Clinical Guidelines

All these guidelines have had input from a number of local specialists in Palliative Medicine working in different settings. Some have had wider consultation and approval for use in a specific geographical area e.g. Bristol, North Somerset and South Gloucestershire (BNSSG) or Wessex. The source and (where applicable) geographical area is identified for each one.

• Guidelines on the management of pain due to cancer in adults (BPCC). Includes advice on starting and changing opioids plus easy opioid conversion tables. (Updated 2017)
   
• BNSSG Community anticipatory prescribing for end of life symptoms during the COVID-19 pandemic for patients with any diagnosis including COVID-19
  Developed by BNSSG Palliative Care consultants, trust and CCG pharmacists. Approved by Clinical Cabinet.
   
  This guidance contains a range of resources for anticipatory prescribing to facilitate good symptom control at the end of life. It takes into account the extraordinary circumstances of the COVID pandemic by suggesting non-injectable options for certain groups of patients. A decision aid flow diagram is available here. Prescribers need to be aware that there may be shortages of our usual injectable medications, consider providing only 5 doses of each drug for less complex patients. Consider anticipatory prescribing for any patient in their last 4 weeks of life. A new EMIS protocol will be distributed in late April to support the process. Secondary care have aligned their discharge medication to comply with this guidance. We will be updating this page as resources become available.
  
  

  1. Non complex patients

  Suitable for patients who are: opioid naïve who do not have severe symptoms and who are not already on a range of medicines for symptom control.

  Choose one option:

  A: Non injection pack: If a carer can administer medications: (adjust morphine dose if eGFR <30 or if very frail). Carer leaflet available here. These can be authorised for DNs to administer on the usual Community Palliaitve Care Drug Chart if needed.

  B: Injection pack: If no carer to administer medications (adjust opioid according to eGFR)

  Process: Either Prescribe on FP10, send to local or designated pharmacy and authorise on Community Palliative Care Drug Chart or use process for Just in Case Packs coming soon.
  
  

  2. Complex patients 

  Suitable for those with complex severe symptoms, OR already on opioids OR history of complex symptoms e.g. medication for more than one symptom, OR can’t tolerate standard medication OR symptoms not controlled on Pack A.

  Choose one option:

  C: Usual injectable guidance table: for most complex. Prescribe and authorise on Community Palliative Care Drug Chart as usual. For patients with COVID-19 also prescribe paracetamol 500mg suppositories for fever. Remember opioids can be used for breathlessness and cough. Consider whether this patient would be appropriate for informal carer administration of injectable medication

  D: Tailored non injections: If a carer can administer these and injections may not be possible due to shortages.

   

  Other resources for anticipatory prescribing and symptom control

1. Flow diagram for anticipatory prescribing during the COVID pandemic
2. Community palliative care prescribing table: usual injectable and syringe pump medication for symptom control (option C). (BPCC) 2015
3. Pharmacies providing Enhanced Service for the Availability of Specialist Medicines and the medication they hold can be found here. Always telephone pharmacy to confirm stock and opening hours during the pandemic as subject to change.
4. Anticipatory Prescribing Guidance Notes 2014 (to support option C)
5. Informal carer administration of subcutaneous injectable medication
   1. Full policy
   2. Quick reference guide
   3. Pack for carer and community clinician
   4. Pack for prescriber
6. RCGP/APM Guide: Community Palliative, End of Life and Bereavement Care in the COVID-19 pandemic. Useful general symptom control advice. Note BNSSG guidance is broadly in line, with this guide. Where there are differences they have been approved by the BNSSG working party.
7. Anticipatory Prescribing: full standard operating procedure and guideline (BNSSG) 2015 (Detail for option C: usual guidance)

• Subcutaneous Fentanyl and Alfentanil in Palliative Care: Information for Primary Care (St Peter's Hospice)
• Palliative Care Guidelines for the use of steroids in patients with cancer (St Peter's Hospice)
• Framework for professionals supporting patients deteriorating with Parkinson’s Disease (PD) (St Peter's Hospice and North Bristol NHS Trust)

• An overview of current EOLC services in BNSSG CCG can be found here: remedy pathway - end of life care
• Sirona single point of access