Palliative care - nausea and vomiting: Prescribing a prokinetic Prescribing a prokinetic | Prescribing information | Palliative care - nausea and vomiting | CKS | NICE Search CKS… Menu Prescribing a prokinetic Palliative care - nausea and vomiting: Prescribing a prokinetic Last revised in October 2016 Prescribing a prokinetic Prokinetics (metoclopramide and domperidone) should not be given concurrently with drugs with antimuscarinic activity (for example cyclizine, hyoscine) because (...) such as syncope or tachyarrhythmias arise during treatment. Should be avoided in people who are taking medication that prolongs the QT interval such as ketoconazole and erythromycin. Should be prescribed with caution in people aged over 60 years and people who have existing prolongation of cardiac conduction intervals (particularly the QTc interval), electrolyte disturbance, and an underlying cardiac disease (such as congestive heart failure). These recommendations are based mainly on palliative care

Palliative care - nausea and vomiting Palliative care - nausea and vomiting | Topics A to Z | CKS | NICE Search CKS… Menu Palliative care - nausea and vomiting Palliative care - nausea and vomiting Last revised in October 2016 Nausea is an unpleasant sensation of the need to vomit, which is often accompanied by autonomic symptoms, for example pallor, cold sweat, salivation Management Prescribing information Background information Palliative care - nausea and vomiting: Summary Nausea (...) is an unpleasant sensation of the need to vomit, which is often accompanied by autonomic symptoms (for example pallor, cold sweat, salivation, and tachycardia). Vomiting (emesis) is the forceful ejection of stomach contents through the mouth. There are many causes of nausea and vomiting in the palliative care setting, including: Drugs (for example opioids and cytotoxic drugs). Metabolic causes (for example from hypercalcaemia or renal failure). Gastric stasis (due to drugs, ascites, hepatomegaly, peptic ulcer

Palliative care - malignant skin ulcer: Scenario: End of life care Scenario: End of life care | Management | Palliative care - malignant skin ulcer | CKS | NICE Search CKS… Menu Scenario: End of life care Palliative care - malignant skin ulcer: Scenario: End of life care Last revised in October 2018 Scenario: End of life care End of life care It can often be difficult to be certain that a person is dying, but it is essential to recognize the signs of dying in order to appropriately care (...) for people at the end of life. For more information see the CKS topic on . An individualised care plan including the areas of symptom control and anticipatory prescribing should be created. For more information see the CKS topic on . Basis for recommendation These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Care of dying adults in the last days of life [ ]. The basis for the NICE recommendations has been briefly summarized in this section

Palliative care - malignant skin ulcer Palliative care - malignant skin ulcer | Topics A to Z | CKS | NICE Search CKS… Menu Palliative care - malignant skin ulcer Palliative care - malignant skin ulcer Last revised in October 2018 A malignant ulcer is a proliferative or cavitating primary or secondary cancer in the skin.It may appear as a crater-like wound, a nodular 'fungus' Management Prescribing information Background information Palliative care - malignant skin ulcer: Summary A malignant (...) the type, site and size of the ulcer, the presence of necrotic tissue, condition of the surrounding skin, and the presence of complications. Discussing with the person their concerns, treatment priorities, and advising that healing is unlikely to be a realistic goal, but that the aim is to maintain the person’s quality of life as much as possible. Ensuring a professional with expertise in wound management is involved in the person's care (such as a district nurse, palliative care or tissue viability

Palliative care - malignant skin ulcer: Metronidazole Metronidazole | Prescribing information | Palliative care - malignant skin ulcer | CKS | NICE Search CKS… Menu Metronidazole Palliative care - malignant skin ulcer: Metronidazole Last revised in October 2018 Metronidazole Contraindications and cautions Metronidazole is contraindicated in people with known hypersensitivity to nitroimidazoles [ ; ] . Do not prescribe metronidazole to a person with: Known metronidazole or nitroimidazole

Palliative care - general issues Palliative care - general issues | Topics A to Z | CKS | NICE Search CKS… Menu Palliative care - general issues Palliative care - general issues Last revised in April 2020 Palliative care is defined as the active holistic care of people with advanced, progressive illness. Management Background information Palliative care - general issues: Summary Palliative care is defined as the active holistic care of people with advanced, progressive illness. Professionals (...) providing general palliative care services should: Be involved as early as possible after diagnosis. Aim to meet the needs of the patient and their family within the limits of their knowledge and competence. Seek specialist advice or refer the patient to specialist services, when necessary. During the course of the illness, the patient's needs as well as the needs of their family or carers, should be assessed (and managed) at key points (e.g. at the time of diagnosis, around treatment episodes

Palliative care - general issues: Scenario: Management approach Scenario: Management approach | Management | Palliative care - general issues | CKS | NICE Search CKS… Menu Scenario: Management approach Palliative care - general issues: Scenario: Management approach Last revised in April 2020 Scenario: Management approach From age 16 years onwards. How should I assess and manage the person's physical symptoms? Assess the person's physical needs at key points during the course of the illness (...) the literature based on clinical experience [ ; ], and the General Medical Council guidance for doctors, Treatment and care towards the end of life: good practice in decision making [ ]. A qualitative study found that doctors tend to underestimate the severity of symptoms (for example dyspnoea) and this is associated with under-treatment of those symptoms [ ]. Expert opinion in a review article on palliative cancer care is that symptom management to optimize quality of life is the foundation of cancer care

Palliative care - dyspnoea: Scenario: Known cause of dyspnoea Scenario: Known cause of dyspnoea | Management | Palliative care - dyspnoea | CKS | NICE Search CKS… Menu Scenario: Known cause of dyspnoea Palliative care - dyspnoea: Scenario: Known cause of dyspnoea Last revised in April 2020 Scenario: Known cause of dyspnoea From age 16 years onwards. How should I manage dyspnoea of known cause in palliative care? In all cases: Consider to relieve dyspnoea. Consider symptomatic treatment (...) is available. Start 24% oxygen if the saturation is 90% or less. If the person develops stridor due to acute airway obstruction by a malignant cause, or superior vena cava obstruction, corticosteroid use may be beneficial in this situation but initiation should ideally be discussed with a palliative care consultant. However, if specialist advice is not available, when needed, consider: Giving a single oral dose of dexamethasone 16 mg immediately, if the person can swallow. If they are unable to take oral

Palliative care - dyspnoea: Scenario: End of life care Scenario: End of life care | Management | Palliative care - dyspnoea | CKS | NICE Search CKS… Menu Scenario: End of life care Palliative care - dyspnoea: Scenario: End of life care Last revised in April 2020 Scenario: End of life care How should I manage dyspnoea in the terminal phase? It can often be difficult to be certain that a person is dying, but it is essential to recognize the signs of dying in order to appropriately care (...) for people at the end of life. For more information see the CKS topic . An individualised care plan including the areas of symptom control and anticipatory prescribing should be created. For more information see the CKS topic . Identify and treat reversible causes of breathlessness in the dying person, for example pulmonary oedema or pleural effusion. Consider non-pharmacological management of breathlessness in a person in the last days of life. Do not routinely start oxygen to manage breathlessness

Palliative care - general issues: Scenario: Terminal phase Scenario: Terminal phase | Management | Palliative care - general issues | CKS | NICE Search CKS… Menu Scenario: Terminal phase Palliative care - general issues: Scenario: Terminal phase Last revised in April 2020 Scenario: Terminal phase From age 16 years onwards. How should I assess prognosis? Attempt to estimate the person's prognosis and discuss this with them, if appropriate. Estimating the prognosis helps in the planning (...) collaboration with the Royal College of Physicians, the Royal College of General Practitioners, GPs with a special interest in palliative care, and national disease associations [ ; ; ]. Expert opinion from published literature was also considered [ ; ]. Estimating the prognosis helps in the planning of appropriate treatment and care [ ]. If prognosis is not discussed, or predictions are inaccurate, people may make inappropriate treatment decisions, or inadequately prepare for death [ ]. Doctors may lack

Palliative care - dyspnoea: Scenario: Symptomatic treatment Scenario: Symptomatic treatment | Management | Palliative care - dyspnoea | CKS | NICE Search CKS… Menu Scenario: Symptomatic treatment Palliative care - dyspnoea: Scenario: Symptomatic treatment Last revised in April 2020 Scenario: Symptomatic treatment From age 16 years onwards. What simple measures may help dyspnoea in palliative care? Keep the room cool, improve air circulation with a fan or open window, and encourage relaxation (...) on palliative care guidelines [ ] and expert opinion from the palliative care literature [ ; ; ; ; ; ; ]. When should an opioid be considered? Consider using a strong opioid in people who need symptomatic treatment of dyspnoea, especially those with shortness of breath who are near the end of life. Continue with non-pharmacological strategies when initiating an opioid. See . Immediate-release oral morphine is the usual opioid of choice: Other routes of administration may be considered, but use of nebulized

Palliative care - dyspnoea: Scenario: COVID-19 Management Scenario: COVID-19 | Management | Palliative care - dyspnoea | CKS | NICE Search CKS… Menu Scenario: COVID-19 Palliative care - dyspnoea: Scenario: COVID-19 Management Last revised in April 2020 Scenario: COVID-19 Management From birth onwards. How should my management vary when considering the possibility of COVID-19? For people who are in the palliative phase of their illness and where there is also the possibility that they have (...) sulfate 2.5 mg to 5 mg subcutaneously as required. Midazolam 2.5 mg subcutaneously as required. Basis for recommendation These recommendations are based on the National Institute for Health and Care Excellence (NICE) COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community [ ]. © .

Palliative care - dyspnoea Palliative care - dyspnoea | Topics A to Z | CKS | NICE Search CKS… Menu Palliative care - dyspnoea Palliative care - dyspnoea Last revised in April 2020 Breathlessness is an objective observable sign, whereas dyspnoea is a subjective described symptoms of difficulty in breathing. Management Prescribing information Background information Palliative care - dyspnoea: Summary Breathlessness is an objective observable sign, whereas dyspnoea is a subjective described (...) obstructive pulmonary disease, heart failure, and anxiety. Assessment of someone with dyspnoea in a palliative care setting involves asking about: Features of the dyspnoea (for example severity, timing, onset, and precipitating and exacerbating factors). Associated physical symptoms (for example cough, sputum, haemoptysis, wheeze, stridor, pleuritic pain, fatigue, and panic). Effect on the person’s quality of life. An appropriate examination for the stage of the person's illness should be carried out

Palliative care - cough: Scenario: End of life care Scenario: End of life care | Management | Palliative care - cough | CKS | NICE Search CKS… Menu Scenario: End of life care Palliative care - cough: Scenario: End of life care Last revised in April 2020 Scenario: End of life care End of life care It can often be difficult to be certain that a person is dying, but it is essential to recognize the signs of dying in order to appropriately care for people at the end of life. For more information (...) see the CKS topic on . An individualised care plan including the areas of symptom control and anticipatory prescribing should be created. For more information see the CKS topic on . Basis for recommendation These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Care of dying adults in the last days of life [ ].The basis for the NICE recommendations has been briefly summarized in this section. For detailed information on the evidence NICE

Palliative care - cough: Scenario: Known cause of cough Scenario: Known cause of cough | Management | Palliative care - cough | CKS | NICE Search CKS… Menu Scenario: Known cause of cough Palliative care - cough: Scenario: Known cause of cough Last revised in April 2020 Scenario: Known cause of cough From age 16 years onwards. What management should be considered for all people with cough in palliative care? Treat the underlying cause of the cough if possible and appropriate. The decision (...) relief and improved quality of life. For further information, see . Manage dyspnoea if present. See the CKS topic on . Provide holistic care of the person by considering management of other physical symptoms, and the psychological, social, and spiritual needs of the person and their family. For more information, see the CKS topic on . Basis for recommendation These recommendations are based on palliative care guidelines [ ] and expert opinion from medical and palliative care literature [ ; ; ]. How

Palliative care - cough: Scenario: Symptomatic treatment Scenario: Symptomatic treatment | Management | Palliative care - cough | CKS | NICE Search CKS… Menu Scenario: Symptomatic treatment Palliative care - cough: Scenario: Symptomatic treatment Last revised in April 2020 Scenario: Symptomatic treatment From age 16 years onwards. When should I consider symptomatic treatment for cough? Consider symptomatic treatment if one or more of the following applies: The option of treating the underlying (...) cause is not possible or is inappropriate. The person remains distressed by symptoms despite treatment of the underlying cause. The person is in the terminal phase of life. For information on recognizing the terminal phase, see the CKS topic on . Basis for recommendation These recommendations are based on pragmatic advice and expert opinion from the palliative care literature [ ; ]. Cough may be very distressing in the terminal phase of cancer. The act of coughing may cause or aggravate pain, it may

Palliative care - constipation: Scenario: End of life care Scenario: End of life care | Management | Palliative care - constipation | CKS | NICE Search CKS… Menu Scenario: End of life care Palliative care - constipation: Scenario: End of life care Last revised in October 2016 Scenario: End of life care End of life care It can often be difficult to be certain that a person is dying, but it is essential to recognize the signs of dying in order to appropriately care for people at the end of life (...) . For more information see the CKS topic . An individualised care plan including the areas of symptom control and anticipatory prescribing should be created. For more information see the CKS topic . Basis for recommendation These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Care of dying adults in the last days of life [ ] Care of dying adults in the last days of life. The basis for the NICE recommendations has been briefly summarized

Palliative care - constipation: Scenario: Assessment Scenario: Assessment | Management | Palliative care - constipation | CKS | NICE Search CKS… Menu Scenario: Assessment Palliative care - constipation: Scenario: Assessment Last revised in October 2016 Scenario: Assessment From age 16 years onwards. How should I assess a person with constipation in palliative care? Attempt to diagnose the cause of constipation — this will include an abdominal and rectal examination (avoid rectal examination (...) in people receiving chemotherapy). Exclude bowel obstruction. Features which suggest obstruction include: Known presence of intra-abdominal tumour. Absence of passage of flatus per rectum. Nausea and vomiting. Colicky, abdominal pain. Abdominal distension. Abdominal tenderness without guarding or rebound. Active, tinkling bowel sounds; or quiet or absent bowel sounds (a late sign). Identify when the constipation first became a problem (if constipation pre-dates the illness requiring palliative care

Palliative care - constipation: Scenario: Management Scenario: Management | Management | Palliative care - constipation | CKS | NICE Search CKS… Menu Scenario: Management Palliative care - constipation: Scenario: Management Last revised in October 2016 Scenario: Management From age 16 years onwards. How should I prevent constipation when prescribing a constipating drug? When introducing an opioid (or any other constipating drug), advise the person of the risks of constipation, and prescribe (...) , which also softens stools) if colic is a problem. Adjust the dose of softener to produce a comfortable stool (comfort is more important than the frequency or number of stools). In a palliative care situation, higher and more frequent doses than specified by the product licence may be needed. Avoid: Phosphate enemas (if possible) as they can sometimes cause water and electrolyte disturbances, especially in people aged 65 years or older, and when co-morbidities are present. Bulk-forming laxatives (e.g

Palliative care - constipation: How should I prevent adverse effects of rectal laxatives? Preventing adverse effects of rectal laxatives | Prescribing information | Palliative care - constipation | CKS | NICE Search CKS… Menu Preventing adverse effects of rectal laxatives Palliative care - constipation: How should I prevent adverse effects of rectal laxatives? Last revised in October 2016 How should I prevent adverse effects of rectal laxatives? Suppositories: Must be placed alongside