MEDICATION PROCESSES FOR PALLIATIVE CARE DRUGS WORKSHOP Shailesh Panchmatia Head of Medicines Management Alex Clarke - Pharmacist Nottingham CityCare Partnership JUNE 2014
LEARNING OUTCOMES • Understand the role of the GP in the optimum operation of medication processes in palliative care
FORMAT • Workshop style • Discuss case studies – start with allocated then move on-n 10mins • Feedback at end
SCENARIO 1 • A community nurse contacts the surgery to request a palliative care drug to be written on a DNS1 • The receptionist takes the message and prepares the DNS1 • A duty GP signs the prescription • What could go wrong with this system?
SCENARIO 2 a) Elderly patient on Zomorph 60mg BD. What 24 hour dose of SC morphine in a syringe driver would you prescribe? b) After a few days on the syringe driver, The patient is requesting 10mg morphine SC tds for breakthrough pain. What would be the new dose of morphine to put into the syringe driver?
MORPHINE PROPERTIES • Oral bioavailability = 25% of dose • Substantial hepatic first pass effect • Renal impairment – can cause accumulation • Half life = 2-3 hours • Dosing in renal/hepatic impairment- consult specialists
SCENARIO 3 • A patient has been prescribed anticpatory drugs • The patient is risk assessed by the Macmillan team and found to be suicidal • The patient has already attempted to overdose on her oramorph • What advice would you give?
SCENARIO 4 • You get a phone call from a DN who is in a palliative care patient's house • The nurse telephones you to say that the patient is suffering from breakthrough pain, and that the next prn morphine of 2.5mg SC is not due for another 3 hours • What are the current accepted processes to deal with this situation?
VERBAL ORDERS • NOT ALLOWED FOR NEW DRUGS- ONLY FOR EXISTING DOSE CHANGES • USE ONLY IN EMERGENCY SITUATIONS • Prevent by planning a 1 step dose increase on DNS1 and writing ‘hourly’ for frequency(with a maximum) • If patient in dire pain and DNS1 not written up to authorise: • Verbal message by Doctor to nurse. 2 nd nurse to phone back to confirm message • Fax copy to be received within 24 hours(fax) and original within 72 hours
SCENARIO 5 • You get a phone call from a community nurse to say that she cant find a fentanyl patch that was put on 3 days ago. The patient is not consenting to a body check, and is refusing all oral and parenteral medicines • What advice would you give?
SCENARIO 6 • DNS 1 – CHART A • Written up for the first time for an elderly palliative patient • The patient is suffering from pain and nausea • Any comments on what's wrong or can be improved?
SUMMARY • Use the new charts for AP and SP • Plan for dose change increases • Be aware of fentanyl risks
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