Palliative Care For The Patient With Incurable Cancer or Advanced Disease

GUIDELINES & P R O T O C O L S
A D V IS O R Y C O M M IT T E E
Palliative Care for the Patient with Incurable Cancer or Advanced Disease
Part 1: Approach to Care
Effective Date: June 15, 2010
Scope
This guideline presents assessment and management strategies for primary care practitioners caring for adult
patients (> 19 years) with incurable cancers and end stage chronic disease of many types and their families.
NOTE: Care gaps have been identified at important transitions for this group of patients:
• Upon receiving a diagnosis of incurable cancer
• When discharged from active treatment to the community
• While still ambulatory but needing pain and symptom management
• At the transition when end of life care may be needed
Diagnostic Code: 239 (neoplasm of unspecified nature)
WHO Definition of Palliative Care

Palliative care is an approach that improves the quality of life of patients and their families facing the
problem associated with life-threatening illness, through the prevention and relief of suffering by means
of early identification and impeccable assessment and treatment of pain and other problems, physical,
psychosocial, and spiritual.
Assessment
A palliative approach is needed for patients living with active, progressive, life-limiting illnesses who need pain
and symptom management and support around practical or psychosocial issues, have care needs that would
benefit from a coordinated or collaborative care approach, and/or have frequent emergency room visits. Assess
where patients are in their illness trajectory, functional status, and symptom burden. Clarify goals of care.
Estimating prognosis allows optimal use of limited time for patients and families. Rapid change in clinical
condition is an understandable and helpful sign. Although prognoses can only be estimated, poor prognostic
factors include:
• progressive weight loss (especially > 10% over 6 months)
• rapidly declining level on the Palliative Performance Scale (PPS) (refer Appendix A)
• dyspnea
• dysphagia
• cognitive impairment
Palliative Care Part 2: Pain and Symptom Management is available at www.bcguidelines.ca/guideline_palliative2.html

Palliative Care Pari 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html
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Investigations (Refer Appendix B)
Before ordering investigations, ensure that the results will change management to improve quality of life and/
or prognostication, consistent with a patient's goals of care. Investigations may be indicated in the following
situations to:
• better understand and manage distressing clinical complications,
• assist in determining prognosis,
• clarify appropriate goals of care, and
• determine whether all options have been considered before admission to hospice.
Management
Evaluate performance status and then symptom burden in order to accurately assess a patient's needs for
added supports and symptom management. A common use of assessment scales among providers (e.g. PPS,
Edmonton Symptom Assessment System [ESAS]) facilitates communication and collaboration.
a. Monitor patient’s functional capacity.

Use the PPS (refer Appendix A) to base care on a patient's functional capacity and prognosis. “The single
most important predictive factor in cancer is performance status and functional ability - if patients
are spending more than 50% of their time in bed/lying down, prognosis is likely to be about 3 months or
less” .1
b. Co-ordinate care with allied health care providers.

To enhance co-ordination with allied health providers involved in the care of the patient, the following are
recommended:
• Application of the PPS to determine a need for increased patient support:
• For a drop from PPS 70% to 60%, refer to the hospice palliative care program (submit a Palliative
Benefits Application for prognoses < 6 months and discuss and/or complete a home No CPR form
(refer Resources)).
• For a drop from PPS 40% to 30%, increase home support or hospice care.
• For a PPS of 20% or 10%, use the End of Life (EOL) Care check list (found on page 4).
• A bereavement follow-up call and/or visit by a physician, a suitable allied health professional, or a
trained hospice volunteer.
c. Evaluate symptom burden.

Use a scale like the ESAS (refer Appendix C) to assess symptom management. The ESAS may be provided
to the patient to complete while in the reception area. Pain and other symptoms are assigned a numerical
rating between 0 (none) and 10 (most severe imaginable). Record the level and range of symptom severity,
aiming for < 3 and thoroughly assess for values > 4. For ESAS symptom scores, using pain as an example, a
useful frame of reference is:2
• 0-1: no pain or minimal pain
• 3: able to watch TV or read newspaper without paying much attention to pain
• 5: pain is too distracting to find much pleasure in activities (e.g. TV, reading)
• > 5: on the verge of being or already overwhelmed by pain
• 10: the worse pain that you could imagine
d. Establish goals of care with patients and families.

• As the underlying condition progresses, a patient's goals of care often become less disease-specific and
more palliative.
• Discuss a patient's wishes before clinical deterioration, possibly over several visits. Start by determining
how much the patient desires to know about their disease and how much they desire to participate in
decision making. When translation is required, a professional interpreter (rather than family member) is
advisable.
• Determine the patient's understanding of the disease and condition.
• Discuss the anticipated course of illness, treatment choices, and options in relation to a patient's
preferences, needs, and expectations.
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• Document advance care planning discussions and the existence of any Advance Directive/
Representation Agreement. Document whether the No CPR +/- Planned Home Death forms are
completed (refer Resources Section).
• Identify and appoint a legal substitute decision maker, ideally a person familiar with the patient's
preferences and able to make informed choices.
• Establish plans for key decisions for acute episodes, crisis events, and declining function in relation
to life-sustaining therapies and hospitalizations, considering all co-morbidities.
• Clarify the patient's preferred place of care.
• Establish caregiver's ability to provide care at home if that is the patient's preference.
• Review both regularly and when there is a change in clinical status.
e. Management strategies: non-pharmacologic.

• Lifestyle management
• Exercise: Regular exercise and activity has been proven to improve quality of life and function in
cancer survivors.3
• Nutrition: Nutritional needs are different for patients with cancer, i.e. appetite is often reduced and
forcing additional food may contribute to nausea or vomiting. When the goal is life prolongation, a
consultation with a dietician may be helpful.
• Rest: Fatigue is a common accompaniment of cancer or its treatment. Adequate rest and pacing of
activities is important. Poor sleep will contribute to a lower quality of life for both patient and
caregiver.
• Family support:
• Caregivers who take time off work can apply for the Employment Insurance (EI) Compassionate Care
Benefit (refer Resource Section).
• Application can be made to the Palliative Benefits Program when a patient's life expectancy is
estimated to be < 6 months (refer Resource Section).
• Completing the “ Notification of Expected Death in the Home” form means families can avoid waiting
for a physician to pronounce death.
• Patient self management (refer Patient Information and Resource Sheet)
• Encourage patients to have an advance care planning discussion with family and/or caregivers (for
an example see the “ My Voice” booklet in the Resource Section).
• Symptom reporting: Suggest that patients record symptoms using a numerical rating scale (0 = none
to 10 = extreme) and report symptoms consistently > 4.
• Medications: Suggest that patients keep up-to-date medication profiles to carry with them to
appointments and ER visits, including flowsheets to record break-through medication. Ensure that
treatment of incident pain is understood.
• Bowel protocol: Constipation, an opioid side effect, does not improve over time. Provide written
instructions for a bowel protocol that patients may self administer (refer Patient Information and
Resource sheet).
• Providing help 24/7: Includes contact numbers (and hours, where applicable) for the GP on call,
home nursing, and HealthLinkBC (call 811).
f. Management strategies: pharmacotherapy.

See “ Palliative Care Guideline Part 2: Pain and Symptom Management” available at www.bcguidelines.ca/
guideline_palliative2.html
g. Referral to a specialist (refer Appendix D).
h. Indications for referral to a tertiary palliative care unit.

• Control of pain and other symptoms when these cannot be met in the community.
• Support for severe psychological, spiritual, or social distress.
i. Ongoing care.
• Planned visits.
• A shared care plan, complete with planned follow-up visits, helps patients and family feel supported.
Planned visits proactively anticipate care transitions and care crises.
3 Diagnostic
Palliative Care for the PATiENT wiTH Incurable Cancer or A dvanced DiSEASE Code: 239
• Recommended visit frequency depends on prognosis, e.g., if the illness is stable (PPS > 70%),
quarterly visits are recommended; if the illness is changing monthly, then visit monthly. More
frequent planned visits are warranted in the face of more rapid decline.
• Monitoring and Documentation (refer Appendix E - Cancer Management Flow Sheet).
• Prognostic factors: Monitor for impending transition or crisis, e.g. new or accelerated weight loss,
dyspnea, cognitive impairment, or change in PPS.
• Signs and symptoms: Each visit, record pain scale for each pain type and location.
• Medications: In addition to slow release opioid, record use of breakthrough meds, antinauseants,
and bowel protocol. Also consider adjuvant analgesics (see “ Palliative Care Guideline Part 2:
Pain and Symptom Management” available at www.bcguidelines.ca/guideline_palliative2.html).
• Care plan: Ensure that supports for patient and family are arranged through Home and Community
Care www.health.gov.bc.ca/hcc/ and also document discussions regarding patient goals and
advance directives.
• Palliative care emergencies: recognize and respond.
Emergency Investigation Intervention

Spinal cord compression Stat MRI (CT if MRI Dexamethasone, surgical decompression and/or
is not available) radiotherapy
Superior vena cava CT chest Dexamethasone, SVC stent or radiotherapy
compression
Pathological fracture X-ray, CT Internal/external fixation, sufficient analgesia
Acute renal failure / Ultrasound Ureteral stents or nephrostomies
obstructive nephropathy
Other: airway obstruction, As required Anticipate and provide crisis orders
hemorrhage, seizures
MRI - magnetic resonance imaging; CT - computed tomography; S^C - superior vena cava
j. Allied health care and referral to the local hospice palliative care program.
• High quality palliative care is generally provided via a team approach and GPs are important team
members as they often have good relationships with patients and families and the knowledge and
expertise to co-ordinate and provide care for the whole patient. Team members may include
medical specialists, advanced practice nurses, home care nurses, social workers, case managers,
pharmacists, occupational therapists, physiotherapists, dieticians, spiritual care workers, hospice
volunteers, and home support workers.
• Patients are often best educated by allied health providers when it comes to topics such as myths about
opioids, proper use of breakthrough medications, managing side effects, accessing help after hours, how
to plan a home death, etc.
• Refer to the local hospice palliative care program early in the illness trajectory so patients and their
families can learn what home supports are available before they are required.
k. Actively dying: The End of Life (EOL) Care check list.

Points to consider when patients enter the dying phase:
• Review a patient's goals of care, preferred place of care, what to do in an emergency.
• Refer to home nursing if not already arranged.
• Ensure that the required forms are completed (No CPR and/or Planned Home Death).
• Discontinue non-essential medications.
• Arrange for subcutaneous (SC) / transdermal medication administration or a drug kit to be placed in the
home when a patient is no longer able to take medications by mouth (refer Appendix F).
• Arrange for a hospital bed +/- pressure relief mattress.
• Arrange for a Foley catheter as needed.
• Leave an order for a SC anti-secretion medication (e.g., atropine, glycopyrrolate). Refer Palliative Care
Part 2: Pain and Symptom Management - Dyspnea at www.bcguidelines.ca/guideline_palliative2.html
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l. Bereavement (see “Palliative Care Guideline Part 3: Grief and Bereavement” available at www.bcguidelines.
ca/guideline_palliative3.html).
It is important to predict and be prepared to manage complex grief, of which 3 types have been determined:
Complexity Comments
Non complex Usual care would be follow-up after death and at 6 and 12 months.
Middle complexity More time and support is required (e.g., children of a dying parent).
Very complicated Characterized by bizarre grieving (includes people with mental illness).
Follow-up is important, but recognition of and preparation for complex grieving optimally takes place before
death occurs.
Rationale
Patients diagnosed with incurable cancer may not identify themselves as requiring palliative care. A palliative
approach addresses the needs for pain and symptom management, and psychosocial and spiritual support of
patients and their families, even if they chose to undergo life-prolonging chemotherapy, radiotherapy, and/or
surgery. A proactive chronic disease management approach will help prevent care gaps that may occur during
transitions in the cancer journey and/or when the patient is not supported by a cancer agency or community
hospice palliative care program.
References
(These references were chosen to be helpful and do not form an exhaustive list.)
1. Royal College of General Practitioners. The gold standards framework. Prognostic indicator guidance to
aid identification of adult patients with advanced disease, in the last months/ year of life, who are in
need of supportive and palliative care. Version 2.25 c2006. [cited 2010 March 22]. Available from
www.healthcareforlondon.nhs.uk/assets/End-of-life-care/Prognostic-Indicator-Guide-2008.pdf
2. Lynn J, Schuster J, Wilkinson A, et al. Improving care for the end of life: a sourcebook for health care
managers and clinicians. Oxford University Press. 2008.
3. Cramp F, Daniel J. Exercise for the management of cancer-related fatigue in adults. [Cochrane Review]. In:
The Cochrane Library, Issue 2, 2008.
Resources
BC EOL Care: www.health.gov.bc.ca/hcc/endoflife.html
BC Palliative Care Benefits Program Application form: www.health.gov.bc.ca/exforms/pharmacare/349fil.pdf
BC Palliative Care Benefits Program Physician Guide: www.health.gov.bc.ca/pharmacare/outgoing/palliative-
physguide.pdf
BC Pharmacare Special Authorities Branch: 1-877-657-1188, fax: 1-250-405-3587
BC Provincial Palliative Care Consult Line (available for physicians only, 24/7): 1-877-711-5757
BCCA Pain and Symptom Management Clinics at each of 5 regional cancer centres: www.bccancer.bc.ca/PPI/
InfoforNewPatients/CancerCentres.htm
Community Healthcare and Resource Directory (CHARD): http://info.chardbc.ca/faq.asp
(Toll free) 1-877-330-7322, (Lower Mainland) 604-215-7109
Fraser Health Hospice Palliative Care Symptom Guidelines: www.fraserhealth.ca/professionals/resources/
hospice_palliative_care/hospice_palliative_care_symptom_guidelines
General Practice Services Committee (GPSC) - Palliative Care Initiative:
www.gpscbc.ca/family-practice-incentive/palliative-care-initiative
Gold Standards Framework: www.goldstandardsframework.nhs.uk/
Health Care Providers' Guide to Consent to Health Care:
www.health.gov.bc.ca/library/publications/year/2011/health-care-providers'-guide-to-consent-to-health-care.pdf
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Joint Protocol for Expected/Planned Home Death: www.health.gov.bc.ca/hcc/pdf/expected_home_death.pdf
My Voice Advance Care Plan booklet: www.fraserhealth.ca/your_care/advance_care_planning/resources/
No CPR Form: www.health.gov.bc.ca/exforms/bcas/302.1fil.pdf
Notification of Expected Death in the Home form: www.health.gov.bc.ca/exforms/mspprac/3987fil.pdf
Palliative Care Integration Project: http://meds.queensu.ca/palliativecare/assets/ccp_lite.pdf
Abbreviations
CPR cardiopulmonary resuscitation

CT computed tomography
EI Employment Insurance
ESAS Edmonton Symptom Assessment System
MRI magnetic resonance imaging
PPS Palliative Performance Scale
SC subcutaneous
SVC superior vena cava
Appendices
Appendix A: Palliative Performance Scale (PPS) Including Instructions for Use

Appendix B: Possible Investigations and Interventions
Appendix C: Edmonton Symptom Assessment System (ESAS)
Appendix D: Indications for Referral to a Specialist
Appendix E: Cancer Management Flow Sheet
Appendix F: Contents of typical home drug kit & medications that may be given by SC route
This guideline is based on scientific evidence current as of the Effective Date.
The guideline was developed by the Family Practice Oncology Network and the Guidelines and Protocols Advisory
Committee. The guideline was approved by the British Columbia Medical Association and adopted by the Medical
Services Commission.
A mobile version of this and other guidelines is also available at www.BCGuidelines.ca
The principles o f the G uidelines and Protocols A dvisory Com m ittee are to:
C ontact Inform ation
• encourage appropriate responses to common medical situations Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
• recommend actions that are sufficient and efficient, neither excessive nor deficient Victoria BC V8W 9P1
E-mail: hlth.guidelines@gov.bc.ca
• permit exceptions when justified by clinical circumstances Web site: www.BCGuidelines.ca
DISCLAIMER
The Clinical Practice Guidelines (the “Guidelines”) have been developed by the Guidelines and Protocols Advisory Committee on behalf
of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more
preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or
professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.
W e cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need m edical
advice, please contact a health care professional.
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Appendix A: Palliative Performance Scale (PPS)
PPS Ambulation Activity & Evidence of Self-Care Intake Conscious Level

Level Disease
100 % Full N orm al a c tiv ity & w o rk Full N orm al Full
No e vid e n ce o f disease
90 % Full N orm al a c tiv ity & w o rk Full N orm al Full
S om e e vide nce of disease
80% Full N orm al a c tiv ity w ith e ffo rt Full N orm al or Full
S om e e vide nce of disease red uce d
70% R educed U n ab le norm al jo b /w o rk Full N orm al or Full

S ig n ifica n t disease red uce d
60% R educed U n ab le h o b b y /h o u s e w o rk O ccasio na l N orm al or Full

S ig n ifica n t disease a ssista n ce necessary red uce d or co n fu sio n
50 % M ainly S it/L ie U n ab le to do any w o rk O ccasio na l N orm al or Full

Extensive disease assista n ce required red uce d or co n fu sio n
40 % M ainly in Bed U n ab le to do m o s t a ctivity M a in ly a ssista nce N orm al or Full o r d ro w sy

Extensive disease red uce d + /- co n fu sio n
30 % T otally Bed U n ab le to do any a ctivity Total Care N orm al or Full o r d ro w sy

B ou nd Extensive disease red uce d + /- co n fu sio n
20 % T otally Bed U n ab le to do any a ctivity Total Care M in im al to Full o r d ro w sy

B ou nd Extensive disease sips + /- co n fu sio n
10 % T otally Bed U n ab le to do any a ctivity Total Care M o u th care D row sy or co m a

B ou nd Extensive disease only + /- co n fu sio n
0% Death - - - -
Copyright 2001 © Victoria Hospice Society
1. PPS scores are determined by reading horizontally at each level to find a ‘best fit' for the patient which is then
assigned as the PPS% score.
2. Begin at the left column and read downwards until the appropriate ambulation level is reached, then read across to
the next column and downwards again until the activity/evidence of disease is located. These steps are repeated until
all five columns are covered before assigning the actual PPS for that patient. In this way, ‘leftward' columns (columns
to the left of any specific column) are ‘stronger' determinants and generally take precedence over others.
Example 1: A patient who spends the majority of the day sitting or lying down due to fatigue from advanced disease
and requires considerable assistance to walk even for short distances but who is otherwise fully conscious level with
good intake would be scored at PPS 50%.
Example 2: A patient who has become paralyzed and quadriplegic requiring total care would be PPS 30%. Although
this patient may be placed in a wheelchair (and perhaps seem initially to be at 50%), the score is 30% because he or
she would be otherwise totally bed bound due to the disease or complication if it were not for caregivers providing
total care including lift/transfer. The patient may have normal intake and full conscious level.
Example 3: However, if the patient in example 2 was paraplegic and bed bound but still able to do some self-care
such as feed themselves, then the PPS would be higher at 40 or 50% since he or she is not ‘total care.'
3. PPS scores are in 10% increments only. Sometimes, there are several columns easily placed at one level but one
or two which seem better at a higher or lower level. One then needs to make a ‘best fit' decision. Choosing a ‘half-fit'
value of PPS 45%, for example, is not correct. The combination of clinical judgment and ‘leftward precedence' is
used to determine whether 40% or 50% is the more accurate score for that patient.
4. PPS may be used for several purposes. First, it is an excellent communication tool for quickly describing a
patient's current functional level. Second, it may have value in criteria for workload assessment or other
measurements and comparisons. Finally, it appears to have prognostic value.
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Definition of Terms for PPS
As noted below, some of the terms have similar meanings with the differences being more readily apparent as one reads
horizontally across each row to find an overall ‘best fit' using all five columns.
1. Ambulation
The items ‘mainly sit/lie,’ ‘mainly in bed,’ and ‘totally bed bound’ are clearly similar. The subtle differences are related
to items in the self-care column. For example, ‘totally bed bound' at PPS 30% is due to either profound weakness
or paralysis such that the patient not only can't get out of bed but is also unable to do any self-care. The difference
between ‘sit/lie' and ‘bed' is proportionate to the amount of time the patient is able to sit up vs need to lie down.
‘Reduced ambulation’ is located at the PPS 70% and PPS 60% level. By using the adjacent column, the reduction of
ambulation is tied to inability to carry out their normal job, work occupation or some hobbies or housework activities.
The person is still able to walk and transfer on their own but at PPS 60% needs occasional assistance.
2. Activity & Extent of Disease

‘Some,’ ‘significant,’ and ‘extensive’ disease refer to physical and investigative evidence which shows degrees of
progression. For example in breast cancer, a local recurrence would imply ‘some' disease, one or two metastases in the
lung or bone would imply ‘significant' disease, whereas multiple metastases in lung, bone, liver, brain, hypercalcemia
or other major complications would be ‘extensive' disease. The extent may also refer to progression of disease despite
active treatments. Using PPS in AIDS, ‘some' may mean the shift from HIV to AIDS, ‘significant' implies progression in
physical decline, new or difficult symptoms and laboratory findings with low counts. ‘Extensive' refers to one or more
serious complications with or without continuation of active antiretrovirals, antibiotics, etc.
The above extent of disease is also judged in context with the ability to maintain one's work and hobbies or activities.
Decline in activity may mean the person still plays golf but reduces from playing 18 holes to 9 holes, or just a par 3, or
to backyard putting. People who enjoy walking will gradually reduce the distance covered, although they may continue
trying, sometimes even close to death (e.g. trying to walk the halls).
3. Self-Care
‘Occasional assistance’ means that most of the time patients are able to transfer out of bed, walk, wash, toilet and eat
by their own means, but that on occasion (perhaps once daily or a few times weekly) they require minor assistance.
‘Considerable assistance’ means that regularly every day the patient needs help, usually by one person, to do some
of the activities noted above. For example, the person needs help to get to the bathroom but is then able to brush his or
her teeth or wash at least hands and face. Food will often need to be cut into edible sizes but the patient is then able to
eat of his or her own accord.
‘Mainly assistance’ is a further extension of ‘considerable.' Using the above example, the patient now needs help
getting up but also needs assistance washing his face and shaving, but can usually eat with minimal or no help. This
may fluctuate according to fatigue during the day.
‘Total care’ means that the patient is completely unable to eat without help, toilet or do any self-care. Depending on the
clinical situation, the patient may or may not be able to chew and swallow food once prepared and fed to him or her.
4. Intake
Changes in intake are quite obvious with ‘normal intake' referring to the person's usual eating habits while healthy.
‘Reduced' means any reduction from that and is highly variable according to the unique individual circumstances.
‘Minimal' refers to very small amounts, usually pureed or liquid, which are well below nutritional sustenance.
5. Conscious Level
‘Full consciousness’ implies full alertness and orientation with good cognitive abilities in various domains of
thinking, memory, etc. ‘Confusion’ is used to denote presence of either delirium or dementia and is a reduced level of
consciousness. It may be mild, moderate or severe with multiple possible etiologies. ‘Drowsiness’ implies either fatigue,
drug side effects, delirium or closeness to death and is sometimes included in the term stupor. ‘Coma’ in this context
is the absence of response to verbal or physical stimuli; some reflexes may or may not remain. The depth of coma may
fluctuate throughout a 24 hour period.
© Copyright Notice.
The Palliative Performance Scale version 2 (PPSv2) to o l is copyright to Victoria Hospice Society and replaces the first PPS published in 1996 [J Pal Care. 9(4):26-32]. It cannot be altered o r used in any
way other than as intended and described here. Programs may use PPSv2 with appropriate recognition.
Appendix B: Possible Investigations and Interventions
Reason for Investigation Investigation Possible Interventions

Reversible causes of bone Bone scan (for metastases) Radiotherapy, bisphosphonates
pain X-ray/CT spine (for compression Cementoplasty
fracture)
Reversible causes of Chest x-ray (for pleural effusion) Thoracentesis, pleurodesis
dyspnea CT pulmonary angiogram or V/Q scan Anticoagulation
(for pulmonary embolism)
Pulmonary function testing Bronchodilators
Pulse oximetry, Arterial blood gases Supplemental O2 if hypoxemic
CBC & diff, BNP Treat infection, anemia, CHF if present
Reversible causes of Calcium (ionized) (for hypercalcemia) Hydration, bisphosphonates, calcitonin
confusion Electrolytes (for hyponatremia)
eGFR (for renal failure) Hydration, ureteric stents
CBC & diff/cultures (for sepsis) Treatment of sepsis or infection
CT head (for cerebral metastases) Dexamethasone, radiotherapy
KUB x-ray (for fecal loading) Aggressive bowel protocol
Bladder scan or in/out catheterization Urinary catheterization
Reversible causes of Hemoglobin (for anemia) RBC transfusion
fatigue Potassium (for hypokalemia) Potassium supplementation
eGFR, liver function tests (for renal or
hepatic dysfunction)
Reversible causes of CT abdomen (for common bile duct Common bile duct stent
jaundice obstruction)
Reversible causes of eGFR (for pre-renal failure) Hydration
nausea & vomiting 3 views of abdomen (bowel obstruction) Stent, venting gastrostomy, medical treatment
of small bowel obstruction, bowel protocol
Obvious or suspected Ultrasound Diagnostic/therapeutic paracentesis
malignant ascites Albumin, eGFR, liver function tests Spironolactone/furosemide
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Appendix C: Edmonton Symptom Assessment System (ESAS)
= —=—Capital _!P_
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CARTTASlllil HEALTHGROUP
Edmonton Symptom Assessment System

Numerical Scale
Regional Palliative Care Program
Please circle the numbe that best describes
No pain 0 2 3 4 5 6 7 8 9 10 Worst possible pain
Not tired 0 2 3 4 5 6 7 8 9 10 Worst possible

tiredness
Not nauseated 0 2 3 4 5 6 7 8 9 10 Worst possible nausea
Not depressed 0 2 3 4 5 6 7 8 9 10 Worst possible

depression
Not anxious 0 2 3 4 5 6 7 8 9 10 Worst possible anxiey
Not drowsy 0 2 3 4 5 6 7 8 9 10 Worst possible

drowsiness
Best appetite 0 2 3 4 5 6 7 8 9 10 Worst possible

appetite
Best feeling of 0 2 3 4 5 6 7 8 9 10 Worst possible feeling

well-being of well-being
No shortness of 0 2 3 4 5 6 7 8 9 10 Worst possible

breath shortness of breath
Other problem 0 2 3 4 5 6 7 8 9 10
Complete by (check one)

Patient's Name
□ Patient
Date Time □ Caregiver
□ Caregiver assisted
Bruera E, Kuehn N, Miller MJ, et al. The Edmonton Symptom Assessment System (ESAS): a simple method of the assessment of palliative care
patients. J Palliat Care. 1991;7:6-9.
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Appendix D: Indications for Referral to a Specialist
Indication Procedure Physician Specialty

OBSTRUCTED LUMEN
Stenting
C o m m o n bile d u c t (CBD) C B D ste n t G a stro e n te ro lo g ist
E sophageal ste n t T h o ra cic/G I surgeon

E sophagus
B ra ch yth e ra p y R adiation o n c o lo g is t
D uodenum D uodenal ste n t

G a stro e n te ro lo g ist, GI surgeon
C olon C o lo n ic ste n t
U reter U reteric ste n t U ro lo g ist
S up erior ven a cava (SVC) SVC ste n t Interve ntion al ra d io lo g ist
B ron chu s R adiotherapy, bra ch yth e ra p y R adiation o n c o lo g is t
Venting
High sm all bo w e l o b s tru c tio n Venting g a s tro s to m y
GI surgeon
L o w e r bo w e l o b s tru c tio n D e -fu n ctio n in g c o lo s to m y
U reter N e p h ro sto m y U ro lo g ist

HEMORRHAGE
R a dio thera py R adiation o n c o lo g is t
H e m o p tysis
Laser th e ra p y R e sp iro lo g ist
U p pe r GI e n d o s c o p y G a stro e n te ro lo g ist
H em atem esis
R a dio thera py R adiation o n c o lo g is t
V ag in al/ute rine R a dio thera py R adiation o n c o lo g is t
Rectal Laser c o a g u la tio n G a stro e n te ro lo g ist
H em aturia R a dio thera py R adiation o n c o lo g is t
Skin su rfa ce o f tu m o u r R a dio thera py R adiation o n c o lo g is t
EFFUSION
T h o ra ce n te sis GP, ra d io lo g is t
P leurodesis R e sp iro lo g ist

Pleural effusion
Pleural c a th e te r T h o ra c ic surgeon
C h em o th erap y, ra d io th e ra p y M ed ica l o n c o lo g is t
P aracentesis GP, ra d io lo g is t
M a lig n a n t ascite s
P eritoneal c a th e te r Interve ntion al ra d io lo g ist
PAIN
B one p a in /p a th o lo g ic a l fracture s R a dio thera py R adiation o n c o lo g is t
C a nce r o f th e pancreas C o eliac plexus b lo c k A n e sth e tist, g a s tro e n te ro lo g is t (U/S)
Severe o p io id re sista n t pain K eta m ine by co n tin u o u s su b cu ta n e o u s P alliative care ph ysicia n

infusion (CSCI) or Lid o ca in e CSCI
N euroaxial b lo c k A n e sth e tist
V ertebral co m p re ssio n fra ctu re s V e rte b ro p la sty Interve ntion al ra d io lo g ist, neurosurgeon
> 5 0 % o f th e c o rte x o f fe m u r or In tra m e d u lla ry nailing O rth o p e d ic surgeon

hu m eru s involved
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Appendix E: Cancer Management Flow Sheet
P a tie n t E n co u n te rs, D ia g n o s tic /C lin ic a l D a ta /P ro g n o stic D ata, by Date
Review: Enter Review Date: dd-mm-yyyy Baseline: Date: Date: Date: Date:
lbs lbs lbs lbs lbs

WEIGHT
Prognostic
kg kg kg kg kg
Performance Status - P PS (0-100%) % % % % %
Dyspnea (0-10)
Cognitive Impairment/Confusion
Pain 1: location: type: (0-10)

Symptoms (VAS 0-10)
Nausea (0-10)
Constipation
Other 1 (ie: fatigue)
Other 2 (ie: disease specific S x - dysphagia)
Lungs / BP (query Hypotension)
Liver/Spleen/Abdomen
Spine/Bone
Signs
C N S (query Cord compression)
Nodes
Skin /Edema
Lab (use for tumour marker, Hb, INR, Ca++, albumin etc.)
Systemic:
X
cc Biological:
r
e
c
n Hormonal:
a
c
iti
n Radiation
A
M edications
Other: ( b is p h o s p h o n a te , p a ra c e n te s is , R B C tra n s fu s io n , etc.)
Opioid SR:
Control
Opioid IR:
Antiemetic: (eg: metoclopramide)

Symptom
Bowel Protocol:
Adjuvant 1: (query neuropathic pain)
Adjuvant 2: (query dexamethasone)
DNR О H o m e D N R fo rm ЦЦ E x p e c te d h o m e d e a th fo rm
Care Plan
P a llia tiv e C a re d B e n e fits F orm ЦЦ D is c u s s io n :

P ro g ra m R e fe rra l d H o m e c a re
A d v a n c e D ire c tiv e d D is c u s s io n
P re fe rre d p la c e o f c a re :
Proxy: Phone:
Copyright © 2006 Family Practice Oncology Network, BCCA.
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Appendix F: Contents of typical home drug kit & medications that may be given by SC route
Contents of a typical home drug kit1

Atropine 0.6 mg/mL - 10 amps Hydromorphone 50 mg/mL - 2 amps
Atropine 1% gtts - 5 mL bottle Lorazepam 1 mg sublingual - 20 tablets
Dexamethasone 20 mg/5 mL - 2 vials Methotrimeprazine 25 mg/mL - 10 amps
Diclofenac 100 mg supp - 10 supps Metoclopramide 10 mg/2 mL - 4 amps
Dimenhydrinate 50 mg/mL - 10 amps Midazolam 10 mg/2m L- 5 vials
Fentanyl 25 mcg/hr patch - 2 patches Morphine 10 mg/mL - 20 amps
Fentanyl 50 mcg/hr patch - 2 patches Morphine 50 mg/mL - 10 amps
Glycopyrrolate 0.4 mg/2 mL - 5 vials Phenobarbital 120 mg/mL - 10 amps
Haloperidol 5 mg/mL - 5 amps Prochlorperazine 10 mg supps -10 supps
Hydromorphone 2 mg/mL - 10 amps Sufentanil 50 mcg/mL - 10 amps (for SL use)
Hydromorphone 10 mg/mL - 10 amps
Availability, usage procedures, and contents o f emergency drug kits vary throughout the province; contact your local Home
Health Care Office o r Palliative Care Team for information.
Medications that may be given by the SC route in the primary care setting2 (maximum volume per SC injection site = 2 ml)
Atropine (0.6 mg/mL) Ketorolac (30 mg/mL)
Calcitonin Lidocaine
Chlorpromazine (25 mg/mL) Lorazepam (4 mg/mL)
Clodronate (30, 60 mg/mL) Low molecular weight heparin
Codeine (15, 30 mg/mL) Loxapine (50 mg/mL)
Dexamethasone (4 mg/mL) Methadone (Special Access)
Dimenhydrinate (Gravol® 50 mg/mL)* Methylnaltrexone (Relistor®) (20 mg/mL)
Diphenhydramine (Benadryl® 50 mg/mL) Midazolam (5 mg/mL)
Droperidol (2.5 mg/mL) Methotrimeprazine (Nozinan®) (25 mg/mL)
Epinephrine Metoclopramide (5 mg/mL)
Fentanyl (50 mcg/mL) Morphine (10, 50 mg/mL)**
Furosemide (10 mg/mL - note max. 20 mg. SC/site) Naloxone (0.4 mg/mL)
Glycopyrrolate (0.2 mg/mL) Octreotide
Haloperidol (5 mg/mL) Ondansetron (2 mg/mL)
Heparin Potassium Chloride (2 mEq/mL)
Hydromorphone (2,10, 50 mg/mL) Phenobarbital (120 mg/mL)
Hydroxyzine (50 mg/mL) Ranitidine (25 mg/mL)
Hyoscine butylbromide (20 mg/mL) Scopolamine (0.4, 0.6 mg/mL)
Ketamine (10 mg/mL) Sufentanil (50 mcg/mL)
* caution - sterile SC abscesses and skin necrosis
** caution - SC nodules if concentration > 50 m g/m l
References
1. Fraser Health Hospice Palliative Care. Palliative Care Kit Package. Fraser Health, B.C. July 14, 2006. [Information on file].
2. Derek Doyle, Geoffrey Hanks, Nathan Cherny, Kenneth Calman. Oxford Textbook of Palliative Medicine: 3rd ed. New york:
Oxford University Press; 2005. p 218.
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ADVISORY COMMITTEE
Part 2: Pain and Symptom Management
Effective Date: September 30, 2011
Introduction
This guideline presents strategies for the assessment and management of cancer pain, and symptoms associated with
advanced disease. The guideline is divided into seven sections, providing recommendations for evidence-based symptom
management (Palliative Care Guidelines, Part 2). The recommendations are algorithm-based to facilitate quick access to
the information required. It is intended for use in patients 19 years of age or older.
Key symptom areas addressed are:

Pain
Dyspnea
Nausea and Vomiting
Constipation
Delirium
Fatigue and Weakness
Depression
Diagnostic Code: Neoplasm of unspecified nature: 239
Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html,

Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html
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GUIDELINES & P R O TO C O L S
ADVISORY COMMITTEE
Pain Management
Scope
This section presents assessment and management strategies for dealing with cancer pain and pain associated with
advanced disease.
Salient Principles in this Section:

• Opioid management principles
• Utilizing adjuvant medication for pain-specific management
Included in this Section:
A - Pain management algorithm
B - Tables for opioid conversion
C - Analgesic medication reference tables
Pain Assessm ent (Refer A ppendix A - Cancer Pain Management A lgorithm )

a) Symptom assessment. Use the OPQRSTUV mnemonic to assess pain:
O Onset e.g., When did it start? Acute or gradual onset? Pattern since onset?
P Provoking / palliating What brings it on? What makes it better or worse, e.g., rest, meds?
Q Quality Identify neuropathic pain (burning, tingling, numb, itchy, etc.)
R Region / radiation Primary location(s) of pain, radiation pattern(s)
S Severity Use verbal descriptors and/or 1-10 scale
T Treatment Current and past treatment; side effects
U Understanding Meaning of the pain to the sufferer, “total pain”
V Values Goals and expectations of management for this symptom
b) Physical exam: Look for signs of tumor progression, trauma, or neuropathic etiology: hypo- or hyper-esthesia,
allodynia (pain from stimuli not normally painful).
Pain Management Strategies (Refer A ppendix A)

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

Difficult constipation fentanyl transdermal or methadonea
Renal failure fentanyl transdermal or methadonea morphineb, codeine, meperidinec
Compliance & time release formulations, e.g., morphine,
convenience hydromorphone, oxycodone
Neuropathic pain oxycodone or methadoned (anecdotal
evidence)
Opioid naive low dose morphine, hydromorphone or fentanyl transdermal patch
oxycodone (risk of delayed absorption and overdose
potential), sufentanil
Injection route (e.g., SC) morphine, hydromorphone, (methadonee: oxycodone (injectable) is not available in
second line) Canada
a. Fentanyl is primarily (75%) cleared as inactive metabolites by the kidney and methadone is cleared hepatically.
b. Morphine is the least preferred in renal failure because of renally cleared active metabolites.
c. Meperidine (Demerol®) should not be used for the treatment of chronic pain.
d. If a patient in your practice is started on methadone by a palliative care physician, in order to renew prescriptions, it is possible to obtain individual
patient methadone prescribing authorization through the College of Physicians and Surgeons of British Columbia.
e. Injectable methadone may be obtained through the Health Canada Special Access Program at www.hc-sc.gc.ca/dhp-mps/acces/drugs-drogues/index-
eng.php. Consultation with a palliative care physician is suggested prior to initiation.
Opioid S w itching (“ ro tation” )

• Switch to another opioid when inadequate analgesia is obtained despite dose-limiting adverse effects (AEs).
This allows for clearance of opioid metabolites and possibly more effective opioid receptor agonist profile from
the new drug.
• Switch to an equianalgesic dose of the second opioid, bearing in mind that published ratios are only a guide
and that reassessment and dose modification are required.
• When switching because of AEs (e.g., delirium or generalized hyperalgesia), determine the equianalgesic dose
and reduce this dose by 25%. Observe closely, allowing for onset of the new and wearing-off of the previous
drug.
• Refer Appendix B - Equianalgesic Conversion for Morphine.
Opioid AEs (switch if not managed symptomatically and AE persists for > 1 week)
• Constipation:
Stepwise escalation of regular oral stimulant or osmotic laxative on opioid initiation. Consider
methylnaltrexone* for refractory cases. Refer to Part 2 Section: Constipation, and the associated
Appendix A - Constipation Management Algorithm.
• Nausea:
Resolves after ~ 1 week. Consider metoclopramide* first line; avoid dimenhydrinate (Gravol®).
• Sedation:
Stimulants may be helpful if sedation persists, e.g., methylphenidate, dextroamphetamine,
or modafanil.
• Myoclonus:
May respond to benzodiazepines but may be a sign of opioid toxicity requiring hydration, opioid
dose reduction or rotation.
• Delirium:
Assess for other causes, e.g., hypercalcemia, UTI.
• Pruritus, sweating:
Try opioid rotation.
*Cancer, GI malignancy, GI ulcer, Ogilvie’s syndrome and concomitant use of certain medications (e.g. NSAIDs, steroids, and
bevacizumab) may increase the risk of GI perforation in patients receiving methylnaltrexone. [Health Canada MedEffect Notice:
www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/relistor_hpc-cps-eng.pdf]
3
PALLiATiVE C are for the PATiENT wiTH I ncurable C ancer or A dvanced DiSEASE - P art 2: PAiN and S ymptom M anagement
A djuvant Analgesics
• Select based on type of pain and AE profile. Optimize dosing of one drug before trying another. Discontinue
adjuvant drug if ineffective.
Severe opioid-resistant cancer pain

• Consult a palliative care specialist for advice.
A bbreviations
AEs adverse effects
GI gastrointestinal
NSAIDs non-steroidal anti-inflammatory drugs
SC subcutaneous
TENS transcutaneous electrical nerve stimulation
UTI urinary tract infection
Appendices
Appendix A - Cancer Pain Management Algorithm
Appendix B - Equianalgesic Conversion for Morphine
Appendix C - Medications Used in Palliative Care for Pain Management
The princip le s o f the G uidelines and P roto cols A d viso ry Com m ittee are to :
Contact Inform ation
• recommend actions that are sufficient and efficient, neither excessive nor deficient Victoria BC V 8W 9P1
DISCLAIMER
The Clinical Practice Guidelines (the “Guidelines”) have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical
Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to
the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health
care professional, nor are they intended to be the only approach to the management of clinical problems. We cannot respond to patients o r patient
advocates requesting advice on issues related to m edical conditions. If you need m edical advice, please contact a health care professional.
4
P alliative C are for the P arent wiTH I ncurable C ancer or A dvanced DiSEASE - P art 2: PAiN and S ymptom M anagement
A ppendix A: C ancer Pain M anagem ent Algorithm
*Use gastric cytoprotection (re fe r A ppe ndix C - M edications U sed in P alliative Care: Gastric Cytoprotection)
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A ppendix B: Equianalgesic Conversion fo r Morphine
Opioid Equianalgesic Dose For 20 mg Oral Morphine
(for chronic dosing)
DRUG SC/IV (mg) PO (mg) COMMENTS
morphine 10 20*
codeine 120 200 m etabolized to m orphine
fen ta nyl patch see ta b le be lo w - useful w h en PO / PR routes not an option
fentanyl 0.1 (100 m cg) usually dosed prn
less than 1 h o ur effect
hydrom o rpho ne 2 4
m ethadone ava ila ble throu gh Special 1 va ria b le equivalence: palliative o r pain consultation
Access Programme (1-7) advised
oxyco do ne not ava ila ble in C anada 13.3 va ria b le equivale nce
(6.7-20)
sufentanil 0.02 (20 m cg) usually dosed prn
less than 1 h o ur effect
* Clinical experience in chronic pain suggests that 10 mg SC/IV is equivalent to 20 to 30 mg PO morphine (1:2 to 1:3 conversion ratio). In practice, many
centers use the conversion of 10 mg SC/IV = 20 mg PO (1:2). In 2010 Health Canada recommended using the conversion of 10 mg SC/IV morphine =
30 mg PO (1:3) particularly when converting from morphine to fentanyl transdermal systems. In addition, Health Canada advises that there is insufficient
data available to guide conversion to fentanyl transdermal systems from IV/IM morphine doses greater than 90 mg and such conversions should be
done carefully and conservatively. Refer http://hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/fentanyl_2_hpc-cps-eng.pdf
Fentanyl Transdermal Equianalgesic Conversion Chart*

Morphine Hydromorphone PO (mg/day) Oxycodone Fentanyl Patch
PO (mg/day) PO (mg/day) (mcg/hr)
60 - 134 12 - 26 40 - 89 25
135 - 179 27 - 35 90 - 119 37.5
180 - 224 120 - 149 50
1
6
4
4
3
2 25 - 269 45 - 53 150 - 179 62.5

2 70 - 314 54 - 62 180 - 209 75
315 - 404 63 - 80 210 - 269 100
4 05 - 494 81 - 98 270 - 329 125
4 95 - 584 99 - 116 330 - 389 150
585 - 674 117 - 134 390 - 449 175
6 75 - 764 135 - 152 450 - 509 200
765 - 854 153 - 170 510 - 569 225
855 - 944 171 - 188 570 - 629 250
945 - 1034 189 - 206 630 - 689 275
1035 - 1124 207 - 224 690 - 749 300
*The Dose C onversion G uidelines are to be used to convert adult patients from th e ir current oral o r parenteral opio id analgesic to the fentanyl
patch only. The Dose Conversion Guidelines are unidirectional fo r use in chro nic pain only. They should not be used to convert patients from the
fentanyl transderm al system to oth er opioids, as this may result in overdose and toxicity. Refer to Health Canada website:
http://hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/fentanyl_ 2_hpc-cps-eng.pdf
Approximate Breakthrough Doses Recommended for Fentanyl Transdermal Patch

B rea kthrou gh should be 10% o f the total daily opioid dose
Patch Strength Oral Morphine Oral Hydromorphone Oral Oxycodone
mcg/hour Immediate Release (mg) Immediate Release (mg) Immediate Release (mg)
12 * 5 1 2.5 to 5
25 10 2 5 to 7.5
50 20 4 10 to 15
75 30 6 15 to 25
100 40 8 20 to 30
* fentanyl patch is labelled 12 mcg/hr but delivers 12.5 mcg/hr
Tables adapted from: Analgesic approximate equivalence charts. Fraser Health Hospice Palliative Care Clinical Practice Committee, May 30, 2005
[document on file] and Fraser Health Hospice Palliative Care Program. Principles of Opioid Management. November 24, 2006. [cited September 7,
2010]. Available from: www.fraserhealth.ca/media/16FHSymptomGuidelinesOpioid.pdf
A ppendix C: M edications0 Used in Palliative Care fo r Pain M anagem ent
Analgesics GI Medications Other

A ceta m ino ph en, N S A ID s G astric C ytop rotectio n and D yspepsia Bone Pain A d ju va n ts
O pioids
N e uro pathic Pain A d ju va n ts
A ntisp asm o dics, S keletal M uscle R elaxants
“Refer to guideline and/or algorithm for recommended order of use.
Tailor dose to each patient; those w ho are elderly, cachectic, debilitated o r w ith renal o r hepatic d ysfu nction may require reduced dosages;
con sult the m ost current product m onograph fo r th is inform ation: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp
ACETAMINOPHEN, NSAIDs
Generic Name Trade Name Available Dosage Standard Adult DoseA Drug Plan CoverageB Approx. cost
Forms Palliative Fair per 30 days
Care PharmaCare
& &
IR tabs, caplet:
(N
Ю
a
acetam in oph en Tylenol®, 325, 325 to 650 mg PO q4-6 h Yes, LC A No
^
CO
Panadol®, G 500 mg
'
SR tabs: 650 mg 650 to 1300 mg PO q 8 h Yes No $6 -1 2 C (G)
$ 11 - 21 C
Supps: 325, 650 mg 650 mg PR q4-6h Yes No $ 9 9-1 49(G )
[m ax: 4 g P O /PR pe r day]
celecoxib Celebrex® Caps: 100, 200 mg 100 to 200 mg PO bid Yes S pecial $42-84
A u th o rity
IR tabs:
(N
00
diclofe nac Voltaren®, G 25, 50 mg 25 to 50 mg PO tid Yes, LC A Yes, RDP
$ $
-6
-3
(G
)
00
2
SR tabs:
CD ^
75, 100 mg 75 to 100 mg PO once daily Yes, LC A Yes, RDP
$ $
-2 5
(G
88 02
)
13
Supps:
CD
50, 100 mg 50 mg PR tid Yes, LC A Yes, LC A
$ $
61
( 4
ibuprofen Advil®, Motrin®, Tabs:200, 300, 400, 200 to 400 mg PO q4h Yes, LC A Yes, LC A
$ $
- 31
5
( 6
G 600 mg [m ax: 24 00 mg per day]
indom ethacin G Caps: 25, 50 mg 25 to 50 mg PO tid No Yes, RDP $ 1 5-2 4 (G )
Supps: 50, 100 mg 50 to 100 mg PR bid No Yes $ 5 3-5 8 (G )
ke to ro la c Toradol®, G Tabs: 10 mg 10 mg PO qid [lim it duration] No No $10 (G )
$15
per 5 days
Inj: 10, 30 mg per mL 10 to 30 mg IM /IV */S C * q 6 h No No $34 (G )
[lim it duration] $19-58
per 2 days
naproxen Naprosyn®, G IR tabs: 250, 375, 250 to 500 mg PO bid Yes, LC A Yes, LC A $7 -14 (G )
500 mg $17-31
EC tabs: 250, 375, Yes, RDP Yes, RDP $ 1 3-3 1(G )
500 mg $27-63
SR tab: 750 mg 750 mg PO daily Yes, RDP Yes, RDP $33 (G), $42
Supp: 500 mg 500 mg PR bid Yes, LC A Yes, LC A $ 56 (G)
Abbreviations: caps capsules; EC enteric coated; G generics; IM intravenous; inj injection; IR Immediate Release; IV intravenous; LCA subject
to low cost alternative program; m ax maximum dose; PO by mouth; PR per rectum; RDP subject to reference drug program; SR slow release; SC
subcutaneous; supps suppositories (rectal); tabs tablets
A Preferred route of administration for NSAIDs is oral or rectal.

B PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost
separated as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations in Palliative Care Part 2 - Information
About Provincial Drug Coverage
CRetail cost (without prescription)
* This route of administration is used in practice, but not approved for marketing for this indication by Health Canada.
Tailor dose to each patient; those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require
reduced dosages; consult the most current product monograph for this information:
OPIOIDS
Generic Name Trade Name Available Dosage Standard Adult DoseA Drug Plan CoverageB Approx. cost
Care PharmaCare
fentanyl D u rag esic Patch: 12, 25, 37, 50, 12 to 100 mcg per h applied Yes, LC A S pecial $2 4 -1 8 6 (G )
MAT®, G 75, 100 m cg pe r h to skin eve ry 72 hours Authority, $ 1 13 -372C
LC A
G Inj: 50 mcg per m L 25 to 100 m cg su b lin g u a l* per Yes No $2-4 (G)
dose PRN per dose
IR tabs: 8 mg 8 mg PO q4h
C
h yd rom o rpho ne Dilaudid®, G 1, 2, 4, 2 to Yes, LC A Yes, LC A
M СЯ
$ $
22
-6 6
88
(G
)
H ydrom orph SR caps: 3, 6 , 12, 3 to 30 mg PO q12h Yes S pecial $4 2-2 42
Contin® 18, 24, 30 mg a u thority
Dilaudid®, G Inj:
2, 10, 20, 50, 100 2 to 10 mg SC q4h Yes, LC A Yes, LC A $1 8 4 -4 5 5 (G )
mg per m L $221-541
m orphine M.O.S.®, IR tabs: 5, 10, 25, 30, 5 to 60 mg PO q4h Yes, LC A Yes, LC A $21-114 (G )
MS-IR®, 40, 50, 60 mg $2 4-3 43
Statex®, G
M-Eslon®, SR tabs: 10, 15, 20, 10 to 200 mg PO q12h Yes, LC A Yes, LC A $ 1 8-8 4 (G )
M .O.S. SR®, 30, 60, 100, 200 mg $1 8-1 56
MS Contin®, G
G Inj: 1,2, 5, 10,15, 25, 2 to 25 mg SC q4h Yes Yes $1 7 1 -5 1 2 (G )
50 mg per m L
m ethadone M etadol™ Tabs: 1, 5, 10, 25 mg 1 to 25 mg PO q 8 h Yes No $16-161
M etadol™ , Oral Solution: 1, 2, Yes No, $ 2-8

com p ou nde d 5, 10, 20, 25 mg per Yes (com pounded)
mL $4-88
oxycodone Oxy. IR®, IR tabs: 5, 10, 20 mg 5 to 20 mg PO q4h Yes, LC A Yes, LC A $ 2 5-6 4 (G )
Supeudol®, G $5 1-1 30
OxyContin® SR tabs: 5, 10, 15, 5 to 80 mg PO q12h Yes S pecial $4 0-2 70

20, 30, 40, 60, 80 mg A u th o rity
s u fe n ta n ilD G Inj: 50 mcg per mL F or in cide nt pain: 12.5 mcg Yes Yes $7 (G ) per
su b lin g u a l*D /d o se PRN; dose
in crem en tal do ses titrated q 2 h
PRN up to 75 mcg
Abbreviations: G generics; h hour; inj injection; IR Immediate Release; PO by mouth; PRN as needed; SC subcutaneous;
SR slow release; tabs tablets
A Dosage requirements may go beyond range shown in table i.e. there is no maximum dose for opioids, unless limited by side
effects or toxicity.
B PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and
brand name cost separated as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations
in Palliative Care Part 2 - Information on Provincial Drug Coverage
CLower cost of range represents 25 mcg Duragesic® patches
DSufentanil is a potent opioid, initiation by a primary care provider for opiate naive patients is not recommended, instead refer for Palliative Care
Consult. Sublingual sufentanil may be considered for patients receiving at least 60 mg PO morphine equivalents
over the last 7 days. Refer to Fraser Health Guideline: Sublingual sufentanil for management of incident pain in palliative
patients (this is expected to be available in the future at http://fraserhealth.ca/EN/hospice_palliative_care_symptom_guidelines/).
* This route of administration is used in practice, but not approved for marketing for this indication by Health Canada.
NEUROPATHIC PAIN ADJUVANTS

Generic Name Trade Name Available Dosage Standard Adult Dose Drug Plan CoverageA Approx. cost
Care PharmaCare
cannabidiol, Sativex® Buccal spray: single 1 spra y bu ccally/sublin gua l No No $ 6 52 -978
D-9-T com b in ation product BID, increase by 1 spra y per
strength day up to 8 to 12 sprays per
day
clonazepam ^ Rivotril®, G Tabs: 0.25, 0.5, 1, 0.5 mg PO at bedtim e, up to Yes, LC A Yes, LC A $3 -22 (G )
2 mg 2 mg qid $6-44
de sip ra m in e t G Tabs: 10, 25, 50, 75, 10 to 25 mg PO at bedtim e; Yes, LC A Yes, LC A $ 1 2-5 8 (G )
100 mg increase q3-7 days up to
150 mg per day
d e x a m e th a so n e t G Tabs: 0.5, 0.75, 2, 2 mg PO /SC * daily to 8 mg Yes, LC A Yes, LC A $ 1 4-7 9 (G )
4 mg bid (am & noon)
Inj: 4, 10 mg per mL Yes, LC A Yes, LC A $ 5 5-8 3 (G )
d u lo xe tin e t Cymbalta® Caps: 30, 60 mg 30 to 60 mg PO daily No No $59-118
g a b a p e n tin t Neurontin®, G Tabs: 100, 300, 400, 300 to 1200 mg PO tid Yes, LC A Yes, LC A $4 9 -1 7 6 (G )
600, 800 mg $9 9-3 53
n o rtrip tylin e t Aventyl®, G Caps: 10, 25 mg 10 to 150 mg PO at bedtim e Yes, LC A Yes, LC A $4 -43 (G )
$7-87
p re g a b a lin t Lyrica® Caps: 25, 50, 75, 75 mg PO bid, increase q7 No No $ 1 02 -140
150, 300 mg days up to 300 mg bid
to p ira m a te t Topamax®, G Tabs: 25, 100, 200 25 mg PO da ily increase q7 No Yes, LC A $20-115 (G )
mg days up to 200 mg bid $4 1-2 29
Sprinkle caps: 15, No Yes $3 9-6 22
25 mg
v a lp ro ic a cidt Depakene®, G Caps/tabs: 250, 500 250 mg PO at bedtim e Yes, LC A Yes, LC A $8 -48 (G )
mg increase q3 days up to 500 $1 8-1 06
mg tid
Abbreviations: caps capsule; G generics; inj injection; LCA subject to low cost alternative program; PO by mouth;
SC subcutaneous; tabs tablets, D-9-T Delta-9-Tetrahydrocannabinol
A PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and
+ This indication (i.e. neuropathic pain) not approved by Health Canada; duloxetine approved for treating diabetic neuropathy.
* This route of administration is used in practice, but not approved by Health Canada.
ANTISPASMODICS
Generic Name Trade Name Available Dosage Standard Adult Dose Drug Plan Coverage* Approx. cost
Forms P alliative1 per 30 days
1Fair
Care PharmaCare
bella do nn a & G Supps: B elladonna 1 supp PR qid Yes 11 Yes $330 (G )
O pium 15 mg, O piu m 65 mg 1
hyoscine Buscopan® Tabs: 10 mg 10 mg PO qid up to 60 mg Yes 11Yes $4 2-6 3
butylbro m ide per day 1
Buscopan®, G Inj: 20 mg per mL 10 to 20 mg SC q 6 h [max: Yes, LC A 1 Yes, LC A $511 (G)
100 mg per day] 1 $557
tizan id ine Zanaflex®, G Tabs: 4 mg 2 mg PO daily increase q3-4 No ] S pecial $ 6 -10 7 (G)
days up to 4 to 12 mg tid 1 Authority, $ 12-221
LC A
SKELETAL MUSCLE RELAXANTS
baclofen Lioresal®, G Tabs: 10, 20 mg 5 mg PO bid increase q3 Yes, LC A ' Yes, LC A $9 -55 (G )
days up to 20 mg tid 1 $21-124
cyclo be nzap rin e Flexeril®B, G Tabs: 10 mg 5 mg PO tid to 10 mg qid No ; Yes, LC A $ 1 8-4 9 (G)
1
Abbreviations: G generics; inj injection; LCA low cost alternative program; max maximum dose; PO by mouth; SC subcutaneous; supps suppositories
(rectal); tabs tablets
B Flexeril® brand no longer available
GASTRIC CYTOPROTECTION and DYSPEPSIA

Forms P alliative per 30 days
1Fair
Care PharmaCare
e so m ep razole Nexium® DR Tabs: 20, 40 mg 20 mg to 40 mg PO daily No j Special $68
1 A u th o rity
DR Granules: 10 mg 1 $136 -272
1
1
la nso prazo le Prevacid®, G DR Caps: 15, 30 mg 15 mg to 30 mg PO daily No j Special $27 (G), $65
Authority,
FasTabs: 15, 30 mg LC A $65
1
1
m isoprostol G Tabs: 100, 200 mcg 100 to 200 mcg PO qid No j Yes $3 3-5 6
1
om e pra zole Losec®, G DR caps: 10, 20 mg 20 mg PO daily No j Special $36 (G), $36
1 Authority,
om e pra zole Losec®, G DR tabs: 10, 20 mg 20 mg PO daily No LC A $36 (G)
1
m agnesium 1 $72
pa ntop razo le Pantoloc®, G EC Tabs: 40 mg 40 mg PO daily Yes, LC A Special $33 (G)
1 Authority, $66
! LC A
Inj: 40 mg 40 mg IV daily No ; No $444
I
pa ntop razo le Tecta® EC Tabs: 40 mg 40 mg PO daily Yes 1 Special $45
m agnesium i A u th o rity
rabeprazole Pariet®, G EC Tabs: 10, 20 mg 10 to 20 mg PO daily Yes, LC A Special $11-21 (G )
1 Authority, $2 2-4 3
! LC A
ranitidine Zantac®, G Tabs: 75, 150, 300 150 mg PO bid Yes, LC A ; Yes, LC A $ 1 2-2 3 (G )
mg N SAID c y to p ro te c tio n : 1 $1 2-2 3
1
300 mg PO bid 1
Inj: 25 mg per mL 50 mg S C q 8 h Yes, LC A 1 Yes, LC A $246 (G )
1 $272
Abbreviations: caps capsule; DR delayed release; EC enteric coated; FasTabs delayed-release tablets; G generics; inj injection;
IV intravenous; PO by mouth; SC subcutaneous; tabs tablets
+ This route of administration is used in practice, but not approved for marketing for this indication by Health Canada
BONE PAIN ADJUVANTS for Nociceptive bone pain (without hypercalcemia)

F or treatin g m align an cy related hyp erca lcem ia see w w w .b c c a n ce r.b c.ca /H P I/C h e m o th e ra p yP ro to co ls/S u p p o rtive C a re /d e fa u lt.h tm
Care PharmaCare
calcitonin Miacalcin® Nasal spray: 200 N o c ic e p tiv e b o n e p a in : No No $69-277
units pe r spray one nasal spra y daily up to
tw o sprays bid
Calcimar® Inj: 200 units pe r mL N o c ic e p tiv e b o n e p a in : No Yes $215 - 1723
(2 m L m ulti-dose vial) 50 units S C * at bedtim e up
to 200 units bid
Caltine® Inj: 100 units per 1 $253 - 1013
m L am pule
clo dro nate Bonefos®, Caps: 400 mg 800 mg PO bid or Yes, LC A Yes, LC A $157
Clasteon® 1600 mg PO daily (Clasteon®)
[m ax: 3200 mg pe r day] $242
(Bonefos®)
p am idronate Aredia®, G Inj: 90 mg per 10 mL 90 mg IV m onthly Yes, LC A Special $281 (G )
Authority, $523
LC A
zo le d ro n ic acid Zometa® Inj: 4 mg per 5 mL 4 mg IV m onthly Yes No $598
Abbreviations: caps capsules; G generics; inj injection; IV intravenous; LCA low cost alternative program; max maximum dose;
PO by mouth; SC subcutaneous
* Caltine® not approved for subcutaneous route for marketing for this indication by Health Canada.
References
Cardario. Drug Information Reference. Vancouver: The BC Drug and Poison Information Centre, 2003.
Fraser Health [page on the internet]. Vancouver: Fraser Health; c2009 [cited 2010 Aug 11]. Hospice Palliative Care Symptom Guidelines. Available
from: www.fraserhealth.ca/professionals/hospice_palliative_care/
Hospital Pharmacists' Special Interest Group in Palliative Care. Care Beyond Cure: Management of Pain and Other Symptoms. Montreal: Association
des pharmaciens des etablissements de sante du Quebec, 2009.
Repchinsky C, editor. Compendium of Pharmaceuticals and Specialties. 2010. Toronto: Canadian Pharmacists Association, 2010.
Rostom A, Dube C, Wells GA, Tugwell P, Welch V, Jolicoeur E, McGowan J, Lanas A. Prevention of NSAID-induced gastroduodenal ulcers.
Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD002296. DOI: 10.1002/14651858.CD002296. [Content updated 2010].
Semla TP, Beizer JL, Higbee MD. Geriatric dosage handbook. 15th ed. Hudson(OH):Lexi-Comp, 2010.
Twycross R, Wilcock A, Dean M, et al. Palliative Care Formulary. Canadian Edition. Nottingham: Palliativedrug.com Ltd, 2010.
GUIDELINES & P R O TO C O L S
ADVISORY COMMITTEE
Dyspnea
Scope
This section presents assessment and management strategies for dealing with dyspnea occurring in patients with cancer
or advanced disease.
Salient Principle in this Section:

• Use opioids first line for pharmacological management of dyspnea
A - Dyspnea management algorithm
B - Dyspnea medication reference tables
Dyspnea Management (Refer Appendix A - Dyspnea Management Algorithm)
D efinition: Breathing discomfort that varies in intensity but may not be associated with hypoxemia, tachypnea, or
orthopnea. Occurs in up to 80% of patients with advanced cancer.1
Dyspnea Assessm ent

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

• Proven therapy includes opioids for relief of dyspnea. Oxygen is only beneficial for relief of hypoxemia.4
• Adequate control of dyspnea relieves suffering and improves a patient’s quality of life.5
• Treat reversible causes where possible and desirable, according to goals of care.
• Always utilize non-pharmacological treatment: education and comfort measures.
• Pharmacological treatment: Opioids, +/- benzodiazepines or neuroleptics, +/- steroids.
Drug Comments
Opioids • If opioid naive, start w ith m orphine 2.5-5 mg PO (SC dose is h a lf the PO dose) q4h or
(drugs of first choice) e q u ia n a lg e sic dose of h yd rom o rpho ne o r oxycodone.
• B rea kthrou gh should be h a lf o f th e q4h dose ordered q1h prn.
• If opioid tolerant, increase curre nt dose by 25-50% .
• W hen initiating, start an a n tie m e tic (m e to clo p ra m id e ) and bowel protocol.
• T h e ra p e u tic doses used to tre a t dysp ne a do not decrea se oxygen satu ra tion o r cause differences
in resp irato ry rate o r C O 2 le ve ls .3
• N ebulized form s have N O T been show n to be su p e rio r to oral op io ids and are not re co m m e n d e d .6

BRITISH
COLUMBIA
MEDICAL
ASSOCIATION
О
BRITISH
C o l u m b ia
Ministry o f
Health
BC Cancer Agency
CARE + RE SE ARC H
Anagencyofthe RruvfnchiHealthServkesAuthority

Drug Comments
Benzodiazepines • P rescribe prn fo r an xie ty and resp irato ry “ panic a tta cks”.
• Lo raze pam 0.5-2 mg SL q2-4h prn.
• C o n sid e r SC m id azo lam in rare cases
Neuroleptics • M e tho trim ep razin e 2.5 -5 mg P O /S C q 8 h, then titra te to effect.
Corticosteroids • D e xam e th ason e 8-24 mg P O /S C /IV qam de pe nd ing on seve rity and cause o f dyspnea.
• P articu la rly fo r bronchial obstruction, lym p ha nge tic carcino m a tosis, and S VC syndrom e; also fo r
b ronchospasm , radiation pn eu m onitis and id iop athic interstitial p u lm o nary fibrosis.
Supplemental O2 • Indicated only fo r hypoxia (in su fficie n t evide nce o f benefit o th e rw is e ).5
References
1. Kobierski, L et al. Hospice Palliative Care Program. Symptom 4. Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions
Guidelines. Fraser Health Authority. 2009 April. Available at: www. to improve the palliative care of pain, dyspnea, and depression at the
fraserhealth.ca/professionals/resources/hospice_palliative_care/ end of life: a clinical practice guideline from the American College of
hospice_palliative_care_symptom_guidelines Physicians. Ann Intern Med. 2008;148(2):141-6.
2. Schwartzstein RM, King TE, Hollingsworth H. Approach to the patient 5. Kobierski et al, “Dyspnea”, Hospice Palliative Care Program Symptom
with dyspnea. UpToDate. 2009 Jan 1;17.1. Guidelines, Fraser Health Authority, 2006.
3. Membe SK, Farrah K. Pharmacological management of dyspnea 6 . Fraser Health Authority. Hospice Palliative Care Symptom Guidelines -
in palliative cancer patients: Clinical review and guidelines. Dyspnea. 2009. Available at www.fraserhealth.ca/media/Dyspnea.pdf
Health Technology Inquiry Service. Canadian Agency for Drugs &
Technologies in Health. 2008 July.
Abbreviations
ABG arterial blood gas
BNP brain natiuretic peptide
CT computed tomography
ECG electrocardiogram
IV intravenous
PO by mouth
SC subcutaneous
SL sublingual
SVC superior vena cava
Appendices
Appendix A - Dyspnea Management Algorithm
Appendix B - Medications Used in Palliative Care for Dyspnea and Respiratory Secretions

The princip le s o f the G uidelines and P rotocols A d viso ry Com m ittee are to :
DISCLAIMER
14
P alliative C are for the P atient with I ncurable C ancer or A dvanced D isease - P art 2: P ain and S ymptom M anagement
A ppendix A: Dyspnea M anagem ent A lgorithm
Reversible Causes o f Dyspnea

Dyspnea screen
(0-10 scale)
Cardiovascular
Anemia
Arrythmia
CHF
Deconditioning
Myocardial Ischemia
Pericardial Effusion
Pulmonary emboli
R espiratory
Bronchial Obstruction
Bronchospasm/Asthma
COPD/Emphysema
Infection
Interstitial Fibrosis
Lymphangitic carcinomatosis
Pleural Effusion
Radiation pneumonitis
Treat hypoxem ia if present O ther

Anxiety/panic disorder
Ascites
f Cachexia
Neuromuscular disease
Treat sym ptom of dyspnea
r
E ducation
C om fort measures
(patient and caregiver)
Air flow (fan) / environment Breath control
Positioning Energy conservation
Loose clothing
Relaxation
Modify Lifestyle
Use of breakthrough
medications
Pharm acological treatm ent Proper Inhaler technique
r \
Incident dyspnea C risis dyspnea
Timed Opioid (PO/SC/SL) Opioid (IV/SC)
+/- Benzodiazepine (SC/SL) & Benzodiazepine (IV/SC)
Refractory dyspnea
I
Palliative Care Consult
---------------- 1---------------
Unremitting dyspnea
______ i ______
Palliative sedation
BC Cancer Agency
CARE + RESEARCH
BRITISH
COLUMBIA
BRITISH
Ministry o f
MEDICAL
A ppendix B: M edications0 Used in Palliative Care fo r Dyspnea and R espiratory Secretions
“ R e fe r to g u id eline a n d /o r algo rithm fo r recom m ended o rd e r o f use.
Tailor dose to each patient. Those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require
reduced dosages. Consult most current product monograph for information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp
OPIOIDS*
Generic Name Trade Name Available Dosage Standard Adult Dose Drug Plan CoverageB Approx. cost
Forms (opioid-naive)A Palliative Fair per 30 days
Care PharmaCare
hyd rom o rpho ne Dilaudid®, G IR tabs: 1, 2, 4, 8 mg 0.5-1 mg PO q4h Yes, LC A Yes, LC A $7 -15 (G )
$8-17
m orphine M.O.S.®, IR tabs: 5, 10, 25, 30, 2.5-5 mg PO q4h Yes, LC A Yes, LC A $10-21 (G)
MS-IR®, 40, 50, 60 mg $11-24
Statex®, G
G Inj: 1, 2, 5, 10, 15, Crisis dyspnea: 5 mg IV/SC Yes Yes $ 1 a m p ( 10 m g/
25, 50 mg per m L q5-10 min. D ouble dose if no ml)
effect eve ry third dose
oxyco do ne O xy IR®, IR tabs: 5, 10, 20 mg 2.5-5 mg PO. T itrate to q4h Yes, LC A Yes, LC A $23 (G ) - 50
Supeudol®, G
BENZODIAZEPINES
Forms Palliative 1 Fair
Care PharmaCare
lo raze pam Ativan®, G Tabs: 0.5, 1, 2 mg 0.5-2 mg P O / sub lin gu al Yes, LC A ; Yes, LC A $0 .04-0 .0 8
q2-4h PRN 1 (G)
1
1 $0 .08-0 .1 6
1
1 per ta b le t
Sublingual tabs: Yes 11 Yes $0 .12-0 .2 3
0.5, 1, 2 mg 1 per ta b le t
1
Inj: 4 mg per mL 0.5-2 mg SC+ q2-4h PRN Yes 11 Yes $2 .93 pe r vial
1
1
m idazolam G Inj:
1 mg per mL, 5 2.5-5 mg SC+ q5-15 min prn Yes ; No $1 .4 5 /m L (1
mg per mL i m g/m L v ia l)
i
i $3 .9 2 /m L (5
i
i m g/m L v ia l)
NEUROLEPTICS
Generic Name Trade Name Available Dosage Standard Adult Drug Plan CoverageB Approx. cost
Forms Starting Dose Palliative Fair per 30 days
Care PharmaCare
m etho - Nozinan®, G Tabs: 2, 5, 25, 50 mg 2.5-5 mg PO q 8 h, titra te to Yes, LC A Yes, LC A $1-2 (G )

trim e p ra zin e effect
N ozinan® Inj: 25 m g/m L 6.25 mg SC q 8 h, titra te to Yes Yes $ 3 .5/am p (25

effect m g/m L)
Tailor dose to each patient. Those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require
reduced dosages. Consult most current product monograph for information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp
CORTICOSTEROIDS
Forms Dose Palliative Fair per 30 days
Care PharmaCare
dexamethasone G Tabs: 0.5, 0.75, 2, 8-24 mg PO/SC/IV every Yes, LCA Yes, LCA $36-55 (G)
morning, taper if possible
4 mg
Inj: 4, 10 mg per $101-304 (G)

mL
MEDICATIONS FOR RESPIRATORY SECRETIONS

Forms Dose Palliative Fair
Care PharmaCare
atropine G Inj: 0.4, 0.6 mg per 0.2-0.8 mg SC q4h and q1h PRN Yes Yes $1.5-2 (G) per
dose
mL
Drops: 1% solution 1 to 4 drops sublingual+ q4h prn No Yes $3.15 per 5 mL

bottle
glycop yrro la te G Inj: 0.2 mg per mL 0.2-0.4 mg SC+/sublingual+/PO+ Yes Yes $11-45 (G)
q4h to q 8h per 24 h
Abbreviations: G generics; h hour; inj injection; IR Immediate Release; PO by mouth; PRN as needed; SC subcutaneous; SR slow release; tabs tablets
* Not an exhaustive list. Other opioids may be appropriate.

A For opioid-tolerent patients, increase current dose by 25-50%.
B PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost
separated as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations in Palliative Care Part 2 - Information
about Provincial Drug Coverage
+ This route of administration is used in practice, but not approved for marketing for this indication by Health Canada
References
Hospital Pharmacists’ Special Interest Group in Palliative Care. Care Beyond Cure: Management of Pain and Other Symptoms. Montreal: Association
ADVISORY COMMITTEE
Nausea and Vomiting (N&V)
Scope
This section presents assessment and management strategies for dealing with nausea and vomiting occurring in patients
with cancer or advanced disease.

• Select antinausea medication based on the etiology of the nausea and vomiting
A - Nausea and vomiting management algorithm
B - Hypodermoclysis protocol
C - Antinausea medication reference tables
Nausea and Vomiting Management (Refer Appendix A - Nausea and Vomiting Management Algorithm)
Assessm ent
• Common, but can be controlled with antiemetics.
• Identify and discontinue medications that may be the cause.
• Further assessment may include lab tests and imaging to investigate, e.g., GI tract disturbance, electrolyte /
calcium imbalance, intracranial disease, and sepsis.
• Good symptom control may require rehydration which can be carried out in the home, hospice, or residential
care facility using hypodermoclysis, a simple, safe and effective technique that avoids venous access (refer
Appendix B - Hypodermoclysis Protocol).
Management Strategies
• Non-pharmacological: modifications to diet (e.g., small bland meals) and environment (e.g., control smells and
noise), relaxation and good oral hygiene, acupressure (for chemotherapy-induced acute nausea but not for
delayed symptoms).
• Pharmacological: match treatment to cause, e.g., if opioid-induced, metoclopramide (sometimes IV or SC initially)
and domperidone are most effective. Most drugs are covered by the BC Palliative Care Drug Plan except
olanzapine and ondansetron (refer Appendix C - Medications Used in Palliative Care for Nausea and Vomiting).
• Consider pre-emptive use of anti-nauseates in opioid-naive patients.
Abbreviations
GI gastrointestinal
IV intravenous
N&V nausea & vomiting
SC subcutaneous

BRITISH
COLUMBIA
MEDICAL
О
Br it is h
Ministry o f
Д З BC Cancer Agency
ГАОС
C A R E J.
+ D RCE SCC
E AAD
R Cru H
Anедокуof the Pnvfncfol Heotih ServicesAuthority

Appendices
Appendix A - Nausea and Vomiting Management Algorithm
Appendix B - Hypodermoclysis Protocol
Appendix C - Medications Used in Palliative Care for Nausea and Vomiting
DISCLAIMER
19
PALLiATiVE C are for the P arent wiTH I ncurable C ancer or A dvanced DiSEASE - P art 2: PAiN and S ymptom M anagement
A ppendix A: Nausea and Vom iting M anagem ent A lgorithm
Patient and family education

N o n-p harm a colo gical m ea sure s e.g., e n viro nm en ta l m odification
(co n sid e r sm ells, noise, etc.); good oral hygiene; acu pre ssure; fizzy drinks;
visu alizatio n, distraction, relaxation
C o nsu ltation w ith a R egistered D ietitian at w w w .h e a lth lin kb c.ca /d ie titia n /
G en eral sup po rtive m easures, e.g., food m odification, restricted intake, sips,
cool and bland food, avoiding lying fla t after eating
Treat underlying causes

e.g., hypercalcem ia, urosepsis, constipation, urem ia,
intracranial pressure, bowel obstruction, dehydration,
m edication ad verse effects
I
Treat disease-specific issues
i.e., m atch m edication to etiology
Chemical Vestibular &

Gastroenterological CNS Cause unknown
(drugs/toxins) motion-related
D is te n s io n o r lu m e n • haloperidol • dim en hydrina te E m o tio n a l/a n x ie ty : • haloperidol

c o m p re s s io n : • lorazepam
• m etho trim ep razin e
• p ro chlorpe razin e • scop olam in e
• m etoclop ram id e • nabilone
• m etho trim ep razin e • m etoclop ram id e
• do m pe rido ne In c re a s e d ICP:
• m etho trim ep razin e • on da nse tro n • d e xam e th aso ne
O b s tru c tio n • granisetron • d im en hydrina te
• haloperidol
• octreo tide
O p io id -in d u c e d
• m etoclop ram id e
• do m pe rido ne
• m ethylna ltrexon e
O th e r va g a l s tim u li:
• m etho trim ep razin e
• p ro chlorpe razin e
• on da nse tro n
Re-evaluate drug effect

C o n sid e r increasing dose, trying a n o th e r drug from the sam e class, or adding a n o th e r class o f drug.
R e-eva lua te pa tien t’s status and hydration.
BC Cancer Agency
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A ppendix B: H ypoderm oclysis Protocol
Hypodermoclysis is a simple, safe and effective technique for subcutaneously administering fluids to a patient who
requires hydration. It avoids the need for venous access in patients who, at the end of life, often have very poor veins. In
the home/hospice/residential care facility settings, it can be carried out without the need for fully IV credentialed nursing
staff. Refer to the local Home and Community Care office (refer Palliative Care Part 2 - Resources) for when and how to
refer.
There are two critical considerations regarding initiating hypodermoclysis in palliative patients:
1. Objectives and timelines must be clear and agreed upon by the family and caregivers.
2. Will adding fluids to a patient whose organ function is failing precipitate cardiac failure and/or cause or worsen
lung secretions?
Procedure:
• A 23-25 gauge butterfly needle is inserted under the skin at a 30-45 degree angle. Ask patients which site is preferred
of the following choices:
- For ambulatory patients, consider using chest (subclavicular area), back (infrascapular area) and upper abdominal
wall (avoiding waist).
- For bed-bound patients, use medial or lateral thighs or upper abdomen.
- Avoid previously irradiated skin, anterior or lateral thigh if edema is present, abdomen if ascites is present, breast
tissue, lateral placement near the shoulder, arms, and perineum/groin.
• The fluids used are commonly normal saline (0.9%), normal saline/dextrose (2/3-1/3) and Ringer’s Lactate. Dextrose
cannot be used as a hypodermoclysis solution.
• The infusion rate can be up to 75 ml/hr. Solutions are infused by gravity, i.e., a pump is usually not necessary.
• Some patients may only require 1 litre 3-4 times per week, rather than daily administration. A smaller volume (1 liter per
day) is often adequate to maintain hydration in terminally ill patients requiring hydration for symptom control.
• Potassium chloride up to 40 mEq per litre may be added to the solution. Do not mix hypodermoclysis solutions with
other medications. If medications are being administered by the SC route, use separate site(s).
• Change the solution bag every 24 hours. Change the tubing every 72 hours. Change the SC site if painful, red,
hard or leaking.
Subcutaneous hypodermoclysis sites may last up to 7 days. Daily assessment of client condition and insertion site is
necessary.
BC Cancer Agency
BRITISH
COLUMBIA
MEDICAL
О
Br it is h
Ministry o f
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Anagencyof the Provincial Health ServicesAuthority

A ppendix C: M edications0 Used in Palliative Care fo r Nausea & Vom iting
Tailor dose to each patient; those w ho are elderly, cachectic, debilitated o r w ith renal o r hepatic d ysfu nction may require reduced dosages ;
con sult m ost current product m onograph fo r th is inform ation: http://w ebprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp
ANTI-EMETICS
Forms P alliative Fair per 30 days
Care | PharmaCare
i
dexamethasone G Tabs: 0.5, 0.75, 2, 2 mg P O /S C */ Yes, LC A ' Yes, LC A

1 $ 1 4-7 9 (G)
4 mg IV daily to 8 mg bid 1
1
(AM & noon)
Inj: 4, 10 mg per 1 $ 5 5-8 3 (G)
1
mL 1
1
dronabinol Marinol® Caps: 2.5, 5, 10 mg C h e m o th e ra p y re la te d No Special $256-511
(D-9-T) n ausea a n d v o m itin g : 2.5 1 A u th o rity
to 5 mg PO qid 1
dimenhydrinate Gravol®, G IR caps/tabs: 15, 50 mg PO q 6 h to q4h Yes, LC A
1' No $3-4 (G )
50 mg 1
1
L/A caplets: 100 100 mg PO q12h to q 8 h Yes 11 No $2 8-4 3
mg 1
1
Inj: 50 mg pe r mL 50 mg IM /IV /S C * q 6 h to q4h Yes, LC A 1i No $9 3-1 40 (G)
i $112-167
i
Supps: 25, 50, 100 50 to 100 mg PR q12h to Yes 1i No $ 2 8-4 4 (G)

mg q 8h i $5 2-6 4
i
domperidone G Tab: 10 mg 10 to 20 mg PO tid to qid Yes, LC A 1 Yes, LC A $12-31 (G)

i
i
granisetron Kytril®, G Tab: 1 mg 1 mg to 2 mg P O /IV /S C * No Special $ 4 37 -875 (G)

daily o r 1 mg bid 1 Authority, $583-1166
! LC A
Inj: 1 mg per mL No 11 No $ 2 26 8-45 36
1
1
haloperidolt G Tabs: 0.5, 1, 2, 5, 0.5 mg P O /S C */IV bid to 2.5 Yes, LC A 1 Yes, LC A $2 -18 (G )
10 mg mg q 6 h i
i
Inj: 5 mg per mL Yes, LC A 11 Yes, LC A $ 2 57 -513 (G)

1
1
methotrimeprazine G Tabs: 2, 5, 25, 50 5 to 12.5 mg PO q4h to Yes, LC A ' Yes, LC A
1 $3-25
mg q24h 1
1
Nozinan® Inj: 25 mg pe r mL 6.25 to 25 mg S C * q4h to Yes 11 Yes $104 -622
q24h 1
1
metoclopramide G Tab: 5, 10 mg 5 to 20 mg PO qid Yes, LC A 1 Yes, LC A $7 -15 (G )
1
1
Inj: 5 mg per mL 10 to 20 mg S C */IV q 6 h Yes, LC A 1 Yes, LC A $ 3 20 -640 (G)
i
i
nabilone C e sam e t® Caps: 0.25, 0.5, 1 to 2 mg PO bid No 11 Yes $402 -804

1 mg 1
1
octreotide* Sandostatin®, Inj: 50, 100, 200, 50 to 200 mcg SC q 8 h Yes, LC A No $243-881 (G )
G 500 mcg per mL $485-1761
S andostatin Inj LAR: 10, 20, 30 LAR: 10 to 30 mg IM every No No $ 1 36 2-22 58

LAR® mg per vial 4 w e eks
ondansetron Zofran®, G IR tabs: 4, 8 mg 4 to 8 mg P O /S C q 8 h to No S pecial $ 434-994 (G )

q 12 h A uthority, $8 68 -198 7
LC A
ODT: 4, 8 mg $848-1941
Inj: 2m g pe r mL $8 57 -257 0
(G)
$1 27 9-38 38
prochlorperazine G Tabs: 5, 10 mg 5 to 10 mg P O /IM /IV /P R Yes, LC A Yes, LC A $11-26 (G )
tid-q id
Inj: 5 mg pe r mL $6 7-1 79 (G)
Supp: 10 mg $8 1-1 08 (G)
scopolaminet T ransd erm V® Patch: 1.5 mg 1 to 2 * patches applied to Yes No $46-91

skin eve ry 72 hours
A bb reviation s: caps capsules; D-9-T D elta-9-T e tra hydro can na bin ol; G generics; inj injection; IM intram uscular; IR im m e dia te release;
IV intravenous; LCA sub je ct to low cost a lte rna tive program ; L/A Long acting (com b ine d im m e dia te and sustained release); LAR slow
release (injection); PR per rectum ; ODT ora lly disinte gratin g tablet; PO by m outh; SC sub cutan eo us; supps su p p o sito rie s (rectal); tabs
tab lets
A P ha rm aC are cove rag e and cost as o f N o vem b er 2010 (sub je ct to revision). C ost does not include dispensing fee. G e n e ric and brand
nam e cost separated as indicated by (G). O btain coverage, eligibility, m edication cove rag e inform ation and e xp la natio ns here:
Inform ation on P rovincial Drug C overage
t T his indication (i.e. nausea and vo m itin g ) used in practice, but not approved fo r m arketing by Health C anada.
* D ose o f 2 patches o f s cop olam in e tra n sd e rm a l patch (applied sim u lta n e o u sly) used in practice, but not ap pro ved fo r m arketing by
H ealth Canada.
* T his route o f ad m in istra tion co m m o n ly used in P alliative Care, but not approved by Health C anada
References
BC Cancer Agency
BRITISH
COLUMBIA
MEDICAL
О
BRITISH
Ministry o f
CARE + RE SE ARC H
Anagencyofthe Rruvfnchi Health ServkasAuthofity

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

• Prevent constipation by ordering a bowel protocol when regular opioid medication is prescribed
A - Constipation management algorithm
B - Laxation medication reference tables
C - Hypertext link to BCCA bowel protocol
Constipation Management (Refer Appendix A - Constipation Management Algorithm)
Constipation Assessm ent

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

• There are many etiologies, e.g., reduced food/fluid/mobility and AEs of medications.
• Avoid rectal interventions (enemas, suppositories, manual evacuation) except in crisis management.
Contraindicated when there is potential for serious infection (neutropenia) or bleeding (thrombocytopenia), or
when there is rectal/anal disease.
• Exclude impaction when a patient presents already constipated. Abdominal X-ray can be useful when physical
examination is inconclusive.
• When risk factors are ongoing, as they are in most cancer patients, suggest laxatives regularly versus prn. Adjust
dose individually. Laxatives are most effective when taken via escalating dose according to response, termed
“bowel protocol”.
• Sennosides (e.g., Senokot®) are the first choice of laxative for prevention and treatment. Patients with irritable
bowel syndrome may experience painful cramps with stimulant laxatives and often prefer osmotic laxatives such
as lactulose or polyethylene glycol (PEG). There is weak evidence that lactulose and sennosides are equally
effective;1 however lactulose can taste unpleasant and also cause bloating.
• If rectal measures are required, generally a stimulant suppository is tried first, then an enema as the next option.
• BC Palliative Care Drug Plan covers laxatives written on a prescription for eligible patients.
Palliative Care Part 1: Approach to Care is available at w w w .bcguidelines.ca/guideline_palliative1.htm l,

Palliative Care Part 3: Grief and Bereavement is available at w w w .bcguidelines.ca/guideline_palliative3.htm l
BRITISH
COLUMBIA
MEDICAL
ASSOCIATION
О
B r it is h
C o l u m b ia
Ministry of
Health
BC Cancer Agency
CARE + RESEARCH
AnagencyofthaProvincialHtatihStrvtasAuthority
Family Practice Oncology Network

• For patients with opioid-induced constipation, after a trial of first-line recommended stimulant laxatives and
osmotic laxatives, methylnaltrexone may be helpful. Cancer, GI malignancy, GI ulcer, Ogilvie’s syndrome and
concomitant use of certain medications (e.g., NSAIDs, steroids and bevacizumab) may increase the risk of
GI perforation in patients receiving methylnaltrexone. [Health Canada MedEffect Notice: www.hc-sc.gc.ca/dhp-
mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/relistor_hpc-cps-eng.pdf]
• Patient handouts on constipation and bowel protocol are available at www.bccancer.bc.ca/HPI/FPON
References
1. Agra Y, Sacristan A, Gonzalez M, et al. Efficacy of senna versus lactulose in terminal cancer patients treated with
opioids. J Pain Symptom Manage. 1998;15(1):1-7.
Abbreviations
AEs adverse effects
BM bowel movement
GI gastrointestinal
NSAIDs non-steroidal anti-inflammatory drugs
PEG polyethylene glycol
Appendices
Appendix A - Constipation Management Algorithm
Appendix B - Medications Used in Palliative Care for Constipation
The princip le s o f the G uidelines and P rotocols A d viso ry Com m ittee are to:
DISCLAIMER
25
P a llia t iv e C a r e for t h e P a tie n t w it h In c urable C an cer or A d v an c e d D is e as e - P a r t 2 : P a in and S ym ptom M anagement
A ppendix A: C onstipation M anagem ent A lgorithm
Assessm ent
Switch to less constipating opioid

e.g., fentanyl or methadone
Consider prokinetic agent

e.g., domperidone, metoclopramide Add or switch to
osmotic laxative
Add or switch to
Consider methylnaltrexone1'
osmotic laxative
No Success
Palliative Care Consult
о
available at www.bccancer.bc.ca/HPI/FPON
contraindicated in patients with renal failure
1 cancer, GI malignancy, GI ulcer, Ogilvie’s syndrome and concomitant use of certain medications (e.g. NSAIDs, steroids and bevacizumab) may
increase the risk of GI perforation in patients receiving methylnaltrexone.
[Health Canada MedEffect Notice: www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/relistor_hpc-cps-eng.pdf]
Appendix B: Medications” Used in Palliative Care for Constipation
LAXATIVES
Forms Palliative Fair
Care PharmaCare
bisacodyl Dulcolax®, G Tabs: 5 mg 5 to 10 mg PO x 1 dose Yes, LC A No $0 .05 (G )

$ 0.21
per tab
Supps: 10 mg 10 mg PR x 1 dose $0.51 (G ) per
supp
glycerin supp G Supps: 2.65 g 1 supp PR x 1 dose Yes No $0.25 (G)B

per supp
g lycerin -sod ium Microlax® Micro-enema: 5 m L PR x 1 to 2 doses Yes No $ 1 .8 0 B
citrate-so dium 5 mL per m icro
lauryl sulfo ace ta te - enem a
sorb ic acid-so rb itol
lactulose G Oral solution: 667 15 m L PO daily to Yes, LC A Special $7 -28 (G )
mg per m L 30 m L PO bid Authority, per 30 days
LC A
m e th yln a ltre xo n e C Relistor® Inj: 12 mg pe r 0.6 8 to 12 mg SC eve ry 2 days No No $616
mL per 30 days
m ineral oil enem a F leet enem a Enema: 130 mL 120 m L PR x 1 dose Yes No $ 8B
m ineral oil® per enem a
phosphates F leet enema®, Enema: 22 g per 120 m L PR x 1 dose Yes No $ 6 B (G ) $ 8 B
enem aD G 100 mL per enem a
p o lye th ylen e glycol Lax-A-Day®, Powder: 17g 17 gram s in 250 m L fluid PO No No $ 2 7 -5 1 B
3350 (PEG ) P egalax™ , sachets daily per 30 days
R estoraLA X ™ ,
G
sen no side s Senokot®, G Tabs: 8 .6 , 12 mg 2 tab s PO at bedtim e Yes, LC A No $3 -14 (G )
to 3 tab s tid $1 0-4 7
per 30 days
Oral syrup: 8.8 mg 10 m L PO at bedtim e $ 1 4-8 6 per 30
per 5 mL to 15 m L tid days
sorbitol G Oral solution: 70% 15 to 45 m L PO da ily to qid No No $ 1 0 -1 19B (G )

per 30 days
Abbreviations: G generics ; LC A subject to low cost alternative program; PO by mouth; PR per rectum; SC subcutaneous; supps suppositories (rectal);
tabs tablets
A PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost
separated, as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations here: Information on Provincial Drug
Coverage
B Approximate retail cost (without prescription)
C Cancer, gastrointestinal malignancy, gastrointestinal ulcer, Ogilvie’s syndrome and concomitant use of certain medications (e.g. NSAIDs, steroids and
bevacizumab) may increase the risk of GI perforation in patients receiving methylnaltrexone. [Health Canada MedEffect Notice:
www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010 /relistor_hpc-cps-eng.pdf]
D contraindicated in patients with renal failure
References
ADVISORY COMMITTEE
Delirium Management
Scope
This section presents assessment and management strategies for dealing with delirium occurring in patients with cancer
or advanced disease.

• Look for and treat reversible causes of delirium
• Utilize neuroleptics first line for pharmacological treatment
A - Delirium management algorithm
B - Delirium medication reference tables
Delirium Management (Refer Appendix A - Delirium Management Algorithm)
D efinition: A state of mental confusion that develops quickly, usually fluctuates in intensity, and results in reduced
awareness of and responsiveness to the environment. It may manifest as disorientation, incoherence and memory
disturbance.
Delirium Assessm ent

• May be hypoactive, hyperactive or mixed
• Look for underlying reversible cause (refer Fraser Health Authority. Hospice Palliative Care Symptom Guidelines
- Delirium/Restlessness)0
• Ascertain stage of illness and whether delirium is likely to be reversible or terminal and irreversible
• Review advanced care plan and discuss goals of care with substitute decision maker
• Refer patient/family to Home and Community Care (refer Palliative Care part 2 - Resources) or timely access to
caregiver support and access to respite and/or hospice care
Delirium Management Strategies

• Treat reversible causes if consistent with goals of care
• Avoid initiating benzodiazepines for first line treatment
• Refer to Appendix A - Delirium Management Algorithm
• Avoid use of antipsychotics in patients diagnosed with Parkinson’s disease or Lewy Body Dementia.
Abbreviations
IM intramuscular
IV intravenous
PO by mouth
SC subcutaneous
“available at w w w .fraserhealth.ca/m edia/07FH S ym ptom G uidelinesD elirium .pdf

BRITISH
COLUMBIA
MEDICAL
О
BRITISH
Ministry of
ГДОС
CARE + -L. RESEARCH
D EC C ID TU
Лиogimyoftb* PruvmcmlHtatihSenkwAuthority
ASSOCIATION COLUMBIA Health Family Practice Oncology Network

Appendices
Appendix A - Delirium Management Algorithm
Appendix B - Medications Used in Palliative Care for Delirium and Terminal Agitation
DISCLAIMER
29
Appendix A: Delirium Management Algorithm
*F o r clinical fea tu res o f dem entia, depression and delirium , refer to Cognitive Impairm ent in the Elderly - Recognition, Diagnosis
and M anagem ent at w w w .b cg u id e lin e s.ca /g u id e lin e _ co g n itive .h tm l
Appendix B: Medications0 Used in Palliative Care for Delirium and Terminal Agitation
ANTIPSYCHOTICS
Generic Name Trade Name Available Dosage Standard Adult Dose Drug Plan Coverage* Approx. cost
Forms P alliative 1Fair
Care i PharmaCare
haloperidol G Tabs: 0.5, 1, 2, 5, M ild re s tle s s n e s s : Yes,’ LC A 1 Yes,’

1 LC A $4-9 (G )
10 mg 0.5 to 1.5 mg PO tid 1
1
D e liriu m a n d ag itatio n : 1 $4 -29 (G )
1
0.5 to 5 mg PO q 8 h to q4h 1
Inj: 5 mg per mL M ild re s tle s s n e s s : Yes,’ LC A ' Yes,’
1 LC A $385 (G )
0.25 to 0.75 mg S C * tid 1
1
D e liriu m a n d ag itatio n : 1 $ 3 85 -770 (G)
1
0.5 to 5 mg S C * q 8 h to q4h 1
lo xap inet G Tabs: 2.5, 5, 10, 2.5 to 10 mg P O /S C * daily Yes,’ LC A 1 Yes,’
1 LC A $3 -17 (G )
25, 50 mg to tw ice daily 1
Inj: 50 mg pe r mL Yes j Yes $ 2 22 -445 (G)
1
m etho- G Tabs: 2, 5, 25, 50 D e liriu m : 10 to 50 mg SC * Yes,’ LC A 11Yes,’ LC A $ 1 9-7 5 (G)
trim e p ra zin e t mg q30m in until re lie f then 10 to 1
50 mg P O /S C * q 8 h to q4h.
Nozinan® Inj: 25 mg pe r mL Yes j Yes $311-1244
1
ola n za p in e t Zyprexa®, G Tabs: 2.5, 5, 7.5, 2.5 to 10 mg PO da ily to No Special $ 4 1 -32 8 (G)
10, 15, 20 mg tw ice daily ; A u th o rity B, $58-466
! LC A (20
mg only)
Z yp re xa Z yd is® Oral dissolving No Special $4 9-1 94 (G)
tabs: 5, 10, 15, 20 ' Authority, $116-463
mg ! LC A
q u e tia p in e t Seroquel®, G Tabs:25, 100, 200, 12.5 to 50 mg PO daily to No 11Yes,’ LC A $7 -27 (G )
300 mg tw ice daily 1 $1 6-6 4
risp erid on et Risperdal®, G Tabs: 0.25, 0.5, 1, 0.5 to 2 mg PO da ily to Yes 1 Yes
1 $11-62 (G )
2, 3, 4 mg tw ice daily 1 $11-62
Risperdal® M-tab: 0.5, 1, 2, 3, Yes 11 Yes $24-132
4 mg 1
OTHER
phenobarbital* G Inj:30 mg pe r mL, E pile psy/te rm ina l agitation: Yes Yes $2 2-4 59 (G)
120 mg per m L 60 mg S C * bid up to 120 1
1
mg tid 1
Abbreviations: G generics; inj Injection; LCA subject to low cost alternative program; M-tabs oral disintegrating tablets; PO by mouth; SC subcutaneous;
tabs tablets
Coverage
BOlanzapine 20 mg is the only strength of regular tablets (not oral dissolving tablets) which are covered with Special Authority
+ This indication (i.e. delirium) used in practice, but not approved for marketing by Health Canada
* This indication (i.e. terminal agitation) used in practice, but not approved for marketing by Health Canada
* This route of administration used in practice, but not approved for marketing by Health Canada.
References
G U ID E L IN E S & P R O T O C O L S
ADVISORY COMMITTEE
Fatigue and Weakness
Scope
This section presents assessment and management strategies for dealing with fatigue and weakness occurring in patients
with cancer or advanced disease.

• Except when a patient is dying, recognize that fatigue is a treatable symptom with a major impact on quality
of life
A - Fatigue and weakness management algorithm
B - Medications used for fatigue and weakness reference tables
Fatigue and Weakness Management (Refer to Appendix A - Fatigue and Weakness Management Algorithm)
D efinition: Fatigue is a subjective perception/experience related to disease, emotional state and/or treatment. Fatigue is
a multidimensional symptom involving physical, emotional, social and spiritual well-being and affecting quality of life.1
Fatigue Assessm ent

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

• After treating reversible causes and providing non-pharmacological treatment recommendations, consider
pharmacological treatment (Refer Appendix B), if consistent with patient’s goals of care
• Refer Fatigue and Weakness Management Algorithm
References
1.Ferrell BR, Grant M, Dean GE, Funk B, Ly J. Bone tired: The experience of fatigue and impact on quality of life.
Oncology Nursing Forum. 1996;23(10):1539-47.
Appendices
Appendix A - Fatigue and Weakness Management Algorithm
Appendix B - Medications Used in Palliative Care for Fatigue

Й Ю BC Cancer Agency
Г A DC -L.
CARE + D ГС С А ОГII
RESEARCH
BRITISH
COLUMBIA
BRITISH
Ministry of
MEDICAL
ASSOCIATION C o l u m b ia Health Family Practice Oncology Network
DISCLAIMER
advocates requesting advice on issues related to m edical co n d itio n s. If you need m edical advice, please contact a health care professional.
33
PALLiATivE C a r e for t h e P a r e n t wiTH I n c u r a b l e C a n c e r or A d v an c e d DisEAsE - P a r t 2 : PAiN and s ym pto m M anagement
Appendix A: Fatigue and Weakness Management Algorithm
Non-pharm acological Treatments
General measures Education o f patient and Stress management

• Individualized graded caregivers • Cognitive behavioural
exercise program • Normalize interventions
• Nutrition • Energy conservation • Support Groups
• Assessment by Home and • Sleep hygiene
Community Care for support • Fatigue scale
in the home1
No —
r
Methylphenidate
or
Dextroamphetamine
or
Modafanil (only if fatigue > 6/10)
tRefer to “Guide to Your Care” at www.health.gov.bc.ca/library/publications/year/2007/Guide_to_Your_Care_Booklet2007_Final.pdf
BC Cancer Agency
CARE + RESEARCH
BRITISH
COLUMBIA
BRITISH
Ministry of
MEDICAL
Appendix B: Medications” Used in Palliative Care for Fatigue
PSYCHOSTIMULANTS
Generic Name Trade Name Available Standard Adult Dose Drug Plan CoverageA Approx. cost
Dosage Forms (note age specific recommendations)
Palliative 1 Fair per 30 days
Care i PharmaCare
methylphenidatet Ritalin®, G IR tabs: 5, 10, Age over 65 years: Yes,’ LCA 11 Yes,’ LCA $6-16 (G)
20 mg Not recommended 1 $11-32
1
Age 18 to 65 years: 1
1
Start: 5 mg PO bid (AM and 1
noon); use 2.5 mg for frail patients 1
1
Max: 15 mg PO bid (AM and noon) 1
Biphentin® SR caps: 10, 15, Once dose stabilized on IR, give No 1■ No $21-54
20, 30 mg equivalent daily dose as SR o r XR form ■
once daily in AM
1 Special
CD
CD
Concerta® XR tabs: 18, 27, No
00
00
$
$
36, 54 mg ! Authority 8
Ritalin® SR, G SR tabs: 20 mg No 11 Yes, LCA $ 10 (G)
1 $20
d e xtro Dexedrine® IR tabs: 5 mg Age over 65 years: No 11 Yes $20 - $156
amphetamine* Not recommended 1
1
Age 18 to 65 years: 1
1
Start: 2.5 mg PO bid (AM then in 4 to 6 h) 1
1
Max: 20 mg PO bid (AM then in 4 to 6 h) 1
SR caps: 10, Once dose stabilized on IR, give equivalent No 11 Yes $28 - $ 112
15 mg daily dose as SR form once daily in AM 1
'г
§
m odafim lt Alertec®, G Tabs: 100 mg Age over 65 years: No Special
$$
34
2 2
со
Start: 100 mg PO qAM ■AuthorityC,
Max: 100 mg PO bid (AM and noon) LCA
1
Age 18 to 65 years: 1 $60-120 (G)
1
Start: 100 mg PO bid (AM and noon) 1 $83-167
Max: 200 mg PO bid (AM and noon) 1
Abbreviations: caps capsules; G generics; h hours; IR immediate release; LCA subject to low cost alternative program; max maximum dose; PO by
mouth; qAM every morning; SR sustained release; tabs tablets; XR extended release
Coverage
BSpecial authority required to obtain coverage for Concerta® for ADHD as second line treatment
CSpecial authority required to obtain coverage for modafinil for patients with narcolepsy
+ This indication (i.e. depression) used in practice, but not approved for marketing by Health Canada
References
BC Cancer Agency
CARE + RESEARCH
BRITISH
COLUMBIA
MEDICAL B r it is h
Ministry of AneffencyoftheProvincialHealthServicesAuthority

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

• Before diagnosing and treating major depressive disorder, first effectively treat pain and other symptoms, then
differentiate the symptom of depression from normal grieving
• When prescribing antidepressants for this group of patients, select antidepressants with the least drug
interactions
A - Depression management algorithm
B - Antidepressant medication reference tables
Depression Management (Refer Appendix A: Depression Management Algorithm)
Assessm ent
• Depression occurs in 13-26% of patients with terminal illness12 can amplify pain and other symptoms, and is often
recognized too late in a patient’s life.
• Patients are at high risk of suicide and have an increased desire for hastened death.3
• A useful depression screening question is, “Have you been depressed most of the time for the past two weeks?”4
• A diagnosis of depression in the terminally ill may be made when at least two weeks of depressed mood is
accompanied by symptoms of hopelessness, helplessness, worthlessness, guilt, lack of reactivity, or suicidal
ideation.
• DSM-IV criteria for depression are not very helpful because vegetative symptoms like anorexia, weight loss, fatigue,
insomnia, and impaired concentration may accompany end stage progressive illness.
• Risk factors include: personal or family history of depression, social isolation, concurrent illnesses (e.g., COPD,
CHF), alcohol or substance abuse, poorly controlled pain, advanced stage of illness, certain cancers (head
and neck, pancreas, primary or metastatic brain cancers), chemotherapy agents (vincristine, vinblastine,
asparagines, intrathecal methotrexate, interferon, interleukin), corticosteroids (especially after withdrawal), abrupt
onset of menopause (e.g. withdrawal of hormone replacement therapy, use of tamoxifen).
Management Strategies
• Non-pharmacological treatments are the mainstay of treatment for the symptom of depression without a diagnosis of
primary affective disorder.
• Treatment of pain and other reversible physical symptoms should occur before initiating antidepressant medication.
• If a diagnosis of primary affective disorder is uncertain in a depressed patient, consider psychiatric referral and
a trial of antidepressant medication (refer Appendix B). Consider drug interactions, adverse side effect profiles, and
beneficial side effects when choosing an antidepressant.
• In the terminally ill, start with half the usual recommended starting dose of antidepressant.5
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• First line therapy is with a selective serotonin reuptake inhibitor (SSRI)2 or selective serotonin norepinephrine
reuptake inhibitor (SSNRI) or noradrenergic and specific serotonergic antidepressant (NaSSA).
• Tricyclic antidepressants (especially nortryptiline and desipramine) can be considered due to their co-analgesic
benefit for neuropathic pain (refer Appendix B - Medications Used in Palliative Care for Depression). Avoid with
constipation, urinary retention, dry mouth, orthostatic hypotension, or cardiac conduction delays.
• When anticipated survival time is short, consider psychostimulants due to their more immediate onset of effect,2 but
avoid them in the presence of agitation, confusion, insomnia, anxiety, paranoia, or cardiac comorbidity.
• If life expectancy is 1-3 months, start a psychostimulant and an antidepressant together and then withdraw the
stimulant while titrating the antidepressant upwards.
References
1. Lloyd-Williams M, Friedman T. Depression in palliative care patients - 4. Chochinov HM, Wilson KG, Enns M, et al. “Are you depressed?”
a prospective study. Eur J Cancer Care 2001;10:270-4. Screening for depression in the terminally ill. Am J Psychiatry
2. Fraser Health Authority. Hospice Palliative Care Symptom Guidelines. 1997;154:674-6.
Depression. c2006. Available from: http://www.fraserhealth.ca/ 5. Rodin G, Katz M, Lloyd N, et al. The management of depression in
professionals/hospice_palliative_care/ cancer patients: A clinical practice guideline. Cancer Care Ontario.
3. Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, 2006 Oct. Available at: www.cancercare.on.ca/common/pages/
and desire for hastened death in terminally ill patients with cancer. UserFile.aspx?fileId=13930
JAMA 2000;284:2907-11.
Abbreviations
CHF congestive heart failure
COPD chronic obstructive pulmonary disease
DSM-IV Diagnostic and Statistical Manual of Mental Disorders 4th edition
NaSSA noradrenergic & specific serotonergic antidepressant
SSRI selective serotonin reuptake inhibitor
SSNRI selective serotonin norepinephrine reuptake inhibitor
TCA tricyclic antidepressant
Appendices
Appendix A - Depression Management Algorithm
Appendix B - Medications Used in Palliative Care for Depression
DISCLAIMER
37
Appendix A: Depression Management Algorithm
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Appendix B: Medications” Used in Palliative Care for Depression
ANTIDEPRESSANTSA
Generic Name Trade Name Standard Adult Dose Drug Plan Coverage0 Approx. cost Therapeutic
A vaila ble (palliative)B Palliative Fair per 30 days Considerations
D osage Form s Care PharmaCare
NaSSA: Noradrenergic and Specific Serotonergic Antidepressant
mirtazapine Remeron®, G Start: 7.5 to 15 mg PO at bedtime Yes, LCA Yes, LCA $6-19 (G) • Useful for night-time
Remeron RD® $20-60 sedation
Goal: 15 to 45 mg PO at bedtime
Tabs: 15, 30, • Rapid dissolve
45 mg Max: 60 mg+ PO at bedtime formulation
RD: 15, 30, 45
mg
SSNRI: Selective Serotonin Norepinephrine Reuptake Inhibitors
fuloxetine Cymbalta® Start: 30 mg PO qAM No No $59-118 • Effective for diabetic
Caps: 30 mg, neuropathy
Goal: 30-60 mg PO qAM
60 mg • Should not be given
Max: 60 mg PO qAM to individuals with
chronic hepatic
disease or excessive
alcohol consumption
S
venlafaxine XR Effexor XR®, G Start: 37.5 mg PO qAM Yes, LCA Yes, LCA • May cause nausea
$$
35
-06
0 21
- -9
XR caps: 37.5,
Goal: 75 to 225 mg PO qAM
1
75,
150 mg Max: 375 mg+ PO daily
SSRI: Selective Serotonin Reuptake Inhibitors
citalopram Celexa®, G Start: 10 mg PO qAM Yes, LCA Yes, LCA $12-$22 (G) • Least
Tabs: 10, 20, $27-43 pharmacokinetic
40 mg drug interactions
Max: 60 mg PO qAM
escitalopram Cipralex® Start: 5 mg PO qAM Yes Yes $27-$56
Tabs: 10, 20 mg
Max: 30 mg+ PO qAM
TCA: Tricyclic Antidepressants
desipramine G Start: 10 to 25 mg PO qAMD Yes, LCA Yes, LCA $22-29 (G) • increase dose every
Tabs: 10, 25, 50, 3 to 7 days until goal
Goal: 50 to 75 mg PO qAMD
75, 100 mg reached
Max: 200 mg PO qAMD • may help
neuropathic
<N
S
nortriptyline Aventyl®, G Start: 10 to 25 mg PO at bedtime Yes, LCA Yes, LCA

$$
2 3
12
pain
cn
Caps: 10, 25 mg
Goal: 50 to 75 mg PO at bedtime • useful for night-time
Max: 150 mg PO at bedtime sedation
• anticholinergic side
effects
• desipramine and
nortriptyline least
anticholinergic of
TCAs
• monitor for postural
hypotension
Abbreviations: caps capsules; G generics available; IR immediate release; LCA subject to low cost alternative program; max maximum dose; PO by
mouth; qAM every morning; RD oral disintegrating tablet; SR sustained release; tabs tablets; XR extended release
A Not a complete list of antidepressants

B Start doses listed are recommended starting doses for geriatric patients (half the recommended doses for adults), except for duloxetine
C PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost
Coverage
D Bedtime dosing may be appropriate for patients experiencing sedation with desipramine
+ This maximum dose used in palliative care, but not approved for marketing by Health Canada
Tailor dose to each patient; those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages ;
consult most current product monograph for this information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp
PSYCHOSTIMULANTS
Generic Name Trade Available Dosage Standard Adult Dose Drug Plan CoverageA Approx. cost
Name Forms (note age spe cific reco m m en datio ns) P alliative 1 Fair per 30 days
Care i PharmaCare
methylphenidatet Ritalin®, G IR tabs: 5, 10, Age over 65 years: Yes, LCA ' Yes, LCA $6-16 (G)
1
20 mg Not recommended $11-32
Age 18 to 65 years:
Start: 5 mg PO bid (AM and
noon); use 2.5 mg for frail patients
Max: 15 mg PO bid (AM and noon)
Biphentin® SR caps: 10, 15, 20, Once dose stabilized on IR, give equivalent No No
i
30 mg daily dose as SR or XR form once daily in AM $21-54
Concerta® XR tabs: 18, 27, 36, No Special $68 - $89

54 mg AuthorityB
Ritalin® SR tabs: 20 mg No Yes, LCA $10 (G)

SR, G $20
dextro- Dexedrine® IR tabs: 5 mg Age over 65 years: No i Yes $20 - $156

amphetaminet Not recommended
Age 18 to 65 years:
Start: 2.5 mg PO bid (AM then in 4 to 6 h)
Max: 20 mg PO bid (AM then in 4 to 6 h)
SR caps: 10, Once dose stabilized on IR, give equivalent No Yes $28 - $ 112
i
15 mg daily dose as SR form once daily in AM
modafinilt Alertec®, G Tabs: 100 mg Age over 65 years: No Special $32-60 (G)
Start: 100 mg PO qAM AuthorityC, $42-83
Max: 100 mg PO bid (AM and noon) LCA
Age 18 to 65 years: $60-120 (G)
Start: 100 mg PO bid (AM and noon) $83-167
Max: 200 mg PO bid (AM and noon)
Abbreviations: caps capsules; G generics; h hours; IR immediate release; LCA subject to low cost alternative program; max maximum dose; PO by
mouth; qAM every morning; SR sustained release; tabs tablets; XR extended release
Coverage
BSpecial authority required to obtain coverage for Concerta® for ADHD as second line treatment
CSpecial authority required to obtain coverage for modafinil for patients with narcolepsy
+ This indication (i.e. depression) used in practice, but not approved for marketing by Health Canada
References
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ADVISORY COMMITTEE
Resources
Allied Health Care and Supports (Refer Palliative Care 1 - Approach to Care - Management at
www.bcguidelines.ca/gpac/guideline_palliative1.html#managementj
Consider referral to Home Nursing Care when patient’s Palliative Performance Scale (PPS) at
www.bcguidelines.ca/pdf/palliative1_appendix_a.pdf is transitioning from 70% to 60% or lower.
Consider an application to the BC Palliative Care Drug Plan - (Plan P) when patient is in the last 6 months of life and has
a PPS of 50% or less.
Physician and Patient Resources
BC Provincial Palliative Care Consult Line (available for physicians only, 24/7): 1-877-711-5757
Family Practice O ncology Network: www.bccancer.bc.ca/HPI/FPON/Guidelines+and+Protocols.htm

Providing comprehensive support for family physicians caring for cancer patients including the development of useful
resources and tools. Information to supplement this guideline, includes expanded sections on pain, dyspnea, nausea
and vomiting (including Medical Management of Malignant Bowel Obstruction), and constipation. Additional informa
tion includes Patient Daily Opioid Dosing Record, Methadone Licence Application Form, Bowel Performance Scale, BC
Cancer Agency Bowel Protocol, Patient Bowel Protocol Handout and Compounded Formulations for the Symptomatic
Management of Mucositis.
General Practice Services Committee (GPSC) - Palliative Care Initiative: www.gpscbc.ca/family-practice-incentive/

palliative-care-initiative
HealthLink BC: www.HealthLinkBC.ca

Dial 8-1-1 to speak to a nurse, a pharmacist, or dietician, for free information and resources for B.C. residents.
TTY (deaf and hearing-impaired) call 7-1-1.
Home and Com m unity Care - www.health.gov.bc.ca/hcc/

Home and community care services provide a range of health care and support services for eligible residents who have
acute, chronic, palliative or rehabilitative health care needs. For more information, refer to A Guide to Your Care, available
at http://www.health.gov.bc.ca/library/publications/year/2007/Guide_to_Your_Care_Booklet2007_Final.pdf
Practice S upport Program (PSP): www.practicesupport.bc.ca/psp/practice-support-program

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

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References
1. Kobierski, L et al. Hospice Palliative Care Program. Symptom Guide 5. Rodin G, Katz M, Lloyd N, et al. The management of depression in
lines. Fraser Health Authority. 2009 April. Available at: cancer patients: A clinical practice guideline”. Cancer Care Ontario.
www.fraserhealth.ca/professionals/resources/hospice_palliative_care/ 2006 Oct. Available at: www.cancercare.on.ca/common/pages/
hospice_palliative_care_symptom_guidelines UserFile.aspx?fileId=13930
2. Schwartzstein RM, King TE, Hollingsworth H. Approach to the patient 6 . Brietbart W, Dickerman AL. Assessment and management of depres
with dyspnea. UpToDate. 2009 Jan 1; 17.1. sion in palliative care. UpToDate. 2008 Jan 31; 16.1.
3. Membe SK, Farrah K. Pharmacological management of dyspnea in 7. Lorenz KA, Lynn J, Dy SM, et al. Evidence for improving palliative
palliative cancer patients: Clinical review and guidelines. Health Tech care at the end of life: A systematic review. Ann Intern Med. 2008 Jan
nology Inquiry Service. Canadian Agency for Drugs & Technologies in 15;148(2):147-159
Health. 2008 July.
4. Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions
to improve the palliative care of pain, dyspnea, and depression at the
end of life: a clinical practice guideline from the American College of
Physicians. Ann Intern Med. 2008 Jan;148(2):141-6.
Abbreviations
AEs adverse effects NSAIDs non-steroidal anti-inflammatory drugs
ABG arterial blood gas PEG polyethylene glycol
BM bowel movement SC subcutaneous
BNP brain natiuretic peptide SL sublingual
CHF congestive heart failure SSRI selective serotonin reuptake inhibitor
COPD chronic obstructive pulmonary disease SSNRI selective serotonin norepinephrine reuptake
CT computed tomography inhibitor
DSM-IV Diagnostic and Statistical Manual of Mental SVC superior vena cava
Disorders 4th edition SUPP suppository
ECG electrocardiogram TENS transcutaneous electrical nerve stimulation
GI gastrointestinal TCA tricyclic antidepressant
IV intravenous UTI urinary tract infection
N&V nausea & vomiting
NaSSA noradrenergic & specific serotonergic
antidepressant
DISCLAIMER
42
P a llia t iv e C a r e for t h e P a t ie n t w it h In c urable C an cer or A dvanced D is e as e - P a r t 2 : P a in and S ym ptom M anagement
INFORMATION ABOUT PROVINCIAL DRUG COVERAGE
WHO IS ELIGIBLE FOR COVERAGE UNDER THE BC PALLIATIVE CARE DRUG PLAN
(PLAN P)?
❖ BC PharmaCare offers coverage of palliative care medications to all B.C. residents who:
■ have a life expectancy of up to six months
■ are living at home*
■ have been diagnosed with a life-threatening illness or condition, and
■ consent to the focus of care being palliative rather than treatment aimed at a cure.
❖ “ H o m e ” is defined as w h e re ve r the person is living, w h e th e r in th e ir ow n hom e o r living w ith fa m ily o r friends, o r living in a
sup po rtive living reside nce o r hospice th a t is not covered un de r P ha rm aC are Plan B (fo r residents o f Licensed R esidential
C are Facilities).
❖ For guidance in determining patient’s medical eligibility, please refer to Appendix A - BC

Palliative Care Benefits Program Physician Guide at www.health.gov.bc.ca/pharmacare/
outgoing/palliative-physguide.pdf
❖ Residents of residential care facilities covered under PharmaCare Plan B (Permanent

Residents of Licensed Care Facilities) are not eligible for Plan P.
❖ Individuals admitted to residential care facility hospice beds for short-term stays, who meet the
palliative care medication coverage criteria, are eligible for Plan P.
❖ New B.C. residents, from other provinces, may qualify for coverage under Plan P. For more
information, contact Health Insurance B.C. (HIBC) at the phone numbers below.
HOW TO APPLY?
❖ Once a physician has determined that a patient meets the medical criteria, the physician
completes a B.C. Palliative Care Benefits Program Application (HLTH 349) available at www.
health.gov.bc.ca/pharmacare/outgoing/palliative.html and faxes it to Health Insurance BC
(HIBC) at 250-405-3587.
❖ Since the B.C. Palliative Care Drug Plan (Plan P) covers only specific drugs for palliative care
treatment, patients should be encouraged to register for Fair PharmaCare to obtain optimal
coverage for other eligible drugs.
❖ Registration for Fair PharmaCare can be completed by patients or their family members, online
at www.health.gov.bc.ca/pharmacare/fpcreg.html or by calling Health Insurance B.C. (HIBC) at
604-683-7151 (Vancouver and the Lower Mainland) or 1-800-663-7100 (toll-free, for the rest of
B.C.).
WHAT MEDICATIONS ARE COVERED?
❖ A list of the items covered by PharmaCare Plan P is available at www.health.gov.bc.ca/

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

44
P a llia t iv e C a r e for t h e P a t ie n t w it h In c urable C an cer or A dvanced D is e as e - P a r t 2 : P a in and S ym ptom M anagement
ADVISORY COMMITTEE
Part 3: Grief and Bereavement
Scope
This guideline addresses the needs of adult patients with incurable cancer or advanced disease (but can be useful for
adults dying of any cause), as well as the needs of their caregivers or family, including children. Information and tools are
provided to improve a primary care provider’s comfort and skills in dealing with this type of loss.
Diagnostic Code: 309 (adjustment reaction)
Working Definitions: Grief and bereavement are distinguished from each other, although bereavement includes many
aspects of grief.
Grief: An expected response to loss

Anticipatory Grief: Response to anticipated losses
Complicated Grief: Occurs when there is a debilitating intensity or duration of ‘normal’ grief responses that adversely
affect the ability to cope with normal life events.
Bereavement: The state where, following death, the family creates meaning and sense out of the new reality of life
without their loved one/person who died.
Grief
A. Assessment of grief
• Consider using the distress screening tool (refer Appendix A - Screening Tools for Measuring Distress) to ascertain the
degree of psychosocial, spiritual, and physical distress. This is best given to the patient to be filled out while
waiting to be seen. Scores of 5+ on the distress thermometer are significant and the problem checklist provides valuable
assessment information.
• Be aware of the potential desire for hastened death; if present, assess for suicide risk.
• Focus on personal strengths and coping mechanisms; what has worked in the past?
• Protective factors / resiliency for a patient or caregiver:
• Has an internalized belief in his / her own ability to cope effectively.
• Perceives the need for AND is willing to access social support.
• Is predisposed to a high level of optimism / positive state of mind.
• Has spiritual / religious beliefs that assist in coping with the death.
All of us grieve differently due to age, gender, personal, religious, and cultural differences; enquire regarding cultural and
individual preferences (refer Appendix B - Cultural Diversity and Individual Preferences ) and be aware of age differences
(refer Appendix C - Children and Death).
Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html

Palliative Care Part 2: Pain and Symptom Management is available at www.bcguidelines.ca/guideline_palliative2.html
H U BC Cancer Agency
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B. Management of grief
a. Non-pharmacological management: the relationship between the physician and the patient is one of the most
potent therapeutic tools for assisting patients who are dealing with grief. Reassurance about the normal pattern of
grief and a commitment to supporting the patient in an ongoing way is the mainstay of care. It may involve a
scheduled follow-up visit as necessary. Within that context, the following aspects of management should be
considered.
TABLE 1: Non-pharmaceutical Management of Grief
Acknowledgement of Use whatever words are appropriate in the context of the relationship with the patient and
loss(es) family. Patient handout: Normal Manifestations of Grief (refer Appendix D).
Education • Normalize responses to loss, e.g., “you are not going crazy”.
• Discuss what to expect when grieving.
Lifestyle management • Explore what is personally helpful to the patient, e.g., rest, exercise, social connections,
spiritual support, home support, compassionate care benefits program.
Resources Patient handout: Normal Manifestations of Grief (refer Appendix D).
b. Pharmacological management: In general, there is a limited place for pharmacological management in normal
grief. The physician must be alert to the possibility of underlying disease and incipient pathologic grief and treat
accordingly, but it is unwise to interrupt the normal constituents of grief such as depressed mood, anxiety, insomnia
and anger.
c. Other supports: Other support options are patient and caregiver support groups, on-line support groups, spiritual
care and/or faith based communities, and hospice/palliative care programs including volunteer support. Refer for
individual counselling when requested and appropriate.
Bereavement
Bereavement includes the period of adjustment following a person’s death and it encompasses many elements of grief,
including complicated grief. Anticipate / screen for complicated grief reactions and also consider using the Bereavement
Risk Assessment Tool (refer Appendix E) to assess risk.
A. Risk factors for complicated grief in bereavement

a. Co-morbidities: mental illness; cognitive impairment; substance abuse.
b. Concurrent stressors: multiple losses; significant other with life-threatening illness.
c. Circumstances around the death: received as preventable; sudden, unexpected, traumatic or untimely.
d. Lack of Supports: social isolation; disenfranchised grief; cultural or language barriers.
e. Relationships: anger; ambivalence; resentment; insecurity.
B. Assessment of bereavement (Refer Appendix F - Bereavement Algorithm)

• The following tools may be useful in support of the ongoing physician patient relationship:
• Issues with different ages, especially children (refer Appendix C - Children and Death).
• Bereavement Risk Assessment Tool (refer Appendix E).
• Bereavement Algorithm (refer Appendix F).
• Guide to Bereavement Assessment and Support (refer Appendix G).
• Caregiver Questionnaire (refer Appendix H).
• Timing for assessment of caregivers for bereavement / grief

• 2 - 8 weeks: assess for grief related depression (refer Appendix I - Distinguishing Grief and Depression) and
other health issues (eg. sleep, nutrition)
• 6 months: assess for complicated grief if not already identified and treated.
• Criteria for Diagnosing Complicated Grief

Yearning for the deceased must be experienced at least daily over the past month or to a distressing and disruptive
degree, i.e., intense and intrusive thoughts, unusual sleep disturbance, suicidal ideation, and the persistence for at least
six months of four of the following eight symptoms:
• difficulty moving on or reengaging with life
• numbness / detachment
2
P a llia t iv e C a r e fo r t h e P a r e n t wiTH I n c u r a b l e C a n c e r or A dvanced DiSEASE - P a r t 3 : GRiEF and B e r ea v e m e n t
• excessive bitterness or anger about the death
• feeling that life is empty
• a sense that the future holds no meaning without the deceased
• trouble accepting the death
• being on edge or agitated
• difficulty trusting others since the loss; social withdrawal
These symptoms can cause marked dysfunction in social, occupational, self care, or other important domains.
C. Management of bereavement (refer Appendix F - Bereavement Algorithm)
a. Non-pharmacological
TABLE 2: Non-pharmacological Management of Bereavement
At time of death (or • Personally contact the bereaved person / family.

ASAP there-after) • Acknowledge the death and reactions including feelings such as guilt, relief, or shock.
• Ascertain and address immediate concerns about care, the death, or the funeral.
• Arrange for follow-up contact.
After death Self management • Provide information about grief, i.e., what to expect and what is helpful
(refer Appendix D - Normal Manifestations of G rief (Patient Handout).
• Provide information about local resources (e.g., bereavement groups,
spiritual / religious supports, grief counsellors) and online resources
(refer Appendix J - Grief and Bereavement Guideline Resource Links
(Patient Handout)).
• Share Be Gentle with Yourself (Patient Handout - refer Appendix K).
Ongoing care contact • Within 2 weeks, acknowledge, or contact family.

• Contact again at 1-2 months, 6 months, and 11-12 months
(anniversary of the death).
• Recognize that holidays, birthdays, and wedding anniversaries are
tough.
• Be aware that the second year can also be difficult.
b. Pharmacological Management
85% of grief in bereavement is normal grief, not requiring pharmacological management.12
TABLE 3: Pharmacological Management of Bereavement
Benzodiazepines • Benzodiazepines have a very limited role in the management of acute grief.
Treating grief-related • Treat grief-related major depression once you are confident it is pathological.
major depression: • If depression is suspected while a person is acutely grieving, start by recommending
antidepressants regular exercise, counselling, and supports. If symptoms are worse or not improving by
8 weeks post-death, start antidepressant medication (refer Depression - Diagnosis and
Management at BCGuidelines.ca).
Treating complicated grief • Assess in the context of the person’s life, personality, culture, and the nature of the
illness/death.
• Refer to a bereavement counsellor, psychologist, or psychiatrist who will provide
targeted psychotherapy, Complicated Grief Treatment (CGT), in addition to possible
pharmacologic management.
P a llia t iv e C a r e fo r t h e P a tie n t w it h Inc u r able C a n cer or A dvanced D is e as e - P a r t 3 : G rief a n d B ereavem ent

Rationale
Family physicians often feel unprepared and uncomfortable about knowing how to support those going through intense
grief. They may both mourn the death of their patient and the patient’s death may also trigger their own past grief.
Grief and bereavement services should be available to all patients and families based on assessed needs. Everyone
grieves losses, but it is important to recognize especially vulnerable groups such as the elderly, children, the socially
isolated, the mentally ill, the disenfranchised and culturally diverse groups such as new immigrants and the Aboriginal
community.
It is not necessary to alter normal grieving, but it is helpful to provide a listening ear, to be supportive, and to provide
information. In the case of complicated grief, assess early and refer, realizing that a primary care provider needs to
continue to play a key role on the team.
“There’s no way around grief and loss: you can dodge all you want, but sooner or later you just have to go through it, and,
hopefully come out the other side. The world you find there will never be the same as the world you left.” - Johnny Cash
Useful References
1. Zhang B, El-Jawahri A, Prigerson H. Update on bereavement 7. Holland JC, Andersen B, Breitbart BS, et al. Distress management.
research: Evidence-based guidelines for the diagnosis and treatment J Natl Compr Canc Netw 2010;8:448-85. Available from: www.jnccn.
of complicated bereavement. J Palliat Med. 2006;9(5):1188-1203. org/content/8/4/448.full
2. Zisook S, Shear K. Grief and bereavement: what psychiatrists need 8 . Kearney MK, Weininger RB, Vachon ML, et al. Self-care of
to know. World Psychiatry. 2009;8:67-74. physicians caring for patients at the end of life: “Being connected... a
3. National Consensus Project for Quality Palliative Care. Clinical key to my survival”. JAMA. 2009;301(11):1156-64, E1.
practice guidelines for quality palliative care, 2 nd edition 9. Prigerson HG, Jacobs SC. Perspectives on care at the close of life.
[homepage on the Internet]. c2009. Available from: http://www. Caring for bereaved patients: “all the doctors just suddenly go”.
nationalconsensusproject.org/guideline.pdf JAMA. 2001;286(11):1369-76.
4. Victoria Hospice Society, Cairns M, Thompson M, Wainwright W. 10. Ngo-Metzger Q, August KJ, Srinivasan M, et al. End-of-life care:
Transitions in dying and bereavement: A psychosocial guide for guidelines for patient-centered communication. Am Fam Physician.
hospice and palliative care. Baltimore: Health Professions Press; 2008;77(2):167-74.
2003. 11. Zhang B, El-Jawahri BS, Prigerson H. Update on bereavement
5. Downing GM, Wainwright W, editors. Medical care of the dying. 4th research: evidence-based guidelines for the diagnosis and treatment
Edition. Victoria: Victoria Hospice Society, 2006; p. 641-668. of complicated bereavement. J of Palliat Med. 2006;9(5):1188-1203.
6 . Dyson T, Statton MA, Sutherland L. Psychosocial care. Hospice 12. Shear K, Frank E, Houck PR, et al. Treatment of complicated grief: a
Palliative Care symptom guidelines. Fraser Health [homepage on randomized controlled trial. JAMA. 2005; 293(21):2601-2608.
the Internet]. c2009. Available from: www.fraserhealth.ca/media/ 13. Stroebe MS, Hansson RO, Stoebe W, et al (Editors). Handbook
psychosocial% 20care.pdf of Bereavement Research and Practice: Advances in Theory and
Intervention. Washington DC: American Psychological Association;
2008.
Resources
• BC Association of Clinical Counsellors (BCACC): www.bc-counsellors.org

(Toll free) 1-800-909-6303, (Victoria) 250-595-4448
• BC Bereavement Helpline (BCBH): www.bcbereavementhelpline.com/
• British Columbia Hospice Palliative Care Association: www.hospicebc.org
• Community Healthcare and Resource Directory (CHARD): http://info.chardbc.ca/faq.asp
• General Practice Services Committee (GPSC) - Palliative Care Initiative:
www.gpscbc.ca/family-practice-incentive/palliative-care-initiative
• Employment Insurance Compassionate Care Benefits program:
www.servicecanada.gc.ca/eng/sc/ei/benefits/compassionate.shtml
• Lower Mainland Grief Recovery Society: www.lmgr.ca/index.htm
(Lower Mainland) 604-643-9637
• Victoria Hospice: www.victoriahospice.org
250-370-8715 (24 hours)
• Physician Health Program British Columbia: www.physicianhealth.com/
1-800-663-6729 (24/7)
4
PALLiATiVE C a r e fo r t h e P a r e n t wiTH I n c u r a b l e C a n c e r or A dvanced DiSEASE - P a r t 3 : GRiEF and B e r ea v e m e n t
Appendices
Appendix A - Screening Tools for Measuring Distress

Appendix B - Cultural Diversity and Individual Preferences
Appendix C - Children and Death
Appendix D - Normal Manifestations of Grief (Patient Handout)
Appendix E - Bereavement Risk Assessment Tool
Appendix F - Bereavement Algorithm
Appendix G - Guide to Bereavement Assessment and Support
Appendix H - Caregiver Questionnaire
Appendix I - Distinguishing Grief and Depression
Appendix J - Grief and Bereavement Guideline Resource Links (Patient Handout)
Appendix K - Be Gentle with Yourself (Patient Handout)
Associated Documents

The FPON has developed additional appendices including sections on communicating bad news and evidenced based
recommendations regarding preserving patient hope. These appendices can be found at www.bccancer.bc.ca/HPI/FPON/
Guidelines+and+Protocols.htm
The principles o f the G uidelines and Protocols A dvisory Com m ittee are to:
• recommend actions that are sufficient and efficient, neither excessive nor deficient Victoria BC V 8W 9P1
DISCLAIMER
care professional, nor are they intended to be the only approach to the management of clinical problems. W e cannot respond to patients or patient
advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.
P a llia t iv e C a r e fo r t h e P a tie n t w it h Inc u r able C a n cer or A dvanced D is e as e - P a r t 3 : G rief a n d B ereavem ent

Appendix A
SCREENING TOOLS FOR MEASURING DISTRESS Second, please indicate if any of the following has been a
problem for you in the past week including today. Be sure to
check YES or NO for each.
YES NO Practical Problems YES NO Physical Problems
Instructions: First please circle the number (0-10) that best □ □ Child care □ □ Appearance
describes how much distress you have been experiencing in □ □ Housing □ □ Bathing/dressing
the past week including today.
□ □ Insurance/financial □ □ Breathing
□ □ Transportation □ □ Changes in urination
□ □ W ork/school □ □ Constipation
□ □ Treatm ent decisions □ □ Diarrhea
Extreme distress 10 • O '
□ □ Eating
9 F a m ily P ro b lem s □ □ Fatigue

□ □ Dealing with children □ □ Feeling Swollen
8 □ □ Dealing with partner □ □ Fevers
7 □ □ A bility to have children □ □ Getting around

□ □ Family health issues □ □ Indigestion
6 □ □ M em ory/concentration
E m o tio n a l P ro b lem s
5 □ □ Mouth sores
□ □ Depression
□ □ N ausea
4 □ □ Fears
□ □ Nose dry/congested
□ □ Nervousness
□ □ Pain
3 □ □ Sadness
□ □ Sexual
2 □ □ W o rry
□ □ Skin dry/itchy
□ □ Loss of interest in
□ □ S leep
1 usual activities
□ □ Tingling in hands/feet
No distress □ □ Spiritual/religious
concerns
Other Problems:
Version 1.2011,10/12/10© National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. DIS-A
R eproduced w ith perm ission from the NCCN 1.2011 Distress M anagem ent G uidelines. To view the m ost recent and com plete G uidelines, go online to w w w .n c cn .o rg .
Appendix B: Cultural Diversity and Individual Preferences
C onsiderations fo r cultural and individual patient preferences in grief / bereavement discussions
• When a patient and physician enter into grief and bereavement discussions, each brings individual cultural backgrounds
and values that influence the discussions.
• Although understanding cultural norms is important, physicians must be careful to avoid stereotyping patients based on
their cultures.
• An individual's culture is influenced by the culture of the family, religion, spirituality, education, occupation, social class,
friends, and personal preferences.
• Asking open-ended questions can elicit a patient's preferences for physician frankness, decision making, and direct versus
indirect communication.
• Physicians may prevent misunderstanding and promote trust by respectfully listening to a patient's beliefs and values.
• Assess individual preferences and tailor discussions appropriately.
• Consider a patient's sex, age, health literacy, health status, previous health care experiences, social status, culture, and
race / ethnicity.
• Avoid assumptions about what the patient is likely to want and ask directly about values and preferences.
Useful Questions to Help Determ ine Preferences
Factors Useful questions Rationale

Social, “Tell me about your family” “Have you or your The physician may offend or stereotype the
educational, and family had significant experience with someone patient because of incorrect assumptions if he/
fam ily factors who has had a serious illness or who has died? she does not ask about the patient's background.
If so, how did that experience affect you?” Misunderstandings between physician and patient
may occur if social, educational, and family
preferences are not assessed.
Cultural, religious, “ Is there anything I should know about your The physician may be regarded as disrespectful
and spiritual cultural, religious or spiritual views?” if the patient's cultural, religious, and spiritual
factors preferences are not addressed. The patient may
reject medical advice if the physician does not
understand how the patient views the physician's
role and advice in the context of culture, religion, or
spirituality.
Adapted from: Ngo-Metzger Q, August KJ, Srinivasan M, et al. End-of-life care: Guidelines for patient-centered communication.
Am Fam Physician. 2008;77(2):167-74.
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Appendix С: Children and Death
Developmental Possible
Age Concept of Death Grief Response Signs of Distress
State / Task Interventions
Egocentric. Believes Seen as abandonment. Seen Intensive response, but brief. Regression: sleeping Short interactions. Frequent
world centers around as reversible, not permanent. Very present oriented. Most and eating disorders - repetition. Comforting.
them. Narcissistic. No Common statements, “ Did aware of altered patterns of bedwetting. Touching.
2-4
cognitive understanding. you know my daddy died - care.
Preconceptual - unable to when will he be home?”
grasp concepts.
Gaining sense of autonomy. Death still seen as reversible. Verbalization. Great concerns Regression: nightmares, Symbolic play. Drawing /
Exploring world outside Great personification with process. How? Why? sleeping and eating stories. Allow / encourage
of self. Gaining language. of death. Feelings of Repetitive questioning. disturbances, violent play. expression of energy / feelings
Fantasy thinking/wishing. responsibility because of Attempts to take on role of about anger. Talk about it.
4-7
Initiative stage seeing self as wishes, thoughts. Common person who died.
initiator. Concerns of guilt. statements, “ It’s my fault; I
was mad at her and wished
she’d die.”
Concrete - operational. Death as punishment. Fear of Specific questioning. Regression: problems at Answer questions. Encourage
Industry versus inferiority. bodily harm; mutilation. This Desire for complete detail. school, withdrawn from expression of range of
Beginning of socialization. is a difficult transition period Concerned with how others friends. Sleeping and eating feelings. Encourage / allow
Development of cognitive - still wants to see death as are responding. What is the disturbances. Overwhelming control. Be available but allow
7-11*
ability. Beginning of logical reversible but beginning to right way? How should they concern with body. Suicidal alone time. Symbolic play.
thinking. see it as final. be responding? Starting to thoughts (desire to join Talk about it.
have ability to mourn and the one who died). Role
understand mourning. confusion.
Formal operation problem “Adult” approach. Ability to Depression. Denial. Depression. Anger. Anger Encourage verbalization. Do
solving. Abstract thinking. abstract. Beginning to truly Regression: more often towards parents. Non- not take control. Encourage
11-18* Integration of one’s own conceptualize death. Work at willing to talk to people compliance. Rejection self-motivation. Listen. Be
personality. making sense of teachings. outside of family. Traditional of former teaching. Role available. Do not attempt to
mourning. confusion. Acting out. take away grief.
*it is during these 2 age / stages that most children / young adults struggle with their own body image issues, they also seem
to struggle the most with changing body images of illness and death. It is important to prepare them in advance about what
they may see and then allow them to verbalize their feelings about what they saw.
© Margaret Metzgar M.A., Sl/K LMHC. Used with permission from author. Margaretm@pacmed.org
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Appendix D: Normal Manifestations of Grief (Patient Handout)
THE GRIEF JOURNEY
When a death occurs Adjusting to loss As life goes on

SOCIAL SOCIAL SOCIAL
• Withdrawal from others • Rushing into new relationships • More interest in daily affairs of self / others
• Unrealistic expectations of self and others • Wanting company but unable to ask • Ability to reach out and meet others
• Poor judgment about relationships • Continued withdrawal and isolation • Energy for social visits and events
• Self-consciousness
PHYSICAL PHYSICAL PHYSICAL
• Shortness of breath and palpitations • Changes in appetite and sleep patterns • Physical symptoms subside
• Digestive upsets • Shortness of breath and palpitations • Sleep pattern and appetites are more settled
• Low energy, weakness, and restlessness • Digestive upsets • Gut-wrenching emptiness lightens
EMOTIONAL EMOTIONAL EMOTIONAL
• Crying, sobbing, and wailing • Intense and conflicting emotions • Emotions are less intense
• Indifference and emptiness • Magnified fear for self or others • Feeling of coming out of the fog
• Outrage and helplessness • Anger, sadness, guilt, depression • More peace; less guilt
MENTAL MENTAL MENTAL
• Confusion, forgetfulness, and poor concentration • Sense of going crazy • Increased perspective about the death
• Denial and daydreaming • Memory problems • Ability to remember with less pain
• Constant thoughts about the person who died • Difficulty concentrating/understanding • Improved concentration and memory
and/or the death • Wild dreams or nightmares • Dreams and nightmares decrease
SPIRITUAL SPIRITUAL SPIRITUAL
• Blaming God or life • Trying to contact the person who died • Reconnection with religious / spiritual beliefs
• Lack of meaning, direction, or hope • Sensing the presence of the person who died; • Life has new meaning and purpose
• Wanting to die or join the person who died visitations • Acceptance of death as part of life cycle
• Continued lack of meaning
WHAT HELPS WHAT HELPS WHAT HELPS
• Pace yourself moment to moment • Recognize and express emotions • Reflect on progress since death
• Make no unnecessary changes • Acknowledge changes • Begin envisioning a future
• Talk about the person and the death • Understand grief and know that others • Engage in new activities
• Use practical and emotional supports experience similar responses • Establish new roles and relationships
Adapted from “The Grief Journey”; Victoria Hospice Society.
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Appendix E: Bereavement Risk Assessment Tool © Victoria Hospice Society 2008
Assessment Date Assessed by ID# Patient / Deceased Name Bereaved Name
Comments
R isk Indicators and Protective Factors
I. Kinship
□ a) spouse/partner of patient or deceased
□ b) parent/parental figure of patient or deceased
II Caregiver
□ a) family member or friend who has taken primary responsibility for care
III. Mental Health
□ a) significant mental illness (eg major depression, schizophrenia, anxiety disorder)
□ b) significant mental disability (eg developmental, dementia, stroke, head injury)
IV. Coping
□ a) substance abuse / addiction (specify)
□ b) considered suicide (no plan, no previous attempt)
□ c) has suicide plan and a means to carry it out OR has made previous attempt
□ d) self-expressed concerns regarding own coping, now or in future
□ e) heightened emotional states (anger, guilt, anxiety) as typical response to stressors
□ f) yearning/pining for the deceased OR persistent disturbing thoughts/images > 3 months*
□ g) declines available resources or support
I I h) inability to experience grief feelings or acknowledge reality of the death > 3 months*
V. Spirituality / Religion
□ significant challenge to fundamental beliefs / loss of meaning or faith / spiritual distress
VI. Concurrent Stressors
□ a) two or more competing demands (eg single parenting, work, other caregiving)
I I b) insufficient financial, practical or physical resources (eg 4 income, no childcare, illness)
□ c) recent non-death losses (eg divorce, unemployment, moving, retirement)
□ d) significant other with life-threatening illness / injury (other than patient/deceased)
VII. Previous Bereavements
□ a) unresolved previous bereavement(s)
□ b) death of other significant person within 1 year (from time of patient’s death)
□ c) cumulative grief from > 2 OTHER deaths over past 3 years
I I d) death or loss of parent/parental figure during own childhood (less than age 19)
VIII. Supports & Relationships
□ a) lack of social support/social isolation (perceived or real - eg housebound)
□ b) cultural or language barriers to support
□ c) longstanding or current discordant relationship(s) within the family
□ d) relationship with patient/deceased (eg abuse, dependency)
IX. Children & Youth
□ a) death of parent, parental figure or sibling*
□ b) demonstration of extreme, ongoing behaviours/symptoms (eg sep anxiety+, nightmares)
□ c) parent expresses concern regarding his/her ability to support child’s grief
I I d) parent/parental figure significantly compromised by his/her own grief
X. Circumstances Involving the Patient, the Care or the Death
□ a) patient/deceased less than age 35
□ b) lack of preparedness for the death (as perceived or demonstrated by bereaved)*
□ c) distress witnessing the death OR death perceived as preventable*
□ d) violent, traumatic OR unexplained death (eg accident, suicide, unknown cause)*
□ e) significant anger with OTHER health care providers (eg “my GP missed the diagnosis”)
I I f) significant anger with OUR hospice palliative care program (eg “you killed my wife”)
XI. Protective Factors Supporting Positive Bereavement Outcome
□ a) internalized belief in own ability to cope effectively
□ b) perceives AND is willing to access strong social support network
□ c) predisposed to high level of optimism/positive state of mind
□ d) spiritual/religious beliefs that assist in coping with the death
Aug-08
* this indicator can only be identified after the death
More information on this tool is available at: www.victoriahospice.org/health-professionals/clinical-tools
Used with permission from Victoria Hospice Society, www.victoriahospice.org

Appendix F: Bereavement Algorithm
DEPRESSION
(10-25%)
Add Pharmacological Rx
Nonpharmacologic Rx
(Depression - Diagnosis
• Regular exercise
and Management, at
• Counselling
BCGuidelines.ca)
• Provide support
• Regularly reassess
6 months post death

ASSESS for YES COMPLICATED GRIEF
COMPLICATED (10-15%)
GRIEF
Psychosocial support
Combined treatment with
targeted psychotherapy &
possibly antidepressants
Adjustment to death \
and reengaged in 1
relationships and
activities У -^ -
Source: Family Practice Oncology Network
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Appendix G: Guide to Bereavement Assessment and Support
WHAT YOU MIGHT HEAR / SEE RISK FACTORS WHAT ELSE HELPS
A bility to Cope
Partner, parent, or care provider of Reframe / encourage, refer (hospice,
Concerns re: identity, future
deceased seniors, support services)
Lack of comprehension or expected Mental illness / disability or depression Mental health / depression protocol
reactions
History of unhelpful coping strategies Explore history / context of coping and
Ongoing struggle with activities of daily
(e.g., substance abuse, declines person's perspective, give homework*
living, concern about coping
support / resources)
A plan / the means to complete suicide, Suicidal ideation Suicide protocol, refer to mental health /
previous attempts community resources
Grief Reactions
Inability > 6 months to address / work Explore cause(s), expression and
Ongoing heightened reaction(s) (e.g.,
through emotional responses to death impact, refer for counselling / therapy,
pining, hopelessness, anger, guilt)
give homework*
Ongoing disbelief, denial of death or Inability to experience grief or Explore cause(s), refer for bereavement
lack of reaction acknowledge reality of death counselling
Ongoing anger / disconnection with Spiritual / religious angst Encourage connection with faith
beliefs, God, meaning community, spiritual advisor
Other Stressors
Concerns about finances, children, Competing demands; limited practical Explore options, recommend practical
work resources help, give homework*
Other multiple losses Explore impact of multiple griefs,
Loss of job, divorce, home
normalize reactions
Cumulative grief, recent multiple / Identify and acknowledge enormity
Confused, overwhelmed, loss of sense
unresolved deaths; significant childhood / impact of grief, refer for therapy /
of ‘self'
death(s) counselling
Supports
Perceived lack of support including Acknowledge perceptions; reframe,
Isolation, concern no one cares or
language / cultural barriers; support social connections, give
understands them
disenfranchised grief homework*
Relationships
Unresolved family tensions / issues re: Longstanding or current discordant Explore possibility of resolution; support
care, death, estate or relationships (e.g., relationships in family (including with mediation / advice, refer for family
abuse) deceased) therapy / counselling
Anger, distrust of health care provider(s) Negative perceptions / circumstances Be open, non-defensive, support
(regarding diagnosis, care, system) of care appropriate follow up, give homework*
The Death
Concerns re: sudden, distressing, Negative circumstances and trauma Review the death, be factual, explore
violent, untimely nature of death; connected to the death present / future issues and impact, refer
extreme blame, fear, guilt, anger for counselling
LISTEN & BE PRESENT EXPLORE & ACKNOWLEDGE NORMALIZE & FOLLOW UP
Adapted from the Bereavement Risk Assessment Tool, © 2008 Victoria Hospice Society.
* Refer to examples o f homework in grieving: Palliative Care Part 3, Section B, Table 1: Non-pharmaceutical Management o f Grief
BC Cancer Agency
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Appendix H: Caregiver Questionnaire
Please CIRCLE a number from 1-5 to indicate your choice:
1. Do / did you feel overwhelmed by providing care?
Not at all Somewhat More often Most often All of the time
1 2 3 4 5
2. Do you feel isolated from family and friends?
1 2 3 4 5
3. Are you worried about your ability to cope now or later?
1 2 3 4 5
4. Are you feeling sad or depressed?
1 2 3 4 5
5. Alcohol intake: . (drinks per day / week)
6. Exercise: . (sessions / week)
7. Sleep changes: О Yes О No
8. Eating: О More ЦЦ Less
9. What changes have occurred in your life due to personal loss?
Source: Family Practice Oncology Network
BC Cancer Agency
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MEDICAL B R IT ISH
Appendix I: Distinguishing Grief and Depression
Feeling Grief Depression
Mood states • Greater range of moods and • Moods and feelings are more static,
feelings little variability
• Quick shifts from sadness to normal • Consistent sense of depletion,
state in the same day psychomotor retardation, anorexia,
• Variability in mood, activity, and / or decreased sexual interest or
communication, appetite, and compulsive communication, eating,
sexual interest in the same week and / or sexual behaviour
Expression o f anger • Open, externally directed • Absence of externally directed

anger, internally directed
Expression o f sadness • Weeping • Difficulty weeping or controlling

weeping
Self-concept • Guilt associated with specific • The loss confirms the person is bad
aspects of the loss or worthless
• Experience the world as empty • Focus on punitive thoughts, guilt
• Preoccupation with the loss has global aspect
• Preoccupation with self
Responsiveness • Periodic • Static

• Want solitude but respond to • Fear of being alone or
warmth and involvement unresponsiveness to others
Pleasure • Periodic • Restrict all pleasure

• Want solitude but respond to • Loss of sense of humour
warmth and involvement
Reaction to others • Others want to offer support • Others often feel irritated
• Rarely feel like reaching out
Content adapted from the Victoria Hospice Society.
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Appendix J: Grief and Bereavement Guideline Resource Links (Patient Handout)
• BC Bereavement Helpline: www.bcbereavementhelpline.com

Dial: 604-738-9950, (Toll Free) 1-877-779-2223
The BC Bereavement Helpline (BCBH) is a non-profit free, and confidential service that connects the public to grief support
services within the province of BC. Services include: helpline for referral and support, community network of support and
information, brochures of available support in BC, e.g., “Ten Things to Know about Grief” (available in many different
languages) and “5 Tips to Help the Grieving”.
• BC Cancer Agency: www.bccancer.bc.ca

Multiple experiences of loss and grief happen throughout the cancer experience, from diagnosis to treatment to post
treatment. The loss may be temporary or permanent, life-altering, or a minor inconvenience. The following pages provide
some information on grief and loss in the context of cancer, as well as support services available:
www.bccancer.bc.ca/PPI/copingwithcancer/emotional/dealingemotions/lossgrief.htm
• BC C hildren’s Hospital: www.bcchildrens.ca

For those who may be grieving the loss of a child, a brother or sister, another family member, or a friend who are looking for
grief support resources and information: www.bcchildrens.ca/YourVisit/Familyservices/GriefAndLoss/default.htm
• BC Hospice Palliative Care A ssociation (BCHPCA): www.hospicebc.org

Dial: 604-267-7024, (Toll Free) 1-877-410-6297
BCHPCA's vision is that all people in BC and the Yukon have access to quality end-of-life care. Their mission is to build
capacity in communities to support this vision. The following link leads you to a directory of hospices and hospice
societies: www.hospicebc.org/membership/our-program-members . There are also many excellent books that cover a wide
range of topics related to dying, death and bereavement: www.hospicebc.org/research-education/books . Check with your
local library or book store.
• Canadian Virtual Hospice: www.virtualhospice.ca

The Canadian Virtual Hospice provides support and personalized information about palliative and end-of-life care to
patients, family members, health care providers, researchers, and educators:
www.virtualhospice.ca/en_US/Main+Site+Navigation/Home/Topics/Topics/Emotional+Health/Grief+Work.aspx
• Suicide A ttem pt Follow-up, Education and Research (SAFER): http://youthinbc.com/safer/

Dial: 604-675-3985
Works to reduce suicide risk among those in crisis, to assist family and friends who care about them, and to promote
healing among those bereaved by suicide. Also available for family physicians to consult.
• Victoria Hospice: www.victoriahospice.org

Victoria Hospice's commitment to care continues through bereavement education, resource materials, and services,
including several excellent brochures: www.victoriahospice.org/about-us/publications#bereave
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Appendix K: Be Gentle with Yourself (Patient Handout)
Thoughts on Coping w ith Loss
Grief is a process that takes time, patience, and understanding. There are, however, some things you can do to take some
control during this painful time. Your physical health is often the easiest place to begin.
Start by:
• Reducing alcohol, caffeine and sugar intake.
• Drinking enough water each day.
• Eating a healthy diet.
• Getting as much rest as you can.
• Learning to say no to things you don't have energy to do.
• Believing in yourself and your ability to adjust to your loss.
• Participating in some form of physical activity each day.
• Allowing yourself time to mourn.
• Not isolating yourself, i.e., share your pain with a compassionate person or find a counsellor with experience in grief and
loss.
• Nurturing yourself, i.e., use art, poetry, meditation, music, journaling, massage, or anything that makes you feel good.
• Talking about your grief, i.e., try to give your sorrow words or write them in a journal. It is healthy to share your memories
both happy and sad with people who care.
A dditional thoughts
• We have tears for a purpose. Some scientists believe that crying is important to our bodies to relieve the toxins that build
up from stress and emotional pain. When we repress our tears it can lead to illness. However it works, experience tells us
that crying is healing. If you don't feel comfortable crying in the presence of others, allow time to cry alone. It will relieve
the pressure and help you to control your grief in social settings.
• You are the best authority on your grief. Well meaning friends may try to help by keeping you busy or making sure you are
never alone. It is important for you to determine for yourself what is best.
• Spend time with people you trust. Try not to isolate yourself with your feelings. Friends who do not judge your behaviour,
who allow you to talk about your grief, and who accept your feelings are invaluable.
• Recognize your physical and psychological limitations. Most people experience fatigue during grief. Don't hesitate to
excuse yourself from commitments you feel too tired or sad to attend. Avoid situations you believe may cause you stress
or anxiety, instead allow time for simple activities that sooth and relax and provide creative outlets of your own choosing.
Allow yourself to just ‘be'.
• Use all resources that are available to you. If you have a faith or religion that gives you comfort, this is a time to depend on
it. Sharing feelings with others, even strangers, who have had similar experiences can give perspective and assure you that
you will survive. Grief counselling in groups or individually can assist you in understanding your grief and help you to cope
with its manifestations.
Above all, BE GENTLE WITH YOURSELF
Source: Living through Loss Counselling Society o f BC, adapted May 10, 2010.
Й И BC Cancer Agency
BRITISH
COLUMBIA
MEDICAL
О
B R IT ISH
Ministry of
rCARE
A D C J. D СС СA or U
+ RESEARCH
AnagencyofthePrvvinclci HealthServkosAuthority

Palliative Care For The Patient With Incurable Cancer or Advanced Disease

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Palliative Care For The Patient With Incurable Cancer or Advanced Disease

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GUIDELINES & P R O T O C O L S

Diagnostic Code: 239 (neoplasm of unspecified nature)

WHO Definition of Palliative Care

Palliative Care Part 2: Pain and Symptom Management is available at www.bcguidelines.ca/guideline_palliative2.html

ASSOCIATION C o l u m b ia Health Fam ily Practice O n co lo g y Network

a. Monitor patient’s functional capacity.

b. Co-ordinate care with allied health care providers.

c. Evaluate symptom burden.

d. Establish goals of care with patients and families.

e. Management strategies: non-pharmacologic.

f. Management strategies: pharmacotherapy.

g. Referral to a specialist (refer Appendix D).

h. Indications for referral to a tertiary palliative care unit.

Emergency Investigation Intervention

k. Actively dying: The End of Life (EOL) Care check list.

CPR cardiopulmonary resuscitation

Appendix A: Palliative Performance Scale (PPS) Including Instructions for Use

This guideline is based on scientific evidence current as of the Effective Date.

A mobile version of this and other guidelines is also available at www.BCGuidelines.ca

PPS Ambulation Activity & Evidence of Self-Care Intake Conscious Level

70% R educed U n ab le norm al jo b /w o rk Full N orm al or Full

60% R educed U n ab le h o b b y /h o u s e w o rk O ccasio na l N orm al or Full

50 % M ainly S it/L ie U n ab le to do any w o rk O ccasio na l N orm al or Full

40 % M ainly in Bed U n ab le to do m o s t a ctivity M a in ly a ssista nce N orm al or Full o r d ro w sy

30 % T otally Bed U n ab le to do any a ctivity Total Care N orm al or Full o r d ro w sy

20 % T otally Bed U n ab le to do any a ctivity Total Care M in im al to Full o r d ro w sy

10 % T otally Bed U n ab le to do any a ctivity Total Care M o u th care D row sy or co m a

ASSOCIATION C o l u m b ia Health Fam ily Practice O n co lo g y Network

2. Activity & Extent of Disease

Reason for Investigation Investigation Possible Interventions

Fam ily Practice O n co lo g y Network

Edmonton Symptom Assessment System

Please circle the numbe that best describes

No pain 0 2 3 4 5 6 7 8 9 10 Worst possible pain

Not tired 0 2 3 4 5 6 7 8 9 10 Worst possible

Not nauseated 0 2 3 4 5 6 7 8 9 10 Worst possible nausea

Not depressed 0 2 3 4 5 6 7 8 9 10 Worst possible

Not anxious 0 2 3 4 5 6 7 8 9 10 Worst possible anxiey

Not drowsy 0 2 3 4 5 6 7 8 9 10 Worst possible

Best appetite 0 2 3 4 5 6 7 8 9 10 Worst possible

Best feeling of 0 2 3 4 5 6 7 8 9 10 Worst possible feeling

No shortness of 0 2 3 4 5 6 7 8 9 10 Worst possible

Complete by (check one)

ASSOCIATION C o l u m b ia Health Fam ily Practice O n co lo g y Network

Indication Procedure Physician Specialty

E sophageal ste n t T h o ra cic/G I surgeon

D uodenum D uodenal ste n t

S up erior ven a cava (SVC) SVC ste n t Interve ntion al ra d io lo g ist

B ron chu s R adiotherapy, bra ch yth e ra p y R adiation o n c o lo g is t

U reter N e p h ro sto m y U ro lo g ist

V ag in al/ute rine R a dio thera py R adiation o n c o lo g is t

Rectal Laser c o a g u la tio n G a stro e n te ro lo g ist

H em aturia R a dio thera py R adiation o n c o lo g is t

Skin su rfa ce o f tu m o u r R a dio thera py R adiation o n c o lo g is t

P leurodesis R e sp iro lo g ist

C a nce r o f th e pancreas C o eliac plexus b lo c k A n e sth e tist, g a s tro e n te ro lo g is t (U/S)

Severe o p io id re sista n t pain K eta m ine by co n tin u o u s su b cu ta n e o u s P alliative care ph ysicia n

N euroaxial b lo c k A n e sth e tist

> 5 0 % o f th e c o rte x o f fe m u r or In tra m e d u lla ry nailing O rth o p e d ic surgeon

Fam ily Practice O n co lo gy Network

lbs lbs lbs lbs lbs

Performance Status - P PS (0-100%) % % % % %

Pain 1: location: type: (0-10)