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Physician Resources - Clinical Pearls

Hospice Pearls For Treating Symptoms
Treatment of Pain: Some of many ways to treat pain;

1. Don't be scared of opiates. They are the best method of treating certain type of pain and have been used for thousands of years.


2. Short acting morphine works best for people with cancer in the soft tissues of their body. Starting dose is 5-10mg oral or 1-3mg IV q 4 hr prn pain.


3. People with a history of opiate addiction will need large amounts of opiates to control legitimate pain


4. There is no maximum dose of opiates: the body can take in thousands of mgs a day as long as the increases are given gradually.


5. Increasing opiates by 25-50% will help pain and not cause respiratory depression.


6. Long acting opiates such as MS-Contin, Oxy-Contin or fentynyl patches should be ordered if patients are taking short acting medications frequently.


7. If a person is still complaining of pain, they are not at risk of developing respiratory depression.


8. Do not start fentynyl patches without any other medication. The patch does not reach peak levels until 12-24 hours after it is first started.


9. Patients with tumors in their bones will have more relief from steroids and NSAIDS than opiates.


10. Patients with neuropathic pain with respond better to Neurontin than opiates or NSAIDS.


11. DO NOT use opiate/acetaminophen combo pills b/c the amount of acetaminophen limits the amount of opiate the patient.


12. Darvocet/Darvon and Demerol are poor choices for hospice pain management.


13. The DEA will not investigate you for using opiates to treat pain. Some physicians write 50 scripts per week and have never received a call.

Difficulty Breathing

1. Opiates and benzodiazepines are very affective for treating SOB. They do not improve oxygenation, but they remove the sense of panic from the patient. They may be used separately or together. If you are going to only use one, Opiates are superior.


2. Any breathing implement short of a ventilator is appropriate for hospice. Do not be afraid to order liquid O2, c-pap, or bi-pap

Nausea

1. In addition to the traditional anti-emetics (compazine, Tigan, Reglan and Phenergan), steroids benzodiazepines, and other older antipsychotics (haldol) often help with nausea.


2. Hospice frequently uses a transdermal gel from compounding pharmacies for nausea relief that is a combination of Ativan, Metaclopramide, Decadron, and Phenergan. It works quite well when swallowing is compromised.


3. Patients with a total bowel obstruction should be offered a Sandostatin drip in lieu of an N-G tube to suction. It costs a lot more, but is much more comfortable.

(Sandostatin(Octreatide) 50mcg/hr subcutaneous infusion (may increase)