Symptom Management

PAIN

Objective

The objective of pain management is to ensure that the patient is free from pain at night, at rest, during the day and during movement.

NON-PHARMACOLOGICAL

Effective pain control requires holistic assessment of ‘Total pain’ which includes physical, psychological, social and spiritual aspects.
This is critical for effective pain management. Issues such as positioning, management of anxiety, family support, play for children etc. should be attended to in the assessment and management of the patient.

PHARMACOLOGICAL

The treatment of long-term pain associated with life limiting illness is guided by the following principles

Accurate diagnosis and treatment of the cause of the pain (see other chapters)
Assessment of the severity (mild/moderate/severe) and type of pain (nociceptive/neuropathic)
Appropriate analgesics: Non opioid, opioids and adjuvants and other modalities e.g. radiotherapy and bisphosphonates (bone pain), surgery (pathological fractures)

By the clock

Regular analgesia is given to the patient to prevent exacerbations
PRN medication (i.e. given as required) does not work for chronic pain

By the mouth

Oral medication is the standard preferred for long term pain management

By the patient

Required dose of analgesia is determined on an individual basis. This should be kept under regular review

By the ladder

The analgesic ladder

A two- or three- step analgesic ladder enables person-centred step-wise treatment of pain. Analgesia is selected by moving up the ladder where pain increases, or where pain is not controlled, moving down the ladder e.g. if the cause of the pain is removed (e.g. following amputation or chemotherapy for a tumor).

Mild Pain - Step 1

Paracetamol 1g 6-8 hourly (max 4g daily) Children: 10-15-20mg/kg 8 hourly
Or NSAIDs
- Aspirin 300-600mg, 6-8 hourly (max 2.4g/day)
- Ibuprofen 400mg, 6-8 hourly (max 2.4g/day), children 5-10mg/kg (max 40mg/kg/day)
- Diclofenac 50 mg 8 hourly, or 100mg slow release 24 hourly, {max 150mg/daily), (not in children)

Note: use only one NSAID at any one time, avoid long term use of NSAIDs, considering contraindications e.g. renal/heart failure, PUD, pregnancy, asthmatics etc. NSAID are not to be used in children

Moderate Pain - Step 2 (not used in children)

Codeine phosphate 30-60mg 6-8 hourly (max 240mg daily), Always prescribe codeine with a laxative (not tramadol) e.g. Give Bisacodyl 10mg at night, unless the patient has diarrhoea
Tramadol 50-100 mg 8 hourly (max daily dose 400mg/daily)

Notes: both codeine and tramadol can be combined with non-opiates and/or adjuvants, but not used together at the same time, or used at the same time as strong opiates e.g. morphine

Severe Pain - Step 3

Immediate release Morphine is the drug of choice for severe pain

Formulation and starting dose

Immediate release (green) morphine 1mg/1ml - starting dose for adults 2.5-5mg, i.e. 2.5-5ml, 4 hourly
Immediate release (red) strong morphine 10mg/1ml - starting dose for adults 2.5-5mg i.e. 0.25-0.5ml, 4 hourly
Morphine sulphate tablets (MST) 10mg tablets - starting dose 10mg, 12 hourly

Children

Over 1 year, dose start at 0.2mg/kg/dose, 4 hourly
Under 1 year, dose start at 0.1mg/kg/dose, 4 hourly
Maximum starting dose of morphine is 3mg 4 hourly, even for children larger than 15kg.

Notes:

If a patient cannot swallow, morphine can be administered and absorbed via mucous membranes e.g. buccal (liquid) and rectal (tablets)
If the patient no longer requires morphine, the dose should be gradually reduced to avoid withdrawal symptoms (sweating nausea, agitation)
Pethidine is not recommended for use in chronic pain due to its short duration of action and its side effects

Titration (i.e. increasing dose to achieve pain relief)

When pain is helped - but not totally relieved - by a starting dose of morphine the regular dose can be increased by 30-50% every 48 hours until pain is controlled.
Where breakthrough doses are prescribed, dose increment can be calculated as follows (new dose = total regular morphine daily dose+ total breakthrough doses)
There is no maximum dose of morphine, the correct dose is a dose which takes away the pain without causing unacceptable side effects.

Use of morphine to control ‘breakthrough pain’

Breakthrough pain is a flare in pain of rapid onset, moderate to severe intensity and of short duration. Liquid immediate release morphine can help breakthrough pain. The dose given is equivalent to the regular four hourly dose of immediate release morphine e.g. if taking MST 10mg 12 hourly, the breakthrough dose is 20/6= 3.3mg as required (in practice give 2.5mg liquid morphine as required).
If taking 10mg of immediate release morphine 4 hourly, the breakthrough dose = 10mg as required.

Dose conversion (changing from other opiates to or from morphine)

Oral codeine to oral morphine, ratio 10:1, Calculation: divide total daily dose codeine dose by 10 e.g. codeine 30mg 8 hourly = total daily dose codeine 90mg = total daily dose 9mg morphine
Oral tramadol to oral morphine, ratio 5:1 calculation: divide total daily dose tramadol by 5 e.g. 50mg every 8hrs tramadol = total daily dose 150mg = total daily dose 30mg morphine
Oral morphine to fentanyl patch (central hospitals only) ratio 100:1 calculation: multiply total daily dose of morphine in mg by 10 to obtain the total daily dose fentanyl in microgram (μg); divide by 24 to obtain μg/hr patch strength e.g. morphine 10mg four hourly = total daily dose morphine 60mg = total daily dose 600μg fentanyl = 25μg/hour fentanyl patch

Use of morphine in special circumstances

Immediate release morphine can be used in the management of acute pain (see other sections). When used for wound care and/or dressing changes it can be effective where administered 30 minutes -one hour before the dressing change.
In children (e.g. for dressing change in burns) use morphine 0.2mg/kg as a single dose one hour before procedure.

Other considerations

Monitor and manage constipation which is a common side effect of opiates e.g. attend to intake of regular fluids (water), bisacodyl 10mg at night and/or other local remedies for constipation e.g. green mango, papaya
Patients and their caregivers should be carefully educated on how to administer immediate release morphine as four hourly dosages. This should be reviewed during follow up appointments.
Doses of four hourly immediate release liquid morphine are administered at the following times each day: 6am, 10am, 2pm, 6pm and 10pm. The 2am dose can be avoided by administration of a double dose of morphine administered at 10pm.
Opiates are controlled drugs. Prescribers are referred to the DDA ACT for further guidance.

Complications

Opiate toxicity (overdose) causes respiratory depression, and drowsiness (check for pinpoint pupils and muscle twitching). Patients with renal failure (and severe jaundice) are at risk of toxicity as morphine is excreted by the kidneys. Dose frequency of morphine in confirmed or suspected renal failure should be reduced to 8 hourly.

Guidance for use of Fentanyl patches (central hospitals only)

Fentanyl is a strong opiate used for the management of severe chronic cancer pain. It is much stronger than morphine. *Serious, lifethreatening or fatal respiratory depression may occur with the use of Fentanyl. Be aware of situations which increase the risk of respiratory depression, modify dosing in patients at risk and monitor patients closely, especially on initiation or following a dose increase*
Fentanyl is delivered via transdermal patch replaced every 3 days (72 hours), available dose of patch: 12.5ug/hourly
Patients should only be started on a fentanyl patch where they have already had their pain controlled by morphine. For details of the conversion from morphine to fentanyl, see ‘dose conversion’ above

ADJUVANT ANALGSICS

‘Adjuvant’ analgesics are drugs whose primary action is not analgesia but which can be used to control pain. They are used in situations such as neuropathic or bone pain, smooth or skeletal muscle spasms. They can be used alone, or in conjunction with step 1, 2 and 3 analgesics

Tricyclic anti-depressants: neuropathic (nerve involvement) pain,

Amitriptyline 12.5- 25mg at night. Effect should be reviewed after 2-4 weeks. maximum dose 75mgs at night

Anti - convulsant

Gabapentin 300mg, single dose on day one; then 300mg, 12 hourly on day two; 300mg 8 hourly from third day onwards
Monitor for drowsiness

Corticosteroids

Reduce pain related to oedema e.g. liver capsule pain (hepatoma), sciatic nerve root compression (cervical cancer) headache (brain tumor, brain metastases)

Dexamethasone 4-8 mg, 12 hourly. Reduce by 2 mg daily to the lowest effective dose
Children
- < 1 year, 0.5-1mg 12 hourly,
- 1-5 years 2mg 12 hourly,
- 6-11 years 4mg 12 hourly (max 16mg/day)
Prednisolone 30mg once daily for 7 days, gradually reduce to lowest effective dose, depending on prognosis

Note: Monitor steroid side effects: poor sleep, psychosis, dyspepsia

COMPLICATIONS AND REFERRAL CRITERIA

Where pain persists or is complex, referral to next level of care and/or specialist palliative care providers should be considered

NAUSEA AND VOMITING

Clinical Description

Common causes (see relevant chapter for details). Gastrointestinal - gastric status, intestinal obstruction, Oral/oesophageal candidiasis, indigestion drugs - opioids, antibiotics, iron, NSAIDs metabolic - hypercalcaemia, renal failure, Constipation, Infections - malaria, gastroenteritis, urinary tract infection, severe pain, anxiety, fear etc.

Treatment

NON-PHARMACOLOGICAL

Encourage clear fluids - small sips better absorbed
Ginger chewed or boiled as a drink may help or diluted malambe juice

PHARMACOLOGICAL

Pattern of nausea and vomiting

Causes

Suggested drugs

Poor stomach emptying

Main symptoms are;

· vomiting

· vomiting relieves nausea

· Patient feels full quickly

· May have reflux

· Opioids

· Constipation

· Stomach and bowel conditions

· Metoclopramide 10-20 mg 8 hourly before meals

Blood chemistry disturbances

· Nausea is the main symptom Vomiting does not relieve nausea

· Drugs

· Renal failure

· Hypercalcaemia

· Chemotherapy induced nausea and vomiting

· Ondansetron 8mg 30 mins before chemo, then twice daily for 1-2 days after chemo

· Haloperidol 0.5 - 1.5mg nocte

Inflammation or swelling in the head

· May be worse on movement

· Vomiting does not relieve nausea

· May be worse in the morning

· Ear infections

· Brain tumours

· Meningitis

· Malaria

· Dexamethasone 2 – 8 mg 24 hourly

Vomiting with diarrhoea

· Exclude constipation with overflow

· Infectious diarrhoea

· Promethazine 25mg every 8hrs or as below

Partial bowel obstruction

· Large volume vomiting

· Patient still passing occasional flatus/stools

· Constipation

· Abdominal or pelvic tumour

· Metoclopramide 10 – 20 mg IM

· STOP if increasing abdominal pain and prescribe as below

Complete bowel obstruction

· Large volume vomiting Patient not passing flatus or faeces

· Abdominal or pelvic tumour

· Promethazine 25mg s/c 8 hourly

COMPLICATIONS AND REFERRAL CRITERIA

Where nausea and vomiting persists or the patient become dehydrated, referral to next level of care and/or specialist palliative care providers should be considered

ANOREXIA (LOSS OF APPETITE)

Clinical Description

Common causes (see relevant chapter for details). Cancer, opportunistic infections, pain, weakness/fatigue, treatment side effects (antibiotics/chemotherapy), sore mouth, dysphagia, anxiety, depression, strong food smells during cooking

NON-PHARMACOLOGICAL

Small frequent meals, served in appetizing manner, support the patient to sit upright whilst eating and to eat with other family members
explain to the patient and family that anorexia is normal as disease progresses
encourage gentle exercise

PHARMACOLOGICAL

Appetite stimulants:

Prednisolone 5-15mg 24 hourly (maximum seven days)
Multivitamins 24 hourly (long term)

COMPLICATIONS AND REFERRAL CRITERIA

Tube feeding / enteral feeding are not indicated. Patient and family support should be continued.

DIARRHOEA

Clinical Description

Common causes (see relevant chapter for details)

Infectious (refer to specific chapters), check for constipation with overflow diarrhoea in immobile patients on opiates, other

NON-PHARMACOLOGICAL

Encourage oral fluids if dehydrated
Attention to skin care and regular change of linen (see section on pressure/bed sores)

PHARMACOLOGICAL

Morphine 2.5mg-5mg 4 hourly or MST 10mg every 12hrs
Loperamide 4mg STAT then 2mg after each loose stool

COMPLICATIONS AND REFERRAL CRITERIA

IV fluids maybe indicated in certain situations when patient becomes dehydrated (e.g. as a result of chemotherapy)

CONSTIPATION

Clinical Description

Common causes (see relevant chapter for details)

Cancer, drugs (especially opiates, ondansetron), debility

NON-PHARMACOLOGICAL

Encourage fluid intake and eating papaya, ambulation/gentle exercise where possible, manual evacuation may be needed for faecal impaction

PHARMACOLOGICAL

osmotic laxatives - lactulose or liquid paraffin
stimulant laxatives - Bisacodyl 10mg nocte
lubricant - Glycerine suppository 1, 24 hourly (not long term)

COMPLICATIONS AND REFERRAL CRITERIA

Faecal impaction is very distressing and painful which may require referral for further management and/or manual evacuation where indicated

HALITOSIS (BAD BREATH)

Clinical Features

Common causes (see relevant chapter for details)

poor dental and oral hygiene, oral thrush, dry mouth, lung cancer, necrotic ulcers

NON-PHARMACOLOGICAL

cleaning with soft toothbrush, mouthwash with boiled salty water, modify diet - e.g. exclude garlic and onions, stop smoking, sucking pineapple or orange

PHARMACOLOGICAL

crushed metronidazole (400mg) in diluted sobo orange squash as mouthwash, crushed prednisolone (10mg) to reduce odor and pain

MOUTH SORES (CANDIDIASIS)

Clinical DescriptionCommon causes (see relevant chapter for details)

Candidiasis, viral, drug induced e.g. chemotherapy, malnutrition, immunosuppression

NON-PHARMACOLOGICAL

See under Halitosis

PHARMACOLOGICAL

Antifungal: Fluconazole 100mg once daily
Nystatin oral suspension 100,000units/ml
advise patient to use Nystatin pessaries orally 12 hourly
Stop Amitriptyline
Stop or reduce steroids if taking high dose
“miracle paint” = acyclovir 200mg+5ml nystatin + (2x200mg metronidazole tablets crushed) : mix together and use as a mouthwash or paint on oral ulcers twice a day

CACHEXIA/SEVERE WASTING (WEIGHT LOSS)Common causes (see relevant chapter for details)

Cancer

NON-PHARMACOLOGICAL

Counselling the family to avoid over feeding

COMPLICATIONS AND REFERRAL CRITERIA

Tube feeding / enteral feeding are not indicated. Patient and family support should be continued

DYSPHAGIA (DIFFICULTY SWALLOWING)Common causes (see relevant chapter for details)

Esophageal pathology e.g. Candida, Cancer

NON-PHARMACOLOGICAL

Small meals, soft food, support patient sit upright (see anorexia)

PHARMACOLOGICAL

Dexamethasone 16mg STAT, if effective 8mg 12 hourly for a week then reduce dose (with Nystatin pessaries (suck) to prevent oesophageal candida)

COMPLICATIONS AND REFERRAL CRITERIA

Consider referral for stenting in oesophageal cancer

ASCITES (MALIGNANT AND NON-MALIGNANT)

Common causes (see relevant chapter for details)

SIGNS AND SYMPTOMS

Malignant: cancers - liver, KS, cervical ovarian cancer
Non-malignant: Complication from abdominal infection e.g. tuberculosis, cardiac failure, renal failure

INVESTIGATIONS

Full blood count
Liver function
Urea, creatinine and electrolytes
Ascitic tap for LDH, Protein, Microscopy, gram stain, ZN stain, geneXpert and cytology

Treatment

NON-PHARMACOLOGICAL

comfortable positioning, counselling the patient and family, salt reduction

PHARMACOLOGICAL

Furosemide 40 to 80 mg 24 hourly, can be combined with Spironolactone 25 to 100mg 24 hourly

COMPLICATIONS AND REFERRAL CRITERIA

Where necessary patients can be referred for therapeutic tapping although this provides short term relief only, note potential risk of infection, perforation, continuous leakage of fluid, induction of hypovolemic shock from repeated tapping

BREATHLESSNESS

Common causes (see relevant chapter for details)

SIGNS AND SYMPTOMS

TB, pleural effusion, pneumonia, heart failure, pulmonary embolism, COVID, severe pain/ascites

Treatment

NON-PHARMACOLOGICAL

Sit upright in comfortable position, sit near open window to ensure good ventilation, fanning face can help to reduce experience of breathlessness, relieve anxiety therapeutic drainage of effusion (risk of infection if recurrent drainage).

PHARMACOLOGICAL

Immediate release oral morphine 2.5mg 4 hourly can reduce the experience of breathlessness higher doses may be used if patient is also in pain, monitor response, stop if not helping.

COMPLICATIONS AND REFERRAL CRITERIA

Think carefully before referring a patient for oxygen therapy. If the cause is irreversible, will it really benefit the patient?

CHRONIC COUGH

Common causes (see relevant chapter for details)

SIGNS AND SYMPTOMS

TB, pneumonia, asthma and other respiratory/cardiac conditions, drugs: ACE inhibitors

INVESTIGATIONS

depend on suspected cause

Treatment

NON-PHARMACOLOGICAL

comfortable (semi-prone) positioning, sips of lemon juice in warm water

PHARMACOLOGICAL

Immediate release morphine 2.5mg 4 hourly
monitor response, stop if not helping

HICCUP

Common causes (see relevant chapter for details)

In advanced disease this is often caused by sub-diaphragmatic irritation e.g. from invasive tumour. it can be a troublesome distressing symptom and maybe difficult to control

NON-PHARMACOLOGICAL

Manage and relieve anxiety
Reduce gastric distention (e.g. ascetic tap, small frequent meals etc.)

PHARMACOLOGICAL

Haloperidol 5-10mg by mouth STAT, maintenance 1.5-3mg at bedtime
Chlorpromazine 10-25mg by mouth (maintenance 25-50mg 8 hourly)

BLEEDING

Common causes (see relevant chapter for details)

SIGNS AND SYMPTOMS

Cancer of cervix, oral cavity, head and neck

INVESTIGATION

Depend on suspected cause

Treatment

NON-PHARMACOLOGICAL

Reassure patient and relieve anxiety, use of dark colored / green cloths to mop up blood loss

PHARMACOLOGICAL

Tranexamic acid 500mg 8 hourly - start as soon as bleeding commences and stop once bleeding stops

COMPLICATIONS AND REFERRAL CRITERIA

Consider referral for transfusion in case of massive or persistent bleeding

SPASTICITY

Common causes (see relevant chapter for details)

cerebral palsy, post-stroke

Treatment

NON-PHARMACOLOGICAL

Improve independence e.g. use of CP chair for feeding, rehabilitation therapy (physio, speech, OT)

PHARMACOLOGICAL

Baclofen is not indicated for these conditions

DROWSINESS

Common causes (see relevant chapter for details)

Commonly drug induced, especially when using high dose of opiates and or in renal failure, hypercalcaemia

Treatment

NON-PHARMACOLOGICAL

Attention to determine cause, prevent aspiration during feeding (NG tube and/or upright positioning)

PHARMACOLOGICAL

Carefully review drugs being taken by the patient, monitor urine output (if reduced, suggests renal impairment). If opiate toxicity (drowsy, pin point pupils, muscle twitching, reduced respirations) then STOP opiates and monitor carefully before reintroducing. In hypercalcaemia (drowsiness, nausea, constipation, bone pain) use of IV normal saline 2-3 litres/24 hr, bisphosphonates at central hospital (see section under oncology for details)

COMPLICATIONS AND REFERRAL CRITERIA

Refer to the rehabilitation technicians for occupational therapy. This must happen concurrently with all other treatment

DELIRIUM

Clinical Description

Uncontrolled pain, medications, infections, urinary retention, constipation, metabolic, brain metastases, alcohol withdrawal.
Common causes (see relevant chapter for details)

Treatment

NON-PHARMACOLOGICAL

Ensure safe environment, explanation to patient and caregivers, encourage caregiver to stay with patient at all times, recovery position (if unconscious to protect airway)

PHARMACOLOGICAL

Haloperidol 1.25-5mg up to 8 hourly (oral or subcutaneously)

COMPLICATIONS AND REFERRAL CRITERIA

Refer for thorough investigations to confirm the exact cause

URINARY INCONTINENCE/VOIDING DIFFICULTIES

Clinical Description

see section under prostatic cancer and BPH, rectovaginal fistula

Common causes (see relevant chapter for details)

Treatment

NON-PHARMACOLOGICAL

Train and support family to optimize personal hygiene (regular bathing and change of clothing/bed linen). Convene catheter or insertion of in-dwelling catheter may assist with comfort and nursing of bed ridden patients

PHARMACOLOGICAL

Refer for difficult catheterization, further investigations to ascertain the cause if necessary

PRESSURE/BED SORES

Clinical Description

Immobility, advanced disease, cachexia. Occasionally need referral for surgical debridement

Treatment

NON-PHARMACOLOGICAL

support for family members to conduct regular (2 hourly) turning, clean/dry bed linen, positioning

PHARMACOLOGICAL

see section on management of pain

COMPLICATIONS AND REFERRAL CRITERIA

Depending on the level of care, refer appropriately for comprehensive care.

FUNGATING WOUNDS

Clinical Description

Fungating wounds are a complication of cancer and may develop in patients with advanced disease (advanced cancer). Common causes (see relevant chapter for details)

Treatment

NON-PHARMACOLOGICAL

smells associated with fungating wounds can be very distressing for patients and family members, use of charcoal/coffee in the room may absorb some of the smells

PHARMACOLOGICAL

crush metronidazole tablets and apply as powder to the surface of fungating wound once or twice daily.

COMPLICATIONS AND REFERRAL CRITERIA

Depending on the level of care, referral is necessary for appropriate management

ITCHING (DRY SKIN ETC.)

Clinical Description

This is due to Kaposi’s sarcoma, side effect of opiates and chemotherapy, see under common skin conditions eg. scabies, psychosis. Common causes (see relevant chapter for details)

Treatment

NON-PHARMACOLOGICAL

reduce use of soap and stones (as this dries the skin), keep nails short, use gel from aloe vera leaves as emollient, assess psychological status

PHARMACOLOGICAL

antihistamines such as Cetirizine 10mg daily, Chlorpheniramine (Piriton) 4g 8 hourly sometimes helps, low dose steroids (e.g. prednisolone 5mg daily) can help to reduce severe generalised itching, emulsifying ointment e.g. zinc oxide

SPINAL CORD COMPRESSION (LATE PRESENTATION)

Clinical Description

Metastatic cancer (breast, prostate, renal etc.), presents with neurological deficit (weakness, paresthesia, incontinence of stool and urine). Refer to neurosurgery for imaging and possible intervention (surgical/radiotherapy) only if patient presents early (within 24 hours of neurological symptom onset). Common causes (see relevant chapter for details)

Treatment

NON-PHARMACOLOGICAL

see under constipation, urinary symptoms, bed sores.

PHARMACOLOGICAL

if seen early, trial of high dose dexamethasone may temporarily reverse some of the neurological sequelae. Dexamethasone 16-20mg IV or PO STAT. Review after 24 hours. if improved then continue Dexamethasone 8mg 12 hourly for one week, if no change then no need to continue.

COMPLICATIONS AND REFERRAL CRITERIA

Depending on the level of care, refer for appropriate care

DEPRESSION (INCLUDING ANXIETY COMPLICATED DISORDERS, BEREAVEMENT, POOR SLEEP ETC.)

Clinical Description

Psychological impact of advanced incurable disease
Common causes (see relevant chapter for details)

Treatment

NON-PHARMACOLOGICAL

Symptoms can be common in patients with advanced disease. Holistic care, including pain management and spiritual support of the patient and family caregivers can assist. Allowing the patients to engage in activities of daily living including cooking, attending prayers etc. can reduce these symptoms.

PHARMCOLOGICAL

Antidepressants (e.g. amitriptyline , fluoxetine) are rarely indicated, refer to section on depression for details of drugs
Benzodiazepines (e.g. lorazepam and diazepam) are highly addictive, and use should be avoided

COMPLICATIONS AND REFERRAL CRITERIA

Depending on the level of care, referral might be necessary for appropriate care