ID:257579961           
<?xml version="1.0" encoding="UTF-8" ?><SystmOneTemplates><!--Exported on 30 Mar 2020 15:00--><!--Exported by PLENDERLEITH, Steve (Dr)--><TemplateDefinition Male="y" Female="y" Type="0"><template Cid="0" width="864" height="636" codes="" readCodesToAutoLinkDrugsTo="" codesToAlwaysInclude="" keyWordLetterTemplateDefaultForPrinting="-1"><page Cid="1" name="Introduction" colour="-1"><formattedText Cid="15" x="372" y="744" w="204" h="24"><p><p><t b="b">May be used in some practices.</t></p></p></formattedText><comboBox Cid="19" x="288" y="708" w="444" text="Register &amp; / OR prognosis" bias="65" amendNotes="y" blank="n" showTimeComponent="n" codes="XaKdU;XaZ7j;X76Ao;Xa982;XaZb7;XaZbA;XaZbD;XaZbE"><rc rc="XaKdU" desc=""/><rc rc="XaZ7j" desc=""/><rc rc="X76Ao" desc=""/><rc rc="Xa982" desc=""/><rc rc="XaZb7" desc=""/><rc rc="XaZbA" desc=""/><rc rc="XaZbD" desc=""/><rc rc="XaZbE" desc=""/></comboBox><formattedText Cid="6" x="289" y="6" w="408" h="30"><p><p><t b="b" fg="0xff005eb8">For project information, template updates and additional resources.</t></p></p></formattedText><hyperLink Cid="7" x="684" y="6" w="168" h="24" URL="www.futureplanning.org.uk" DisplayText="Future Planning Website"/><hyperLink Cid="3" x="683" y="31" w="108" h="24" URL="http://www.futureplanning.org.uk/supported_by.html" DisplayText="Supported by"/><formattedText Cid="8" x="324" y="31" w="360" h="24"><p><p><t fnt="Arial" b="b" fg="0xff005eb8">Project supported as part of an NHS and Hospice partnership.</t></p></p></formattedText><formattedText Cid="9" x="12" y="0" w="270" h="72"><p><p al="1"><t sz="20" b="b">Anticipatory Medications</t></p><p al="1"><t sz="16" b="b">Subcutaneous Drug</t></p><p al="1"><t sz="14" b="b">Dose Calculation Worksheet</t></p></p></formattedText><view Cid="72" x="228" y="192" w="624" h="408" KeyView="22305"/><formattedText Cid="59" x="12" y="192" w="180" h="36"><p><p><t sz="16" b="b">LINK to PAGE for...</t></p></p></formattedText><pageLink Cid="20" x="84" y="228" w="108" h="24" PageNumber="2" DisplayText="  PAIN CONTROL"/><pageLink Cid="21" x="48" y="264" w="144" h="24" PageNumber="3" DisplayText="    NAUSEA &amp; VOMITING"/><pageLink Cid="24" x="60" y="300" w="132" h="24" PageNumber="4" DisplayText="   BREATHLESSNESS"/><pageLink Cid="23" x="108" y="336" w="84" h="24" PageNumber="5" DisplayText="    ANXIETY"/><pageLink Cid="22" x="96" y="372" w="96" h="24" PageNumber="6" DisplayText="    AGITATION"/><pageLink Cid="25" x="84" y="408" w="108" h="24" PageNumber="7" DisplayText="      SECRETIONS"/><pageLink Cid="26" x="48" y="444" w="144" h="24" PageNumber="8" DisplayText="      COLIC (of any type)"/><pageLink Cid="95" x="108" y="480" w="84" h="24" PageNumber="9" DisplayText="      COVID-19"/><formattedText Cid="13" x="12" y="612" w="708" h="36"><p><p><t sz="14" b="b" fg="0xffef3511">V 1.2</t><t sz="14" fg="0xffef3511"> of the </t><t sz="14" b="b" fg="0xffef3511">FP Anticipatory Meds Worksheet</t><t sz="14" fg="0xffef3511"> - March 2020  </t><t sz="14" fg="0xff330033">&#169; Copyright reserved. SHFT/Solent NHS Trust</t></p></p></formattedText><formattedText Cid="2" x="0" y="84" w="852" h="108"><p><p al="1"><t fnt="Arial" b="b">The purpose of this template and linked webpages is to guide you to safe starting doses of (primarily) End of Life anticipatory medications.</t></p><p al="1"><t fnt="Arial" b="b">AND to help with symptom management in the very last days of life.</t></p><p/><p al="1"><t fnt="Arial" sz="14" b="b" fg="0xffff0033">This template is not approved as a device by the MHRA as it neither calculates doses</t></p><p al="1"><t fnt="Arial" sz="14" b="b" fg="0xffff0033">nor does anything fancy with Artificial Intelligence. </t></p><p al="1"><t fnt="Arial" sz="14" b="b" fg="0xff330033">As ever it relies on you to apply clinical knowledge and make the calculations.....</t></p></p></formattedText></page><page Cid="27" name="PAIN" colour="-215353"><title Cid="34" x="12" y="12" width="252" text="End of Life Pain Control"/><title Cid="45" x="456" y="12" width="396" text="Subcutaneous Drug Dose Worksheet" colour="-13172638"/><formattedText Cid="111" x="36" y="48" w="792" h="48"><p><p><t sz="14" b="b" fg="0xff003399">Find the section that represents your patient&apos;s CURRENT treatment, and then click the associated link to view the suggested treatment pathway.</t></p></p></formattedText><hyperLink Cid="60" x="648" y="144" w="108" h="24" URL="www.futureplanning.org.uk/Opioid_Naive" DisplayText="Opioid Naive"/><hyperLink Cid="62" x="648" y="228" w="108" h="24" URL="www.futureplanning.org.uk/Weak_Opioid" DisplayText="Weak Opioids"/><hline Cid="48" x="156" y="240" length="96"/><formattedText Cid="46" x="252" y="108" w="323" h="90"><p><p><t sz="11">&#x9;       Co-codamol 8/500 or 15/500 upto 8/day</t></p><p><t sz="11">&#x9;       Co-codamol 30/500 &lt; 6 tabs/day</t></p><p><t sz="11">Opioid Naive </t><t sz="11" b="b">OR   </t><t sz="11">  Tramadol less than (&lt;) 200mg/day</t></p><p><t sz="11">&#x9;       Buprenorphine patch 5microg/hr</t></p><p><t sz="11">&#x9;             (Continue patch &amp; replace as usual</t><t sz="10">)</t></p></p></formattedText><vline Cid="44" x="24" y="324" length="276" vertical="y"/><formattedText Cid="37" x="36" y="324" w="216" h="48"><p><p><t sz="14" b="b">Oral PRNs</t></p><p><t sz="14" b="b">Immediate Release</t></p></p></formattedText><vline Cid="43" x="12" y="156" length="444" vertical="y"/><hline Cid="53" x="216" y="420" length="36"/><formattedText Cid="36" x="48" y="228" w="144" h="28"><p><p><t sz="14" b="b">Weak Opioids</t></p></p></formattedText><hline Cid="47" x="168" y="156" length="84"/><formattedText Cid="49" x="252" y="216" w="264" h="72"><p><p><t sz="11">Co-dydramol or Co-codamol 30/500 =&gt; 6tabs/day</t></p><p><t sz="11">Tramadol greater or equal to (=&gt;) 200mg/day</t></p><p><t sz="11">Buprenorphine patch =&gt; 10microg/hr</t></p><p><t sz="11">                    (Continue patch &amp; replace as usual)</t></p></p></formattedText><formattedText Cid="35" x="48" y="144" w="156" h="29"><p><p><t sz="14" b="b">None or Minimal</t></p></p></formattedText><formattedText Cid="42" x="12" y="120" w="300" h="28"><p><p><t u="u" sz="16" b="b" fg="0xff450173">Patient&apos;s CURRENT ORAL Opioids</t></p></p></formattedText><hline Cid="61" x="528" y="156" length="120"/><hline Cid="67" x="492" y="240" length="156"/><hyperLink Cid="65" x="648" y="480" w="168" h="24" URL="www.futureplanning.org.uk/Modified_Release" DisplayText="Modified Release Opioids"/><formattedText Cid="57" x="252" y="540" w="288" h="60"><p><p><t sz="11">It is generally best to continue patch use at End of Life.</t></p><p><t sz="11">This link allows you to work out the appropriate PRN</t></p><p><t sz="11">drug and dose for a given patch strength.</t></p></p></formattedText><hline Cid="70" x="516" y="492" length="132"/><formattedText Cid="40" x="36" y="480" w="176" h="28"><p><p><t sz="14" b="b">Oral Modified Release</t></p></p></formattedText><hline Cid="55" x="204" y="492" length="48"/><hyperLink Cid="66" x="648" y="552" w="108" h="24" URL="www.futureplanning.org.uk/Opioid_Patches" DisplayText="Opioid Patches"/><hline Cid="71" x="516" y="564" length="132"/><hline Cid="58" x="156" y="564" length="96"/><formattedText Cid="41" x="36" y="552" w="176" h="28"><p><p><t sz="14" b="b">Opioid Patches</t></p></p></formattedText><formattedText Cid="38" x="36" y="408" w="176" h="28"><p><p><t sz="14" b="b">Sublingual/Buccal PRNs</t></p></p></formattedText><hline Cid="68" x="552" y="348" length="96"/><formattedText Cid="39" x="24" y="300" w="144" h="28"><p><p><t sz="14" b="b" fg="0xff6502a7">STRONG OPIOIDS</t></p></p></formattedText><formattedText Cid="51" x="252" y="324" w="312" h="60"><p><p><t fnt="Berlin Sans FB" sz="10">Morphine IR 10mg/5ml liquid or Sevredol Tablets</t></p><p><t fnt="Berlin Sans FB" sz="10">Oxycodone IR (e.g. Oxynorm) 5mg/5ml liquid or capsules (e.g. Shortec)</t></p><p><t fnt="Berlin Sans FB" b="b" fg="0xffff0066">( BEWARE -</t><t fnt="Berlin Sans FB" sz="10">Concentrated Liquid Morphine &amp; Oxycodone</t><t fnt="Berlin Sans FB" b="b" fg="0xffff0066">)</t></p></p></formattedText><hline Cid="69" x="468" y="420" length="180"/><hline Cid="50" x="180" y="348" length="72"/><formattedText Cid="54" x="252" y="468" w="276" h="60"><p><p><t sz="11">Morphine MR Capsules (e.g. MST, MXL, Zomorph)</t></p><p><t sz="11">Oxycodone MR Tablets (e.g. Longtec, Oxycontin)</t></p><p><t b="b" fg="0xffff0066">( BEWARE</t><t sz="11" b="b" fg="0xffff0066"> - </t><t sz="11">12 hourly and 24hourly preparations</t><t b="b" fg="0xffff0066">)</t></p></p></formattedText><hyperLink Cid="64" x="648" y="408" w="156" h="24" URL="www.futureplanning.org.uk/Difficult_EoLdrugs" DisplayText="Difficult EoL Drugs"/><formattedText Cid="52" x="252" y="396" w="240" h="60"><p><p><t sz="11">Unless a really clear plan is already in place, </t></p><p><t sz="11">please discuss with your local </t></p><p><t sz="11">         Palliative Care or Chronic Pain Team.</t></p></p></formattedText><hyperLink Cid="63" x="648" y="336" w="108" h="24" URL="www.futureplanning.org.uk/Oral_PRNs" DisplayText="Oral PRNs"/></page><page Cid="28" name="N&amp;V" colour="-5768025"><view Cid="79" x="12" y="108" w="420" h="505" KeyView="180913"/><hyperLink Cid="115" x="732" y="576" w="108" h="24" URL="www.futureplanning.org.uk/Difficult_EoLdrugs" DisplayText="Difficult Drugs"/><formattedText Cid="114" x="456" y="576" w="396" h="36"><p><p><t sz="16" b="b" fg="0xff990099">Current anti-emetic is ineffective?</t></p></p></formattedText><formattedText Cid="126" x="12" y="12" w="660" h="36"><p><p al="1"><t sz="20" b="b" fg="0xff003333">Anticipatory Medications &amp; Management of Nausea &amp; Vomiting</t></p></p></formattedText><formattedText Cid="112" x="192" y="60" w="648" h="48"><p><p al="2"><t sz="14" b="b" fg="0xff003399">Find the section that represents your patient&apos;s CURRENT treatment, and then click the associated link to view the suggested treatment pathway.</t></p></p></formattedText><formattedText Cid="81" x="456" y="120" w="396" h="36"><p><p><t sz="16" b="b" fg="0xff990099">Patient is not currently taking an oral anti-emetic?</t></p></p></formattedText><formattedText Cid="94" x="528" y="156" w="204" h="24"><p><p al="2"><t b="b">Follow this link for guidance . . . </t></p></p></formattedText><hyperLink Cid="82" x="732" y="156" w="108" h="24" URL="www.futureplanning.org.uk/NandV_No_Orals" DisplayText="No Oral"/><hline Cid="83" x="456" y="192" length="397"/><formattedText Cid="80" x="456" y="216" w="400" h="36"><p><p><t sz="16" b="b" fg="0xff990099">Patient is currently on an effective oral anti-emetic?</t></p></p></formattedText><formattedText Cid="88" x="456" y="408" w="276" h="36"><p><p><t sz="16" b="b">Ondansetron . . . . . . . . . . . . . . . . . . . </t></p></p></formattedText><formattedText Cid="87" x="456" y="360" w="276" h="36"><p><p><t sz="16" b="b">Haloperidol . . . . . . . . . . . . . . . . . . . . . .</t></p></p></formattedText><formattedText Cid="86" x="456" y="312" w="276" h="36"><p><p><t sz="16" b="b">Cyclizine . . . . . . . . . . . . . . . . . . . . . . . .</t></p></p></formattedText><formattedText Cid="90" x="456" y="504" w="276" h="36"><p><p><t sz="16" b="b">Other. . . . . . . . . . . . . . . . . . . . . . . . . . . .</t></p></p></formattedText><hyperLink Cid="92" x="732" y="360" w="108" h="24" URL="www.futureplanning.org.uk/NandV_Haloperidol" DisplayText="Haloperidol"/><hyperLink Cid="91" x="732" y="312" w="108" h="24" URL="www.futureplanning.org.uk/NandV_Cyclizine" DisplayText="Cyclizine"/><formattedText Cid="89" x="456" y="456" w="276" h="36"><p><p><t sz="16" b="b">Levomepromazine . . . . . . . . . . . . . .</t></p></p></formattedText><formattedText Cid="85" x="456" y="264" w="276" h="36"><p><p><t sz="16" b="b">Metoclopramide or Domperidone . .</t></p></p></formattedText><hyperLink Cid="76" x="732" y="264" w="108" h="24" URL="www.futureplanning.org.uk/NandV_Prokinetics" DisplayText="Prokinetics"/><hyperLink Cid="98" x="732" y="504" w="108" h="24" URL="www.futureplanning.org.uk/Difficult_EoLdrugs" DisplayText="Difficult Drugs"/><hyperLink Cid="97" x="732" y="408" w="108" h="24" URL="www.futureplanning.org.uk/NandV_Ondansetron" DisplayText="Ondansetron"/><hyperLink Cid="93" x="732" y="456" w="132" h="24" URL="www.futureplanning.org.uk/NandV_Levomepromazine" DisplayText="Levomepromazine"/><hline Cid="113" x="456" y="552" length="395"/></page><page Cid="29" name="Breathlessness" colour="-4139778"><title Cid="74" x="12" y="12" width="396" text="End of Life Mx of Breathlessness"/><view Cid="105" x="408" y="372" w="456" h="264" KeyView="171331"/><formattedText Cid="106" x="12" y="36" w="744" h="84"><p><p><t sz="14" b="b" fg="0xff009900">Non Pharmacological</t></p><p><t>    Optimise positioning, usually more upright rather than laying flat.</t></p><p><t>    Use of fan, or increased airflow by opening windows, can improve the sensation of breathlessness. A cooler room may help.</t></p><p><t>     If tolerated, seems to be most effective if cool air moves over the face</t><t sz="14">.</t></p></p></formattedText><formattedText Cid="110" x="12" y="468" w="420" h="168"><p><p><t sz="18" b="b">Cautions </t><t sz="14" b="b">  -   Oxygen</t></p><p><t>Only use for patients with hypoxaemia (sats &lt; 92%) who show benefit.</t></p><p><t>If sats are normal then this is an expensive &quot;open window&quot;.</t></p><p><t>In the last days and hours of life, other pharmacological approaches</t></p><p><t>            with opioids or benzodiazepines may be preferable to oxygen.</t></p><p/><p><t sz="14">                   -   </t><t sz="14" b="b">Nebulisers</t></p><p><t>Saline nebulisers are likely to aggravate cough. Patients in the last</t></p><p><t>days of their life may not have the strength to perform an effective cough.</t></p></p></formattedText><formattedText Cid="109" x="12" y="384" w="360" h="84"><p><p><t sz="14" b="b" fg="0xff000099">Stridor</t></p><p><t fg="0xff000099">     Suggest discussion with specialist palliative care team</t></p><p><t fg="0xff000099">     If associated anxiety or panic, treat as above</t></p><p><t fg="0xff000099">     Consider use of dexamethasone s/c</t></p></p></formattedText><formattedText Cid="108" x="12" y="300" w="840" h="84"><p><p><t sz="14" b="b" fg="0xff990033">Associated anxiety or panic with severe refractory breathlessness</t></p><p><t b="b" fg="0xff990033">   Trial PRN midazolam 2.5 &#8211; 5mg (up to hourly)</t></p><p><t>    If effective, and needing more than 2 doses in 24 hours -  </t><t b="b" fg="0xff990033">Syringe Driver CSCI midazolam 5-20mg over 24hrs (depending on PRN requirements)</t></p><p><t>    If ineffective, discuss with specialist palliative care. </t><t fg="0xff990033">Consider use of levomepromazine 6.25 &#8211; 12.5mg s/c PRN</t></p></p></formattedText><formattedText Cid="107" x="12" y="120" w="780" h="180"><p><p><t sz="14" b="b" fg="0xffff6600">Opioids</t></p><p><t>    Can be helpful for breathlessness at rest or on minimal exertion. (opioids do not improve breathlessness on exertion)</t></p><p><t>    Regular delivery of opioid (via syringe driver) is thought to be superior to prn use</t></p><p/><p><t sz="14" b="b" fg="0xffff6600">Opioid Na&#239;ve</t></p><p><t b="b" fg="0xffff6600">Syringe Driver CSCI morphine 5-10mg over 24 hours. (Consider oxycodone if morphine sensitive or impaired renal function)</t></p><p/><p><t sz="14" b="b" fg="0xffff6600">Established Opioids</t></p><p><t>    If used for another reason e.g. pain; dose increase may be beneficial for breathlessness (suggest discussion with palliative care team)</t></p><p><t>    If already using a fentanyl patch, continue the patch and add additional via syringe driver. Dose, as above.</t></p></p></formattedText><hyperLink Cid="148" x="612" y="96" w="246" h="24" URL="www.futureplanning.org.uk/Breathlessness" DisplayText="Breathlessness Resources"/></page><page Cid="32" name="Secretions" colour="-853328"><title Cid="122" x="12" y="12" width="528" text="End of Life Management of Respiratory Secretions"/><formattedText Cid="132" x="24" y="48" w="816" h="144"><p><p><t sz="14">This advice relates to upper airways secretions collecting in the throat and upper airways of a semi-concious patient in the last days/hours of life.</t></p><p><t sz="14">Research has shown that secretions &amp; associated noises often distress clinicians more than family, &amp; family more than the patient.</t></p><p><t sz="14">Secretions often indicate that a patient is unconcious, unaware &amp; hence, not swallowing or coughing to clear saliva.</t></p><p><t sz="14">Explanation often provides more relief than medication.</t></p><p><t sz="14">Treatment if required, where a patient is aware &amp; coughing unsuccesfully, should start as soon as secretions develop.</t></p></p></formattedText><formattedText Cid="135" x="24" y="492" w="816" h="144"><p><p><t sz="16" b="b" fg="0xff330033">Also consider</t></p><p><t sz="14">Examination (auscultation) may be advisable for patients with a history of left sided heart failure or with evidence, or at high risk, of a LRTI or aspiration. Hyoscine will do nothing for purulent chest secretions of pulmonary oedema. Ensuring carers do not give food or fluid when this cannot be safely managed may reduce further aspiration.</t></p><p><t sz="14">In these cases careful consideration of the appropriateness of treatment with diuretics or antibiotics (potentially in hospital) should take place. The patients previous wishes should be considered. If clearly dying and not considered a reversible deterioration then palliative care advice may be helpful.</t></p></p></formattedText><formattedText Cid="134" x="24" y="192" w="684" h="108"><p><p><t sz="16" b="b" fg="0xff000099">Anticipatory Prescription</t></p><p><t sz="14">Prescribe -</t><t sz="14" b="b"> Hyoscine butylbromide [Buscopan&#174; ] 10 Ampules 20mg / ml SC Inj.</t></p><p><t sz="14">Also supply a signed </t><t sz="14" i="i">Community Palliative Care PRN Admin Order</t><t sz="14"> with</t></p><p><t sz="14" b="b"> Hyoscine butylbromide 20mg SC PRN 4hrly.</t></p><p><t sz="14" b="b">     Seek advice if requiring more than 4 doses in 24hrs. (up to x4 / 24hrs)</t></p></p></formattedText><formattedText Cid="136" x="24" y="300" w="684" h="84"><p><p><t sz="16" b="b" fg="0xffff6600">Syringe Driver</t></p><p><t sz="14">Starting dose should be based upon the response to initial PRN doses.</t></p><p><t sz="14">Usual ranges are pre-printed on the </t><t sz="14" i="i">Community Palliative Care Syringe Driver Admin Order</t><t sz="14"> with</t></p><p><t sz="14" b="b"> Hyoscine butylbromide 60-120mg CSCI over 24hrs.</t></p></p></formattedText><formattedText Cid="137" x="24" y="432" w="684" h="60"><p><p><t sz="16" b="b" fg="0xff990033">Consider</t></p><p><t sz="14">Reducing doses or using PRN dosing only if known to have an eGFR &lt;30ml/min.</t></p></p></formattedText><formattedText Cid="138" x="672" y="300" w="168" h="84"><p><p al="1"><t sz="16" b="b" fg="0xffff6600">Alternative Drugs</t></p><p al="1"><t sz="14">For those areas </t></p><p al="1"><t sz="14">using glyco 1st</t></p><p al="1"><t sz="14">line.</t></p></p></formattedText><hyperLink Cid="139" x="708" y="384" w="108" h="20" URL="www.futureplanning.org.uk/EoLSecretions" DisplayText="Alternatives"/></page><page Cid="31" name="Agitation" colour="-1979137"><hyperLink Cid="121" x="720" y="540" w="127" h="24" URL="www.futureplanning.org.uk/EoL_Agitation" DisplayText="Agitation"/><formattedText Cid="124" x="12" y="588" w="576" h="36"><p><p><t sz="20" b="b">Anticipatory Medications Only </t><t sz="16" b="b">for Agitation, Delirium &amp; Anxiety</t></p></p></formattedText><formattedText Cid="125" x="12" y="12" w="576" h="36"><p><p><t sz="20" b="b" fg="0xff330033">End of Life Management of Agitation, Delirium &amp; Anxiety</t></p></p></formattedText><formattedText Cid="128" x="12" y="540" w="48" h="36"><p><p><t sz="20" b="b">Or</t></p></p></formattedText><formattedText Cid="130" x="672" y="588" w="168" h="36"><p><p al="2"><t sz="14" b="b" fg="0xff003399">Also select link.</t></p></p></formattedText><hline Cid="131" x="564" y="600" length="146"/><formattedText Cid="129" x="360" y="540" w="336" h="36"><p><p al="2"><t sz="14" b="b" fg="0xff003399">Select link to view suggested medications.</t></p></p></formattedText><formattedText Cid="118" x="24" y="396" w="816" h="60"><p><p><t sz="20" b="b" fg="0xffcc0033">  Third - </t><t sz="14" b="b">Support &amp; education of family members/ carers around non-pharmacological management. </t></p><p al="2"><t sz="14" b="b">Carers leaflet for printing.</t></p></p></formattedText><formattedText Cid="120" x="24" y="456" w="816" h="72"><p><p><t sz="20" b="b" fg="0xff660066">  Fourth - </t><t sz="14" b="b">Medication</t></p><p><t sz="14">       &#8226;&#x9;</t><t sz="14" b="b" fg="0xffff0033">if eGFR 30 or less. Start with half PRN doses, expect prolonged duration of action &amp; avoid syringe driver,</t></p><p al="2"><t sz="14" b="b" fg="0xffff0033">if possible.</t></p></p></formattedText><formattedText Cid="119" x="24" y="48" w="828" h="144"><p><p><t sz="20" b="b" fg="0xff66cc00">  First</t><t sz="18" b="b" fg="0xff66cc00"> - </t><t sz="14" b="b">Establish patient is dying, rather than this being a reversible cause of hyperactive delirium:</t></p><p/><p><t sz="14" b="b">Does the previous illness trajectory fit this deterioration? If not, consider;</t></p><p><t sz="14">         &#8226;&#x9;Medication side effects (opioid toxicity, anticholinergics, benzodiazepines) </t></p><p><t sz="14">         &#8226;&#x9;Brain tumour/ metastases - missed steroids, raised ICP or subclinical constant seizures</t></p><p><t sz="14">         &#8226;&#x9;New Fluid and electrolyte disturbances (dehydration, hypercalcaemia, hyponatraemia)</t></p><p><t sz="14">         &#8226;&#x9;Metabolic disorders (hyperthyroidism, hyperglycaemia)</t></p></p></formattedText><formattedText Cid="117" x="24" y="204" w="828" h="192"><p><p><t sz="20" b="b" fg="0xffff9900">  Second - </t><t sz="14" b="b">Where possible, aim to reverse any potential causes of agitation, delirium or anxiety.</t></p><p><t sz="14">       &#8226;&#x9;have long term oral sedatives been replaced? - e.g. anti-psychotics, BDZs, anti-epileptics? </t><t sz="14" fg="0xffcc0033">Consider seeking advice.</t></p><p><t sz="14" b="b">If unable to communicate, consider;</t></p><p><t sz="14">       &#8226;&#x9;pain. Ongoing but poorly controlled due to reduced oral meds. New due to pressure areas, stiffness, etc.</t></p><p><t sz="14">       &#8226;&#x9;a full bladder or distress from not being able to get to the toilet - catheter or pads &amp; re-assure.</t></p><p><t sz="14">       &#8226;&#x9;loaded &amp; uncomfortable bowels - though appears unfair, an enema/suppositories will help.</t></p><p><t sz="14">       &#8226;&#x9;thirst is unusual, having a dry mouth is not. Allow sips if able, wet and clean the mouth &amp; tongue.</t></p><p><t sz="14">       &#8226;&#x9;psychological or spiritual distress. A chaplain, imam, relative or friend may be better than a drug.</t></p><p><t sz="14">       &#8226;&#x9;disturbance. Sometimes families have to be guided to give the patient some space/quiet/time.</t></p></p></formattedText></page><page Cid="96" name="COVID-19" colour="-1250582"><title Cid="99" x="12" y="12" width="288" text="COVID-19 Issues to consider." colour="-3407872"/><formattedText Cid="103" x="12" y="612" w="708" h="36"><p><p><t sz="14" b="b" fg="0xffef3511">V 1.2</t><t sz="14" fg="0xffef3511"> of the </t><t sz="14" b="b" fg="0xffef3511">FP Anticipatory Meds Worksheet</t><t sz="14" fg="0xffef3511"> - March 2020</t></p></p></formattedText><formattedText Cid="100" x="12" y="48" w="840" h="36"><p><p><t sz="14">We will endeavour to keep this page and more importantly the Future Planning webpages it links to as up to date as possible.</t></p></p></formattedText><formattedText Cid="104" x="12" y="84" w="588" h="228"><p><p><t fnt="Arial">The chart visible and downloadable on the LINK gives ideas for drugs that may be used if syringe drivers, staff or drugs become scarce during this crisis. </t></p><p><t fnt="Arial">As is usual in Palliative Care all drugs are used &quot;off licence&quot;. Most have had long established use in End of Life settings across the world. A few in the red sections have some evidence but not a lot of experience.</t></p><p/><p><t fnt="Arial">I have put together this chart with advice from many but with the thought; </t></p><p><t fnt="Arial" i="i">&quot;If I find myself looking after my (&gt;75 year old) parents or residents in a care home, without resources or support, then how can I best use my knowledge to provide them with acceptable End of Life care&quot;.</t></p><p/><p><t fnt="Arial">I also think we should be using Morphine Modified Release tablets given PR, before Fentanyl Patches as there is better evidence and good science to expect a faster response. COVID19 is thought to be excreted from the rectal route, as well as oropharyngeal &amp; respiratory, so use of gloves is encouraged when giving medication by any route oral, buccal, SL or PR.</t></p><p><t fnt="Arial">Dr Steve Plenderleith, Consultant in Palliative Medicine.</t></p></p></formattedText><hyperLink Cid="102" x="600" y="156" w="240" h="24" URL="www.futureplanning.org.uk/COVID_EoLdrugchart" DisplayText="P&amp;SEH End of Life Drugs chart"/><formattedText Cid="101" x="612" y="12" w="228" h="36"><p><p><t fnt="Comic Sans MS" sz="16" fg="0xff333333">March 2020</t></p></p></formattedText><formattedText Cid="146" x="96" y="504" w="396" h="96"><p><p><t sz="16" b="b" fg="0xff0033cc">LINKS to other COVID resources.</t></p><p><t>These are in no way &quot;comprehensive&quot; but are offered as a collection the documents that appear to be helpful, well laid out and wherever possible less than 2 sides of A4. Pictures and ease of reading also feature.</t></p></p></formattedText><hyperLink Cid="147" x="516" y="528" w="264" h="24" URL="www.futureplanning.org.uk/COVID19_GeneralGuidance" DisplayText="Selection of General Guidance "/><hline Cid="145" x="12" y="480" length="840"/><button Cid="140" x="12" y="432" w="288" h="31" actionId="SUBACTION~let~WordLetterTemplate~149747" label="Print Comm Palliative Syringe Driver Admin Order"/><button Cid="141" x="12" y="372" w="288" h="31" actionId="SUBACTION~let~WordLetterTemplate~149742" label="Print Comm Palliative PRN Admin Order Sheet"/><formattedText Cid="142" x="312" y="384" w="552" h="72"><p><p><t sz="14">Hampshire Area &amp; District Prescribing Commitee approved Admin Orders.</t></p><p><t sz="14">Identical to those used by Solent and Southern Health Community Teams.</t></p><p><t i="i">(These links can be changed if this template is being used in another county using different forms.)</t></p></p></formattedText><formattedText Cid="143" x="12" y="336" w="396" h="36"><p><p><t sz="14" b="b">Palliative PRN &amp; Syringe Driver Administration Orders</t></p></p></formattedText><hline Cid="144" x="12" y="324" length="840"/></page></template><Name>Anticipatory Meds Subcut Drug Dose Worksheet</Name><Description>V1.3</Description><Category>Future Care Planning</Category><Icon>mortarPestle</Icon><Source>132543</Source><SourceGroup>-1</SourceGroup><Position>-1j-36d1d-3k113s-21b3t19292n-t-3p-3a3h1o3g1735f-1o3u-31-1p3e2d-2s3m1d3a</Position></TemplateDefinition></SystmOneTemplates>