in impaired renal function +

ACE: angiotensin converting enzyme; BP: blood pressure; GI: gastrointestinal; HF: heart failure; HR: heart rate; K : potassium. References: Cruz-Jentoft, A., Bolana, B., Rexach, L. (2012). Drug therapy optimization at the end of life. Drugs Aging 2012: 29(6); 511-521. Gadoud, A., Jenkins, S., Hogg, K.J. (2013). Palliative care for people with heart failure: Summary of current evidence and future direction. Palliative Medicine. Published by SAGE @ http://sagepublications.com/content/early/2013/07/05/0269216313494960/ Goodlin, S.J. (2009). Palliative care in congestive heart failure. J Am Coll Cardiol. 2009;54; 386-369.

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Dyspnea Heart Failure Symptom Management Guideline For adults, age 19 and older in British Columbia Dyspnea is the most common, recurrent symptom associated with heart failure (HF) and may affect up to 90% of patients. In end stage HF, dyspnea is usually related to volume overload. Patients may, however, experience severe dyspnea without hypoxia, hypercapnea or volume overload. The experience of dyspnea can range from mild to severe and include a feeling of impending doom. A combination of pharmacologic management and self-management strategies are best employed to reduce and control symptoms of dyspnea. As heart failure advances, therapy should be tailored to the patients' subjective experience rather than to physiologic parameters.

Approach to Managing Dyspnea Initial pharmacologic approach

Assessment  Ask the patient to describe their symptoms and severity (0–10 scale).  Ask: “Are you short of breath”?  Use the Edmonton Symptom Assessment System (ESAS) in the setting of

multiple symptoms, and as a useful way to trend burden of the symptom.  Assess for alternative underlying causes; consider co-morbid conditions

such as anemia, and chronic obstructive pulmonary disease (COPD).  When cause of dyspnea is thought to be due to either HF or for

example COPD, measurement of BNP may assist in clarifying the underlying cause. (BNP > 500 pg/ml or NTPro BNP >900 pg/ml- more likely to be related to HF).  Obtain a full medical history and complete a full physical exam concentrating on symptoms and possible causes (this will lead to accurate diagnosis in two-thirds of cases).

 Treat volume overload http://www.bcheartfailure.ca/wp-

content/uploads/downloads/2012/06/HF-Algorithm-v6-1a21.pdf  Combination of loop and thiazide diuretic may improve response.  Standard heart failure therapies (ACE/ARB, vasodilators, eg. Nitrates).  Oxygen for hypoxemia only (access the home O2 application through your health authority websites).

Persistent Symptoms (despite optimal medication)  Initiate and titrate opioid therapy as they are effective in both

pain and dyspnea.

Dyspnea tips  Treat the subjective symptom of dyspnea with medications.  A combination of pharmacologic and non-pharmacologic

self-management strategies is most effective.  In advanced disease, it is important to treat constant dyspnea and plan

for episodes of breakthrough dyspnea and severe persistent dyspnea.

 Opioids are safe in cardiopulmonary disease. Start low, go slow.  Opioids with few/no active metabolites are preferred in renal

failure/frailty-avoid Tylenol #3 and morphine.  Always order a laxative with opioids as constipation is a

common reason for non-adherence with opioids.  Breakthrough pre activity dose can be useful for incident

management of dyspnea (usually 10% of total daily dose q1h).  Consider consultation with palliative care physician if symptoms

persistent.

Non-pharmacologic Approach  Pace activity to reduce severity of dyspnea episodes.  Prepare for exertional activities, (take your medication as prescribed

before your activity, this includes opioids).  Pursed-lip breathing can be an effective strategy for relief of dyspnea.  Movement of air-flow can improve symptom (use fans, open windows).  Plan ahead about what to do to reduce anxiety which can worsen

symptom.  Ensure family or friends are aware of the strategies to support the

patient during incident and crisis dyspnea.  Noninvasive positive pressure ventilation.  Relaxation can be an effective strategy for relief of dyspnea.

Fentanyl patch should not be used as an initial opioid, but may be a good choice for long term therapy Addition of Benzodiazepines for management of anxiety or dyspnea may be required in addition to opioid therapy http://www.bcguidelines.ca/pdf/palliative2_dyspena.pdf Medication (Generic/Trade) hydromorphone (dilaudid)

Available doses forms IR tabs 1,2,4,8 mg

morphine (MOS,MS-IR, Statex) MOS, MS Oxycodone (Oxy IR, Supeudol)

IR tabs: 5,10,25,30,40,50,60 mg

Initial Dose and titration 0.5mg-1mg PO q1h, PRN. Once regular dose is achieved then should adjust to BID or q4hr dosing schedule. 2.5-5 mg PO q1h PRN

Injection: 1,2,5,10,15,25,50mg per/ml IR tabs: 5,10,20 mg

Crisis dyspnea: 5 mg SC q15 minutes. 2.5-5 mg PO, titrate to q4h

January 2015

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Edema/Ascites Heart Failure Symptom Management Guideline For adults, age 19 and older in British Columbia

Edema is common in Heart Failure (HF) and can cause significant discomfort and even cellulitis. In end stage HF, edema may be even more pronounced with ascites. Management of edema and ascites involves non-pharmacological, pharmacological, and procedural interventions along with self-management strategies, and should be tailored to the patient’s goals of care.

Approach to Managing Edema/Ascites Assessment  A comprehensive assessment must include a physical, psychosocial, and patient environment assessment, medications, review of labs and diagnostics. Assessment needs to determine the cause, effect and impact on quality of life for the patient.  Use of the Palliative Performance Scale (PPS) and Edmonton Symptom Assessment System (ESAS) to assess and monitor symptomatic burden.  Edema and ascites should be assessed according to history and physical examination.  Symptoms of ascites include: abdominal pain or pressure, early satiety, nausea and vomiting, dyspnea, orthopnea.  Physical exam findings include elevated jugular venous pressure, increased abdominal girth, shifting dullness, or fluid wave.  Depending on the goals of care, diagnostic tests could include blood work such as, electrolytes, albumin, blood counts, coagulation test and/or along with abdominal imaging.

Edema/Ascites Tips Identify and treat the underlying cause as appropriate. Consider:  Exacerbating conditions such as: poor nutrition, liver or renal disease.  Medications which provoke fluid retention such as: NSAIDS, steroids, vasodilators and calcium channel blockers.

Non-pharmacological Approach  Counsel patient on importance of salt and fluid restriction.  Elevation of legs to assist with fluid return.  Light support hose may also be used if they have sufficient cardiac output *Use of compression stockings may worsen HF in some cases -use with caution.  In conditions of malnourishment, review protein intake.  Focused prevention of skin breakdown and early wound care consultation if available.

Interventions:  Assess patient’s prognosis and goals prior to considering interventions such as paracentesis.  If paracentesis not indicated, manage pain or dyspnea from ascites with medication.

Possible interventions:  For ascites: ultrasound/paracentesis o Given the invasiveness of the procedure and burden of recurrent visits, a full discussion of risks and benefits should accompany this procedure. o Paracentesis can provide temporary symptomatic relief; the following needs to be considered,  Usually requires repeat drainage.  The cost of a long- term tunnelled catheter is not paid for by MSP at this time.

January 2015

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Edema/Ascites Management Guidelines | Page 2 Pharmacological Approach http://circ.ahajournals.org/content/120/25/2597.full#T4 Name furosemide

Dose forms IV, PO, SC (maximum of 20mg sub q in one site)

Dose 20 mg daily or bid to a maximum of 600 mg

Comments Not necessary to reduce the dose with change in route.

For treatment of exacerbation: Step 1 – Initiate or double the current dose for three consecutive days or until an accumulated weight loss of 2.5-5 kg. (Doses > 80 mg should be split into twice daily dosing) Step 2 – After 3 days, if not at target weight, increase dose by 50-100%. Step 3 – After a further 3 days, and if not at target weight can add Metolazone ( see below for dosing) metolazone

PO

2.5 to 10 mg daily used in combination with loop diuretic (given 30 minutes prior to loop diuretic). Can be given in divided doses twice daily

spironolactone (mineralocorticoid receptor antagonists)

Oral

Edema: 12.5 mg to 25 mg per day Ascites: 25 mg per day to 100 mg per day; typical dose for ascites is 100 mg per day spironolactone with 40mg per day furosemide.

Start with daily dosing of metolazone for 3 days or 3 times per week dosing (Mon, Wed, Fri) and monitor response closely including renal function and electrolytes. In cases of ascites, it is important to give higher doses of mineralocorticoid receptor antagonists to enable diuretic action. Monitor electrolyte and renal function.

For refractory or persistent symptoms, recommend consultation with a palliative care physician or the Palliative Care Consultation Line Telephone: 1-877-711-5755

January 2015

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Fatigue Heart Failure Symptom Management Guideline For adults, age 19 and older in British Columbia

Fatigue is defined as a sustained sense of exhaustion with a decreased capacity for physical and/or mental work. Fatigue is also subjective and is the most disabling symptom in chronic heart failure. Studies show it is a multidimentional symptom with both clinical and psychological characteristics effecting patients’ quaility of life. A combination of pharmacological and self-management strategies a r e best employed to reduce and control symptoms of fatigue.

Approach to Managing Fatigue Assessment 



Document history, physical examination, medications, sleep history, psychosocial assessment, environment assessment, review of laboratory and imaging studies. Assessment needs to focus on determining the cause, effect and impact on quality of life for the patient.

Non-pharmacological Approach       

Fatigue tips 

 

Identify and treat the underlying cause as appropriate; consider co-morbid conditions such as anemia, chronic obstructive pulmonary disease, depression, dehydration, endocrine imbalances, hypercapnea, hypoxia, medications (eg. beta blockers, opioids, antidepressants), bradycardia, poor nutrition, poor sleep, sepsis, pain, diarrhea, nausea or vomiting, hypokalemia, hypernatremia, and hypomagnesaemia. Collect Edmonton Symptom Assessment System (ESAS ) score to assist with monitoring and documenting symptomatic burden. A combination of pharmacologic and nonpharmacologic self-management strategies is most effective.

Assess and give fluids as appropriate. Nurition counselling. Sleep, aromatheraphy. Massage, music. Exposure to natural enviornment. Pace activities to reduce severity of fatigue and help patient to adapt life to day to day condition. Prepare for exertional activities, including premedication as indicated (eg. Nitro, opioids).

Initial pharmacological Approach Treat underlying causes: (content retrieved from FH’s symptom guideline for fatigue available at) www.fraserhealth.ca/media/11FHSymptomGuidelinesFatigu e.pdf)  Depression – refer to provincial Depression symptom guideline http://www.bcguidelines.ca/guideline_mdd.html  Rule out endocrine imbalances – (Diabetes management and thyroid hormone replacement).  Hypokalemia – change loop diuretic to potassium sparing; may need potassium supplement.  Insomnia – consider sedative or hypnotic medication (may have high risk of delirium).  Sepsis – give antibiotics and antipyretics where appropriate.

January 2015

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Fatigue Management Guidelines | Page 2 Persistent Symptoms Psychostimulants Not first line therapy

This medication class should be used in consultation with a palliative care physician and a physician experienced in heart failure care. Patients who are elderly, cachexic, debilitated, have renal or hepatic dysfunction may require reduced doses http://www.bcguidelines.ca/submenu_palliative.html http://www.bcguidelines.ca/pdf/palliative2_fatigue_appendix_b.pdf Persistent Symptoms

Name Methylphenidate (Risk of arrhythmia and agitation…..should only be used in specific cases)

Trade Name Ritalin

Dose forms IR tabs 5, 10, 20 mg

Biphentin

SR capsules 10, 15, 20, 30 mg XR tabs 18, 27, 36, 54 mg SR tabs 20 mg IR tabs 5 mg

Concerta

Dextroamphetamine

Ritalin SR Dexedrine

SR capsules 10,15 mg

Modafinil

Alertec

Tabs 100 mg

Starting dose Not recommended for patients over 65 years of age Age 18-65: 5mg PO BID (AM & noon) Frail patients: 2.5 mg PO BID Once does is stabilized in IR give equivalent daily does as SR or XR once daily in AM Not recommended for patients over 65 years of age Age 18-65 2.5mg PO BID (AM then 4 to 6 hours) Once dose stabilized on IR, give equivalent daily does as SR once daily in AM Age over 65 years 100 mg PO QAM Age 18-65 years 100 mg PO BID (AM and noon)

Reference BCMA palliative care guideline

January 2015

Maximum dose 15 mg PO BID (AM and Noon)

20mg PO BID (AM then 4 to 6 hours)

Age over 65 years 100mg PO BID (AM and noon) Age 18-65 years 200 mg PO BID (AM and noon)

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Nausea and Vomiting Heart Failure Symptom Management Guideline For adults, age 19 and older in British Columbia

Nausea and vomiting occurs in 17% to 32% of patients with heart failure. In this patient population, nausea and vomiting is multi factorial, can occur due to nervous system activation, hypoperfusion, congestion of tissues/organs, or coexistent diseases. Opioids and drugs with anticholinergic properties (e.g., class 1A antiarrhythmic agents, tricyclic antidepressants) can compound the problem of slowed gastric emptying innate to advanced heart failure. In patients receiving palliative care, nausea and vomiting rarely occurs in isolation; it tends to cluster with other symptoms, such as, pain, dyspnea, fatigue and decreased appetite.

Approach to Managing Nausea and Vomiting Assessment

Pharmacological Approach

 Focused physical examination: vital signs, oropharynx/mucous membranes; abdomen, rectum (to assess for constipation/impaction/bowel obstruction); volume status (JVP, decreased urine output, thirst, dry mouth, dizziness, muscle cramps) and nutritional status (weight).

 Consider intravenous hydration or hypodermoclysis to replace lost fluids and electrolytes.  Medications that may be contributing to symptoms should be discontinued.

Principles of Antiemetic Therapy Dietary Approach  Avoid intolerant food and/or restrict intake as appropriate.  Start with sips, ice chips or popsicles once nausea improves; gradually increase from fluids to semi-solid to full food.  Avoid spicy, fatty, excessively salty or sweet foods, or ones with strong odors.  Sit up during and after eating.  Consult with a clinical dietician and provide dietary/nutritional advice (www.healthlinkbc.ca/dietician/).

Non-pharmacological Approach  Treat underlying causes based on mechanism involved, or any reversible causes where possible and desirable according to the goals of care.  Maintain good oral hygiene (brushing teeth and rinsing mouth), especially after vomiting.  Environmental modification: eliminate strong smells and sights; open windows to get fresh air, use a fan, air deodorizers or fresheners.  Cognitive therapies: relaxation, visualization/imagery, hypnosis, distraction.  Consider alternative therapies: acupuncture, acupressure or massage.  Consultation: social worker, physiotherapist, occupational therapist, spiritual practitioner, counselors for psychosocial care, or anxiety reduction.

 Select antiemetics based on the central emetogenic pathways and their corresponding neurotransmitters involved.  Give antiemetics prophylactically to prevent nausea (especially with opioid).  Give antiemetics subcutaneously (if vomiting) on a regular dosing schedule with a breakthrough dose available for persistent symptoms.  Titrate up antiemetics to their full dose before adding another drug.  If symptoms not controlled for 24–48 hours, add another antiemetic from another group, (do not stop initial drug)  Consider combinations but monitor overlapping toxicities.

January 2015

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Nausea and Vomiting Management Guidelines | Page 2 Persistent Symptoms May be due to worsening heart failure – consider consultation with the heart failure team and/or palliative care consultation team if symptoms persist. Causes – Mechanisms & Pathways

Medication (Generic)

Route

Initial Dose and Titration

Gastrointestinal: Delayed gastric emptying, liver distension, gut wall edema, constipation

domperidone* metoclopramide* haloperidol

PO PO, SC, IV PO, SC, IV

10 – 20 mg TID, or QID 5- 10 mg Q6h 0.5 – 2.5 mg q6h – q24h

dexamethasone

PO, SC, IV

4 – 6 mg daily in AM (avoid BID or TID dosing which can lead to insomnia)

Chemoreceptor Trigger Zone: Drugs (opioids, digoxin, steroids, antiarrhythmic agents, spironolactone, SSRI antidepressants) Biochemical (hypercalcemia, uremia, organ failure) Toxins: infection, drug metabolites, ischemic bowel

haloperidol prochlorperazine methotrimeprazine

PO, SC, IV PO, PR, PO, SC

0.5 – 2. 5 mg q6h – q24h 2.5 – 10 mg q4h – q6h 5 – 25 mg q8h – q24h

ondansetron

PO,SC,IV

4 to 8 mg Q6H to Q8H

Vestibular: Motion sickness, opioids

dimenhydrinate scopolamine

PO, SC, IV Transdermal

25 – 50 mg q4h 1.5 mg patch q72h

Precautions:  Use PO route if patient is not vomiting and able to tolerate. Use subcutaneous route if patient is vomiting.  Steroids can contribute significantly to fluid retention which can worsen heart failure. (This side-effect is more common with prednisone; dexamethasone in low doses may be effective for severe nausea).  Methotrimeprazine is an anti-psychotic which has anti-emetic properties and is used in palliative care. Must be used in carefully titrated doses as it can cause hypotension in those with heart failure and ambulatory patients.  Metoclopramide – Assess effectiveness within 2 days. Monitor for adverse movement effects. *Reduce dose in renal impairment.

January 2015

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Pain Heart Failure Symptom Management Guideline For adults, age 19 and older in British Columbia Patients with end-stage heart failure may experience pain from cardiac or non-cardiac causes. Common causes of cardiac pain include angina and edema (peripheral), while non-cardiac pain commonly results from comorbidities and medical interventions. Research concludes, pain is reported to be often severe and occurring at multiple sites, and is significantly associated with degenerative joint disease, arthritis, neuropathy, depression, shortness of breath, and angina. Regardless of the cause, uncontrolled pain can lead to worsening heart failure symptoms, reduced quality of life, and poor outcomes. A holistic approach to treating 'total pain’ should be considered by addressing concerns beyond physical pain, and including the psychosocial, spiritual and emotional needs of the patient.

Approach to Managing Pain Non-pharmacologic Approach

Assessment • Assess pain by taking careful history and physical examination and using standardized tools such as Edmonton Symptom Assessment System (ESAS), OPQRSTUV acronym. • Assessments should include identifying the type, cause and characteristic of the pain symptoms, and determining its correlations to the heart failure, comorbid conditions, medical interventions, other symptoms and/or pain medication. • Physical exam includes looking for signs of disease progression, trauma or neuropathic etiologies.

Pain Tips • Treat the underlying cause of pain using both non-pharmacological and pharmacological approaches and taking into account the context of the patient’s overall condition, prognosis and goals of care.

• Physical therapy, massage, acupuncture, heat/cold, ultrasound. • Repositioning, relaxation, distraction and alternative approaches including pet therapy, music therapy and aromatherapy. • Psychosocial interventions, spiritual counseling, patient education.

Pharmacological Approach • The severity of pain determines the required strength of analgesics as specified by the World Health Organization (WHO) Analgesic Ladder. • Select adjuvant analgesics based on the type and cause of pain (e.g., nociceptive, neuropathic, bone pain), concomitant disease, drug therapy and side effects and interactions experienced. Adjuvant analgesic should be trialed starting with initial low doses, optimize as tolerated and discontinue if ineffective. • Tailor drug dosage and route of administration as appropriate.

Types of Pain Mild Moderate to severe

Treatment Options Start with non-opioids like acetaminophen Start with short-acting opioids, given regularly and with breakthroughs, and titrate to patient’s comfort. Treat intermittent pain with intermittent medications, and persistent or chronic pain with around-the-clock or long acting opioids. Use short-acting opioids for breakthrough pain. Angina and/or Persistent Standard therapy: beta blockers, calcium channel blockers, nitrates, morphine, intracoronary stenting should be considered in the appropriate patient angina Uncontrolled pain Even with opioids

Consult palliative care

General principles of opioid prescribing (BC Heart Failure Network: iPALL) • • • • • • • •

Opioids are usually agents of choice for pain (including dyspnea) refractory to cardiac medications. Opioids are safe and evidence based in cardiopulmonary disease. Use lowest possible dose to achieve comfort, however, there is no ceiling dose. Opioids with few/no active metabolites preferred in renal failure/frailty – avoid Tylenol #3 (due to codeine) or morphine. Treat persistent or chronic pain with around-the-clock or long acting opioids. Consider increasing regular opioid dose when 3 or more breakthroughs are used in 24 hours. Use short-acting opioids for breakthrough pain. Breakthrough doses must always be available (10% of total daily dose and dosed at q1h). Consider switching from short -acting opioids to long acting when the symptom is well controlled with minimal breakthrough usage and when total daily dose of short- acting reaches a starting dose for long- acting opioid. • Always order a regular laxative with regular opioids (stimulant and + or – osmotic laxative). • If side effects are intolerable consider rotating to a different opioid.

December 2014

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Pain Management Guidelines | Page 2

Patients who are elderly, cachetic, debilitated or with renal or hepactic dysfunction may require low dosage G e n er i c / T r a d e N a m e acetaminophen, Tylenol®

NSAIDs

Tylenol #3, traMADol, OxyCODONE

morphine M.O.S.®, MS-IR®, Statex®, G

M-Eslon®, M.O.S. SR®, MS CONTIN®, G Injectable: 10 mg per ml (remember, injection route usually has twice the potency as the PO doses) oxyCODONE (1.5 as potent as morphine) oxy.IR®, Supeudol®, G HYDROmorphone Dilaudid®, G, HYDROmorph CONTIN®, Injectable: 2,10, 20, 50, 100 mcg per ml (Reminder- Injectable is TWICE AS POTENT AS PO) fentaNYL Patch Duragesic, Mat®, G Inj: 50 mcg per ml SUFentanil®, G Inj. 50 mcg per ml

methadone, (to prescribe a methadone license is required)

gabapentin, Neurontin® pregabalin, Lyrica®

December 2014

S t a n d a r d Ad u l t D o se Comments NON-OPIOIDS and OPIOID COMBINATIONS 325 to 650 mg PO q4-6h • Max: 4 g PO/PR per day for short term use; 3.2 g per day for long term 650 mg PR q4-6h use. • Max: 2.6 g PO/PR per day for elderly clients/liver impairment. • Usually contraindicated in heart failure because they antagonize the effects of diuretics and ACE inhibitors, promoting fluid retention resulting in edema and volume overload (Adler, et al., 2009). • Combination agents are generally not recommended; the adjuvant agents may prevent dose escalation (Adler, et al., 2009). • Use caution with caffeine as it may cause tachycardia. Consider using EMTEC 30. • Tramadol should be avoided, there are drug interactions with neuropathic agents as it lowers the seizure threshold. OPIOIDS Start with 2.5 mg-5mg PO • There is no limits to OPIOIDS then reassess q 4h • Meperidine (Demerol®) should not be used for the treatment of chronic pain. • Morphine is the least preferred in renal failure because of renal cleared active metabolites. Start with 10mg PO q12h • Use caution in starting long acting- short acting agents should be trialed before rotating to long-acting. • The total daily dose of short acting preparation must be at least 20 mg 2 to 25 mg SC q4h per day, before you switch to the long acting preparation. • The lowest dose of a long acting preparation is 10 mg and is given twice daily q12h. • Injectable oxyCODONE is not available in Canada. 5 to 20 mg PO q4h

2 to 8 mg PO q3h 3 to 30 mg PO q12h 2 to 10 mg SC q4h

12 to 100 mcg per hr applied to skin every 72hours 25 to 100 mcg sublingual per dose PRN For incident pain: 12.5 mcg sublingual dose PRN; incremental doses titrated q2h PRN up to 75 mcg

• HYDROmorphone is the opioid of choice (comment: not necessarily better than oxyCODONE or methadone) in renal impairment. • Immediate release formulations should be used before slow release preparations to facilitate dose adjustment and reduce the potential risk of toxicity. • FentaNYL is primarily (75%) cleared as inactive metabolites by the kidney. Risk of delayed absorption and overdose potential. • Should not be started on opioid naive patients who are taking less than 50 mg PO morphine equivalent daily. • SUFentanil is a potent opioid- (refer to your local health authority protocol). • SL SUFentanil may be considered for patients receiving at least Morphine PO 60 mg equivalent over the last 7 days. Palliative Care Consult is recommended.

NEUROPATHIC PAIN Dosing: The dose ratio of morphine: methadone is highly variable- eg. from 1:1 Consult palliative care with lower doses to as high as 12: 1 in high doses- caution in switching from one medication to the other is recommended.

100 to 1200 mg PO TID 75 mg PO BID

Once a stable dose is reached, the dosing interval may be extended to every 8 to 12 hours, or longer Use lower doses for patients with renal impairment. Increase q 7 days up to 300 mg BID- use lower doses for patients with renal impairment.

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Addressograph Health Authority Logo

Patient Consent for Implantable Cardioverter Defibrillator (ICD) Deactivation (must be reviewed with/ and signed by patient/ parent/legal guardian/temporary substitute decision maker* prior to deactivation)

Section 1: Physician Discussion I have discussed the following with the patient/family/parent/legal guardian or temporary substitute decision maker who, in my opinion understands the information provided  Turning off the ICD will not cause death  In the event of a dangerous rapid heart rate turning off the ICD will no longer provide a potentially lifesaving therapy such as electric shock and anti-tachycardia pacing  Turning off the device will not be painful, nor will its failure to function cause pain  Turing off the ICD lifesaving therapy function does not turn off the pacemaker function  Patient can change their mind and have the ICD lifesaving therapy turned back on  Shocks at end of life can cause a painful death  There is a plan of care to ensure healthcare professionals contact information is available to the patient if they have new questions or concerns Section 2: Patient or Substitute Decision Maker Consent I ________________________________________________ (Circle: Patient / parent/legal guardian/temporary substitute decision maker name) having been given the full details of the consequences by Dr_____________________ agree to the turning off the lifesaving therapy of (pts name)____________________________ Implantable Cardioverter Defibrillator (ICD). I understand I can change my mind and request the ICD’s lifesaving thearpy to be turned back on. Signed (by patient/ parent/legal guardian/ temporary substitute decision maker*)__________________________ Date __________ *if signed by a temporary substitute decision maker, complete the confirmation of Substitute Decision Maker form.

Signature of physician: ____________________________ Date: ______________Time:__________ Section 3: Telephone Consent I have discussed the points in section 1 and expected effects of ICD deactivation with (print name) ____________________________, who is the patient’s (state relationship) _______________________ and who has given verbal consent as substitute decision maker Physicians name: ______________________Signature _______________ Date (dd/mm/yyyy) ____________ Section 4: Interpreter Declaration I have accurately translated this document and acted as interpreter for the (circle: patient/ parent/legal gauardian/ temporary substitute decision maker) who told me that he/she understands the explanation and consents as described above Interpreter name (print) ______________________ Signature________________ Date ___________ Note: Where possible, at the earlist opportunity, the person who granted consent over the phone should sign Section 2 of this form

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Implantable Cardioverter Defibrillator (ICD) Information Sheet for Health Care Professionals An implantable cardioverter defibrillator (ICD) is a device implanted in a patient’s upper chest which monitors the heart rhythm, can act as a standard pacemaker, can provide anti-tachycardia pacing and if required, can deliver one or more high energy shocks to terminate potentially lethal arrhythmias such as ventricular tachycardia (VT) or ventricular fibrillation (VF). Receiving a shock can be painful and psychologically traumatic and is often described by patients as feeling like a kick in the chest.

Graphic copyright of Hamilton Health Sciences and used with permission.

Limitations of an ICD Although ICDs reduce sudden cardiac death, patients will ultimately die from either heart failure or another disease. As a patient’s disease progresses, physiologic changes may cause more arrhythmias and increase the frequency of shocks. Because ICD shocks can cause pain and anxiety and may not prolong a life of acceptable quality, it is important to consider deactivating the ICD when a patient’s clinical status worsens and death is near.

Deactivating an ICD with a programmer MUST have a physician’s order and a qualified health care provider to apply the magnet

Deactivating an ICD refers to turning off the defibrillator function of the device, not the pacemaker function. Deactivating an ICD is not a difficult procedure; however it does require the use of a programmer - a laptop computer specifically made by the device manufacturer. Typically an ICD is deactivated by a health care provider who is familiar with the programmer and is competent in adjusting the settings of an ICD. It is possible to turn off the pacemaker function of the ICD; however this is generally not something that is done. While deactivating the defibrillator function prevents painful shocks, deactivating the pacemaker does not prevent pain and may actually worsen the patient’s heart failure symptoms by reducing the amount of blood pumped out of the heart.

Deactivating an ICD with a magnet MUST have a physician’s order and a qualified health care provider to apply the magnet

The preferred method of deactivating an ICD is to use a programmer; however one may not always be available, particularly in urgent situations. If a programmer is not available, it is possible to prevent the delivery of a shock with the use of a magnet. Placing a large magnet (the size of a doughnut) over the device will temporarily suspend the arrhythmia detection function of the ICD and prevent the delivery of a shock. The site of magnet placement is important, as a poorly placed magnet may not inhibit shock therapy. Magnets are best placed directly on top of the ICD. When the magnet is removed, the ICD will return to its previous settings.

Things to keep in mind  Deactivating the ICD will not cause the patient’s death; it is simply allowing nature to take its course.  Deactivating the ICD will not cause the patient’s death to be more painful.  Deactivating the ICD will mean that the device will not prevent sudden death in the event of a dangerous arrhythmia.  Patients may reach a point in their lives when their goal of care is to be comfortable during their remaining time and an active ICD is not congruent with that goal.  It is not morally or legally wrong to stop any medical treatment if it no longer meets the patients’ needs. December 2014

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Referral for Deactivation of Implanted Cardioverter Defibrillator (ICD) Client/Patient Contact Information Name: _______________________________________________________ Address: _____________________________________________________ Phone Number: _______________________________________________ Patient’s current location:

Acute Care hospital

Non Acute hospital

Community facility

Home

If Patient Transitioning to End of Life/Palliative care, it is strongly recommended the patient be referred to Home and Community care Name of hospital/ facility ____________________________________________________________________ Referring physician/NP must fax Do Not Resuscitate order or Home DNR form with the deactivation request (completed and signed)

Name/ contact information of family member/legal guardian or temporary substitute decision maker: Name: _________________________________Address ______________________________________ Phone Number: ________________________________ Contact Information for Person Requesting Deactivation of the ICD Name: _______________________________________________________ Position: RN Nurse Practitioner GP Internist Cardiologist Family member Phone Number: _________________________ Fax number: ________________________________ Primary Care Physician contact information (if different from above): _________________________ Is the patient aware the ICD deactivation has been requested? Yes

No

If No explain why

Name and contact information of other health care provider team members that need to be contacted __________________________________________________________________________________________ ____________________________________________________________________________________ Device Details ICD Manufacturer _______________________________________________________ Include with the referral:  

Copy of most recent consultation from palliative care (if available) Any pertinent history o Last Electrophysiology consultation

Comments:

Signature of person requesting: __________________________________ Date:_____________________

Acknowledgment of referral (Device clinic fax back date and time to referring physician/NP)

Your patient has been booked for their ICD deactivation at: _________________________hospital Date ____________________________________ Time ___________________________________

Next

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Device Clinic Contact Information

Clinic Fraser Health Abbotsford Regional Burnaby General Chilliwack General

Address

Phone #

Fax #

32900 Marshall Road Abbotsford BC V2S 0C2

604-851-4700 Ext. 644853

604-851-4852

3935 Kincaid Street Burnaby BC V5G 2X5

604-412-6379

604-412-6213

45600 Menholm Road Chilliwack BC V2P 1P7

604-702-2885 local

604-702-2882

612739 Delta JP Outpatient Care and Surgery Center

5800 Mountain View Boulevard Delta BC V4K 3V6 9750 140 Street Surrey BC V3T 0G9

#604-582-4550 Local

604-582-3773

763959 Langley Memorial

22051 Fraser Highway Langley BC V3A 4H4

#604-534-4121 local

604-533-6474

745276 Peace Arch

15521 Russell Avenue White Rock BC V4B 2R4

604-535-4500 Ext.757544

Ridge Meadows

11666 Laity Street Maple Ridge BC V2X 7G5

604-463-1862

604-466-6990

Royal Columbian

220 Royal Ave New Westminster BC V3L 1H6

604-520-4246

604-520-4803

2268 Pandosy Street Kelowna BC V1Y 1T2

250-862-4450

1200 Hospital Bench Trail BC V1R 4M1

250-368-3311 ext-

Interior Health Kelowna General Kootenay Boundary Regional

250-862-4104

2350 Penticton Regional Royal Inland Shuswap Vernon Jubilee

550 Carmi Avenue Penticton BC V2A 3G6 311 Columbia Street Kamloops BC V2C 2T1 601 10th St NE Salmon Arm BC V1E 4N6 2101 - 32 Street Vernon BC V1T 5L2

Northern Health University Hospital of Northern BC

1475 Edmonton Street Prince George BC V2M 1S2

250-565-2439

250-565-2527

Vancouver Coastal Health Lions Gate Richmond Hospital

# 100 - 123 East 15th North Vancouver BC V7L 2P7 7000 Westminster Highway Richmond BC V6X 1A2

St. Paul's

1081 Burrard Street Vancouver BC V6Z 1Y6

Vancouver General

855 West 12th Ave Vancouver BC V5Z 1N1

604-875- 4244

375 2nd Avenue Campbell River

250-850-2608

250-850-2617

1200 Dufferin Cresent Nanaimo BC V9S 2B7

250-739-5914

250-755-7663

1955 Bay Street Victoria

250-370-8670

250-370-8658

Vancouver Island Health Campbell River Nanaimo General Royal Jubilee

BC V9W 3V1

BC V8R 1J8

Return to Page 1 Final- Provincial Heart Failure End of Life Implantable Cardioverter Defibrillator (ICD) Deactivation Decision Algorithm

Questions to ask yourself to help you determine if a patient is transitioning to an EOL trajectory which should trigger the use of this algorithm 1) Surprise Question- In the next 6 months, would I be surprised to hear this individual had died? 2) Has the patient made a choice for comfort measures or is the patient in need of supportive palliative care? (e.g. non a transplant candidate, VAD at end of life) 3) Does the patient have at least 2 of the following clinical indicators? a) NYHA III or IV, b)Thought to be in last year of life, c) Repeated HF hospitalizations 4) Is the patient having difficult physical or psychological symptoms despite optimal therapy? (Adapted from the Gold Standards Framework, 2008)

Yes Yes

Does the ICD therapy meet the patient’s goals of care?

Reassess at next visit

No

Decision is made by patient and physician to deactivate the ICD after goals of care have been discussed (If patient known to a specialist include her/him in the discussion)

Is the ICD deactivation urgent?

No

Yes

Unplanned/Urgent Physician order ICD Deactivation

· ·

Written or signing of pre-printed order.

Planned/Non-Urgent 1. Provide patient/family with education pamphlet on ICD deactivation. 2. Complete the ICD deactivation referral form and fax to appropriate device clinic. 3. Patient to complete ICD deactivation consent. 4. Physician to sign the ICD deactivation pre printed order or write the order.

Verbal orders accepted in urgent situation if unable to write order but must follow-up by written order or signing of preprinted orders.

If appropriate - patient to complete ICD deactivation consent form

Do you have access to both a programmer and a qualified health care professional to use the programmer?

Yes

No

Best practice is: 1. ICD deactivation is done by a programmer 2. Provider has the competencies to utilize a programmer or magnet 3. The location for the ICD deactivation is chosen by the patient 4. Physician order is written or pre printed orders signed prior to the ICD deactivation

Do you have access to a magnet?

Yes

No

Magnets could be accessed through hospice palliative care program, closest device clinic or ER

Use of magnet is only temporary until a programmer can come to the patient to deactivate the tachyarrhythmia functions

Do you have a qualified health care professional to apply the magnet?

No

Have MRP arrange to have a qualified health care professional to come to the patient to apply the magnet (could be a critical care or ER RN,cardio tech or physician)

Ensure MRP completes the preprinted orders for ICD deactivation

MRP to inform programmer of ICD deactivation request.

Yes

Best practice is for device staff to come to the patient If unable – have MRP arrange transport to the clinic, critical care or ED Ensure the critical care or ED staff are qualified to use the programmer

Ensure MRP completes the preprinted orders for application of magnet

Apply the magnet

Deactivate the ICD using the ICD programmer

Documentation: It is highly recommended that a written order or signing of a pre printed order occur prior to deactivation. In an emergency situation whereby a written order cannot be provided a verbal order will be accepted but it must be accompan ied by a written or signed preprinted order. The details of the advance care planning discussion and subsequent deactivation must be recorded by the physician in the patient’s progress notes and by other health care providers in the nursing notes.

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