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Symptom
Management
Guides

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Symptoms

Select a symptom:

Symptom Management Guides

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Pain - Assessment

Screen for pain using ESAS at each visit.

Onset

When did it begin?


How long does it last?


How often does it occur?

Provoking/Palliating

What brings it on?


What makes it better?


What makes it worse?

Quality

What does it feel like?


Can you describe it?

Region/Radiation

Where is it?


Does it spread anywhere?

Severity

What is the intensity of this symptom (On a scale of 0 to 10, with 0 being none and 10 being worst possible)? Right Now? At Best? At Worst? On Average?


How bothered are you by this symptom?


Are there any other symptom(s) that accompany this symptom?

Treatment

What medications or treatments are you currently using?


How effective are these?


Do you have any side effects from the medications/treatments?


What medications/treatments have you used in the past?

Understanding/Impact on You

What do you believe is causing this symptom?


How is this symptom affecting you and/or your family?

Values

What is your goal for this symptom?


What is your comfort goal or acceptable level for this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)?


Are there any other views or feelings about this symptom that are important to you or your family?

Other Assessment

Physical Assessment (focus on area of pain to determine cause and type of pain).


Pertinent History (risk factors).


Assess risks for addiction.


Associated symptoms: e.g. nausea, vomiting, constipation, numbness, tingling, urinary retention.

Intervention

Symptoms

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Symptom Management Guides

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Pain - Intervention

Considerations for All Patients

Non-Pharmacological

  • Psycho-social-spiritual interventions: patient education, counseling, recreational activities, relaxation therapy imagery, social interaction, spiritual counselling.
  • Other therapies: physiotherapy, occupational therapy, massage, aromatherapy, music therapy, acupuncture, transcutaneous electrical nerve stimulation, reflexology, Reiki, hypnotherapy.
  • Other interventions such as radiation therapy, vertebroplasty, surgery and anesthetic interventions should be considered in patients with difficult to control pain.

Patient Education

  • Taking routine and breakthrough analgesics, adverse effect management, non pharmacologic measures that can be used in conjunction with pharmacologic treatment.

Pharmacological

  • The severity of pain determines the strength of analgesic required specified by the World Health Organization (WHO) Analgesic Ladder.
  • The type and cause of the pain will influence the choice of adjuvant analgesic (e.g. nociceptive, neuropathic, bone metastases).
  • In the presence of reduced kidney function all opioids should be used with caution and at reduced doses and/or frequency.
  • Fentanyl, methadone and oxycodone are the safest opioids of choice in patients with chronic kidney disease.
  • Methadone requires an experienced prescriber, check for significant drug interactions before prescribing any drug to a patient on methadone.
  • When using a transmucosal fentanyl formulation for breakthrough pain the effective dose should be found by upward titration independent of the regular opioid dose.
  • For those with stabilized severe pain and on a stable opioid dose or those with swallowing difficulties or intractable nausea and vomiting, fentanyl transdermal patches may be appropriate, provided the pain is stable.
  • Classify the pain – nociceptive, neuropathic or mixed?
  • The type and cause of the pain will influence the choice of adjuvant analgesic (e.g. nociceptive, neuropathic, bone metastases).
  • The choice of antidepressant or anticonvulsant should be based on concomitant disease, drug therapy and drug side effects and interactions experienced.
  • There is insufficient evidence to support a recommendation for topical opioids.
  • There is insufficient evidence to support first or second line therapy of cancer pain with cannabinoids but they may have a role in refractory pain, particularly refractory neuropathic pain.
  • Transdermal fentanyl should not be used in opioid naïve patients.
  • Specialist palliative care advice should be considered for the appropriate choice, dosage and route of opioid in patients with reduced kidney function or in patients with difficult to control pain.

Adverse effects of opioids

  • Many opioid-naïve patients will develop nausea or vomiting when starting opioids, tolerance usually occurs within 5-10 days. Patients commencing an opioid for moderate to severe pain should have access to an antiemetic to be taken if required.
  • The majority of patients taking opioids for moderate to severe pain will develop constipation. Little or no tolerance develops. The commonest prophylactic treatment for preventing opioid-induced constipation is a combination of stimulant (senna or bisocodyl) and osmotic laxatives (lactulose or PEG 3350).

Mild Pain

Mild Pain - Intervention

(ESAS 1-3)

Pharmacological

Treatment with non-opioids

  • Acetaminophen and NSAIDS including COX-2 inhibitors should be considered at the lowest effective dose.
  • The need for ongoing or long term treatment should be reviewed periodically, if no significant response in one week drugs should be stopped.
  • Long term use of NSAIDs should require gastric mucosa protection.
  • There is insufficient evidence to recommend bisphosphonates for first line therapy for pain management.

Treatment with opioids

  • For mild to moderate pain, weak opioids such as codeine or tramadol could be given in combination with a non-opioid analgesic.
  • If pain is not controlled with these combinations go to 'Moderate Pain' re: initiation and treatment with opioids.

Moderate Pain

Moderate Pain - Intervention

(ESAS 4-6)

Pharmacological

Treatment with opioids if the person is opioid naïve

  • Morphine starting dose is usually 5mg Q4h with 2.5-5mg Q1h prn for breakthrough pain. For elderly or debilitated patients consider a starting dose of 2.5mg Q4h.
  • Hydromorphone starting dose is 1mg Q4h with 0.5-1mg Q1h prn for breakthrough pain. For elderly or debilitated patients consider a starting dose of 0.5 mg Q4h.
  • Oxycodone starting dose is 2.5 mg or one half tablet Q4h with 2.5 mg or one half tablet Q2h prn for breakthrough.(The lowest dose oxycodone tablets available, either in combination with acetaminophen or alone, contain 5mg of oxycodone, equivalent to ~5-10mg of morphine).

Treatment with opioids if the person is taking an opioid

  • As an immediate release preparation with q4h dosing, increase the regular and breakthrough doses by 25%.
  • As a sustained release opioid, increase this dose by 25%. Change the breakthrough dose to 10% of the regular 24h dose, either q1-2h PRN PO or q30 min PRN subcut.
  • Patients with stable pain and analgesic usage, receiving oral morphine, oxycodone or hydromorphone should have the drug converted to a sustained or controlled release formulation given q12h for ease of administration. The short acting breakthrough dose is usually 10% of the total daily dose.
  • The frequency of breakthrough doses for oral opioids is Q1-2h prn. After conversion to a long acting preparation, if pain is not well controlled, reassess the patient and consider why multiple breakthrough doses are being used and the effectiveness of the breakthrough doses.
  • If indicated after proper assessment, the daily dose can be titrated by adding 20 to 30% of the breakthrough doses used in the preceding 24 hrs to the daily sustained release formulation.
  • Make frequent assessments and adjustments to the opioid dose until the pain is better controlled.

Severe Pain

Severe Pain - Intervention

(ESAS 7-10)

Pharmacological

Treatment with strong opioids

If the person is opioid naïve

  • Oral: Morphine 5-10 mg PO q4h and 5mg PO q1h PRN OR hydromorphine 1.0-2.0 mg PO q4h and 1.0 mg PO q1h PRN OR Subcutaneous: Morphine 2.5 - 5 mg subcut q4h & 2.5 mg subcut q30min PRN OR hydromorphone 0.5 - 1.0 mg subcut q4h & 0.5 mg subcut q30min PRN.

If the patient is taking an opioid with q4h dosing

  • Increase the regular and breakthrough doses by 25%.
  • Change frequency of the breakthrough to q1h PRN if PO and q30min PRN if subcut.

If the patient is taking a sustained release opioid

  • Increase the regular dose by 25%
  • Change the breakthrough dose to 10-15% of the regular 24h dose, either q1h PRN PO or q30 min PRN subcut
  • Titrate the dose every 24h to reflect the previous 24h total dose received

If unmanageable opioid-limiting adverse effects are present (e.g. nausea, drowsiness, myoclonus)

  • Consider switching to another opioid and re-titrate or consult palliative care.

For patients with severe uncontrolled pain

  • Consider switching back to an equivalent daily dose of immediate release morphine to allow more rapid titration of dose or switch to a sc preparation/infusion.
  • Meperidine and pentazocine should generally not be used in cancer patients with chronic or acute pain.
  • If there is difficulty getting the pain under control consider a consultation to palliative care.

Severe Pain Crisis

  1. A severe pain crisis requires prompt use of analgesics, adjuvant therapies, reassurance and a calm atmosphere.
  2. Consider a consultation to palliative care or a cancer pain specialist.
  3. If IV access is present, and the person is opioid naïve give stat morphine 5-10 mg IV q10min until pain is relieved;if the person is on opioids give the po prn dose IV q10min until pain is relieved. Monitor carefully.
  4. If no IV access available, and the person is opioid naïve give stat morphine 5-10 mg subcut q20-30min until pain is relieved;if the person is on opioids give the po prn dose subcut q20-30min until pain is relieved.
  5. Titrate dose by 25% every 1 - 2 doses until pain is relieved.
  6. When pain is controlled: If the patient is taking a sustained release opioid increase this dose by 25% and change to q4h dosing po or subcut. Do Not try to manage a severe pain crisis with a long-acting opioid. Change the breakthrough dose to half of the regular dose, either q1h PRN PO or q30 min PRN subcut.

Conversion Ratios

  • It should be noted that these conversion ratios, based on available evidence, are conservative in the direction specified;if converting in the reverse direction, a reduction in dose of one third should be used following conversion, or specialist advice sought.

DrugApproximate Equivalent Dose (a)
ParenteralOral
Codeine120200
Fentanyl0.1-02n/a (b)
Morphine1020 - 30 (c)
Hydromorphone24 - 6
Oxycodonen/a30
Pethidine (Meperidine)75300
Sufentanil0.01 - 0/04n/a (b)
Tramadol(d)(d)
Methadone(e)(e)
  1. From single dose studies using immediate-release dosage forms. These approximate analgesic equivalences should be used only as a guide for estimating equivalent doses when switching from one opioid to another. Additional references should be consulted to verify appropriate dosing of individual agents.
  2. Route of administration not applicable.
  3. With repeated dosing.
  4. Tramadol''s precise analgesic potency relative to morphine is not established. Consult the product monograph for dosing recommendations.
  5. For methadone, see Guide-to-Practice: Pain

Conversion doses from oral morphine to transdermal fentanyl

Oral 24-hour morphine (mg/day)Transdermal Fentanyl (mcg/h)
<9025
90-13437 (if available, otherwise 25)*
135-18950
190-22462 (if available, otherwise 50)*
225-31475
315-404100
405-494125
495-584150
585-674175
675-765200
765-854225
855-944250
945-1034275
1035-1124300

*12mcg/h fentanyl patch may not being covered by ODB, therefore if the patient has a private drug plan, combinations involving the 12mcg/h patch may be considered

Titration Guide

General- principles:
  1. Calculate the total opioid dose taken by the patient in 24 h (regular q4h dose x 6 PLUS the total number of breakthrough doses given x breakthrough dose).
  2. Divide this 24 h total by 6 for the equivalent q4h dose.
  3. Divide the newly calculated q4h dose by 2 for the breakthrough dose.
  4. Use clinical judgment regarding symptom control as to whether to round up or down the obtained result (both breakthrough and regular dosing). Remember to consider available dosage forms (in the case of PO medications especially).
  5. If the patient is very symptomatic a review of how many breakthrough doses have been given in the past few hours might be more representative of his/her needs.

Example:


A patient is ordered morphine 20 mg q4h PO and 10 mg PO q2h PRN, and has taken 3 breakthrough doses in the past 24 h.
  1. Add up the amount of morphine taken in the past 24 h: 6 x 20 mg of regular dosing, plus 3 x 10 mg PRN doses equals a total of 150 mg morphine in 24 hours
  2. Divide this total by 6 to obtain the new q4h dose: 150 divided by 6=25 mg q4h
  3. Divide the newly calculated q4h dose by 2 to obtain the new breakthrough dose: 25 mg divided by 2=12.5 mg q1 - 2h PRN
  4. If this dose provided reasonable symptom control, then order 25mg PO q4h, with 12.5 mg PO q1 - 2h PRN. (It would also be reasonable to order 10mg or 15 mg PO q2h for breakthrough.)

Conversion Guide

(To convert from long-acting preparations to short-acting preparations)

General principles in converting from sustained release to immediate release formulations (for the same drug):
  1. Add up the total amount of opioid used in the past 24 h, including breakthrough dosing.
  2. Divide this total by 6 to obtain equivalent q4h dosing.
  3. Divide the q4h dose by 2 to obtain breakthrough dosing.
  4. Use clinical judgment to adjust this dose up or down depending on symptom control.
  5. Consider available tablet sizes when calculating doses.

Example:


A patient is ordered a long-acting morphine preparation at a dose of 60 mg PO q12h, with 20 mg PO q4h for breakthrough, and has taken 4 breakthrough doses in 24 h.
  1. Add up the amount of opioid taken in 24 h: 2 x 60 mg of long-acting morphine plus 4 x 20 mg of breakthrough is 200 mg of morphine in 24 h
  2. Divide this total by 6 to obtain the equivalent q4h dosing: 200 divided by 6 is approximately 33 mg PO q4h
  3. Divide this q4h dose by 2 for the breakthrough dose 33 mg divided by 2 is 16.5 mg
  4. If the patient had reasonable symptom control with the previous regimen, then a reasonable order would be: 30 mg PO q4h and 15 mg q1 - 2h PO PRN

Follow-Up and ongoing Monitoring

If pain remains unrelieved despite the approaches outlined above, request the assistance of a palliative care consultation team.

Symptoms

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Dyspnea - Assessment

Screen for dyspnea using ESAS at each visit.

Potential Causes of Dyspnea

Respitory System

Potentially Treatable CausesTreatment Options
Chronic obstructive pulmonary disease (COPD)Inhaled bronchodilators; inhaled or systemic corticosteriods
Large airway obstructionRadiotherapy; systemic corticosteroids; stenting; heliox; nebulized epinephrine
Pleural effusionDrain; if recurrent - sclerosing agents; indwelling catheter
PneumoniaAntibiotics
Pulmonary emboliAnti-coagulation; inferior vena cava filter

Cardiovascular System

Potentially Treatable CausesTreatment options
Angina pectorisOptimize conventional medications
Atrial fibrillationMedications for ventricular rate control
Congestive heart failureOptimize conventional medications
Pericardial effusionDrain; if recurrent - sclerosing agents; pericardial window; indwelling catheter
Superior vena cava obstructionCorticosteroids; radiotherapy; stenting

Other Systems

Potentially Treatable CausesTreatment options
AnemiaRed blood cell transfusion
Severe AscitesDrain; if recurrent - indwelling catheter

Onset

When did it begin?


How long does it last?


How often does it occur?

Provoking/Palliating

What brings it on?


What makes it better?


What makes it worse?

Quality

What does it feel like?


Can you describe it?

Region/Radiation

Are there any other associated symptoms?

Severity

What is the intensity of this symptom (On a scale of 0 to 10, with 0 being none and 10 being worst possible)? Right Now? At Best? At Worst? On Average?


How bothered are you by this symptom?


Are there any other symptom(s) that accompany this symptom?

Treatment

What medications or treatments are you currently using?


How effective are these?


Do you have any side effects from the medications/treatments?


What medications/treatments have you used in the past?

Understanding/Impact on You

What do you believe is causing this symptom?


How is this symptom affecting you and/or your family?

Values

What is your goal for this symptom?


What is your comfort goal or acceptable level for this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)?


Are there any other views or feelings about this symptom that are important to you or your family?

Other Assessment

Physical Assessment (as appropriate for symptom).


Pertinent History (risk factors).

Intervention

Symptoms

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Symptom Management Guides

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Dyspnea - Intervention

Considerations for All Patients

Cognitive Behavioural Interventions

  • Provide information and support for management of breathlessness, instructions for breathing control, relaxation, distraction techniques and breathing exercises.
  • Provide goal setting to enhance breathing and relaxation techniques, enable participation in social activities, and develop coping skills.
  • Identify early signs of problems that need medical or pharmacotherapy intervention.

Positioning

  • Suggest positions that maximize respiratory function while reducing physical effort.

Breathing

  • Provide ambient air flow on face & cool facial temperatures (use window, fan, or nasal prongs).
  • Increasing chest expansion can make the most of one's lung capacity and increase oxygen delivery.
  • Consider referral to a respiratory therapist, physiotherapist or nurse with expertise in managing dyspnea.
  • Assess the need for oxygen.
  • Assess breathlessness - what improves and what hinders.

Supportive Counseling

  • The meaning of symptoms cannot be separated from the symptom experience. In order to relieve suffering and provide good symptom support, the health care professional must explore the meaning of the symptom to the patient.

Positioning and Exercise Tips

Positioning

For patients with PPS 100% - 50%

Suggest positions that maximize respiratory function while reducing physical effort.
  1. If patient experiences dyspnea during periods of ambulation, suggest stopping and leaning against the wall or sit leaning slightly forward resting arms on a table.
  2. For patients experiencing dyspnea lying down:
    • Semi to high fowlers position is often most comfortable.
    • For positioning on the side, promote positioning on affected side to maximize lung expansion;ensure pillows are supporting small of the back.

For patients with reduced functional status PPS < 40%

  1. During periods of standing, encourage positioning that allows for good lung expansion such as leaning against a wall.
  2. Promote a sitting position that is comfortable and maximizes air expansion (arm chair or edge of bed) slightly leaning forward securing arms on arm rest or pillows.

For patients with reduced functional status PPS < 30%

  1. Semi to high fowlers position is often most comfortable. For positioning on the side, promote positioning on affected side to maximize lung expansion;ensure pillows are supporting small of the back.
  2. Minimize frequency of position changes.

Breathing Exercises

For patients with PPS 100% - 50% (if able)

Regular Abdominal Breathing (repeat 3 times/day)

  1. Sitting in a comfortable position with back well supported, the hands should be placed palms facing up on one’s lap. If standing, turn palms outwards. This rotates the shoulders out and increases the space for the lungs to expand.
  2. Breathe in through the nose to the count of 4 while pushing out the diaphragm and abdominal muscles giving a sense of breathing around the waist.
  3. Breathe out through pursed lips, making the breath out twice as long as the breath in to the count of 8.
  4. Alternate breathing in through the nose to the count of 4, hold the breath to the count of 7 (..5..6..7), breathe out through pursed lips slowly for a full count of 8.
  5. Repeat 4 times.

Respiratory Muscle Strengthening

These gentle exercises will not make one dyspneic, especially if done slowly using abdominal breathing as much as possible. All 7 exercises should be done, but if the patient is unable to do them all, then it is best if they do as many as they can.

Stretching the Muscles of the chest wall

  1. Breathe in through the nose to the count of 4 while raising arms straight overhead.
  2. Turn palms out and extend arms out and down the sides of the body while breathing out using pursed lips.
  3. Repeat 4 times.

Opening the Chest

  1. Place arms straight out in front of body, palms facing each other.
  2. Breathe in through the nose as the straight arms move out to the sides and push arms back as far as possible
  3. Move arms from back to front of body while breathing through pursed lips.
  4. Repeat 4 times.

Working the Diaphragm (Sniffling)

  1. With mouth closed, breathe in and out of nose quickly.
  2. Work towards doing this for 60 seconds.

Elbow Circles

  1. With hands on shoulders, make a circle with the elbows.
  2. Breathe IN as the elbows go up, breathe OUT as the elbows return.
  3. Make circles forward 10 times and backward 10 times.

Shoulder Circles

  1. Place arms along side of body with palms facing backwards and fingers spread apart.
  2. Breathe IN as shoulders rotate up and back.
  3. Breathe OUT as shoulders push down.
  4. Repeat 10 times.

Chest Fly (Chicken Wings)

  1. Sit with feet shoulders width apart, hands on ears, palms facing forwards.
  2. Exhale while slowly bringing palms together.
  3. Inhale as bringing arms back out.
  4. Repeat 20 times.

Working all the Muscles (Churn the Butter)

  1. Sitting up straight, place hands in prayer position.
  2. Make large circles like churning the butter.
  3. Repeat 10 times, REST, repeat 10 times in the other direction.

For patients with reduced functional status PPS < 40%

  1. Regular abdominal breathing techniques may be used for patients in transitional and even end of life if patient is conscious.
  2. Family members should be encouraged to learn controlled breathing techniques as they may become the natural teachers towards the end of life.

Mild Dyspnea

Mild Dyspnea - Intervention

(ESAS 1-3)

Pharmacological

  • Supplemental oxygen is recommended for hypoxic patients experiencing dyspnea.
  • Supplemental oxygen is not recommended for non-hypoxic, dyspneic patients.
  • Systemic opioids, by the oral or parenteral routes, can be used to manage dyspnea in advanced cancer patients.

Moderate Dyspnea

Moderate Dyspnea - Intervention

(ESAS 4-6)

Pharmacological

Patients with PPS* 100% - 10%

Non Opioids

  • May use benzodiazepines for anxiety.
  • There is no evidence for the use of systemic corticosteroids.

Systemic Opioids for opioid-naïve patients

  • Morphine (or equivalent dose of alternate immediate-release opioid) 5mg po q4h regularly and 2.5mg po q2h prn for breakthrough dyspnea.
  • If the oral route is not available or reliable, morphine 3 mg subcut q4h regularly and 1.5 mg subcut q1h prn for breakthrough dyspnea.

For patients already taking systemic opioids

  • Increase the patient's regular dose by 25%, guided by the total breakthrough doses used in the previous 24 hours.
  • The breakthrough dose is 10% of the total 24-hour regular opioid dose, using the same opioid by the same route. Oral breakthrough doses q2 hrs as needed. Subcutaneous breakthrough doses q1hr as needed, due to more rapid peak effect.
  • Do not use nebulized opioids, nebulized furosemide, nebulized lidocaine or benzodiazepines.

Patients with PPS* 100% - 20%

  • If patient has or may have COPD, consider a 5-day trial of a corticosteroid. Dexamethasone 8 mg/day po or subcut or IV. Prednisone 50 mg/day po. Discontinue corticosteroid if there is no obvious benefit after 5 days.
  • If the patient does not have COPD, but has known or suspected lung involvement by the cancer, weigh the risks before commencing a 5-day trial. - Other potential benefits, such as for appetite stimulation or pain management, may justify a 5-day trial of a corticosteroid.
  • Do not start prophylactic gastric mucosal protection therapy during a 5-day trial of a corticosteroid, but consider such therapy if the corticosteroid is continued past the trial.
  • Prochlorperazine is not recommended as a therapy for managing dyspnea.
  • No comparative trials are available to support or refute the use of other phenothiazines, such as chlorpromazine and methotrimeprazine, however oral promethazine may be used as a second-line agent if systemic opioids cannot be used or in addition to systemic opioids.

Patients with PPS* 30% - 10%

  • Consider a trial of chlorpromazine or methotrimeprazine, if dyspnea persists despite other therapies. Methotrimeprazine 2.5-10 mg po or subcut q6-8h regularly or as needed. Chlorpromazine 7.5-25 mg po q6-8h regularly or as needed.
  • Anxiety, nausea or agitation, may justify a trial of chlorpromazine or methotrimeprazine.

Severe Dyspnea

Severe Dyspnea - Intervention

(ESAS 7-10)

Non-Pharmacological

  • Attend to the meaning of the symptom (or attend to fear/anxiety).
  • If dyspnea is acute or there is an unexpected change further assessment may be required to identify potentially treatable causes.

Pharmacological

Patients with PPS* 100% - 10%

Systemic Opioids - If patient is opioid naïve

  • Give a subcut bolus of morphine 2.5 mg (or an equivalent dose of an alternate opioid). If tolerated, repeat dose every 30 minutes if needed. Consider doubling dose if 2 doses fail to produce an adequate reduction in dyspnea and are tolerated. Monitor the patient's respiratory rate closely, since the time to peak effect of a subcut dose of morphine may be longer than 30 minutes.
  • If intravenous access is available, consider giving an IV bolus of morphine 2.5 mg (or an equivalent dose of an alternate opioid) to achieve a more rapid effect. If tolerated, repeat dose every 30 minutes if needed. Consider doubling dose if 2 doses fail to produce an adequate reduction in dyspnea and are tolerated. Monitor the patient's respiratory rate closely, since IV boluses of morphine result in faster and higher peak effects.
  • Start a regular dose of an immediate-release opioid, guided by the bolus doses used. For the breakthrough opioid dose, consider using the subcut route initially for severe dyspnea until the symptom comes under control.

If patient is already taking systemic opioids

  • Follow the same suggestions as above for opioid naïve patients, with the following changes. Give a subcut bolus of the patient's current opioid using a dose equal to 10% of the regular, 24-hour, parenteral-dose-equivalent of the patient's current opioid (a parenteral dose is equivalent to half the oral dose).
  • Consider giving an IV bolus of the patient's current opioid, using a dose equal to 10% of the regular, 24-hour, parenteral-dose-equivalent of the patient's current opioid.
  • Increase the regular opioid dose by 25%, guided by the bolus doses used.

Psychoactive medications

  • Consider a trial of chlorpromazine or methotrimeprazine, if severe dyspnea persists despite other therapies.
  • Methotrimeprazine 2.5-10 mg po or subcut q6-8h regularly or as needed.
  • Chlorpromazine 7.5-25 mg po or IV q6-8h regularly or as needed.
  • Consider benzodiazepine for co-existing anxiety.

Titration Guide

General- principles:
  1. Calculate the total opioid dose taken by the patient in 24 h (regular q4h dose x 6 PLUS the total number of breakthrough doses given x breakthrough dose).
  2. Divide this 24 h total by 6 for the equivalent q4h dose.
  3. Divide the newly calculated q4h dose by 2 for the breakthrough dose.
  4. Use clinical judgment regarding symptom control as to whether to round up or down the obtained result (both breakthrough and regular dosing). Remember to consider available dosage forms (in the case of PO medications especially).
  5. If the patient is very symptomatic a review of how many breakthrough doses have been given in the past few hours might be more representative of his/her needs.

Example:


A patient is ordered morphine 20 mg q4h PO and 10 mg PO q2h PRN, and has taken 3 breakthrough doses in the past 24 h.
  1. Add up the amount of morphine taken in the past 24 h: 6 x 20 mg of regular dosing, plus 3 x 10 mg PRN doses equals a total of 150 mg morphine in 24 hours
  2. Divide this total by 6 to obtain the new q4h dose: 150 divided by 6=25 mg q4h
  3. Divide the newly calculated q4h dose by 2 to obtain the new breakthrough dose: 25 mg divided by 2=12.5 mg q1 - 2h PRN
  4. If this dose provided reasonable symptom control, then order 25 mg PO q4h, with 12.5 mg PO q1 - 2h prn. (It would also be reasonable to order 10 mg or 15 mg PO q2h for breakthrough.)

Conversion Guide

(To convert from long-acting preparations to short-acting preparations)

General principles in converting from sustained release to immediate release formulations (for the same drug):
  1. Add up the total amount of opioid used in the past 24 h, including breakthrough dosing.
  2. Divide this total by 6 to obtain equivalent q4h dosing.
  3. Divide the q4h dose by 2 to obtain breakthrough dosing.
  4. Use clinical judgment to adjust this dose up or down depending on symptom control.
  5. Consider available tablet sizes when calculating doses.

Example:


A patient is ordered a long-acting morphine preparation at a dose of 60 mg PO q12h, with 20 mg PO q4h for breakthrough, and has taken 4 breakthrough doses in 24 h.
  1. Add up the amount of opioid taken in 24 h: 2 x 60 mg of long-acting morphine plus 4 x 20 mg of breakthrough is 200 mg of morphine in 24 h
  2. Divide this total by 6 to obtain the equivalent q4h dosing: 200 divided by 6 is approximately 33 mg PO q4h
  3. Divide this q4h dose by 2 for the breakthrough dose 33 mg divided by 2 is 16.5 mg
  4. If the patient had reasonable symptom control with the previous regimen, then a reasonable order would be: 30 mg PO q4h and 15 mg q1 - 2h PO PRN

Equianalgesic Conversion Table

SubcutaneousPer OsRatio
Morphine10 mg20 mg
Codeine120 mg200 mg12:1 (PO codeine to PO morphine)
OxycodoneN/A10 - 15 mg1:2 (PO oxycodone to PO morphine)
Hydro-morphone2 mg4 mg1:5 (PO hydromorphone to PO morphine)

Follow-Up and Ongoing Monitoring

  • If dyspnea remains unrelieved despite the approaches outlined above, request the assistance of a palliative care consultation team.

Symptoms

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Symptom Management Guides

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Depression - Assessment

Screen for distress1 at entry to system, critical times, periodically during patient care, or other stressful times2

1. Use Screening for Distress Tool (SDT), which includes Edmonton Symptom Assessment System (ESAS) and Canadian Problem Checklist (CPC)


2. At initial diagnosis, start of treatment, regular intervals during treatment, end of treatment, post-treatment or at transition to survivorship, at recurrence or progression, advanced disease, when dying, and during times of personal transition or re-appraisal such as family crisis, during survivorship, when approaching death (CAPO/CPAC guideline: 'Assessment of Psychosocial Health Care Needs of the Adult Cancer Patient' by Howell et al., 2009; Cancer Care Nova Scotia Distress Management Pathways, draft 2010).

Assessment of risk of harm to self and/or to others

If YES > URGENT referral to appropriate services for emergency evaluation; Facilitate safe environment; One-to-one observation; Initiate appropriate harm reduction interventions to reduce risk of harm to self and/or others. (The presence of other symptoms such as psychosis, severe agitation and confusion (delirium) may also warrant referral to appropriate services for emergency evaluation).


If NO > continue with algorithm.

Assessment to clarify nature and extent of depressive symptoms

Review problem checklist and all ESAS scores in conversation with patient/family and discuss expectations and beliefs about support needs (e.g., Canadian Problem Checklist).


Identify most distressing ESAS symptom(s) and or problem(s) contributing to depression (e.g., life events, insomnia, pain, fatigue, other co-morbid illness) and daily interference.


Assess effectiveness of current symptom and/or co-morbid condition management.


Psychomotor agitation or slowing.

Identify Pertinent history / Specific risk factors for depression

Recurrent, advanced, progressive disease (i.e., vulnerable points).


History: Depression, substance abuse, other mental health problems (e.g., dysthymia).


Current use of depression medication or seeing a psychologist or psychiatrist.


Perceived lack of social support.


Other factors (e.g., younger age, female, live alone, dependent children, financial problems, prior coping issues).

Focused assessment: Specific to problem of depression

Health Care Professionals with appropriate training and skills to complete a depression symptom checklist using validated tool (e.g., CES-D; PHQ-9) or assess for presence of: depressed mood, loss of pleasure, feelings of worthlessness/guilt, diminished concentration, recurrent thoughts of death, fatigue, significant change in appetite and sleep patterns, impaired functioning in daily living. (DSM-IV criteria)


Assess if symptoms persist for 2 weeks or longer (almost all day, every day) (DSM-IV criteria).

Intervention

Symptoms

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Depression - Intervention

Mild Depression

Mild Depression - Intervention

(ESAS 1-3)

Care Pathway 1 - Prevention & Supportive Care

  • Offer referral to psychosocial support (e.g., counseling, support groups, individual etc)

Moderate Depression

Moderate Depression - Intervention

(ESAS 4-6)

Care Pathway 2 - Psychosocial Care

Intervention Options

  • Combine non-pharmacological and pharmacological interventions as appropriate.
  • Referral to other services as required (e.g., psychosocial team, volunteer visits).

Non-Pharmacological

  • Psycho-education and psychosocial interventions (specifically cognitive- behavioral therapy and patient education and information, counseling and individual or group psychotherapy, behavioral therapy, and social support).
  • Relaxation therapy.

Pharmacological

  • A number of anti-depressants are recommended for treatment of depression with choice informed by side effect profiles, interactions, response, patient preference.
  • Monitor for adverse effects.
  • With care team, review the plan for management of depression and other physical symptoms and need for referral unless automatic red flag generated for severe depression (e.g., pain).

Severe Depression

Severe Depression - Intervention

(ESAS 7-10)

Care Pathway 3 - Referral to Physician/ Psychologist/ Psychiatrist

  • Definitive Diagnosis Needed: Referral to appropriate services for evaluation and definitive diagnosis
  • Intervention Options: Psychiatric standard of care

Supportive care interventions for all patients, as appropriate

  • Offer referral to psychosocial support (e.g., counseling, peer-led support groups, individual)
  • Provide education (verbal plus any relevant materials) for the patient and family about:
    • How common emotional distress is in the context of cancer and differing responses
    • Benefits of support groups and other support services
    • Sources of informal support, resources available to patients and families (e.g., accommodation, transportation, financial assistance, additional health/drug benefits)
    • Need for additional psychosocial support if signs and symptoms of depression worsen with specific information regarding symptoms to warrant a call to the physician or nurse.
    • Coping with stress and specific strategies (i.e. relaxation approaches)
    • How to effectively manage symptoms contributing to depression (e.g., fatigue, sleep disturbance)

Symptoms

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Anxiety - Assessment

Screen for distress at entry to system, critical times, periodically during patient care, or other stressful times.

Screen for distress1 at entry to system, critical times, periodically during patient care, or other stressful times2

1. Use Screening for Distress Tool (SDT), which includes Edmonton Symptom Assessment System (ESAS) and Canadian Problem Checklist (CPC)


2. At initial diagnosis, start of treatment, regular intervals during treatment, end of treatment, post-treatment or at transition to survivorship, at recurrence or progression, advanced disease, when dying, and during times of personal transition or re-appraisal such as family crisis, during survivorship, when approaching death (CAPO/CPAC guideline: 'Assessment of Psychosocial Health Care Needs of the Adult Cancer Patient' by Howell et al., 2009; Cancer Care Nova Scotia Distress Management Pathways, draft 2010).

Assessment of risk of harm to self and/or to others

If YES > URGENT referral to appropriate services for emergency evaluation. Facilitate safe environment. One-to-one observation. Initiate appropriate harm reduction interventions to reduce risk of harm to self and/or others. (The presence of other symptoms such as psychosis, severe agitation and confusion (delirium) may also warrant referral to appropriate services for emergency evaluation).


If NO > continue with algorithm.

Assessment to clarify nature and extent of anxiety symptoms

Review problem checklist and all ESAS scores in conversation with patient/family and discuss expectations and beliefs about support needs (e.g., Canadian Problem Checklist).


Identify most distressing ESAS problem or symptom and assess extent of daily life interference.


Review ESAS scores for other contributing symptoms (e.g., dyspnea or other medical/ medication issue).


Identify other concerns contributing to distress (e.g., life events, sleep deprivation).


Identify other symptoms and current management of relevant symptoms (e.g., pain, fatigue, and/or sleep interference/chronic insomnia).

Identify Pertinent history / Specific risk factors for anxiety

History of anxiety problems (e.g., panic attacks, Generalized Anxiety Disorder (GAD)), depression, other mental health problems.


Current medication associated with anxiety or depression or seeing a specialist.


Disease recurrence, advanced or progressive disease (i.e., vulnerable points).


Withdrawal state (e.g., alcohol, substance use).


Other factors (e.g., younger age, female, live alone, dependents, financial problems).

Focused assessment: Specific to problem of anxiety

Health Care Professionals with appropriate training and skills to complete an anxiety symptom checklist using a validated tool (e.g., BAI; STAI; GAD-7) or assess for presence of: tension, uncontrollable or excessive worry, agitation, restlessness, panic attacks, poor concentration, nausea/vomiting, reassurance seeking, significant change in sleep patterns, impaired functioning in daily living (e.g., hypervigilance, scanning, irritability, unable to relax, ruminations).


In what ways do anxiety symptoms affect daily functioning (e.g., sleep, appetite).

Intervention

Symptoms

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Anxiety - Intervention

Mild Anxiety

Mild Anxiety - Intervention

(ESAS 1-3)

Care Pathway 1 - Prevention & Supportive Care

  • Offer referral to psychosocial support (e.g., counseling, support groups, individual etc)

Moderate Anxiety

Moderate Anxiety - Intervention

(ESAS 4-6)

Care Pathway 2 - Psychosocial Care

Intervention Options

  • Combine non-pharmacological and pharmacological interventions as appropriate (e.g., combined education, supportive psychotherapy and anxiolytics for PTSD).
  • Referral to other services as required (e.g., social work, spiritual care provider, volunteer visits).

Non-Pharmacological

  • Psychosocial interventions (CBT (level 1), psychotherapy, individual or group counseling, support groups).
  • Psycho-educational (e.g., about services/ resources, symptom management, self-care strategies).
  • Crisis interventions as appropriate.

Pharmacological

  • Benzodiazepines, anxiolytics, antipsychotics antihistamines and antidepressants as for moderate depression (refer to moderate depression care pathway).
  • SSRIs in longer term management of panic.
  • Monitor adverse effects.
  • Proceed to other associated algorithms if necessary (e.g. sleep, fatigue, pain).

Severe Anxiety

Severe Anxiety - Intervention

(ESAS 7-10)

Care Pathway 3 - Referral to Physician/ Psychologist/ Psychiatry

  • Definitive Diagnosis Needed: Referral to appropriate services for evaluation and definitive diagnosis
  • Intervention Options: Psychiatric standard of care
  • Offer referral to psychosocial support (e.g., counseling, peer-led support groups, individual)

Supportive Care Interventions for All Patients

  • Offer referral to psychosocial support (e.g., counseling, peer-led support groups, individual)
  • Provide education (verbal plus any relevant materials) for the patient and family about:
    • How common anxiety is in the context of cancer and differing responses
    • Benefits of support groups and other support services
    • Sources of informal support, resources available to patients and families (e.g., accommodation, transportation, financial assistance, additional health/drug benefits)
    • The need for additional psychosocial support if signs and symptoms of anxiety worsen
    • Coping with stress and specific strategies (i.e. relaxation, breathing techniques, mindfulness)
    • How to effectively manage symptoms contributing to anxiety (e.g., pain, tension)

Follow-up and Ongoing Management

  • Follow-up and ongoing re-assessment* and change (reduction) from previous score
*Use Screening for Distress Tool (SDT), which includes Edmonton Symptom Assessment System (ESAS) and Canadian Problem Checklist (CPC).

Symptoms

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Nausea & Vomiting - Assessment

Screen for nausea and vomiting at each visit.

Onset

When did it begin?


How long does it last?


How often does it occur?


Is it there all the time?

Provoking/Palliating

What brings it on?


What makes it better?


What makes it worse?

Quality

What does it feel like?


Can you describe it?

Region/Radiation

Do you have nausea with or without vomiting?

Severity

What is the intensity of this symptom (On a scale of 0 to 10, with 0 being none and 10 being worst possible)? Right Now? At Best? At Worst? On Average?


How bothered are you by this symptom?


Are there any other symptom(s) that accompany this symptom?

Treatment

What medications or treatments are you currently using?


How effective are these?


Do you have any side effects from the medications/treatments?


What medications/treatments have you used in the past?


Understanding/Impact on You

What do you believe is causing this symptom?


How is this symptom affecting you and/or your family?

Values

What is your goal for this symptom?


What is your comfort goal or acceptable level for this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)?


Are there any other views or feelings about this symptom that are important to you or your family?

Other Assessment

Physical Assessment: vital signs.


Physical Assessment: hydration status (e.g. decreased urine output, thirst, dry mouth, dizziness, muscle cramps).


Physical Assessment: the abdomen (inspection, palpation, percussion and auscultation).


Physical Assessment: the oropharynx / mucous membranes.


Physical Assessment: the rectum to assess for obstruction /impaction/ constipation; other regions as appropriate, based on information from the interview (e.g. CNS exam or digital rectal examination (DRE) as appropriate).


Pertinent History risk factors, date of last bowel movement.


If vomiting present: Assess frequency, amount, colour.

Intervention

Symptoms

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Nausea & Vomiting - Intervention

Interventions for all patients, as appropriate

  • Consult with the inter-professional team members.
  • Provide education to the patient and family.
  • Provide instructions on how to take antiemetics, including dose and schedule.
  • Ensure that constipation and bowel obstruction are ruled out.

Consult with a Clinical Dietitian and have them provide dietary/nutritional advice

  • Limit spicy, fatty and excessively salty or sweet foods, foods with strong odours and foods not well tolerated.
  • Use small, frequent, bland meals and snacks throughout the day. Suggest small amounts of food every few hours.
  • Hunger can make feelings of nausea stronger.
  • Sip water and other fluids (juice, flat pop, sports drinks, broth, herbal teas such as ginger tea) and suck on ice chips, popsicles or frozen fruit.
  • Reduce meal size when gastric distension is a factor.
  • Ingest liquids and solids separately.
  • Consume food/liquids cold or at room temperature to decrease odours.
  • Sit upright or recline with head elevated for 30-60 minutes after meals.
  • If vomiting, limit all food and drink until vomiting stops;wait 30-60 minutes after vomiting then initiate sips of clear fluid.
  • When clear fluids are tolerated, add dry starchy foods (crackers, dry toast, dry cereal, pretzels).
  • When starch is tolerated increase diet to include protein rich foods (eggs, chicken and finally dairy products).

Environmental modification (where possible)

  • Eliminate strong smells and sights.
  • Optimize oral hygiene, especially after episodes of vomiting. Rinse with ½ tsp baking soda, ½ tsp salt in 2 cups of water.
  • Try rinsing mouth before eating to remove thick oral mucus and help clean and moisten mouth.
  • Wear loose clothing.

Complementary Therapies

  • Acupuncture or acupressure points. Visualization, hypnosis, distraction.

Pharmacological

  • Any unnecessary medications that may be contributing to nausea and vomiting should be discontinued.
  • All medications need to be individually titrated to the smallest effective dose or until undesirable side effects occur.
  • Choose antiemetics based on the most likely neurotransmitter and emetogenic pathways involved.

Step 1

Step 1

Non-Pharmacological

  • Fluid and electrolyte replacement as appropriate
  • Nutritional advice – consider making patient NPO (Nothing per os) if obstructed or until emesis has resolved for several hours; if not obstructed, change diet as appropriate, depending on the cause of nausea.

Pharmacological

For delayed Gastric Emptying or Abdominal Causes

  • Metoclopramide 5-20 mg po/subcut/IV q6h (or tid AC meals plus qhs); may be used q4h if needed; 40-100 mg/24 h subcut/IV continuous infusion
  • Alternative (if metoclopramide is not well tolerated): domperidone 10mg TID to QID (Note: risk of serious abnormal heart rhythms or sudden death (cardiac arrest) may be higher in patients taking domperidone at doses greater than 30mg a day or in patients who are more than 60 years old)

For patients treated with Palliative Radiotherapy

  • For symptoms that occur within 24 hours of administration of radiotherapy: For ondansetron 8 mg po/subcut/IV q8 – 24h; For granisetron 1 mg pbid or 1 mg IV once daily.
  • For anticipatory nausea or vomiting: lorazepam 1-2 mg po/sl/IV/subcut.
  • The above agents are also best given prior to radiation for optimal effect.

For opioid-induced Nausea

  • Metoclopramide 10-20 mg po/subcut/IV q6h.
  • Alternative: Haloperidol 0.5-2.5 mg po/subcut q12h.

For other Chemical/Metabolic Causes

  • Haloperidol 0.5-2.5 mg po/subcut q12h.
  • Alternative: Metoclopramide 10-20 mg po/subcut/IV q6h.

For brain Metastases or Leptomeningeal Carcinomatosis

  • Dexamethasone 4-8 mg po/subcut/IV bid (0800 and 1300 h); if poor response to dexamethasone then consider adding haloperidol1-2 mg po/subcut q12h.

For vestibular Causes

  • Scopolamine (transdermal patch) one or two 1.5 mg patches q72h.
  • Alternative: Dimenhydrinate 25-50 mg po/ subcut/IV q4h.

If psychogenic Factors Play a Role

  • Oxazepam 10 mg po tid or lorazepam 1-2 mg po/sl/subcut/IV tid.
  • Psychological techniques (particularly for chemotherapy-induced nausea and vomiting).

Step 2

Step 2

Non-Pharmacological

  • If nausea is not controlled with a specific antiemetic, add another antiemetic from another group, but do not stop the initial agent
  • Consider combinations but monitor overlapping toxicities
  • Treat gastrointestinal obstruction (may need to consider interventions such as nasogastric tube (NGT), venting gastrostomy tube (PEG), stents, ostomies, possible surgical resection)

Pharmacological

  • Metoclopramide is recommended as the drug of first choice for chronic nausea/vomiting in patients with advanced cancer.
  • Titrate metoclopramide to maximum benefit and tolerance. If not effective add/switch to another dopamine antagonist (e.g. haloperidol).
  • Domperidone may be substituted for patients who can swallow medications and who have difficulties with extrapyramidal reactions.
  • Titrate antiemetics to their full dose, until patient develops undesirable side effects, before adding another drug.
  • For persistent nausea and/or vomiting antiemetics should be prescribed on a regular dosing schedule with a breakthrough dose available.
  • Give antiemetics prophylactically to prevent nausea with high dose opioids and chemotherapeutic agents.
  • For delayed gastric emptying or abdominal causes (excluding bowel obstruction, see above):
    • Metoclopramide 5-20 mg po/subcut/IV q6h (or tid AC meals plus qhs); may be used q4h if needed; 40-100 mg/24 h subcut/IV continuous infusion
    • Alternative (if metoclopramide is not well tolerated): domperidone 5-20 mg po q6h (or tid AC meals plus qhs); causes less extrapyramidal side effects than metoclopramide
  • A combination of different antiemetics is required in approximately 30% of cases. Combination therapy is only beneficial if different neurotransmitters are targeted. If the response to monotherapy is inadequate, the following combinations may be considered:
    • Metoclopramide po/subcut/IV + dexamethasone po/subcut/IV
    • Haloperidol po/subcut + dexamethasone po/subcut/IV

Step 3

Step 3

Pharmacological

  • Ondansetron, although useful for chemotherapy induced nausea, is considered as a fourth line therapy for chronic nausea in Palliative Care.
  • Ondansetron is useful for radiation therapy induced nausea.
  • Dexamethasone is recommended for nausea and vomiting in the advanced cancer population.
  • If dexamethasone combined with either metoclopramide or haloperidol yields insufficient results, the following approaches may be considered:
    • Serotonin (5HT3) antagonists (ondansetron 4 - 8 mg po/subcut/IV bid; granisetron 1 mg po bid/ 1mg IV once daily; or dolasetron 100 mg po/IV oncedaily); in principle, combine with dexamethasone 4 mg po/subcut/IV once daily. Disadvantages of the serotonin antagonists: high costs; side effects include constipation, headaches
    • Methotrimeprazine monotherapy using a starting dose of 5 – 10 mg po tid prn or 6.25-12.5 mg subcut q8h prn. Increase as needed to maximum of 25 mg per dose.
    • Olanzapine monotherapy 2.5 – 5 mg po/sl/subcut once daily or bid
  • Diphenhydramine may be used for the treatment of akathesias secondary to increased doses of metoclopramide.

Follow-Up and Ongoing Monitoring

  • If nausea and vomiting remains unrelieved despite the approaches outlined above, request the assistance of a palliative care consultation team.

Symptoms

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Delirium - Assessment

Management of delirium should include treating reversible causes where possible and desirable. Approximately 25% to 45% of episodes of delirium are reversible.

Causes of Delirium Acronym (Adapted from Capital Health)

DDrugs, drugs, drugs, dehydration, depression
EElectrolyte, endocrine dysfunction (thyroid, adrenal), ETOH (alcohol) and/or drug use, abuse or withdrawal
LLiver failure
IInfection (urinary tract infection, pneumonia, sepsis)
RRespiratory problems (hypoxia), retention of urine or stool (constipation)
IIncreased intracranial pressure
UUremia (renal failure), under treated pain
MMetabolic disease, metastasis to brain, medication errors/omissions, malnutrition (thiamine, folate or B12 deficiency)

Onset

When did it begin?


Has it happened before?

Provoking/Palliating

Are there things which worsen the agitation?


What makes it better?


What makes it worse?


How are you sleeping?

Quality

What does it feel like?


Do you feel confused?


Are you seeing or hearing anything unusual?

Region/Radiation

Do you know what day/month/year it is?


Do you know where you are right now?


Can you tell me your full name?

Severity

What is the intensity of this symptom (On a scale of 0 to 10, with 0 being none and 10 being worst possible)? Right Now? At Best? At Worst? On Average?


How bothered are you by this symptom?


Are there any other symptom(s) that accompany this symptom?

Treatment

What medications or treatments are you currently using?


How effective are these?


Do you have any side effects from the medications/treatments?


What medications/treatments have you used in the past?

Understanding/Impact on You

What do you believe is causing this symptom?


How is this symptom affecting you and/or your family?

Values

What is your goal for this symptom?


What is your comfort goal or acceptable level for this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)?


Are there any other views or feelings about this symptom that are important to you or your family?

Other Assessment

Where a patient is not able to complete an assessment by self reporting, then the health professional and/or the caregiver may act as a surrogate.


Physical Assessment (as appropriate for symptom).


Pertinent History (risk factors).

Intervention

Symptoms

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Delirium - Intervention

General Interventions for All Patients

  • The underlying etiology needs to be identified in order to intervene.
  • Orientation questions alone do not provide accurate assessment.
  • Delirium may interfere with the patient's ability to report other symptom experiences (e.g. pain).
  • Provide explanation and reassure the family that the symptoms of delirium will fluctuate; are caused by the illness; are not within the patient's control; and the patient is not going 'insane'.
  • It is important to understand that some hallucinations, nightmares, and misperceptions may reflect unresolved fears, anxiety or spiritual passage.
  • Include the family in decision making, emphasizing the shared goals of care; support caregivers.
  • Correct reversible factors – infection, constipation, pain, withdrawal, drug toxicity.
  • Review medications; consider opioid rotation to reverse opioid neurotoxicity, discontinue unnecessary drugs or prolong dosing interval for necessary drugs.
  • Anticipate the need to change treatment options if agitation develops, particularly in cases where patient, family and staff safety may become threatened.
  • Misinterpreting symptoms of agitation/restlessness, moaning and/or grimacing as poorly controlled pain, with subsequent administration of more opioids, can potentially aggravate the symptom and cause opioid neurotoxicity.

Non-Pharmacological Interventions for All Patients

  • Report hallucinations that become threatening.
  • Instruct the family to provide gentle, repeated reassurance and avoid arguing with the patient.
  • Watch for the “sun downing” effect (nocturnal confusion), as it may be the first symptom of early delirium.
  • Provide a calm, quiet environment and help the patient reorient to time, place and person (visible clock, calendar, well known or familiar objects).
  • Presence of a well known family member is preferred.
  • Provide a well lit, quiet environment. Provide night light.
  • To prevent over-stimulation, keep visitors to a minimum, and minimize staff changes and room changes.
  • Correct reversible factors – dehydration, nutrition, alteration in visual or auditory acuity (provide aids), sleep deprivation.
  • Avoid the use of physical restraints and other impediments to ambulation. Avoid catheterization unless urinary retention is present.
  • Encourage activity if patient is physically able.
  • When mildly restless provide observation and relaxation techniques (massage, tub baths, gentle music) as applicable.
  • Encourage the family to be present in a calming way.

Mild Delirium

Mild Delirium - Intervention

Pharmacological

  • Titrate starting dose to optimal effect.
  • If a patient is developing 'sun downing' effect (confusion in the evening), psychotropic drugs have a place in treatment.
  • If a patient has known or suspected brain metastases a trial of corticosteroids is worthwhile. Dexamethasone 16 - 32 mg po daily in the morning may be used however, this suggestion is made based on expert opinion and doses may vary from region to region.
  • Haloperidol is the gold standard for management of delirium.
  • If titration with haloperidol is not effective consider using methotrimeprazine.
  • Haloperidol 0.5-1 mg po / subcut bid-tid.

Alternate Agents

  • Risperidone 0.5-1 mg po bid.
  • Olanzapine 2.5 – 15 mg po daily.
  • Quetiapine fumarate 50-100 mg po bid.
  • Methotrimeprazine 5-12.5 mg po or 6.25-12.5 mg subcut q4-6h prn.
  • Chlorpromazine 12.5-50 mg po/subcut q4-12h prn.

Moderate Delirium

Moderate Delirium - Intervention

Pharmacological

  • Titrate starting dose to optimal effect
  • Haloperidol 0.5-2 mg subcut q1h prn until episode under control;may require a starting dose of 5 mg subcut
  • Alternate agents:
    • Risperidone 0.5-1 mg po bid
    • Olanzapine 2.5-15 mg po daily
    • Quetiapine fumarate 50-100 mg po bid
  • Benzodiazepines may paradoxically excite some patients and should be avoided unless the source of delirium is alcohol or sedative drug withdrawal, or when severe agitation is not controlled by the neuroleptic (See Severe Delirium-Intervention)

Severe Delirium

Severe Delirium - Intervention

Pharmacological

  • Titrate starting dose to optimal effect.
  • Palliative sedation is a consideration in refractory delirium and consultation with a palliative care expert or psychiatry is recommended.
  • If agitation is refractory to high doses of neuroleptics, (as outlined in moderate pathway) consider adding lorazepam 0.5-2 mg subcut q4-6h prn or midazolam 2.5-5 mg subcut q1-2h prn in conjunction with the neuroleptic.

Alternate agents to consider

  • Methotrimeprazine 12.5–25 mg subcut q8-12h and q1h prn OR
  • Chlorpromazine 25-50 mg po/subcut q4-6h prn.
  • If above not effective consider:
    • Haloperidol 10 mg subcut. Typically, in palliative care the maximum dose of haloperidol is 20 mg per day OR
    • Methotrimeprazine 25-50 mg subcut q6-8h and q1h prn.

Follow-Up and Ongoing Monitoring

  • If delirium remains unrelieved despite the approaches outlined above, request the assistance of a palliative care consultation team.

Symptoms

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Loss of Appetite - Assessment

Screen for loss of appetite at each visit and validate ESAS score.

Onset

When did you notice your lack of appetite?


Is it there all the time?

Provoking/Palliating

Is there a time of day when your appetite is better/worse?


What do you think may cause your lack of appetite?


Have you had any recent surgery or treatment that you think is affecting your ability or desire to eat?


Are you taking any medications that are affecting your ability to eat?

Quality/Quantity

Compared to your normal food intake, are you eating the same amount? More than usual? Less than usual?


Are you drinking enough fluid?

Related Symptoms

Are there other symptoms that affect your ability to eat? (e.g. nausea/vomiting, constipation/diarrhea, sore or dry mouth, taste changes, bothersome food odours, problems swallowing, early feelings of fullness, pain, shortness of breath, depression)

Severity

How much is the lack of appetite affecting your activities of daily living or ability to function?

Treatment

Are you doing anything to help manage your loss of appetite (e.g. any physical activity, medications, or changes to your diet)? Is it working?

Understanding/Impact on You

How is the lack of appetite affecting you and/or your family?


Do you feel distressed about your inability to eat?


Have you experienced feelings of pressure, guilt or relational stress with regard to food intake and weight loss?

Values

Are there any other views or feelings about this symptom that are important to you or your family?

Weight

Have you lost weight recently without trying? If yes, how much? What was the time frame?


Have you been eating poorly because of a decreased appetite?

Intervention

Symptoms

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Loss of Appetite - Intervention

Interventions for all patients, as appropriate

  • Early consultation with the palliative or supportive care team should be considered.
  • Screen, assess and manage potential causes of secondary cachexia (anti-cancer treatment, other medication and psychosocial factors).
  • Consider stage of disease, progression of disease and Palliative Performance Scale (PPS), or functional status when determining goals of care and treatment plans.
  • Provide emotional support to patient and family.
  • Consider importance of food in the social context and impact on quality of life, cultural issues, patient's accessibility to food.
  • Referral to other health care professionals where appropriate.

Mild Loss of Appetite

Mild Loss of Appetite - Intervention

(ESAS 1-3)

Non-Pharmacological Treatment

  • Suggest eating small, frequent meals and choosing high energy, high protein foods. See Patient Education tools below.
  • Ensure adequate hydration, preferably through energy and protein containing liquids.
  • Suggest making mealtimes as relaxing and enjoyable as possible.
  • Suggest convenience foods, deli or take-out foods, Meals on Wheels® or catering services, Home Making services, or asking friends/family to help out.
  • Taking medication with a high calorie / protein fluid such as milkshakes or nutrition supplements can also increase nutritional intake. This should be reviewed by a dietitian and/or pharmacist because of potential drug/nutrient interaction(s).

Nutritional Strategies: provide patient education tools

  • Healthy Eating Using High Energy, High Protein Foods
  • High Energy and High Protein Menu items
  • Food ideas to help with poor appetite
  • Increasing Fluid Intake
  • Suggestions for Increasing Calories and Protein
  • Eating Well When You Have Cancer
  • Canada’s Food Guide

Exercise

  • Encourage exercise, as tolerated by patient. Walking fifteen minutes a day can help regulate appetite.
  • Patient should start the exercise regimen slowly, and gradually increase the intensity.
  • Exercise can be initiated at most levels above PPS 30-40% but caution should be guiding principle, as well as presence of bony metastases and low blood counts.

Moderate Loss of Appetite

Moderate Loss of Appetite - Intervention

(ESAS 4-6)

Referral to Registered Dietitian

  • Referral to a Registered Dietitian may be based on criteria of weight loss, and/or the presence of significant symptoms that are affecting intake, and cannot be addressed adequately by self-management and/or general patient education tools.

Pharmacological

Prokinetics

  • Metoclopramide 10 mg q4 to 8h. OR domperidone 10mg TID to QID (The risk of serious abnormal heart rhythms or sudden death (cardiac arrest) may be higher in patients taking domperidone at doses greater than 30mg a day or in patients who are more than 60 years old).

Synthetic Progestogens

  • Megestrol acetate: minimum efficacious dose=160 mg daily and titrate to effect maximum dose=480 mg/ day OR medroxyprogesterone acetate (MPA): 200 mg daily

Corticosteroids

  • Initial dose: dexamethasone 4mg daily OR prednisolone 30mg daily in the morning.Prescribe for 1 week, if no benefit, stop. If helpful, increase or decrease to most effective dose; review regularly and withdraw if no longer improving symptoms.
  • Other Considerations: Assess need for a proton pump inhibitor (ie. pantoprazole, rabeprazole)

Severe Loss of Appetite

Severe Loss of Appetite - Intervention

(ESAS 7-10)

  • Consider PPS and ESAS scores to determine the appropriateness and aggressiveness of interventions.
  • Educate that a person may naturally stop eating and drinking as part of the illness progression and the dying process, treatment may not be indicated
  • Focus should be on patient comfort and reducing patient and caregiver anxiety
  • Ice chips, small sips of beverages and good mouth care becomes the norm.
  • Suggest alternate ways to nurture the patient (oral care, massage, reading, conversing).
  • Consider symbolic connection of food and eating with survival and life.
  • Consider consultation with Registered Dietitian, palliative care team, bioethicist, or spiritual counselor regarding the discontinuation of nutrition.

Pharmacological

Prokinetics

  • Metoclopramide 10 mg q4 to 8h. OR domperidone 10mg TID to QID (The risk of serious abnormal heart rhythms or sudden death (cardiac arrest) may be higher in patients taking domperidone at doses greater than 30mg a day or in patients who are more than 60 years old).

Synthetic Progestogens

  • Megestrol acetate: minimum efficacious dose=160 mg daily and titrate to effect maximum dose=480 mg/ day OR medroxyprogesterone acetate (MPA): 200 mg daily

Corticosteroids

  • Initial dose: dexamethasone 4mg daily OR prednisolone 30mg daily in the morning.Prescribe for 1 week, if no benefit, stop. If helpful, increase or decrease to most effective dose; review regularly and withdraw if no longer improving symptoms.
  • Other Considerations: Assess need for a proton pump inhibitor (ie. pantoprazole, rabeprazole)

Follow-Up and Ongoing Monitoring

  • Follow-Up and Ongoing Monitoring with palliative/supportive care team is recommended

Symptoms

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Constipation - Assessment

Screen for constipation at each visit.

Onset

When did it start?


How often does it occur?


How often do your bowels move?

Provoking/Palliating

What makes it better?


What makes it worse (eg: medications, cancer treatments, diet changes, changes in amount of food or fluid eaten, decreased ability to walk or move around)?

Quality

How would you describe your stools (eg: colour, hardness or softness, odour, amount)?


Is there blood or mucous with the stool?

Related Symptoms

Is there any discomfort assosciated with the constipation?


Where do you feel this discomfort?


Can you describe it?


Any abdominal bloating?


Do you have lots of gas?


Do you feel like your rectum is not empty after each bowel movement?


Do you have hemorroids?


Do you have pain in your anal area?


Do you have any drainage from your rectum when you are not having a bowel movement?


Do you have any other symptoms (eg: nausea, vomiting, loss of appetite, urinary symptoms such as leaking urine accidentally or trouble emptying your bladder)?

Severity

When was your last bowel movement?


How often do you feel the urge to pass stool?


Do you need to strain a lot with each bowel movement?

Treatment

What are you doing to manage your bowels?


How effective is this?


Do you have any side effects from the medications or treatments you use for your bowels?


What have you tried?


What tests have been done for the constipation

Understanding/Impact on You

How does the constipation affect your life?


How bothered are you by it?

Values

What are your normal bowel habits?


What does the constipation mean to you?


Has it affected you and your family or caregiver?

Other Assessment

Physical assessment should include vital signs, functional ability, hydration status, cognitive status, abdominal exam, rectal exam and neurological exam if a spinal cord or cauda equine lesion is suspected.


Consider abdominal x-rays if bowel obstruction or severe stool loading of the colon is suspected.

Intervention

Symptoms

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Constipation - Intervention

PPS Definition

Consideration For All Patients

  • Identifying the underlying etiology of constipation is essential in determining the interventions required.
  • Consider the performance status, fluid intake, diet, physical activity and lifestyle when managing constipation.
  • It is not necessary to have a bowel movement every day. As long as stools are soft and easy to pass, every two days is generally adequate.
  • Avoid excessive straining.

Non-Pharmacological Interventions

PPS Stable, Transitional and End of Life (30-100%)

Fluid Intake

  • Encourage fluid intake (1500-2000 ml per day)
  • Encourage sips throughout the day.
  • Minimize caffeine and alcohol intake.

Physical Activity

  • Tailor exercise to patient’s physical ability, condition and preference to optimize adherence.
  • Frequency, intensity and duration of exercise should be based on the patient’s tolerance.
  • PPS 60% and above: walking is recommended (15-20 min once or twice per day or 30-60 min daily, 3-5 times per week).
  • For PPS 30-50% exercises such as low trunk rotation and single leg lifts, for up to 15 to 20 minutes per day, are encouraged, if able.

Personal Considerations

  • Provide privacy during toileting.
  • Attempts at defecating should be made 30 to 60 minutes following ingestion of a meal, to take advantage of the gastro-colic reflex.

PPS Stable and Transitional (40-100%)

Diet

The following dietary recommendations are not applicable if bowel obstruction is suspected.

  • Gradually increase dietary fibre once patient has consistent fluid intake of at least 1500 ml per 24hrs.
  • Aim for at least 25 g of dietary fibre per day by:
    • Choosing 7-10 servings per day of whole fruits and vegetables, instead of juices.
    • Choosing 6-8 servings of grain products per day, selecting 100% whole grain breads and high fibre cereals (>4 grams/serving).
    • Including plant proteins daily as part of the 2-3 servings of meats and alternatives.
  • Consult with dietitian for specific nutritional advice regarding fibre intake.

Personal Considerations

  • Walking to the toilet, if possible, is recommended.
  • If walking is difficult, use a bedside commode.
  • Assuming the squat position on the toilet can facilitate the defecation process.
    • Sitting with feet on a stool may help with defecation.

PPS End of Life (10-30%)

  • Raising the head of the bed may facilitate the defecation process.
  • Simulate the squat position by placing the patient in the left-lateral decubitus position, bending the knees and moving the legs toward the abdomen.

PPS End of Life (10-20%)

  • For patients with PPS 10-20%, consider the burdens and benefits of regular bowel care, using good clinical judgment when making recommendations.

Pharmacological Interventions

  • The recommendations below are based on low level evidence and consensus due to limited available research.
  • Consider etiology of constipation, patient’s preferences, patient’s recent bowel function and response to previous treatments to guide appropriate selection and sequence of pharmacologic treatments.
  • Ask whether the patient is using non-traditional or alternative therapies for bowel management to be aware of what they are using and to consider potential drug interactions and toxicities.
  • Many oral laxatives, suppositories and enemas share common side effects, including cramping, flatulence, nausea and diarrhea, which can be reduced with dose adjustments. Generally avoid laxatives if bowel obstruction is suspected.

Recommended first line agents

  • Oral colonic stimulant (sennosides or bisacodyl) AND/OR
  • Oral colonic osmotic (lactulose or polyethylene glycol)

Recommended second line agents

  • Suppositories (glycerin or bisacodyl) OR
  • Enemas (phosphate enema)

Recommended third line agents

  • Picosulfate sodium-magnesium oxide-citric acid OR
  • Methylnaltrexone (if the patient is taking regular opioids)

Initial 3-Day Trial of methylnaltrexone

  • If no bowel movement for 48 hours, give methylnaltrexone subcutaneously - 8 mg if 38-62 kg or 12 mg if 62-114 kg

Methylnaltrexone is considered effective if a bowel movement occurs within 4 hours after injection.

If Effective

  • The same dose can be offered in the future if no bowel movement occurs for 48 hrs. Doses should not be given more frequently than 48 hrs apart.

If Not Effective

  • The same dose can be repeated every 24 hours for 2 days, if necessary, if a bowel movement does not subsequently occur spontaneously.

If Effective

  • The same dose can be offered in the future if no bowel movement occurs for 48 hrs. Doses should not be given more frequently than 48 hrs apart.

If Not Effective

  • Methylnaltrexone is unlikely to work for this patient at this time. No further doses should be given.

Laxative Table

OralTypeActionFormulationsDosesLatencyNotesODB coverage
BisacodylColonic stimulantStimulates colonic motility; reduces water and electrolyte absorption in colon5 mg tablet5-15 mg qhs; increase up to 15 mg tid6-12 hoursPPS 30-100%Yes
Cascara sagrada barkColonic stimulantStimulates colonic motilityVarious capsule sizes300-1000 mg daily6-12 hoursPPS 30-100% Natural health productNo
Docusate (sodium; calcium)Stool softenerIncreases water penetration of stoolSodium: 100, 200 mg capsule; 4 mg/ml syrup; 10 mg/ml drops
Calcium: 240 mg capsule
Sodium: 100-200 mg daily1-3 daysPPS 30-100% Use calcium salt for patients with sodium restrictionsYes, except for 200 mg sodium capsule
LactuloseColonic osmotic, predominantly softening, secondarily stimulantDisaccharide metabolized by bacteria in colon to produce osmotic effect; secondary peristalsis667 mg/ml syrup15 ml daily to 60 ml tid1-3 daysPPS 30-100% Non absorbable sugar.Yes
Magnesium salts (sulphate; hydroxide; citrate)Osmotic, predominantly softeningOsmotic effect; secondary peristalsisSulphate: 99 gm/100 gm powder
Hydroxide: 80 mg/ml suspension
Citrate: 50 mg/ml liquid
Sulphate: 10-30 gm in 240 ml liquid daily
Hydroxide: 15-60 ml daily to bid
Citrate: 75-150 ml daily
1-3 hoursPPS 30-100% Do not use if renal insufficiency, heart block or myasthenia gravis is present. May affect absorption of other medications – space by at least 2 hoursNo
Picosulfate sodium-magnesium oxide-citric acidColonic stimulant and osmoticStimulates colonic peristalsis; osmotic10 mg - 3.5 gm - 12 gm in each sachet1 sachet in 250 ml water 1-2 times daily until good effect3-6 hours or lessPPS 30-100% Not for use as a regular laxative. Do not use in renal insufficiencyYes
Polyethylene glycol (PEG)Colonic osmotic, predominantly softening, secondarily stimulantOsmotic effect in colon; secondary peristalsisPEG 3350; PEG with electrolytes17-34 gm powder in 125-250 ml non-carbonated fluid 1-3 times daily1-3 daysPPS 30-100% Do not use PEG with electrolytes in renal insufficiencyYes, but only with electrolyes (PegLyte)
PsylliumBulk formingNormalizes stool volume0.3-0.6 gm per gm powder; regular and sugar-free; 525, 550 mg capsule3.4 gm daily to tidPPS 30-100% Do not use if food and fluid intake is poorNo
SennosidesColonic stimulantStimulates myenteric plexus; reduces water and electrolyte absorption in colon8.6 mg tablet; 1.7 mg/ml syrup1-4 tablets or 5-20 ml qhs; increase up to 4 tablets or 20 ml bid6-12 hoursPPS 30-100%Yes
SorbitolColonic osmotic, predominantly softening, secondarily stimulantOsmotic effect in colon; secondary peristalsis70% solution1-3 daysPPS 30-100%No
Rectal or StomalTypeActionFormulationsDosesLatencyNotesODB coverage
Bisacodyl suppositoryPeristalsis stimulatingEvacuates stool from rectum5, 10 mg10 mg every 3 days prn15-60 minutesPPS 20-100% - Avoid if neutropenicYes
Glycerin suppositoryOsmotic - predominantly softeningSoftens stool in rectumAdult suppository Pediatric suppositoryOne daily prn15-60 minutesPPS 20-100% - Avoid if neutropenicNo
Large volume enema (tap water or saline)Colonic dilation and stimulation; lubricationEvacuates stool from descending colonTap water Normal saline solution750-1000 ml10-15 minutesPPS 30-100% - Avoid if neutropenicN/A
Oil retention enemaSoftening and lubricatingSoftens hard stoolMineral oil150-200 ml30-60 minutesPPS 30-100% - Avoid if neutropenicN/A
Phosphate enemaOsmotic and peristalsis stimulatingEvacuates stools from rectum and sigmoid colonSodium and potassium phosphate solution in pre-packed bottlesEvery 3 days prn15-60 minutesPPS 20-100% - Avoid if neutropenic - Avoid in renal insufficiencyYes

Fecal Impaction

  • If stool is impacted in the rectum, use a glycerin suppository to soften the stool, followed 1 hr later by digital disimpaction, if necessary (after pretreatment with analgesic and sedative), and/or a phosphate enema.
  • If stool is higher in the left colon, use an oil retention enema, followed by a large volume enema at least 1 hour later.

Colostomy Patients

  • A patient with a very proximal colostomy may not benefit from colonic laxatives.
  • There is no role for suppositories since they cannot be retained in a colostomy.
  • Enemas may be useful for patients with a descending or sigmoid colostomy.

Paraplegic Patients

  • Oral laxatives may be needed to move stool to the rectum.
  • Assist with emptying the rectum using one or more of the following: suppository, enema, digital emptying.

Symptoms

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Diarrhea - Assessment

Screen for diarrhea at each visit.

Onset

When did it begin?


How long does it last?

Provoking/Palliating

What may be causing the diarrhea?


What makes it better?


What makes it worse (eg: medications, cancer treatments, diet changes, changes in amount of food or fluid eaten)?

Quality

How would you describe your stools (eg: colour, hardness or softness, odour, amount)?


Is there blood or mucous with the stool?


Is the stool oily?


Do you feel an urgency to go to the bathroom?

Related Symptoms

Is there any discomfort assosiated with the diarrhea?


Where do you feel this discomfort?


Can you describe it?


Do you have any abdominal bloating?


Do you have lots of gas?


Do you have any other symptoms (eg: nausea, vomiting, loss of appetite, thirst, fatigue, weakness, fever, feeling like your rectum is not empty after a bowel movement, painful skin around the anus)?

Severity

How often do you have diarrhea?


Does it come and go?


When do you have diarrhea?


Does it ever occur at night?


Do you have accidents?


How frequent are your bowel movements when you have diarrhea?

Treatment

What have you taken to treat the diarrhea?


Do you have any side effects from the medications or treatments for the diarrhea?


What have you tried in the past?


What tests have been done for the diarrhea?

Understanding/Impact on You

How does the diarrhea affect your life?


How bothered are you by it?

Values

What are your normal bowel habits?


What does the diarrhea mean to you?


Has it affected you and your family or caregiver?

Other Assessment

Physical assessment should include vital signs, functional ability, hydration status, cognitive status, abdominal exam, rectal exam and neurological exam if a spinal cord or cauda equine lesion is suspected.


Consider abdominal x-rays if bowel obstruction or severe stool loading of the colon is suspected.

Intervention

Symptoms

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Diarrhea - Intervention

PPS Definition

Considerations for all patients

  • Identifying the underlying etiology of diarrhea is essential in determining the interventions required.
  • Consider performance status, fluid intake, diet, physical activity and lifestyle when managing diarrhea.

Non-Pharmacological Interventions

PPS Stable, Transitional and End of Life (30-100%)

Diet

  • Eat small frequent meals.
  • Limit caffeine, fried, greasy foods and foods high in lactose.
  • Avoid sorbitol containing foods (e.g., sugar-free gum and sugar-free candy).
  • Limit/avoid foods high in insoluble fiber (e.g., wheat bran, fruit skins and root vegetable skins, nuts and seeds, dark leafy greens and legumes such as dried peas).
  • Include foods high in soluble fibre (barley, potatoes, bananas and applesauce).
  • Avoid hyper-osmotic liquids (fruit drinks and sodas). Dilute fruit juices with water.

Fluid Intake

  • Parenteral hydration may be required for severe diarrhea.
  • Provide fluids orally, if dehydration is not severe:

PPS Stable, Transitional and End of Life (10-100%)

Quality of Life

  • Persistent diarrhea can have severe effects on image, mood and relationships.
  • Attention must be paid to understanding the emotional impact from the patient’s perspective.
  • Offer practical strategies to assist with coping:
    • Carefully plan all outings.
    • Carry a change of clothes.
    • Know the location of restrooms.
    • Use absorbent undergarments.

Life Style

  • Take steps to prevent skin excoriation
    • Good skin hygiene:
      • Use mild soap
      • Consider sitz bath
    • Apply a skin barrier product
    • Hydrocolloid dressings may be used as a physical barrier to protect excoriated skin.

PPS End of Life (10-20%)

  • Exercise good clinical judgment regarding the burden and benefits of parenteral fluids for the individual patient.

Pharmacological Interventions

  • The recommendations below are based on low level evidence and consensus due to limited available research.
  • Consider etiology of constipation, patient’s preferences, patient’s recent bowel function and response to previous treatments to guide appropriate selection and sequence of pharmacologic treatments.
  • Ask whether the patient is using non-traditional or alternative therapies for bowel management to be aware of what they are using and to consider potential drug interactions and toxicities.
  • Many oral laxatives, suppositories and enemas share common side effects, including cramping, flatulence, nausea and diarrhea, which can be reduced with dose adjustments. Generally avoid laxatives if bowel obstruction is suspected
  • A single liquid or loose stool usually does not require intervention.
  • A single drug should be used for diarrhea and care should be taken to avoid sub-therapeutic doses.
  • If the perianal skin is inflamed or excoriated, use a topical corticosteroid cream for 1-2 days.

Recommended first line agents

  • Loperamide (2 mg tablets; 2 mg/15 ml solution) is the preferred first-line anti-diarrheal agent:
    • 2 mg orally after each loose stool, up to 16 mg per day.
    • For chronic diarrhea, a regular bid dose can be used, based on the effective 24-hour dose, plus 2 mg after each loose bowel movement, up to 32 mg per day total.
  • For Clostridium difficile diarrhea use metronidazole 500 mg orally tid for 2 weeks.

Recommended second line agents

  • Diphenoxylate/atropine (2.5/0.025 mg tablets):
    • 1-2 tablets orally as needed, up to 4 times per day (maximum 20 mg diphenoxylate per day.
    • Titrate dose down once diarrhea controlled, to determine the maintenance dose.

Recommended third line agents

  • Opioids – consider if the patient is not currently on an opioid for other indications.
  • Octreotide 50-600 mcg per day subcutaneously (dosed bid or tid) for severe, refractory diarrhea.

Symptoms

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Fatigue - Assessment

Screen for fatigue/tiredness at entry to system, periodically during treatment and during post-treatment survivor follow-up.

Review problem checklist and all ESAS scores in conversation with patient/family and discuss expectations and beliefs about support needs (e.g., Canadian Problem Checklist)

Onset

When did it begin?

Provoking/Palliating

What do you do to relieve your fatigue?

Quality

Ask patient to describe fatigue in their own words

Region/Radiation

Do you experience other symptoms with fatigue?

Severity

Is fatigue duration constant or does it change over time?

Treatment

Has there been a change in the medications you are taking, including over - the - counter medications?

Understanding/Impact on You

What do you believe is causing your fatigue?


How is fatigue affecting your activities of daily lifestyle?


How is it affecting your lifestyle (work, social life, concentration, memory)?


How distressing (bothersome) is fatigue?

Values

What is your goal for this symptom?

Assess Treatable Contributing Factors for Fatigue

  • Treatment complications
    • Anemia
    • Infection
    • Fever
  • Weight/caloric intake changes (how much weight loss)
  • Fluid and electrolyte imbalances (sodium, calcium potassium, magnesium)
  • Medications:
    • Opioids
    • Antihistamines
    • Antidepressants
    • Alcohol/recreational drug use
  • Other symptoms/side-effects:
    • Pain (ESAS score > 4, see pain guidelines)
    • Depression (ESAS score = 4, see depression guidelines)
    • Anxiety (ESAS score = 4, see anxiety guidelines)
    • Sleep disturbances (ESAS score = 4, see sleep guidelines)
  • Activity level changes
    • Decreased activity
    • Decreased exercise pattern
  • Co-morbid conditions contributing to fatigue

Conduct Physical exam.

  • Gait
  • Posture
  • Range of motion
  • Eyes (conjunctival pallor if anemic)
  • Oral assessment
    • Cheliosis
    • Angular cheilitis
    • Angular stomatitis
  • Muscle wasting
  • Tachycardia
  • Shortness of breath
    • At rest
    • On exertion

Typical symptoms of fatigue

Tiredness disproportionate to recent activity; impairment of ADLs or disturbance in quality of life; diminished concentration or attention; significant distress or negative mood to feeling fatigued (e.g., sad, frustrated, irritable); sleep disturbance (insomnia or hypersomnia); sleep perceived as non-restorative; decreased motivation or interest in usual activities.

Intervention

Symptoms

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Fatigue - Intervention

For mild fatigue, use prevention and supportive care interventions.
For moderate fatigue, treat contributing factors.
For severe fatigue, urgently manage contributing factors and address safety issues (i.e., falls)

Prevention and Supportive Care Interventions for All Patients and Caregivers

Educate

  • The difference between normal and cancer-related fatigue
  • Treatment-related fatigue patterns/fluctuations
  • Persistence of fatigue post treatment
  • Causes (contributing factors) of fatigue
  • Consequences of fatigue
  • Need to keep physically active during and post treatment
  • Signs and symptoms of worsening fatigue to report to health care professionals

Counsel

Energy Conservation

  • Help patients prioritize and pace activities and delegate less essential activities
  • Balance rest and activities so that prioritized activities are achieved
  • Use of distraction such as games, music, reading, socializing

Encourage patients to use a treatment log or diary

  • To monitor levels and patterns of fatigue
  • To help ascertain peak energy periods
  • To help with planning activities

Non-Pharmacological Interventions for Moderate and Severe Fatigue

  • Advise patients to engage in moderate level of physical activity (e.g., fast walking, cycling, swimming, resistance training) during and after cancer treatment unless contraindicated or previously sedentary (30 minutes per day, 5 days per week as tolerated)
  • Psychosocial Interventions
    • Psycho-educational therapies (individual or group class)
      • Anticipatory guidance about fatigue patterns
      • Coping skills training
      • Coaching in self-management and problem-solving to manage fatigue
    • Refer for Cognitive Behavioural Therapy from trained therapist
    • Supportive expressive therapies: listening, answering patient’s questions, giving reassurance when needed
  • Nutritional consultation
  • Optimize sleep quality (see sleep disturbance guidelines)
  • Stress reduction strategies
    • progressive muscle relaxation
    • yoga/mindfulness programs
    • relaxation guided imagery
    • massage/healing touch
  • Attention restoring therapy: reading, games, music, gardening, experiences in nature
  • Acupuncture may be effective if referred to skilled practitioner

Follow-up and Ongoing Monitoring

  • Evaluate effectiveness of interventions; monitor changes and reassess as required

Symptoms

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Dysgeusia (altered taste) - Assessment

Screen for dysgeusia at each visit.

Onset

When did the symptom begin?


How often does it occur?


How long does it last?

Provoking/Palliating

What makes it better?


What makes it worse?


What do you think may be causing the symptom?


What are the aggravating or alleviating factors (e.g., medications, active treatment, dietary changes)?

Quality

What type of taste changes are you experiencing? (eg., sweetness, sourness, saltiness, etc)


Do you have a dry mouth? (e.g., decrease in amount or consistency of saliva)


Do you have any redness, blisters, ulcers, cracks, or white patchy areas? If so, are they isolated, generalized, clustered or patchy?

Related Symptoms

Do you have any other related or associated symptoms?

Severity

What is the intensity of this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)? Right Now? At Best? At Worst? On Average?

Treatment

If dry mouth: Fluid intake? Are you using any oral rinses? What type? Are they effective? Are you using any saliva substitutes or stimulants? What type? Are they effective?


If associated pain in mouth: Are you using any pain medications? What type – topical/local, oral/injection? Are they effective? Are there any other treatments that you are using to help with pain? Alteration in diet texture?


If associated bleeding from mouth: Does it occur spontaneously? Where is it located? What aggravates it? What treatments have been recommended and have been used?


What is your current oral care routine? How effective is it? Have you had oral infections? What treatments have you used? How effective have they been?


Do you have any side effects from the medications/treatments you have used for any of the above?


What tests have you had for your oral symptoms, if any?

Understanding/Impact on You

How bothered are you by this symptom?


Is your ability to eat or drink affected? By how much?


Do you have any weight loss? How much? Over what time frame?


Is your ability to wear dentures affected?


How does this symptom affect your day to day life?

Values

What is an acceptable level of severity for this symptom (0 – 10 scale)?


What does this symptom mean to you?


How has it affected you and your family and/or caregiver?

Other Assessment

Where a patient is not able to complete an assessment by self-reporting, then the health professional and/or the caregiver may act as a surrogate.


Physical assessment should include vital signs and an oral examination including a dental assessment.

Intervention

Symptoms

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Dysgeusia - Intervention

Considerations for all patients

  • Significant risk factors for the development of oral complications include the type of cancer, type of cancer treatments, cumulative doses of chemotherapy or radiation treatment, method of delivery and duration of treatment.
  • Predisposing medical, dental, and lifestyle factors may increase the severity of the complications.
  • Oral complications can significantly affect the patient's morbidity, ability to tolerate treatment, and overall quality of life.
  • Rigorous assessment, diagnosis and early intervention are important in preventing and decreasing oral complications; this includes the assessment of nutritional status and adequacy of oral intake.
  • Good oral care is important to prevent and decrease oral complications, to maintain normal function of the oral tissues, to maintain comfort, and to reduce the risk of local and systemic infection. (See the table below for the basic oral care plan).
  • A large variety of medications may cause oral complications. Consultation with a pharmacist is strongly recommended.

Oral Care Plans

InterventionBasic Oral Care PlanIntensified Oral Care PlanEnd of Life Oral Care Plan
Flossing
  • Floss at least once daily.
  • Waxed floss may be easier to use and minimize trauma to the gingivae.
  • If flossing causes bleeding of the gums, which does not stop after 2 minutes, it should be discontinued.
  • Flossing may be restarted when the platelet count is > 20x109cells/L or as instructed by cancer care team.
  • Patients who have not flossed routinely before cancer treatment should not begin flossing at this time.
  • Patients with mouth cancers may not be able to floss.
  • Continue until discomfort becomes too great.
  • Discontinue flossing if gums bleed for longer than 2 minutes.
  • Advise patient to try to begin flossing again when platelet count rises >20x109cells/L.
  • Discontinue flossing if patient chooses.
Brushing
  • Use a small, ultra soft-headed, rounded-end, bristle toothbrush (an ultrasonic toothbrush such as sonicare, may be acceptable).
  • Use a prescription strength fluoride toothpaste (e.g., prevident, flouridex, XPur). Spit out the foam but do not rinse mouth.
  • Use remineralizing pastes (e.g., MIpaste, Oral Science) and chewing gum containing recaldent to replenish calcium and phosphate ions.
  • Brush within 30 minutes after eating and before bed. Ensure the gingival portion of the tooth and periodontal sulcus are included.
  • Rinse toothbrush in hot water to soften the brush before using.
  • Brush tongue gently from back to front.
  • Rinse brush after use in hot water and allow to air dry.
  • Change toothbrush when bristles are not standing up straight.
  • If gingival tissue bleeds for more than 2 minutes, brushing may be stopped and teeth cleaned with clean, moist gauze or foam swab (personal preference may guide practice). Once platelets are >20x109cells/L then brushing may be resumed.
Patients with Head & Neck Cancers
  • Brushing may not be appropriate in the area of tumor involvement.
  • Patients should be assessed for the use of daily Fluoride tray.
  • Consult with a dentist.
Dentures
  • Remove dentures, plates and prostheses before brushing.
  • Brush and rinse dentures after meals and at bedtime.
  • Remove from mouth for long periods (at least 8 hours per 24 hours) and soak in rinsing solution.
  • Use ultra soft toothbrush or soften brush bristles under hot water.
  • Encourage patient to continue brushing through treatment phase even when it causes discomfort.
  • If unable to tolerate brushing, seek assistance from nursing or dental staff.
  • To remove debris and mucus consider using moist gauze or a foam swab soaked in rinsing solution.
  • Discontinue use of toothpaste if it is too astringent and dip toothbrush in bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water).
  • If bleeding occurs, encourage gentler brushing.
  • If there has been an oral infection, use a new toothbrush after infection has resolved.
Dentures
  • Keep dentures out of mouth as much as possible, especially if painful.
  • Continue with basic and intensified mouth care plan.
  • Instead of moist gauze may use a warm, moist face-cloth, dipped in bland rinse to loosen thickened secretions and plaque.
Rinsing
  • Rinsing the oral cavity vigorously helps maintain the moisture in the mouth, removes the remaining debris and toothpaste, and reduces the accumulation of plaque and infection.
  • Patients should rinse, swish and spit with a bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water) several times after each brushing or flossing and as needed.
  • Club soda should be avoided, due to the presence of carbonic acids.
  • Commercial mouthwashes with hydroalcoholic base or astringent properties are not recommended for patients with oral complications.
  • Debriding should only be done if absolutely necessary, if tissue is loose causing gagging or choking.
Dentures
  • After removing dentures rinse mouth thoroughly with rinse solution.
  • Brush and rinse dentures after meals and at bedtime.
  • Rinse with rinsing solution before placing in mouth.
  • Remove from mouth for long periods (at least 8 hours per 24 hours) and soak in rinsing solution.
  • Perform in place of brushing if patient is absolutely unable to brush.
  • Seek dental care where possible for removing plaque.
  • In addition to rinsing after meals, encourage rinsing every 1-2 hours while awake and every 4 hours through the night if awake (to minimize complications of decreased saliva).
  • If unable to clean using toothette, gauze or swishing (or tilting head), syringe rinsing solution into different areas of mouth if platelet level is not too low.
  • Continue with basic and intensified mouth care plan.
Moisturizing the Oral Cavity
  • Moisturize the mouth with water or artificial saliva products (e.g., Moi-Stir Spray, Biotene products) or other water soluble lubricants for use inside the mouth.
  • Avoid glycerin or lemon-glycerin swabs as they dry the mouth and do not moisturize.
  • Apply lubricant after each cleaning, at bedtime, and as needed.
  • Water-based lubricant needs to be applied more frequently.
  • Frequent rinsing as needed with basic mouth rinse.
  • Continue with basic mouth care plan with increased frequency and intensity.
  • Continue with basic mouth care plan with increased frequency and intensity, as needed.
  • May use a cool mist humidifier at night.
Lip Care
  • To keep lips moist and to avoid chapping and cracking use water soluble lubricants, lanolin (wax-based), or oil based (mineral oil, coco butter) lubricants.
  • Water soluble lubricants should be used inside and outside the mouth, and may also be used with oxygen, e.g., products compounded with Glaxal base or Derma base (K-Y Jelly, Dermabase).
  • Apply lubricant after each cleaning, at bedtime, and as needed
  • .
  • Water-based lubricants need to be applied more frequently.
  • Avoid oil based lubricants on the inside of the mouth.
  • Petroleum based products should be avoided.
  • Patients should be encouraged not to touch any lip lesions.
  • Continue with basic mouth care plan with increased frequency and intensity.
  • Continue with basic mouth care plan, with increased frequency and intensity, as needed.

General Oral Care

Non-Pharmacological

  • The recommended rinsing solution is a bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 1 liter / 4 cups of water) prepared at least once daily and not refrigerated.
  • Following emesis, rinse with bland rinse immediately to neutralize the mouth.
  • Patients may chew xylitol gum or suck on xylitol lozenges, up to 6 grams a day.
  • While there is no evidence to recommend either for or against the use of club soda, the Oral Care SMG suggests it should be avoided due to the acidic pH, a result of the carbonic acid content found in carbonated soft drinks.

Prevention

Non-Pharmacological

  • Exclusion of the tip of the tongue during radiation therapy.

Pharmacological

  • Zinc gluconate is not recommended for the prevention of dysgeusia in head and neck cancer patients.
  • Amifostine is not recommended solely for the prevention of dysgeusia in head and neck cancer patients.

Non-Pharmacological Management

Non-Pharmacological

  • As taste changes are unique to each person and can vary over time, an individualized approach needs to be taken to identify tolerable foods. Ongoing follow up is recommended.
  • To prevent compromised food intake, patients may need encouragement and support to try foods again that may have resulted in food aversions secondary to taste changes.
  • Dietary and educational counseling is recommended.
  • Encourage patients to:
    • Enjoy foods that taste good
    • Experiment with food flavours to enhance taste
    • Drink plenty of fluids
    • Avoid strong smells

Follow-Up and Ongoing Monitoring

  • If dysgeusia remains unrelieved despite the approaches outlined above, request the assistance of a palliative care consultation team.

Symptoms

Select a symptom:

Symptom Management Guides

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Oral Infections - Assessment

Onset

When did the symptoms begin?


How often do they occur?


How long do they last?

Provoking/Palliating

What makes it better?


What makes it worse?


What do you think may be causing the symptom?


What are the aggravating or alleviating factors (e.g., medications, active treatment, dietary changes)?

Quality

Do you have a dry mouth? (e.g. decrease in amount or consistency of saliva)


Do you have any redness, blisters, ulcers, cracks, or white patchy areas? If so, are they isolated, generalized, clustered or patchy?

Region/Radiation

Where are your symptoms? (e.g., on lips, tongue, mouth)


Do you have any other related or associated symptoms?


If pain in the mouth does it radiate anywhere?

Severity

What is the intensity of this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)? Right Now? At Best? At Worst? On Average?

Treatment

If dry mouth: Fluid intake? Are you using any oral rinses? What type? Are they effective? Are you using any saliva substitutes or stimulants? What type? Are they effective?


If pain in mouth: Are you using any pain medications? What type – topical/local, oral/injection? Are they effective? Are there any other treatments that you are using to help with pain? Alteration in diet texture?


If bleeding from mouth: Does it occur spontaneously? Where is it located? What aggravates it? What treatments have been recommended and have been used?


What is your current oral care routine? How effective is it? Have you had previous oral infections? What treatments have you used? How effective have they been?


Do you have any side effects from the medications/treatments you have used for any of the above? What tests have you had for your oral symptoms, if any?

Understanding/Impact on You

How bothered are you by this symptom?


Is your ability to eat or drink affected? By how much? Are you having difficulty swallowing or chewing? Is it for solids and/or liquids?


Do you have any weight loss? How much? Over what time frame?


Do you have taste changes (dysgeusia)?


Do you have difficulty speaking?


Are you able to wear dentures?


Do any of your symptoms interfere with other normal daily activities?


How does this symptom affect your day to day life?

Values

What is an acceptable level of severity for this symptom (0 – 10 scale)?


What does this symptom mean to you?


How has it affected you and your family and/or caregiver?

Other Assessment

Where a patient is not able to complete an assessment by self-reporting, then the health professional and/or the caregiver may act as a surrogate.


Physical assessment should include vital signs and an oral examination including a dental assessment.

Intervention

Symptoms

Select a symptom:

Symptom Management Guides

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Oral Infections - Intervention

Considerations for all patients

  • Significant risk factors for the development of oral complications include the type of cancer, type of cancer treatments, cumulative doses of chemotherapy or radiation treatment, method of delivery and duration of treatment.
  • Predisposing medical, dental, and lifestyle factors may increase the severity of the complications.
  • Oral complications can significantly affect the patient's morbidity, ability to tolerate treatment, and overall quality of life.
  • Rigorous assessment, diagnosis and early intervention are important in preventing and decreasing oral complications; this includes the assessment of nutritional status and adequacy of oral intake.
  • Good oral care is important to prevent and decrease oral complications, to maintain normal function of the oral tissues, to maintain comfort, and to reduce the risk of local and systemic infection. (See the table below for the basic oral care plan).
  • A large variety of medications may cause oral complications. Consultation with a pharmacist is strongly recommended.
  • If suspect odotogenic infections consultation with a dentist is strongly recommended.

Oral Care Plans

InterventionBasic Oral Care PlanIntensified Oral Care PlanEnd of Life Oral Care Plan
Flossing
  • Floss at least once daily.
  • Waxed floss may be easier to use and minimize trauma to the gingivae.
  • If flossing causes bleeding of the gums, which does not stop after 2 minutes, it should be discontinued.
  • Flossing may be restarted when the platelet count is > 20x109cells/L or as instructed by cancer care team.
  • Patients who have not flossed routinely before cancer treatment should not begin flossing at this time.
  • Patients with mouth cancers may not be able to floss.
  • Continue until discomfort becomes too great.
  • Discontinue flossing if gums bleed for longer than 2 minutes.
  • Advise patient to try to begin flossing again when platelet count rises >20x109cells/L.
  • Discontinue flossing if patient chooses.
Brushing
  • Use a small, ultra soft-headed, rounded-end, bristle toothbrush (an ultrasonic toothbrush such as sonicare, may be acceptable).
  • Use a prescription strength fluoride toothpaste (e.g., prevident, flouridex, XPur). Spit out the foam but do not rinse mouth.
  • Use remineralizing pastes (e.g., MIpaste, Oral Science) and chewing gum containing recaldent to replenish calcium and phosphate ions.
  • Brush within 30 minutes after eating and before bed. Ensure the gingival portion of the tooth and periodontal sulcus are included.
  • Rinse toothbrush in hot water to soften the brush before using.
  • Brush tongue gently from back to front.
  • Rinse brush after use in hot water and allow to air dry.
  • Change toothbrush when bristles are not standing up straight.
  • If gingival tissue bleeds for more than 2 minutes, brushing may be stopped and teeth cleaned with clean, moist gauze or foam swab (personal preference may guide practice). Once platelets are >20x109cells/L then brushing may be resumed.
Patients with Head & Neck Cancers
  • Brushing may not be appropriate in the area of tumor involvement.
  • Patients should be assessed for the use of daily Fluoride tray.
  • Consult with a dentist.
Dentures
  • Remove dentures, plates and prostheses before brushing.
  • Brush and rinse dentures after meals and at bedtime.
  • Remove from mouth for long periods (at least 8 hours per 24 hours) and soak in rinsing solution.
  • Use ultra soft toothbrush or soften brush bristles under hot water.
  • Encourage patient to continue brushing through treatment phase even when it causes discomfort.
  • If unable to tolerate brushing, seek assistance from nursing or dental staff.
  • To remove debris and mucus consider using moist gauze or a foam swab soaked in rinsing solution.
  • Discontinue use of toothpaste if it is too astringent and dip toothbrush in bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water).
  • If bleeding occurs, encourage gentler brushing.
  • If there has been an oral infection, use a new toothbrush after infection has resolved.
Dentures
  • Keep dentures out of mouth as much as possible, especially if painful.
  • Continue with basic and intensified mouth care plan.
  • Instead of moist gauze may use a warm, moist face-cloth, dipped in bland rinse to loosen thickened secretions and plaque.
Rinsing
  • Rinsing the oral cavity vigorously helps maintain the moisture in the mouth, removes the remaining debris and toothpaste, and reduces the accumulation of plaque and infection.
  • Patients should rinse, swish and spit with a bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water) several times after each brushing or flossing and as needed.
  • Club soda should be avoided, due to the presence of carbonic acids.
  • Commercial mouthwashes with hydroalcoholic base or astringent properties are not recommended for patients with oral complications.
  • Debriding should only be done if absolutely necessary, if tissue is loose causing gagging or choking.
Dentures
  • After removing dentures rinse mouth thoroughly with rinse solution.
  • Brush and rinse dentures after meals and at bedtime.
  • Rinse with rinsing solution before placing in mouth.
  • Remove from mouth for long periods (at least 8 hours per 24 hours) and soak in rinsing solution.
  • Perform in place of brushing if patient is absolutely unable to brush.
  • Seek dental care where possible for removing plaque.
  • In addition to rinsing after meals, encourage rinsing every 1-2 hours while awake and every 4 hours through the night if awake (to minimize complications of decreased saliva).
  • If unable to clean using toothette, gauze or swishing (or tilting head), syringe rinsing solution into different areas of mouth if platelet level is not too low.
  • Continue with basic and intensified mouth care plan.
Moisturizing the Oral Cavity
  • Moisturize the mouth with water or artificial saliva products (e.g., Moi-Stir Spray, Biotene products) or other water soluble lubricants for use inside the mouth.
  • Avoid glycerin or lemon-glycerin swabs as they dry the mouth and do not moisturize.
  • Apply lubricant after each cleaning, at bedtime, and as needed.
  • Water-based lubricant needs to be applied more frequently.
  • Frequent rinsing as needed with basic mouth rinse.
  • Continue with basic mouth care plan with increased frequency and intensity.
  • Continue with basic mouth care plan with increased frequency and intensity, as needed.
  • May use a cool mist humidifier at night.
Lip Care
  • To keep lips moist and to avoid chapping and cracking use water soluble lubricants, lanolin (wax-based), or oil based (mineral oil, coco butter) lubricants.
  • Water soluble lubricants should be used inside and outside the mouth, and may also be used with oxygen, e.g., products compounded with Glaxal base or Derma base (K-Y Jelly, Dermabase).
  • Apply lubricant after each cleaning, at bedtime, and as needed
  • .
  • Water-based lubricants need to be applied more frequently.
  • Avoid oil based lubricants on the inside of the mouth.
  • Petroleum based products should be avoided.
  • Patients should be encouraged not to touch any lip lesions.
  • Continue with basic mouth care plan with increased frequency and intensity.
  • Continue with basic mouth care plan, with increased frequency and intensity, as needed.

General Oral Care

Non-Pharmacological

  • The recommended rinsing solution is a bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 1 liter / 4 cups of water) prepared at least once daily and not refrigerated. Following emesis, rinse with bland rinse immediately to neutralize the mouth.
  • Patients may chew xylitol gum or suck on xylitol lozenges, up to 6 grams a day.
  • While there is no evidence to recommend either for or against the use of club soda, the Oral Care SMG suggests it should be avoided due to the acidic pH, a result of the carbonic acid content found in carbonated soft drinks.

Pharmacological

  • If there is pain, consider topical anesthetics (e.g., viscous lidocaine 2% or viscous xylocaine 2%, 2-5 ml) before brushing and before eating to minimize pain and the use of a non-flavoured, non-alcoholic chlorhexidine gluconate 0.12% rinse to aid in plaque control.
  • If allergic to lidocaine, dyclonine 0.5 to 1% (5 ml q6-8 hours, swish and swallow) may be used as needed for pain.
  • With continuous pain, a regularly prescribed oral analgesic allows for more thorough tooth brushing.
  • For excessive salivary secretions, tricyclic antidepressants (e.g., nortriptyline starting at a low dose and scopolamine transdermal 1.5 mg patch every 72 hours) may be considered.

Prevention

Non-Pharmacological

  • It is necessary to follow meticulous oral care plans. (See table under 'Considerations for all patients')

Pharmacological

  • Fluconazole is very effective in the prevention of clinical oral fungal infections and in reducing oral fungal colonization in patients receiving cancer therapy. (Fluconazole 100 mg daily or 400 mg daily for Hematopoietic stem cell transplantation (HSCT) patients)

Pharmacological Management

Fungal Infections

  • Topical agents are considered preferable to systemic agents for the management of mild intra-oral fungal infection due to lower risk of side-effects and drug interactions. If topical agents are not well tolerated or the response rate is poor, then proceed with systemic agents.

Mild Oropharyngeal Candidiasis

  • Clotrimazole or nystatin suspension may be used as first line treatment.
  • Nystatin suspension 100,000 units/ml- 5 ml QID for 7-14 days- swish in mouth, hold for >/=1 minute, then swallow. Soak dentures overnight in solution.

Moderate to Severe Oropharyngeal Candidiasis

  • Systemic fluconazole (100 mg daily) may be used as first line treatment.
  • For fluconazole refractory disease, itraconazole or posaconazole are recommended.
  • For ongoing refractory cases, voriconazole and amphotericin-B may be used.

Bacterial Infections

For management of periodontal and odontogenic infections, the following is recommended:

  • First line: amoxicillin 500 mg po q8h for 7-10 days.
  • Alternative: penicillin V 300-600 mg po q6h for 7-10 days; Alternative: clindamycin 300-450 mg po q6h for 7-10 days.
  • Amoxicillin/ clavulanic acid (Clavulin) 500 mg tablet (contains amoxicillin 500 mg and clavulanic acid 125 mg) po q8h OR the 875 mg tablet (contains amoxicillin 875 mg and clavulanic acid 125 mg) po q12h for 7-10 days.
  • If infection is definitely periodontal in origin then the recommended first line therapy is metronidazole 500 mg po q8h for 7-10 days.

Viral Infections

Herpes Simplex

  • Topical acyclovir: Apply to affected area q3-4 hrs, total of 6 times/day for 7 days; apply sufficient quantity to adequately cover all lesions.
  • Systemic acyclovir for larger lesions: Primary Herpes Simplex Virus (HSV):
    • Acyclovir 200 mg po q4h, 5 times/day for 10 days or 400 mg po tid for 7-10 days. (In immunocompromised patients, consider 400 mg po q4h, 5 times/day for 10 days).
    • Recurrent HSV: Acyclovir 200 mg po q4 hrs, 5 times/day for 5 days.
    • Valacyclovir 500 mg po bid (twice daily) or q12h for 3 days.

Varicella-zoster

  • Acyclovir 400 mg po 5 times/day for 7-10 days.
  • For severe infection, acyclovir 5 mg (base) per kg body weight IV q8 hrs for 5-7 days (administer over at least 1 h).
  • Patients with acute/chronic renal impairment may need dose reduction (e.g., acyclovir 200 mg po q12 hrs when CrCl is 0-10 mL/min).
  • Valcyclovir 1000 mg po tid or q8h for 7 days (superior to acyclovir for post-herpetic infections). Adjust for renal dysfunction.

Follow-Up and Ongoing Monitoring

  • If infection remains unrelieved despite the approaches outlined above, request the assistance of a palliative care consultation team.

Symptoms

Select a symptom:

Symptom Management Guides

home

Oral Mucositis - Assessment

Screen for Mucositis at each visit.

Onset

When did the symptoms begin?


How often do they occur?


How long do they last?

Provoking/Palliating

What makes it better?


What makes it worse?


What do you think may be causing the symptom?


What are the aggravating or alleviating factors (e.g., medications, active treatment, dietary changes)?

Quality

Do you have a dry mouth? (e.g., decrease in amount or consistency of saliva)


Do you have any redness, blisters, ulcers, cracks, or white patchy areas? If so, are they isolated, generalized, clustered or patchy?

Region/Radiation

Where are your symptoms? (e.g., on lips, tongue, mouth)


Does your pain radiate anywhere?


Do you have any other related or associated symptoms?

Severity

What is the intensity of this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)? Right Now? At Best? At Worst? On Average?

Treatment

If dry mouth: Fluid intake? Are you using any oral rinses? What type? Are they effective? Are you using any saliva substitutes or stimulants? What type? Are they effective?


If pain in mouth: Are you using any pain medications? What type – topical/local, oral/injection? Are they effective? Are there any other treatments that you are using to help with pain? Alteration in diet texture?


If bleeding from mouth: Does it occur spontaneously? Where is it located? What aggravates it? What treatments have been recommended and have been used?


What is your current oral care routine? How effective is it? Have you had oral infections? What treatments have you used? How effective have they been?


Do you have any side effects from the medications/treatments you have used for any of the above? What tests have you had for your oral symptoms, if any?

Understanding/Impact on You

How bothered are you by this symptom?


Is your ability to eat or drink affected? By how much? Are you having difficulty swallowing or chewing? Is it for solids and/or liquids?


Do you have any weight loss? How much? Over what time frame?


Do you have taste changes (dysgeusia)?


Do you have difficulty speaking?


Are you able to wear dentures?


Do any of your symptoms interfere with other normal daily activities?


How does this symptom affect your day to day life?

Values

What is an acceptable level of severity for this symptom (0 – 10 scale)?


What does this symptom mean to you?


How has it affected you and your family and/or caregiver?

Other Assessment

Where a patient is not able to complete an assessment by self-reporting, then the health professional and/or the caregiver may act as a surrogate.


Physical assessment should include vital signs and an oral examination including a dental assessment.

Intervention

Symptoms

Select a symptom:

Symptom Management Guides

home

Oral Mucositis - Intervention

Considerations for all patients

  • Significant risk factors for the development of oral complications include the type of cancer, type of cancer treatments, cumulative doses of chemotherapy or radiation treatment, method of delivery and duration of treatment.
  • Predisposing medical, dental, and lifestyle factors may increase the severity of the complications.
  • Oral complications can significantly affect the patient's morbidity, ability to tolerate treatment, and overall quality of life.
  • Rigorous assessment, diagnosis and early intervention are important in preventing and decreasing oral complications; this includes the assessment of nutritional status and adequacy of oral intake.
  • Good oral care is important to prevent and decrease oral complications, to maintain normal function of the oral tissues, to maintain comfort, and to reduce the risk of local and systemic infection.(See the table below for the basic oral care plan).
  • A large variety of medications may cause oral complications. Consultation with a pharmacist is strongly recommended.

Oral Care Plans

InterventionBasic Oral Care PlanIntensified Oral Care PlanEnd of Life Oral Care Plan
Flossing
  • Floss at least once daily.
  • Waxed floss may be easier to use and minimize trauma to the gingivae.
  • If flossing causes bleeding of the gums, which does not stop after 2 minutes, it should be discontinued.
  • Flossing may be restarted when the platelet count is > 20x109cells/L or as instructed by cancer care team.
  • Patients who have not flossed routinely before cancer treatment should not begin flossing at this time.
  • Patients with mouth cancers may not be able to floss.
  • Continue until discomfort becomes too great.
  • Discontinue flossing if gums bleed for longer than 2 minutes.
  • Advise patient to try to begin flossing again when platelet count rises >20x109cells/L.
  • Discontinue flossing if patient chooses.
Brushing
  • Use a small, ultra soft-headed, rounded-end, bristle toothbrush (an ultrasonic toothbrush such as sonicare, may be acceptable).
  • Use a prescription strength fluoride toothpaste (e.g., prevident, flouridex, XPur). Spit out the foam but do not rinse mouth.
  • Use remineralizing pastes (e.g., MIpaste, Oral Science) and chewing gum containing recaldent to replenish calcium and phosphate ions.
  • Brush within 30 minutes after eating and before bed. Ensure the gingival portion of the tooth and periodontal sulcus are included.
  • Rinse toothbrush in hot water to soften the brush before using.
  • Brush tongue gently from back to front.
  • Rinse brush after use in hot water and allow to air dry.
  • Change toothbrush when bristles are not standing up straight.
  • If gingival tissue bleeds for more than 2 minutes, brushing may be stopped and teeth cleaned with clean, moist gauze or foam swab (personal preference may guide practice). Once platelets are >20x109cells/L then brushing may be resumed.
Patients with Head & Neck Cancers
  • Brushing may not be appropriate in the area of tumor involvement.
  • Patients should be assessed for the use of daily Fluoride tray.
  • Consult with a dentist.
Dentures
  • Remove dentures, plates and prostheses before brushing.
  • Brush and rinse dentures after meals and at bedtime.
  • Remove from mouth for long periods (at least 8 hours per 24 hours) and soak in rinsing solution.
  • Use ultra soft toothbrush or soften brush bristles under hot water.
  • Encourage patient to continue brushing through treatment phase even when it causes discomfort.
  • If unable to tolerate brushing, seek assistance from nursing or dental staff.
  • To remove debris and mucus consider using moist gauze or a foam swab soaked in rinsing solution.
  • Discontinue use of toothpaste if it is too astringent and dip toothbrush in bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water).
  • If bleeding occurs, encourage gentler brushing.
  • If there has been an oral infection, use a new toothbrush after infection has resolved.
Dentures
  • Keep dentures out of mouth as much as possible, especially if painful.
  • Continue with basic and intensified mouth care plan.
  • Instead of moist gauze may use a warm, moist face-cloth, dipped in bland rinse to loosen thickened secretions and plaque.
Rinsing
  • Rinsing the oral cavity vigorously helps maintain the moisture in the mouth, removes the remaining debris and toothpaste, and reduces the accumulation of plaque and infection.
  • Patients should rinse, swish and spit with a bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water) several times after each brushing or flossing and as needed.
  • Club soda should be avoided, due to the presence of carbonic acids.
  • Commercial mouthwashes with hydroalcoholic base or astringent properties are not recommended for patients with oral complications.
  • Debriding should only be done if absolutely necessary, if tissue is loose causing gagging or choking.
Dentures
  • After removing dentures rinse mouth thoroughly with rinse solution.
  • Brush and rinse dentures after meals and at bedtime.
  • Rinse with rinsing solution before placing in mouth.
  • Remove from mouth for long periods (at least 8 hours per 24 hours) and soak in rinsing solution.
  • Perform in place of brushing if patient is absolutely unable to brush.
  • Seek dental care where possible for removing plaque.
  • In addition to rinsing after meals, encourage rinsing every 1-2 hours while awake and every 4 hours through the night if awake (to minimize complications of decreased saliva).
  • If unable to clean using toothette, gauze or swishing (or tilting head), syringe rinsing solution into different areas of mouth if platelet level is not too low.
  • Continue with basic and intensified mouth care plan.
Moisturizing the Oral Cavity
  • Moisturize the mouth with water or artificial saliva products (e.g., Moi-Stir Spray, Biotene products) or other water soluble lubricants for use inside the mouth.
  • Avoid glycerin or lemon-glycerin swabs as they dry the mouth and do not moisturize.
  • Apply lubricant after each cleaning, at bedtime, and as needed.
  • Water-based lubricant needs to be applied more frequently.
  • Frequent rinsing as needed with basic mouth rinse.
  • Continue with basic mouth care plan with increased frequency and intensity.
  • Continue with basic mouth care plan with increased frequency and intensity, as needed.
  • May use a cool mist humidifier at night.
Lip Care
  • To keep lips moist and to avoid chapping and cracking use water soluble lubricants, lanolin (wax-based), or oil based (mineral oil, coco butter) lubricants.
  • Water soluble lubricants should be used inside and outside the mouth, and may also be used with oxygen, e.g., products compounded with Glaxal base or Derma base (K-Y Jelly, Dermabase).
  • Apply lubricant after each cleaning, at bedtime, and as needed
  • .
  • Water-based lubricants need to be applied more frequently.
  • Avoid oil based lubricants on the inside of the mouth.
  • Petroleum based products should be avoided.
  • Patients should be encouraged not to touch any lip lesions.
  • Continue with basic mouth care plan with increased frequency and intensity.
  • Continue with basic mouth care plan, with increased frequency and intensity, as needed.

General Oral Care

Non-Pharmacological

  • The recommended rinsing solution is a bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 1 liter / 4 cups of water) prepared at least once daily and not refrigerated. Following emesis, rinse with bland rinse immediately to neutralize the mouth.
  • Following emesis, rinse with bland rinse immediately to neutralize the mouth.
  • Patients may chew xylitol gum or suck on xylitol lozenges, up to 6 grams a day.
  • While there is no evidence to recommend either for or against the use of club soda, the Oral Care SMG suggests it should be avoided due to the acidic pH, a result of the carbonic acid content found in carbonated soft drinks.

Pharmacological

  • Consider topical anesthetics (e.g., viscous lidocaine 2% or viscous xylocaine 2%, 2-5 ml) before brushing and before eating to minimize pain and the use of a non-flavoured, non-alcoholic chlorhexidine gluconate 0.12% rinse to aid in plaque control.
  • If allergic to lidocaine, dyclonine 0.5 to 1% (5 ml q6-8 hours, swish and swallow) may be used as needed for pain.
  • With continuous pain, a regularly prescribed oral analgesic allows for more thorough tooth brushing.
  • For excessive salivary secretions, tricyclic antidepressants (e.g., nortriptyline starting at a low dose and scopolamine transdermal 1.5 mg patch every 72 hours) may be considered.

Mild Oral Mucositis

Mild Oral Mucositis - Intervention

Prevention

Non-Pharmacological

  • Ice chips may be used, especially in patients receiving high-dose melphalan as part of a conditioning regimen for stem cell transplant.
  • IMRT is currently the treatment of choice for head and neck patients.
  • Low energy laser application.
  • See Table 5 in Oral Care Guide

Pharmacological

  • There is no evidence of benefit for the use of chlorhexidine.

Management

Non-Parmacological

  • Start with soft, moist, smooth foods and, if not tolerated, trial extra soft/pureed foods.
  • Choose foods high in calories and protein, 6-8 small meals/snacks daily.
  • Cook solid foods until tender, use moist sauces, choose soft, bland foods.
  • Avoid foods that irritate the mouth or throat.
  • Avoid foods which are abrasive, rough, tart, salty, spicy, acidic, very hot or very cold.
  • Oral commercial nutritional supplements may be necessary.
  • A multivitamin may be considered.
  • There is insufficient evidence to support the use of vitamin B12, beta-carotene calcium, chamomile, glutamine, or curcumin.

Parmacological

  • If topical anaesthetics are not effective for pain relief, non-opioid or opioids analgesics may be required.

Moderate Oral Mucositis

Moderate Oral Mucositis - Intervention

Prevention

Non-Pharmacological

  • See mild mucositis.

Pharmacological

Management

Non-Parmacological

  • See mild mucositis.

Parmacological

  • Patient-controlled analgesia with opioids is the treatment of choice for oral mucositis pain.

Severe Oral Mucositis

Severe Oral Mucositis - Intervention

Prevention

Non-Pharmacological

Pharmacological

  • In patients with hematological malignancies receiving high dose chemotherapy and total body radiation with stem cell transplant, Keratinocyte Growth Factor (KGF) (palifermin) in a dose of 60 mcg/kg/d for 3 days prior to commencing treatment and for 3 days post-transplant is recommended.
  • KGF (palifermin) is not commonly used in Ontario due to high costs and limited availability.

Management

Non-Parmacological

  • Consider extra soft/pureed diet.
  • If only liquids are tolerated, choose high calorie, high protein fluids every 2 hours.
  • Oral commercial nutrition supplements are recommended.
  • A liquid regular strength multivitamin may be recommended.
  • Severe oral mucositis during cancer treatment (grade 3 or 4) may be managed with an appropriately placed feeding tube or total parenteral nutrition depending on the patient’s goals of care.
  • Consult Dietitian if possible.

Parmacological

  • Patient-controlled analgesia with opioids is the treatment of choice for oral mucositis pain.

Follow-Up and Ongoing Monitoring

  • If mucositis remains unrelieved despite the approaches outlined above, request the assistance of a palliative care consultation team.

Symptoms

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Xerostomia (dry mouth) - Assessment

Screen for xerostomia at each visit.

Onset

When did the symptom begin?


How long have you had it?

Provoking/Palliating

What makes it better?


What makes it worse?


What do you think may be causing the symptom?


What are the aggravating or alleviating factors (e.g., medications, active treatment, dietary changes)?

Quality

What is the amount or consistency of saliva?


Do you have any redness, blisters, ulcers, cracks, or white patchy areas? If so, are they isolated, generalized, clustered or patchy?

Related Symptoms

Do you have any other related or associated symptoms? (e.g., pain)

Severity

What is the intensity of this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)? Right Now? At Best? At Worst? On Average?

Treatment

Fluid intake? Are you using any oral rinses? What type? Are they effective?


Are you using any saliva substitutes or stimulants? What type? Are they effective?


If associated pain in mouth: Are you using any pain medications? What type – topical/local, oral/injection? Are they effective? Are there any other treatments that you are using to help with pain? Alteration in diet texture?


If associated bleeding from mouth: Does it occur spontaneously? Where is it located? What aggravates it? What treatments have been recommended and have been used?


What is your current oral care routine? How effective is it?


Have you had oral infections? What treatments have you used? How effective have they been?


Do you have any side effects from the medications/treatments you have used for any of the above?


What tests have you had for your oral symptoms, if any?

Understanding/Impact on You

How bothered are you by this symptom?


Is your ability to eat or drink affected? By how much? Are you having difficulty swallowing or chewing? Is it for solids and/or liquids?


Do you have any weight loss? How much? Over what time frame?


Do you have taste changes (dysgeusia)?


Do you have difficulty speaking?


Are you able to wear dentures?


How does this symptom affect your day to day life?

Values

What is an acceptable level of severity for this symptom (0 – 10 scale)?


What does this symptom mean to you?


How has it affected you and your family and/or caregiver?

Other Assessment

Where a patient is not able to complete an assessment by self-reporting, then the health professional and/or the caregiver may act as a surrogate.


Physical assessment should include vital signs and an oral examination including a dental assessment.

Intervention

Symptoms

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Xerostomia - Intervention

Considerations for all patients

  • Significant risk factors for the development of oral complications include the type of cancer, type of cancer treatments, cumulative doses of chemotherapy or radiation treatment, method of delivery and duration of treatment.
  • Predisposing medical, dental, and lifestyle factors may increase the severity of the complications.
  • Oral complications can significantly affect the patient's morbidity, ability to tolerate treatment, and overall quality of life.
  • Rigorous assessment, diagnosis and early intervention are important in preventing and decreasing oral complications; this includes the assessment of nutritional status and adequacy of oral intake.
  • Good oral care is important to prevent and decrease oral complications, to maintain normal function of the oral tissues, to maintain comfort, and to reduce the risk of local and systemic infection. (See the table below for the basic oral care plan).
  • A large variety of medications may cause oral complications. Consultation with a pharmacist is strongly recommended.

Oral Care Plans

InterventionBasic Oral Care PlanIntensified Oral Care PlanEnd of Life Oral Care Plan
Flossing
  • Floss at least once daily.
  • Waxed floss may be easier to use and minimize trauma to the gingivae.
  • If flossing causes bleeding of the gums, which does not stop after 2 minutes, it should be discontinued.
  • Flossing may be restarted when the platelet count is > 20x109cells/L or as instructed by cancer care team.
  • Patients who have not flossed routinely before cancer treatment should not begin flossing at this time.
  • Patients with mouth cancers may not be able to floss.
  • Continue until discomfort becomes too great.
  • Discontinue flossing if gums bleed for longer than 2 minutes.
  • Advise patient to try to begin flossing again when platelet count rises >20x109cells/L.
  • Discontinue flossing if patient chooses.
Brushing
  • Use a small, ultra soft-headed, rounded-end, bristle toothbrush (an ultrasonic toothbrush such as sonicare, may be acceptable).
  • Use a prescription strength fluoride toothpaste (e.g., prevident, flouridex, XPur). Spit out the foam but do not rinse mouth.
  • Use remineralizing pastes (e.g., MIpaste, Oral Science) and chewing gum containing recaldent to replenish calcium and phosphate ions.
  • Brush within 30 minutes after eating and before bed. Ensure the gingival portion of the tooth and periodontal sulcus are included.
  • Rinse toothbrush in hot water to soften the brush before using.
  • Brush tongue gently from back to front.
  • Rinse brush after use in hot water and allow to air dry.
  • Change toothbrush when bristles are not standing up straight.
  • If gingival tissue bleeds for more than 2 minutes, brushing may be stopped and teeth cleaned with clean, moist gauze or foam swab (personal preference may guide practice). Once platelets are >20x109cells/L then brushing may be resumed.
Patients with Head & Neck Cancers
  • Brushing may not be appropriate in the area of tumor involvement.
  • Patients should be assessed for the use of daily Fluoride tray.
  • Consult with a dentist.
Dentures
  • Remove dentures, plates and prostheses before brushing.
  • Brush and rinse dentures after meals and at bedtime.
  • Remove from mouth for long periods (at least 8 hours per 24 hours) and soak in rinsing solution.
  • Use ultra soft toothbrush or soften brush bristles under hot water.
  • Encourage patient to continue brushing through treatment phase even when it causes discomfort.
  • If unable to tolerate brushing, seek assistance from nursing or dental staff.
  • To remove debris and mucus consider using moist gauze or a foam swab soaked in rinsing solution.
  • Discontinue use of toothpaste if it is too astringent and dip toothbrush in bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water).
  • If bleeding occurs, encourage gentler brushing.
  • If there has been an oral infection, use a new toothbrush after infection has resolved.
Dentures
  • Keep dentures out of mouth as much as possible, especially if painful.
  • Continue with basic and intensified mouth care plan.
  • Instead of moist gauze may use a warm, moist face-cloth, dipped in bland rinse to loosen thickened secretions and plaque.
Rinsing
  • Rinsing the oral cavity vigorously helps maintain the moisture in the mouth, removes the remaining debris and toothpaste, and reduces the accumulation of plaque and infection.
  • Patients should rinse, swish and spit with a bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water) several times after each brushing or flossing and as needed.
  • Club soda should be avoided, due to the presence of carbonic acids.
  • Commercial mouthwashes with hydroalcoholic base or astringent properties are not recommended for patients with oral complications.
  • Debriding should only be done if absolutely necessary, if tissue is loose causing gagging or choking.
Dentures
  • After removing dentures rinse mouth thoroughly with rinse solution.
  • Brush and rinse dentures after meals and at bedtime.
  • Rinse with rinsing solution before placing in mouth.
  • Remove from mouth for long periods (at least 8 hours per 24 hours) and soak in rinsing solution.
  • Perform in place of brushing if patient is absolutely unable to brush.
  • Seek dental care where possible for removing plaque.
  • In addition to rinsing after meals, encourage rinsing every 1-2 hours while awake and every 4 hours through the night if awake (to minimize complications of decreased saliva).
  • If unable to clean using toothette, gauze or swishing (or tilting head), syringe rinsing solution into different areas of mouth if platelet level is not too low.
  • Continue with basic and intensified mouth care plan.
Moisturizing the Oral Cavity
  • Moisturize the mouth with water or artificial saliva products (e.g., Moi-Stir Spray, Biotene products) or other water soluble lubricants for use inside the mouth.
  • Avoid glycerin or lemon-glycerin swabs as they dry the mouth and do not moisturize.
  • Apply lubricant after each cleaning, at bedtime, and as needed.
  • Water-based lubricant needs to be applied more frequently.
  • Frequent rinsing as needed with basic mouth rinse.
  • Continue with basic mouth care plan with increased frequency and intensity.
  • Continue with basic mouth care plan with increased frequency and intensity, as needed.
  • May use a cool mist humidifier at night.
Lip Care
  • To keep lips moist and to avoid chapping and cracking use water soluble lubricants, lanolin (wax-based), or oil based (mineral oil, coco butter) lubricants.
  • Water soluble lubricants should be used inside and outside the mouth, and may also be used with oxygen, e.g., products compounded with Glaxal base or Derma base (K-Y Jelly, Dermabase).
  • Apply lubricant after each cleaning, at bedtime, and as needed
  • .
  • Water-based lubricants need to be applied more frequently.
  • Avoid oil based lubricants on the inside of the mouth.
  • Petroleum based products should be avoided.
  • Patients should be encouraged not to touch any lip lesions.
  • Continue with basic mouth care plan with increased frequency and intensity.
  • Continue with basic mouth care plan, with increased frequency and intensity, as needed.

General Oral Care

Non-Pharmacological

  • The recommended rinsing solution is a bland rinse (1 teaspoon salt, 1 teaspoon baking soda in 1 liter/4 cups of water) prepared at least once daily and not refrigerated. Following emesis, rinse with bland rinse immediately to neutralize the mouth.
  • Patients may chew xylitol gum or suck on xylitol lozenges, up to 6 grams a day.
  • While there is no evidence to recommend either for or against the use of club soda, the Oral Care SMG suggests it should be avoided due to the acidic pH, a result of the carbonic acid content found in carbonated soft drinks.
  • Use prescription strength fluoride toothpaste (e.g., prevident, flouridex, XPur). Spit out the foam but do not rinse mouth.
  • Patients should be assessed for the use of daily Fluoride tray.
  • Moisturize the mouth with water or artificial saliva products (e.g., Moi-Stir Spray, Biotene products) or other water soluble lubricants for use inside the mouth.
  • Avoid glycerin or lemon-glycerin swabs as they dry the mouth and do not moisturize.
  • Apply lubricant after each cleaning, at bedtime, and as needed. Water-based lubricant needs to be applied more frequently.
  • Frequent rinsing as needed with basic mouth rinse.

Prevention

Non-Pharmacological

  • Parotid sparing Intensity Modulated Radiation Therapy (IMRT) is recommended in head and neck patients

Non-Pharmacological Management

  • Add extra moisture to foods, increase fluid consumption. Oral rinses may improve swallowing and taste problems.
  • Soft, mild tasting food is often better tolerated. Moisten food by adding sauces, gravy, butter, dressings, broth or another liquid.
  • Food and drinks should be cold or tepid.
  • Plain ice cubes, sugar-free popsicles, sugar-free gum, frequent sips of cold water, or sprays may increase fluid consumption and help to cool and moisten mouth.
  • Avoid foods, fluids and other items which dry/irritate mouth, including foods and fluids which are highly acidic, high in sugar, caffeine and alcohol.
  • To stimulate residual salivary secretion and to ameliorate the condition of the mucosa, use fresh, lightly acidic fruits, cold cucumber slices, tomato or thin slices of cold apples as long as patient is not experiencing mucositis.
  • The use of milk, jello, sherbet, applesauce and ice cream is also suggested.
  • Acupuncture may stimulate gland secretion and alleviate xerostomia.
  • Artificial saliva products may also be used for a brief course.

Pharmacological Management

  • Oral pilocarpine (sialogogue) 5 mg tid following radiation therapy is recommended in head and neck cancer patients.
  • Results for the use of pilocarpine HCl concomitantly with radiation therapy to reduce xerostomia and salivary gland hypofunction are inconsistent, however in some patients a beneficial effect has been shown on xerostomia.
  • There is insufficient evidence to recommend for or against the use of amifostine. Amifostine reduces xerostomia after radiation therapy however, the possibility of tumor protection remains a clinical concern despite some studies showing that Amifostine reduces xerostomia after radiation therapy.

Follow-Up and Ongoing Monitoring

  • If xerostomia remains unrelieved despite the approaches outlined above, request the assistance of a palliative care consultation team.

Symptoms

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Interactive Symptom Assessment and Collection (ISAAC) Tool

How ISAAC Works

Patients simply enter their symptom severity scores electronically on a touch -screen computer kiosk that sits at their local cancer centre, or through their Internet-linked home computer or by phone using Tele-ISAAC,The assessments are reviewed by the patients' care team, allowing symptoms to be managed more effectively.,ISAAC measures symptom severity based on the Edmonton Symptom Assessment System (ESAS) , which addresses nine common symptoms including pain, nausea, and anxiety.,ESAS scores are reported as a histogram. This includes scores entered both at the cancer clinic and from home, so symptom severity can be tracked over time and across healthcare settings., ISAAC has the capability to notify clinicians by email when the score is in the moderate to severe range. This means they can take appropriate steps to help patients manage their symptoms, including referrals to specialized services when needed

ESAS Tool

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ISAAC Site Locations

Symptoms

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About

About Cancer Symptom Management Guides

Symptom Management Guides have been developed to assist health care professionals in the assessment and appropreate management of a patient's cancer-related symptoms. They have been developed through the Ontario Cancer Symptom Management Collaborative, an initiative of Cancer Care Ontario (CCO).

The app is an algorithm designed to help guide assessment and care planning based on the severity of a patient's identified symptoms. Patients should be screened initially for symptoms using the Edmonton Symptom Assessment System (ESAS). Most symptoms in the app ask you to enter the ESAS score to determine the appropriate care pathway. The app then guides you through clinical assessment and care planning, including boh non-pharmalogical and pharmalogical interventions.

Each care planning guide is a condensed protable companion to the full guide-to-practice that is posted on CCO's website (Click on: CCO's Symptom Management Guide-to-Practice Full Text).

These guides have been through a rigorous interdisciplinary development and review process using the ADAPTE framework approach.

The development of these tools reflect the leadership and dedication of members of Cancer Care Ontario's Symptom Management and Algorithm Working Group and the Canadian Assosiation of Psychological Oncology (CAPO), with support from the Canadian Partnership Against Cancer (CPAC).

Disclaimer

The Working Groups have exercised care in preparing the information embodied in this application. Nonetheless, any person seeking to apply or consult the guidance for practice document is expected to use their independent clinical judgement and skills in the contdext of individual circumstances or seek the supervision of a qualified specialist clinician. CCO, CPAC and CAPO make no representation or warranties of any kind whatsoever regarding their content or use or application and disclaims any responsibility for their application or use in any way. The Edmonton Symptom Assessment System (ESAS) is a valid and reliable assessment tool to screen for the intinsity of nine common symptoms experienced by cancer patients: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath.

Patients can report their ESAS scores electronically at many regional cancer centres using ISACC. Find out more about ISAAC (Interactive Symptom Assessment and Collection)

To view ESAS in more than 30 languages select ISAAC on the app toolbar.

ESAS is used with permission from Capital Health, Edmonton Alberta, 2007

About PPS

The Palliative Performance Scale (PPS) is a reliable and valid tool to assess and quickly describe a patient's functional performance. Palliative Performance Scale

PPS has prognostic significance, can help determine appropriate treatment and guides care planning. For comprehensive management plan for patients with advanced disease, please refer to the Palliative Care Collaborative Care Plans

Developed by the Victoria Hospicse Society

Terms of Use

Use of this Cancer Care Ontario (“CCO”) mobile application (the “app”) constitutes acceptance of the terms and conditions as set out below and at: http://www.cancercare.on.ca/toolbox/applibrary/ (the “Terms and Conditions”). If you do not agree with these Terms and Conditions, immediately exit and delete this app.

User License

Subject to the Terms and Conditions, CCO grants to you a personal, non-exclusive, non-transferable, limited and revocable license to use this app for personal use only. Any use of the app in any other manner, including, without limitation, resale, transfer, modification or distribution of the app or any text, guidelines, information, pictures, barcodes, videos, data, hyperlinks, displays and other content contained within or associated with the app (the “Content”) is prohibited.

Disclaimer

The Content is intended to be for informational purposes and may be used for non-commercial activities only. The Content is not intended to constitute medical advice and should not be relied upon in any such regard. By accessing, reviewing or using the Content, you do so at your own risk. The app and the Content are not intended to replace independent professional judgment or advice given by a physician or other qualified health care professionals.

CCO makes no representations or warranties of any kind, including without limitation, representations or warranties relating to the accuracy of the Content or the suitability of the Content for any specific purpose. The application and the Content is provided “as-is” and may be subject to change, revision or restatement, from time to time. CCO hereby disclaims any and all liability relating to the acts and/or omissions of CCO and any and all liability arising from the use of the app or reliance placed upon the Content.

All trademarks and other intellectual property rights not specifically granted herein (subject to any pre-existing third-party intellectual property rights) are strictly reserved by CCO. The use of the app is governed by the laws of the Province of Ontario, Canada. CCO welcomes comments and feedback regarding this app and the Content. However, CCO cannot answer specific questions about an individual's cancer treatment.

PPS is:

Palliative Performance Scale, a reliable and valid tool used for assessing a patient’s functional status. Measured in 10% increments, from 100% (highest level of function) to 0% (death).

ESAS score is:

Edmonton Symptom Assessment System, a valid and reliable self-assessment tool to screen for the intensity of nine common symptoms. ESAS scores range from 0 (none) to 10 (severe).

Symptoms

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ISAAC Locations

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