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B.C. Home » Ministry of Health » BC Guidelines & Protocols » Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain and Symptom Management

Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain and Symptom Management

Effective Date: September 30, 2011

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html

Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html

This guideline presents strategies for the assessment and management of cancer pain, and symptoms associated with advanced disease. The guideline is divided into seven sections, providing recommendations for evidence-based symptom management (Palliative Care Guidelines, Part 2). The recommendations are algorithm-based to facilitate quick access to the information required. It is intended for use in patients 19 years of age or older.

Diagnostic Code: Neoplasm of unspecified nature: 239

Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain and Symptom Management - Pain Management

Recommendations and Topics

Scope

This section presents assessment and management strategies for dealing with cancer pain and pain associated with advanced disease.

Salient Principles in this Section:

• Opioid management principles
• Utilizing adjuvant medication for pain-specific management

Included in this Section:

1. Pain management algorithm
2. Tables for opioid conversion
3. Analgesic medication reference tables

Pain Assessment (Refer Appendix A - Cancer Pain Management Algorithm)

1. Symptom assessment. Use the OPQRSTUV mnemonic to assess pain:
   

O	Onset	e.g., When did it start? Acute or gradual onset? Pattern since onset?
P	Provoking / palliating	What brings it on? What makes it better or worse, e.g., rest, meds?
Q	Quality	Identify neuropathic pain (burning, tingling, numb, itchy, etc.)
R	Region / radiation	Primary location(s) of pain, radiation pattern(s)
S	Severity	Use verbal descriptors and/or 1-10 scale
T	Treatment	Current and past treatment; side effects
U	Understanding	Meaning of the pain to the sufferer, “total pain”
V	Values	Goals and expectations of management for this symptom

2. Physical exam: Look for signs of tumor progression, trauma, or neuropathic etiology: hypo- or hyper-esthesia, allodynia (pain from stimuli not normally painful).

Pain Management Strategies

(Refer Appendix A)

• Continuous pain requires continuous analgesia; prescribe regular dose versus prn.
• Start with regular short-acting opioids and titrate to effective dose over a few days before switching to slow release opioids.
• Once pain control is achieved, long-acting (q12h oral or q3days transdermal) agents are preferred to regular short-acting oral preparations for better compliance and sleep.
• Always provide appropriate breakthrough doses of opioid medication, ~10% of total daily dose dosed q1h prn.
• Incident pain (e.g., provoked by activity) may require up to 20% of the total daily dose, given prior to the precipitating activity.
• Use appropriate adjuvant analgesics at any step (e.g., NSAIDs, corticosteroids).
• Record patient medications consistently.

Opioid Selection

Issue	Preferred Opioid Medication	Avoid
Difficult constipation	fentanyl transdermal or methadonea
Renal failure	fentanyl transdermal or methadonea	morphineb, codeine, meperidinec
Compliance & convenience	time release formulations, e.g., morphine, hydromorphone, oxycodone
Neuropathic pain	oxycodone or methadoned (anecdotal evidence)
Opioid naïve	low dose morphine, hydromorphone or oxycodone	fentanyl transdermal patch (risk of delayed absorption and overdose potential), sufentanil
Injection route (e.g., SC)	morphine, hydromorphone, (methadonee: second line)	oxycodone (injectable) is not available in Canada

• Fentanyl is primarily (75%) cleared as inactive metabolites by the kidney and methadone is cleared hepatically.
• Morphine is the least preferred in renal failure because of renally cleared active metabolites.
• Meperidine (Demerol®) should not be used for the treatment of chronic pain.
• If a patient in your practice is started on methadone by a palliative care physician, in order to renew prescriptions, it is possible to obtain individual patient methadone prescribing authorization through the College of Physicians and Surgeons of British Columbia.
• Injectable methadone may be obtained through the Health Canada Special Access Program at www.hc-sc.gc.ca/dhp-mps/acces/drugs-drogues/index-eng.php. Consultation with a palliative care physician is suggested prior to initiation.

Opioid Switching (“rotation”)

• Switch to another opioid when inadequate analgesia is obtained despite dose-limiting adverse effects (AEs). This allows for clearance of opioid metabolites and possibly more effective opioid receptor agonist profile from the new drug.
• Switch to an equianalgesic dose of the second opioid, bearing in mind that published ratios are only a guide and that reassessment and dose modification are required.
• When switching because of AEs (e.g., delirium or generalized hyperalgesia), determine the equianalgesic dose and reduce this dose by 25%. Observe closely, allowing for onset of the new and wearing-off of the previous drug.
• Refer Appendix B - Equianalgesic Conversion for Morphine.

Opioid AEs

(switch if not managed symptomatically and AE persists for > 1 week)

• Constipation: Stepwise escalation of regular oral stimulant or osmotic laxative on opioid initiation. Consider methylnaltrexone^* for refractory cases. Refer to Part 2 Section: Constipation, and the associated Appendix A - Constipation Management Algorithm.
• Nausea: Resolves after ~ 1 week. Consider metoclopramide^* first line; avoid dimenhydrinate (Gravol^®).
• Sedation: Stimulants may be helpful if sedation persists, e.g., methylphenidate, dextroamphetamine, or modafanil.
• Myoclonus: May respond to benzodiazepines but may be a sign of opioid toxicity requiring hydration, opioid dose reduction or rotation.Delirium: Assess for other causes, e.g., hypercalcemia, UTI.
• Pruritus, sweating: Try opioid rotation.

*Cancer, GI malignancy, GI ulcer, Ogilvie's syndrome and concomitant use of certain medications (e.g. NSAIDs, steroids, and bevacizumab) may increase the risk of GI perforation in patients receiving methylnaltrexone. [Health Canada MedEffect Notice: www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/relistor_hpc-cps-eng.pdf]

Adjuvant Analgesics

• Select based on type of pain and AE profile. Optimize dosing of one drug before trying another. Discontinue adjuvant drug if ineffective.

Severe opioid-resistant cancer pain

• Consult a palliative care specialist for advice.

List of Abbreviations

AEs	adverse effect
GI	gastrointestinal
NSAIDs	non-steroidal anti-inflammatory drugs
SC	subcutaneous
TENS	transcutaneous electrical nerve stimulation
UTI	urinary tract infection

Appendices

• Appendix A - Cancer Pain Management Algorithm
• Appendix B - Equianalgesic Conversion for Morphine
• Appendix C - Medications Used in Palliative Care for Pain Management

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html
Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html

Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain and Symptom Management - Dyspnea

Scope

This section presents assessment and management strategies for dealing with dyspnea occurring in patients with cancer or advanced disease.

Salient Principle in this Section:

• Use opioids first line for pharmacological management of dyspnea

Included in this Section:

1. Dyspnea management algorithm
2. Dyspnea medication reference tables

Dyspnea Management

(Refer Appendix A - Dyspnea Management Algorithm)

Definition: Breathing discomfort that varies in intensity but may not be associated with hypoxemia, tachypnea, or orthopnea. Occurs in up to 80% of patients with advanced cancer.¹

Dyspnea Assessment

• Ask the patient to describe dyspnea severity using a 1-10 scale.
• Identify underlying cause(s) and treat as appropriate.²
• History and physical exam lead to accurate diagnosis in two-thirds of cases.³
• Investigations: CBC/diff, electrolytes, creatinine, oximetry +/- ABGs and pulmonary function, ECG, BNP when indicated.
• Imaging: Chest X-ray and CT scan chest when indicated.

Dyspnea Management Strategies

• Proven therapy includes opioids for relief of dyspnea. Oxygen is only beneficial for relief of hypoxemia.⁴
• Adequate control of dyspnea relieves suffering and improves a patient’s quality of life.⁵
• Treat reversible causes where possible and desirable, according to goals of care.
• Always utilize non-pharmacological treatment: education and comfort measures.
• Pharmacological treatment: Opioids, +/- benzodiazepines or neuroleptics, +/- steroids.

Drug	Comments
Opioids (drugs of first choice)	If opioid naive, start with morphine 2.5-5 mg PO (SC dose is half the PO dose) q4h or equianalgesic dose of hydromorphone or oxycodone. Breakthrough should be half of the q4h dose ordered q1h prn. If opioid tolerant, increase current dose by 25-50%. When initiating, start an antiemetic (metoclopramide) and bowel protocol. Therapeutic doses used to treat dyspnea do not decrease oxygen saturation or cause differences in respiratory rate or CO2 levels3. Nebulized forms have NOT been shown to be superior to oral opioids and are not recommended.6
Benzodiazepines	Prescribe prn for anxiety and respiratory “panic attacks”. Lorazepam 0.5-2 mg SL q2-4h prn Consider SC midazolam in rare cases
Neuroleptics	Methotrimeprazine 2.5-5 mg PO/SC q8h, then titrate to effect.
Corticosteroids	Dexamethasone 8-24 mg PO/SC/IV qam depending on severity and cause of dyspnea. Particularly for bronchial obstruction, lymphangetic carcinomatosis, and SVC syndrome; also for bronchospasm, radiation pneumonitis and idiopathic interstitial pulmonary fibrosis.
Supplemental O2	Indicated only for hypoxia (insufficient evidence of benefit otherwise).5

References

1. Kobierski, L et al. Hospice Palliative Care Program. Symptom Guidelines. Fraser Health Authority. 2009 April. Available at: www.fraserhealth.ca/professionals/resources/hospice_palliative_care/hospice_palliative_care_symptom_guidelines
2. Schwartzstein RM, King TE, Hollingsworth H. Approach to the patient with dyspnea. UpToDate. 2009 Jan 1;17.1.
3. Membe SK, Farrah K. Pharmacological management of dyspnea in palliative cancer patients: Clinical review and guidelines. Health Technology Inquiry Service. Canadian Agency for Drugs & Technologies in Health. 2008 July.
4. Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;148(2):141-6.
5. Kobierski et al, “Dyspnea”, Hospice Palliative Care Program Symptom Guidelines, Fraser Health Authority, 2006.
6. Fraser Health Authority. Hospice Palliative Care Symptom Guidelines - Dyspnea. 2009. Available at www.fraserhealth.ca/media/Dyspnea.pdf

List of Abbreviations

ABG	arterial blood gas
BNP	brain natiuretic peptide
CT	computed tomography
ECG	electrocardiogram
IV	intravenous
PO	by mouth
SC	subcutaneous
SL	sublingual
SVC	superior vena cava

Appendices

• Appendix A - Dyspnea Management Algorithm
• Appendix B - Medications Used in Palliative Care for Dyspnea and Respiratory Secretions

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html
Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html

Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain and Symptom Management - Nausea and Vomiting (N&V)

Scope

This section presents assessment and management strategies for dealing with nausea and vomiting occurring in patients with cancer or advanced disease.

Salient Principle in this Section:

• Select antinausea medication based on the etiology of the nausea and vomiting

Included in this Section:

1. Nausea and vomiting management algorithm
2. Hypodermoclysis protocol
3. Antinausea medication reference tables

Nausea and Vomiting Management

(Refer Appendix A - Nausea and Vomiting Management Algorithm)

Top
Assessment
• Common, but can be controlled with antiemetics.
• Identify and discontinue medications that may be the cause.
• Further assessment may include lab tests and imaging to investigate, e.g., GI tract disturbance, electrolyte / calcium imbalance, intracranial disease, and sepsis.
• Good symptom control may require rehydration which can be carried out in the home, hospice, or residential care facility using hypodermoclysis, a simple, safe and effective technique that avoids venous access (refer Appendix B - Hypodermoclysis Protocol).

Management Strategies
• Non-pharmacological: modifications to diet (e.g., small bland meals) and environment (e.g., control smells and noise), relaxation and good oral hygiene, acupressure (for chemotherapy-induced acute nausea but not for delayed symptoms).
• Pharmacological: match treatment to cause, e.g., if opioid-induced, metoclopramide (sometimes IV or SC initially) and domperidone are most effective. Most drugs are covered by the BC Palliative Care Drug Plan except olanzapine and ondansetron (refer Appendix C – Medications Used in Palliative Care for Nausea and Vomiting).
• Consider pre-emptive use of anti-nauseates in opioid-naive patients.

Abbreviations

GI	gastrointestinal
IV	intravenous
N&V	nausea & vomiting
SC	subcutaneous

Appendices

• Appendix A - Nausea and Vomiting Management Algorithm
• Appendix B - Hypodermoclysis Protocol
• Appendix C - Medications Used in Palliative Care for Nausea and Vomitimg

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html
Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html

Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain and Symptom Management - Constipation

Scope

This section presents assessment and management strategies for dealing with constipation occurring in patients with cancer or advanced disease.

Salient Principle in this Section:

• Prevent constipation by ordering a bowel protocol when regular opioid medication is prescribed

Included in this Section:

1. Constipation management algorithm
2. Laxation medication reference tables
3. Hypertext link to BCCA bowel protocol

Constipation Management

(Refer Appendix A - Constipation Management Algorithm)

Constipation Assessment
• Understand the patient's bowel habit, both current and when previously well, e.g., frequency of bowel movements (BMs), stool size and consistency, ease of evacuation.
• Goal is to restore a patient's normal BM frequency, consistency, and ease of passage.
• For lower performance status patients (e.g., reduced food intake and activity), lower BM frequency is acceptable as long as there is no associated discomfort.

Constipation Management Strategies
• There are many etiologies, e.g., reduced food/fluid/mobility and AEs of medications.
• Avoid rectal interventions (enemas, suppositories, manual evacuation) except in crisis management. Contraindicated when there is potential for serious infection (neutropenia) or bleeding (thrombocytopenia), or when there is rectal/anal disease.
• Exclude impaction when a patient presents already constipated. Abdominal X-ray can be useful when physical examination is inconclusive.
• When risk factors are ongoing, as they are in most cancer patients, suggest laxatives regularly versus prn. Adjust dose individually. Laxatives are most effective when taken via escalating dose according to response, termed “bowel protocol”.
• Sennosides (e.g., Senokot^®) are the first choice of laxative for prevention and treatment. Patients with irritable bowel syndrome may experience painful cramps with stimulant laxatives and often prefer osmotic laxatives such as lactulose or polyethylene glycol (PEG). There is weak evidence that lactulose and sennosides are equally effective;¹ however lactulose can taste unpleasant and also cause bloating.
• If rectal measures are required, generally a stimulant suppository is tried first, then an enema as the next option.
• BC Palliative Care Drug Plan covers laxatives written on a prescription for eligible patients.
• For patients with opioid-induced constipation, after a trial of first-line recommended stimulant laxatives and osmotic laxatives, methylnaltrexone may be helpful. Cancer, GI malignancy, GI ulcer, Ogilvie’s syndrome and concomitant use of certain medications (e.g., NSAIDs, steroids and bevacizumab) may increase the risk of GI perforation in patients receiving methylnaltrexone. [Health Canada MedEffect Notice: www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/relistor_hpc-cps-eng.pdf]
• Patient handouts on constipation and bowel protocol are available at www.bccancer.bc.ca/HPI/FPON

References

1. Agra Y, Sacristán A, González M, et al. Efficacy of senna versus lactulose in terminal cancer patients treated with opioids. J Pain Symptom Manage. 1998;15(1):1-7.

Abbreviations

AEs	adverse effects
BM	bowel movement
GI	gastrointestinal
NSAIDs	non-steroidal anti-inflammatory drugs
PEG	polyethylene glycol

Appendices

• Appendix A - Constipation Management Algorithm
• Appendix B - Medications Used in Palliative Care for Constipation

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html
Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html

Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain and Symptom Management - Delirium Management

Scope

This section presents assessment and management strategies for dealing with delirium occurring in patients with cancer or advanced disease.

Salient Principle in this Section:

• Look for and treat reversible causes of delirium
• Utilize neuroleptics first line for pharmacological treatment

Included in this Section:

1. Delirium management algorithm
2. Delirium medication reference tables

Delirium Management

(Refer Appendix A - delirium Management Algorithm)

Definition: A state of mental confusion that develops quickly, usually fluctuates in intensity, and results in reduced awareness of and responsiveness to the environment. It may manifest as disorientation, incoherence and memory disturbance.

Delirium Assessment
• May be hypoactive, hyperactive or mixed
• Look for underlying reversible cause (refer Fraser Health Authority. Hospice Palliative Care Symptom Guidelines - Delirium/Restlessness)^α
• Ascertain stage of illness and whether delirium is likely to be reversible or terminal and irreversible
• Review advanced care plan and discuss goals of care with substitute decision maker
• Refer patient/family to Home and Community Care (refer Palliative Care part 2 - Resources) or timely access to caregiver support and access to respite and/or hospice care

Delirium Management Strategies
• Treat reversible causes if consistent with goals of care
• Avoid initiating benzodiazepines for first line treatment
• Refer to Appendix A - Delirium Management Algorithm
• Avoid use of antipsychotics in patients diagnosed with Parkinson's disease or Lewy Body Dementia.

^α available at www.fraserhealth.ca/media/07FHSymptomGuidelinesDelirium.pdf

Abbreviations

IM	intramuscular
IV	intravenous
PO	by mouth
SC	subcutaneous

Appendices

• Appendix A - Delirium Management Algorithm
• Appendix B - Medications Used in Palliative Care for Deliriumand Terminal Agitation

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html
Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html

Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain and Symptom Management - Fatigue and Weakness

Scope

This section presents assessment and management strategies for dealing with fatigue and weakness occurring in patients with cancer or advanced disease.

Salient Principle in this Section:

• Except when a patient is dying, recognize that fatigue is a treatable symptom with a major impact on quality of life

Included in this Section:

1. Fatigue and weakness management algorithm
2. Medications used for fatigue and weakness reference tables

Fatigue and Weakness Management

(Refer Appendix A - Fatigue and Weakness Management Algorithm)

Definition: Fatigue is a subjective perception/experience related to disease, emotional state and/or treatment. Fatigue is a multidimensional symptom involving physical, emotional, social and spiritual well-being and affecting quality of life.¹

Fatigue Assessment
• Assess whether symptom is fatigue or weakness (generalized or localized)
• Distinguish fatigue from depression
• Look for reversible causes of fatigue or weakness (refer Fraser Health, Hospice Palliative Care Symptom Guidelines, Fatigue, available at www.fraserhealth.ca/media/11FHSymptomGuidelinesFatigue.pdf)

Fatigue Management Strategies
• After treating reversible causes and providing non-pharmacological treatment recommendations, consider pharmacological treatment (Refer Appendix B), if consistent with patient’s goals of care
• Refer Appendix A - Fatigue and Weakness Management Algorithm

Reference

1. Ferrell BR, Grant M, Dean GE, Funk B, Ly J. Bone tired: The experience of fatigue and impact on quality of life. Oncology Nursing Forum. 1996;23(10):1539-47.

Appendices

• Appendix A - Fatigue and Weakness Management Algorithm
• Appendix B - Medications Used in Palliative Care for Fatigue

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html
Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html

Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain and Symptom Management - Depression

Scope

This section presents assessment and management strategies for dealing with depression occurring in patients with cancer or advanced disease.

Salient Principle in this Section:

• Before diagnosing and treating major depressive disorder, first effectively treat pain and other symptoms, then differentiate the symptom of depression from normal grieving
• When prescribing antidepressants for this group of patients, select antidepressants with the least drug interactions

Included in this Section:

1. Depression management algorithm
2. Depression medication reference tables

Depression Management

(Refer Appendix A - Depression Management Algorithm)

Assessment

• Depression occurs in 13-26% of patients with terminal illness^1,2 can amplify pain and other symptoms, and is often recognized too late in a patient’s life.
• Patients are at high risk of suicide and have an increased desire for hastened death.³
• A useful depression screening question is, “Have you been depressed most of the time for the past two weeks?”⁴
• A diagnosis of depression in the terminally ill may be made when at least two weeks of depressed mood is accompanied by symptoms of hopelessness, helplessness, worthlessness, guilt, lack of reactivity, or suicidal ideation.
• DSM-IV criteria for depression are not very helpful because vegetative symptoms like anorexia, weight loss, fatigue, insomnia, and impaired concentration may accompany end stage progressive illness.
• Risk factors include: personal or family history of depression, social isolation, concurrent illnesses (e.g., COPD, CHF), alcohol or substance abuse, poorly controlled pain, advanced stage of illness, certain cancers (head and neck, pancreas, primary or metastatic brain cancers), chemotherapy agents (vincristine, vinblastine, asparagines, intrathecal methotrexate, interferon, interleukin), corticosteroids (especially after withdrawal), abrupt onset of menopause (e.g. withdrawal of hormone replacement therapy, use of tamoxifen).

Management Strategies

• Non-pharmacological treatments are the mainstay of treatment for the symptom of depression without a diagnosis of primary affective disorder.
• Treatment of pain and other reversible physical symptoms should occur before initiating antidepressant medication.
• If a diagnosis of primary affective disorder is uncertain in a depressed patient, consider psychiatric referral and a trial of antidepressant medication (refer Appendix B). Consider drug interactions, adverse side effect profiles, and beneficial side effects when choosing an antidepressant.
• In the terminally ill, start with half the usual recommended starting dose of antidepressant.⁵
• First line therapy is with a selective serotonin reuptake inhibitor (SSRI)² or selective serotonin norepinephrine reuptake inhibitor (SSNRI) or noradrenergic and specific serotonergic antidepressant (NaSSA).
• Tricyclic antidepressants (especially nortryptiline and desipramine) can be considered due to their co-analgesic benefit for neuropathic pain (refer Appendix B - Medications Used in Palliative Care for Depression). Avoid with constipation, urinary retention, dry mouth, orthostatic hypotension, or cardiac conduction delays.
• When anticipated survival time is short, consider psychostimulants due to their more immediate onset of effect,² but avoid them in the presence of agitation, confusion, insomnia, anxiety, paranoia, or cardiac comorbidity.
• If life expectancy is 1-3 months, start a psychostimulant and an antidepressant together and then withdraw the stimulant while titrating the antidepressant upwards.

References

1. Lloyd-Williams M, Friedman T. Depression in palliative care patients - a prospective study. Eur J Cancer Care 2001;10:270-4.
2. Fraser Health Authority. Hospice Palliative Care Symptom Guidelines. Depression. c2006. Available from: http://www.fraserhealth.ca/professionals/hospice_palliative_care/
3. Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA 2000;284:2907-11.
4. Chochinov HM, Wilson KG, Enns M, et al. “Are you depressed?” Screening for depression in the terminally ill. Am J Psychiatry 1997;154:674-6.
5. Rodin G, Katz M, Lloyd N, et al. The management of depression in cancer patients: A clinical practice guideline. Cancer Care Ontario. 2006 Oct. Available at: www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13930

List of Abbreviations

ABG	arterial blood gas
CHF	congestive heart failure
COPD	chronic obstructive pulmonary disease
DSM-IV	Diagnostic and Statistical Manual of Mental Disorders 4th edition
NaSSA	noradrenergic & specific serotonergic antidepressant
SSRI	selective serotonin reuptake inhibitor
SSNRI	selective serotonin norepinephrine reuptake inhibitor
TCA	tricyclic antidepressant

Appendices

• Appendix A - Depression Management Algorithm
• Appendix B - Medications Used in Palliative Care for Depression

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html
Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html

Palliative Care for the Patient with Incurable Cancer or Advanced Disease - Part 2: Pain and Symptom Management - Resources

Allied Health Care and Supports

(Refer Palliative Care 1 - Approach to Care - Management at www.bcguidelines.ca/guideline_palliative1.html#management)

Consider referral to Home Nursing Care when patient’s Palliative Performance Scale (PPS) at www.bcguidelines.ca/pdf/palliative1_appendix_a.pdf is transitioning from 70% to 60% or lower.

Consider an application to the BC Palliative Care Drug Plan - (Plan P) when patient is in the last 6 months of life and has a PPS of 50% or less.

Physician and Patient Resources

BC Provincial Palliative Care Consult Line (available for physicians only, 24/7): 1-877-711-5757

Family Practice Oncology Network: www.bccancer.bc.ca/HPI/FPON/Guidelines+and+Protocols.htm Providing comprehensive support for family physicians caring for cancer patients including the development of useful resources and tools. Information to supplement this guideline, includes expanded sections on pain, dyspnea, nausea and vomiting (including Medical Management of Malignant Bowel Obstruction), and constipation. Additional information includes Patient Daily Opioid Dosing Record, Methadone Licence Application Form, Bowel Performance Scale, BC Cancer Agency Bowel Protocol, Patient Bowel Protocol Handout and Compounded Formulations for the Symptomatic Management of Mucositis.

General Practice Services Committee (GPSC) - Palliative Care Initiative www.gpscbc.ca/family-practice-incentive/palliative-care-initiative

HealthLink BC: www.HealthLinkBC.ca Dial 8-1-1 to speak to a nurse, a pharmacist, or dietician, for free information and resources for B.C. residents. TTY (deaf and hearing-impaired) call 7-1-1.

Home and Community Care: www.health.gov.bc.ca/hcc/
Home and community care services provide a range of health care and support services for eligible residents who have acute, chronic, palliative or rehabilitative health care needs. For more information, refer to A Guide to Your Care, available at http://www.health.gov.bc.ca/library/publications/year/2007/Guide_to_Your_Care_Booklet2007_Final.pdf

Practice Support Program (PSP): www.gpscbc.ca/psp/practice-support-program The PSP program offers focused, accredited training sessions for BC physicians to help them improve practice efficiency and to support enhanced delivery of patient care. The PSP have developed an End of Life Care Module with training materials, available at www.gpscbc.ca/psp/EOLtrainingmaterials. The End of Life Algorithm includes information on services and forms to support the coordination and delivery of community-based palliative care, available at www.gpscbc.ca/system/files/EOL_PSP_algorithm_final.pdf

References

1. Kobierski, L et al. Hospice Palliative Care Program. Symptom Guidelines. Fraser Health Authority. 2009 April. Available at: www.fraserhealth.ca/professionals/resources/hospice_palliative_care/hospice_palliative_care_symptom_guidelines
2. Schwartzstein RM, King TE, Hollingsworth H. Approach to the patient with dyspnea. UpToDate. 2009 Jan 1; 17.1.
3. Membe SK, Farrah K. Pharmacological management of dyspnea in palliative cancer patients: Clinical review and guidelines. Health Technology Inquiry Service. Canadian Agency for Drugs & Technologies in Health. 2008 July.
4. Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Jan;148(2):141-6.
5. Rodin G, Katz M, Lloyd N, et al. The management of depression in cancer patients: A clinical practice guideline. Cancer Care Ontario. 2006 Oct. Available at: www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13930
6. Brietbart W, Dickerman AL. Assessment and management of depression in palliative care. UpToDate. 2008 Jan 31; 16.1.
7. Lorenz KA, Lynn J, Dy SM, et al. Evidence for improving palliative care at the end of life: A systematic review. Ann Intern Med. 2008 Jan 15;148(2):147-159

Abbreviations

AEs	adverse effects	NSAIDs	non-steroidal anti-inflammatory drugs
ABG	arterial blood gas	PEG	polyethylene glycol
BM	bowel movement	SC	subcutaneous
BNP	brain natiuretic peptide	SL	sublingual
CHF	congestive heart failure	SSRI	selective serotonin reuptake inhibitor
COPD	chronic obstructive pulmonary disease	SSNRI	selective serotonin norepinephrine reuptake inhibitor
CT	computed tomography	SVC	superior vena cava
DSM-IV	Diagnostic and Statistical Manual of Mental Disorders 4th edition	SUPP	suppository
ECG	electrocardiogram	TENS	transcutaneous electrical nerve stimulation
GI	gastrointestinal	TCA	tricyclic antidepressant
IV	intravenous	UTI	urinary tract infection
N&V	nausea & vomit
NaSSA	noradrenergic & specific serotonergic antidepressant

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html
Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html

Information About Provincial Drug Coverage

Who is eligible for coverage under the bc palliative care drug plan (plan p)?

• BC PharmaCare offers coverage of palliative care medications to all B.C. residents who:
  • have a life expectancy of up to six months
  • are living at home^*
  • have been diagnosed with a life-threatening illness or condition, and
  • consent to the focus of care being palliative rather than treatment aimed at a cure.
    
• For guidance in determining patient’s medical eligibility, please refer to Appendix A - BC Palliative Care Benefits Program Physician Guide at www.health.gov.bc.ca/pharmacare/outgoing/palliative-physguide.pdf
• Residents of residential care facilities covered under PharmaCare Plan B (Permanent Residents of Licensed Care Facilities) are not eligible for Plan P.
• Individuals admitted to residential care facility hospice beds for short-term stays, who meet the palliative care medication coverage criteria, are eligible for Plan P.
• New B.C. residents, from other provinces, may qualify for coverage under Plan P. For more information, contact Health Insurance B.C. (HIBC) at the phone numbers below.

^* “Home” is defined as wherever the person is living, whether in their own home or living with family or friends, or living in a supportive living residence or hospice that is not covered under PharmaCare Plan B (for residents of Licensed Residential Care Facilities).

HOW TO APPLY?

• Once a physician has determined that a patient meets the medical criteria, the physician completes a B.C. Palliative Care Benefits Program Application (HLTH 349) available at www.health.gov.bc.ca/pharmacare/outgoing/palliative.html and faxes it to Health Insurance BC (HIBC) at 250-405-3587.
• Since the B.C. Palliative Care Drug Plan (Plan P) covers only specific drugs for palliative care treatment, patients should be encouraged to register for Fair PharmaCare to obtain optimal coverage for other eligible drugs.
• Registration for Fair PharmaCare can be completed by patients or their family members, online at www.health.gov.bc.ca/pharmacare/fpcreg.html or by calling Health Insurance B.C. (HIBC) at 604-683-7151 (Vancouver and the Lower Mainland) or 1-800-663-7100 (toll-free, for the rest of B.C.).

What Medications are Covered?

• A list of the items covered by PharmaCare Plan P is available at www.health.gov.bc.ca/pharmacare/outgoing/palliative-formulary.pdf. Medications covered by Plan P are subject to PharmaCare’s Low Cost Alternative (LCA) program.

Understanding the Pharmacare Benefit Status of Medications

• Regular benefit drugs do not require Special Authority. Patients may receive full or partial coverage since some of these drugs are included in the Low Cost Alternative (LCA) program or Reference Drug Program (RDP).
• Low Cost Alternative (LCA) Program focuses coverage on lower-priced (usually generic) drugs. Under this program, drugs with the same active ingredient(s) are placed in LCA categories. A price is set for each LCA category. Generic products priced in excess of the set price for the applicable category are not covered by PharmaCare. Brand name products are covered up to the set price for the applicable LCA category. For more information, visit: www.health.gov.bc.ca/pharmacare/lca/lcaindex.html.
• Reference Drug Program (RDP) encourages cost-effective first-line prescribing for common medical conditions. PharmaCare coverage is based on the cost of the reference drug(s) in a therapeutic category. Reference drugs are considered to be medically effective and the most cost-effective in that category. Patients receive full coverage for the reference drug(s). Other drugs not designated as the reference drugs are reimbursed based on the price of the reference drugs and patients are required to pay the difference. For more information, visit: www.health.gov.bc.ca/pharmacare/sa/criteria/rdpcategoriesindex.html.
• Limited Coverage Drugs are not generally considered first-line therapies, or have more cost-effective alternatives. PharmaCare Special Authority approval of coverage is required, and the drugs are subject to LCA rules if a lower cost alternative exists.
• Special Authority grants full benefit status to a medication that would otherwise be a partial benefit or a limited coverage drug. All requests for Special Authority coverage must be submitted by a health care practitioner. For more information, visit: www.health.gov.bc.ca/pharmacare/policy.html#10
• Information on which products PharmaCare covers can be obtained using the B.C. PharmaCare Formulary Search. For more information, visit: www.health.gov.bc.ca/pharmacare/benefitslookup.
• In all cases, coverage is subject to drug price limits set by PharmaCare and to the patient’s PharmaCare plan rules and deductibles.

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html
Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.

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