Gastrointestinal Factors
-PPS 40%
-Minimal oral intake
-Odansetron and metocloparmide routinely
-Pain unchanged, not very well controlled
-In office for urgent reassessment with a bucket
Yes - What is nausea and vomitting?
PPS 10%
HMC 15mg bid with 2mg breakthrough 6 times per day
pain was not well controlled
VN calling to indicate pt is non-responsive and asking for direction on how to proceed.
Yes - What is decreased level of consciousness?
PPS 30%
Oxyneo 80mg bid and Percocet 8 per day
Has had significant nausea with hydromorphone in the past.
VN has sent message that she thinks infusion due to inadequate pain control and concern re:acetaminophen
No-What is no injection route of medication being used?
PPS 30%, decrease LOC
Pain controlled HMC 18mg tid with 4 bt of 2mg
Patients husband with severe rheumatoid arthritis affecting hands
Call from Visit nurse to let you know they have accessed the SRK
Yes - What is medical health of caregiver?
82 year old male with copd comfort care. Started with increased sputum and cough yesterday and today is bed bound. He has taken in minimal fluids. Current medications: Tiazac 120mg, Alsace 10mg, ativan 1mg sl tid, Inhaled Laba/Lama/ICS, ventolin prn. Visiting nurse call and indicates that patient is complaining of pain in his back and is requesting a pump.
What is an opioid naive patient?
PPS 50%
On third round of Fluorouracil, IV hydration
Pain previously well controlled on Morphine 90mg bid and 15mg breakthrough 4 times per day
Oncologist has asked you to see, patient has a prescription for magic mouthwash in their hand
Yes - What is mucositis?
PPS 70%, Stable on first line hormonal therapy
HMC 18mg bid and hydromoprhone 4mg prn
has sudden onset pain about twice per day that are not predictable
VN has requested a csci to allow the patient to control her acute painful episodes more effectively
Yes - What is incident pain?
No - What is long life expectancy?
PPS 30%
HMC 18mg bid, hydromorphone 4mg prn 6 doses per day
Oral route lost
Being seen on home visit
What is volume of subcutaneous injection?
Oral 36+24=60/2=30/6=5mg sc q4h
Yes - 2mg/ml concentration =volume 2.5ml
No - 10mg/ml concentration = volume 0.5ml - waste in hospital
PPS 20%-has rallied from 20% to 30% for 5 days
intermittent sc injections hydromorphone - 10 per day
Daughter and her husband are providing 24/7 care
patient with some delirium partially controlled with HS nozinan sc q8h
Nurse is calling to ask for refill of syringes.
Yes - What is caregiver fatigue?
67 yo male with lung cancer. PPS declined from 60% to 10% in last 3 days. Yesterday was taking HMC 6mg po BID and 1mg breakthrough about every 2 hours. Symptoms response Kit in the home. Visiting nurse calls and reports patient decline. He is mottled and she is initiating scopolamine for secretions. She is requesting a pump.
What is futility of treatment based on logistics?
PPS 50%, pertuzumab with trastuzumab
15 bowel movements per day- max immodium
Pain not well controlled -HMC 12mg tid with 4mg breakthrough 4 per day
Call from VN
Yes- What is poor absorption?
PPS 30%
Admitted to hospital with symptoms of cough and fever during time of pandemic
Patient having chest pain requiring frequent breakthrough
PPS 40%, Mucocitis therefore cannot use oral route
Routine SC morphine 10mg q4h starting at 0800; 6 prn doses at 11am, 3pm, 4pm, 7pm, 3am
Seen on HV
Yes - What is insufficient duration of action of intermittent injections?
PPS 30% -Last contact with pt 3 days ago, eating well
Pain adequately controlled on MS Contin 120mg bid with 25mg 4 times per day
Son calling indicating that patient’s pain is poorly controlled. He indicates patient is sleeping and can’t come to the phone
No-What is suspicious of abuse?
72 yo male with lung cancer. PPS 60%. History of remote MVA with ongoing back pain stable but moderate to severe. Not able to work due to pain. He has a desk job. Oncologist has referred to you requesting a pump so that the patient can attend work.
What is chronic non-malignant pain?
PPS 50%, New hoarse voice
intake poor but patient is hungry
Pain previously well controlled but hasn’t swallowed pain meds for 24 hours
Sent to you by radiation oncologist to address patients difficulty with current medication adherence.
Yes- What is dysphagia or swallowing difficulties due to cranial nerve difficulty?
PPS 40%,Best Supportive care
Past history of stroke with associated dementia
MS Contin 90mg bid, 15mg prn 4 times per day given at 8am, 12pm, 4pm and 8pm because she “seems uncomfortable” by very worried husband
Being seen on home visit - comfortable when examined
No-What is not cognitively able to use bolus safely?
PPS 40%
pain with ambulation in R hip
Has had maximal radiation, dexamethasone 4mg daily
HMC 6mg tid, hydromorphone 2mg prn - 6 per day
Being seen on home visit
Yes - What is incident pain?
PPS 20%
Pain adequately controlled on HMC 15mg tid with 4mg breakthrough 5 times per day
Olanzapine SL tid for agitation, Tranderm V patch for secretions
Husband is main caregiver and has phobia of needles
84 yo female with metastatic breast cancer. At home with her son who “works from home”. He needs to leave the home several times per day for meetings. Her PPS is a weak 30%. HMC 6mg q8h, dilaudid 2mg breakthrough about 4 times per day. Visiting nurse asking for csci so that patient can have pain meds in case her son doesn’t get back in time to give her 14h00 dose of HMC.
PPS 30%, peritoneal carcinomatosis
intake decreased, bowels moving every 5-7 days with mineral oil 30ml qid, senokot 2 bid, Lactulose 30ml bid
Abdo pain adequately controlled- HMC 18mg bid, 4mg hydromprhone prn 6x per day
Visiting nurse is calling to provide you an update.
Yes - What is nausea and vomitting?
PPS 20%, Somnolent but reusable, Delerious
Suspicious of nursing staff
Pain controlled with MS Contin 60mg tid, pt refusing breakthrough medicine
Being seen in hospice setting
Yes - What is Level of Consciousness?
Yes - What is impracticality of repeated SC injections?
PPS 30%
MS Contin 90mg q8h, morphine 25mg prn 5 per day
oral route is lost
being seen on a home visit
What is volume of injection?
Oral MEq=395 (90X3 +25x5) -Sc injections q4h would be 33mg
Yes if 10mg/ml concentration - volume >3ml
No-if 25mg/ml concentration - volume 1.3ml -waste in hospital
PPS 20%
pt on HMC 18mg bid with hydromorphone 4mg prn about twice per day
Husband is main caregiver and recently had cataract surgery
VN is calling asking to move to injectable medication
Yes - What is medical health of caregiver?
75 year old male with pancreatic cancer living in rooming house. He had his Oxyneo 40mg tabs stolen 2 days ago. He suspects his neighbour who he knows has been incarcerated for violent crimes and drug addiction.
What is danger to patient or family?
PPS 50%
Developed nausea when starting on morphine for pain
rotated to hydromorphone with adequate pain control
Gravol added with little benefit.
Patient being seen in clinic.
What is narcotic induced nausea?
No - add antipsychotic, prokinetic or serotonin antagonist
Yes - some evidence that sc route causes less nausea
Cherny N et al. J Clin Oncol. 2001 May 1; 19(9)
PPS 40% current meds:
MS Contin 30mg tid, 15mg q2hprn - about 5 doses per day, Gabapentin 300mg tid, Amitriptyline 50mg qhs, Maxeran 10mg qid, zofran 8mg tid
Atorvostatin 40mg, carvedilol 6.25mg bid, apixiban 2.5mg bid, furosemide 60mg qam, 40mg qnoon, Metformin 500mg bid, ECASA, vit D 2000iu, vit B12 1000mcg, Omega 3 500mg, glucosamine 500mg tid
Yes-What is large pill burden?
No-What is elimination of non-essential pills?
PPS 20%
Methadone 10mg po q8h, 5mg q8hprn
Bowel obstruction with recurrent vomitting
being seen on HV
No: What is no injectable equivalent for medication unavailable?
Could Methadone concentrated liquid sublingually
PPS 20% current meds:
hydromoprhone 2mg sc q4h routine, q1prn
Zofran 8mg sc q8h, maxeran 10mg sc q4hprn
Haldol 1mg sc q8h q2hprn, Dexamethasone 4mg sc bid
Sandostatin 100mcg sc bid, midazolam 2mg sc q2hprn
scopolamine 0.4mg sc q4hprn
Yes - What is complicated medicine regimen?
82yo female with breast cancer and previous treatment with carboplatin. Has significant pain in hands and feet. Finds that in the winter her symptoms are much worse. Current cold spell has resulted in patient being unable to walk to the washroom due to severe pain in her feet. VN is calling to ask for csci so that patient can ambulate more easily.
What in neuropathic pain?