Residential aged care facilities are a frequent site of care for people who are dying. There are some particular considerations in providing good quality palliative care for patients in these facilities.
Tips for improving pain and symptom management for your nursing home patients
- Talk to the nursing staff about concerns regarding your patient’s pain or other symptoms.
- Discuss how to maximise opportunities for (a) pain assessment and (b) provision of timely feedback to you for medication changes.
- Review with the nursing supervisor the facility's method of pain assessment documentation and standards for pain and symptom assessment and treatment.
- Write an order for a registered nurse to do a complete pain assessment on a regular basis.
- Write orders for PRN medication at intervals of every four hours for short acting medications.
- If you know that the patient is likely to need frequent PRN medication, write the order as a scheduled regular four hourly order with the extra notation: hold if no pain, or patient may refuse. The patient should be reviewed regularly until stable.
- Whenever pain or another symptom is constant, write an order for a scheduled regular medication, preferably a long-acting form. For patients who are on a long-acting strong opioid, a PRN as needed or breakthrough dose should also be prescribed. The usual PRN breakthrough dose is 1/6th to 1/12th of the total daily opioid dose.
- Avoid simultaneous orders for multiple opioids. Only one opioid/non-opioid combination product should be prescribed at any one time.
- Plan ahead, as it is common for nursing home residents to have increasing pain related to physical therapy, dressing changes, etc. Write an analgesic order that anticipates painful activity (eg, morphine elixir 5 mg PO 30 min prior to bath).
- Do not forget to order a prophylactic bowel regimen for patients on opioids.
- Include options for non-pharmacological pain therapies (eg, heat, massage, physiotherapy).
(Adapted from the End-of-Life / Palliative Education Resource Centre (EPERC) Fast Fact "Pain Management in Nursing Homes: Analgesic Prescribing Tips”)
Transfer to hospital
Occasionally transfer to hospital may be needed for a palliative care patient in a nursing home. Good written documentation of the patient’s condition and palliative care goals is essential in this situation to minimise inappropriate investigation and management.
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This page was created on 26 May 2009 and is due for review in May 2011.*