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POGO Satellite Manual

5.3 Settings of Care

5.4 Symptom Management

Symptom management in palliative care requires an astute care team that is aligned to the status of the child, as well as the goals of care of the child and family. The first step to best symptom management comes from appropriate identification of the etiology of the symptom. Then, it is important to have an armamentarium of management strategies in the hope of aligning the choice of intervention with the goals of care.

Discussion with your local tertiary care centre and/or palliative care provider(s) may be essential to determining which strategies listed below could be helpful.

Symptom

Management Strategies

Medications & Suggested Initial Doses

Agitation/

Delirium

Consider looking for reversible cause (e.g. low sodium; high calcium). Attempt to help orient the child. Comforting social interactions may be helpful with familiar visitors. Minimize noise and avoid unnecessary stimulation.

  • Lorazepam: 0.02-0.05mg/kg/dose PO/SL/SC/IV q6-8
  • Haloperidol:
    • Acute: 0.025-0.05mg/kg PO, may repeat 0.025mg/kg in 1hr if needed
    • Maintenance: 0.01-0.02mg/kg PO TID
  • Methotrimeprazine (Nozinan): 0.05-0.1mg/kg/dose PO/SC/IV q4-8h or prn (max of 25mg/dose)
  • Olanzapine (oral or disintegrating tab): 2.5-5mg qhs

Bleeding – mucosal

Have dark towels on hand.

 

If bleeding does not respond to medication/transfusion, and is excessive, consider palliative sedation to decrease associated anxiety.

  • Tranexamic acid:
    • PO: 10-25mg/kg (max 1.5g) BID-TID
    • IV: 45mg/kg over 24hrs
    • Topical: apply gauze soaked in 100mg/mL inj solution
  • Fibrin glue (Tisseel or Floseal)
  • Topical epinephrine on gauze (1:1000)
  • Correction of laboratory abnormalities with transfusion:
    • Platelets: 10mL/kg if bleeding and <50
    • FFP: 10mL/kg – contains all factors & complement
    • Cryoprecipitate: 1u/10kg = 0.5g/L rise – contains fibrinogen, FVIII, vWF, FXIII
    • Vitamin K: 2-5 mg/dose PO/ IV

Constipation

Manage proactively when administering opioids. Most adolescents will not disclose so must be asked specifically about bowel habits.

  • Polyethylene glycol 3350: 1g/kg/day (adult 17g)
  • Senna: 5ml (<6 years) or 1-2 tabs (≥ 6 years) qhs
  • Lactulose: 10ml OD; double daily dose until stool produced
  • Suppositories; Enemas
  • Methylnaltrexone: 150 micrograms/kg SC q2-3 days for refractory opioid induced constipation.

Diarrhea

Consider: new illness, diet, medications and treatment, hydration.

  • Decrease laxatives and titrate as needed
  • Maintain hydration
  • Consider holding laxatives for opioid induced constipation.
  • Loperamide: 100-200 micrograms/kg (max 2mg) could be used cautiously for non-infectious diarrhea

Dyspnea/

Respiratory

Try deep breathing and distraction. Oxygen may be beneficial for relief of dyspnea, regardless of O2 saturations. A fan blowing on the face and/or an open window may be effective for decreasing the sensation of breathlessness.

 

Opioids are used for the relief of dyspnea. Benzodiazepines may be used as adjunct if dyspnea also due to anxiety.

  • If opioid naïve, Morphine at low dose (30-50% of dose used for pain) is the drug of choice. If on another opioid, or already on morphine, give breakthrough doses to effect.
  • Midazolam infusion: can be an adjunct for respiratory distress, especially with tumour encroachment or airway obstruction:
    • Buccal/SL/PO: 0.5mg/kg (5-10mg max)
    • SC/IV Infusion: 1-5mcg/kg/min – titrate to effect
  • Lorazepam: may be indicated for anxiety and panic attacks presenting as dyspnea
    • PO/SL: 0.05-1 mg/kg/dose q6-24h

Nausea & Vomiting

Determination of etiology should guide treatment and medication modalities.

 

Strategies to help approach anorexia and aversion to foods might include: small blended meals, sips of fizzy drinks, restricted intake and avoiding lying flat after eating.

 Control smells and noise in the home, good oral hygiene. Visualization, distraction and relaxation have also proved effective.

Select agent(s) based on most responsible mechanism for nausea/ vomiting:

  • Ondansetron: PO/SL/IV/SC: 0.15 mg/kg/dose q8h
  • Granisetron: PO/IV: 20 mcg/kg/dose q12h
  • Metoclopramide: PO/IV 0.1-0.2 mg/kg q6h PO
  • Dimenhydrinate(Gravol):PO/IV 1mg/kg/dose q4-6h PO
  • Dexamethasone: PO/IV 0.1-0.25 mg/kg/dose q6-24h (8mg max)
  • LORazepam (especially for emotional/anxiety related) 0.02-0.05 mg/kg/dose PO/IV q6-8
  • Nabilone: 0.5-2mg PO BID (max adult dose 6mg/day)
  • Olanzapine (oral or disintegrating tab): 2.5-5mg qhs

Pain

A full pain assessment is imperative to effective pain management. Consider whether there is a neuropathic component.

 

Consider integrative therapies such as massage, imagery, music therapy, acupressure, acupuncture, TENS, etc.

 

Consider radiotherapy for local bone pain due to solid tumours/metastases

 

It has been shown that appropriate opioid use does not hasten death, but improves QOL and may actually prolong life. There is no opioid dose limit.

 

Pain from advanced cancer is unlikely to be transient or improve – so imperative to provide REGULAR DOSING, and supplement with PRN for breakthrough pain.

 

If pain is refractory, or side effects are unmanageable (constipation, nausea, urinary retention, pruritus), consider opioid rotation. Refer to an opioid conversion table or a PPC specialist.

  • Acetaminophen: 10-15 mg/kg/dose q4-6 (max 75mg/kg/day)
  • Ibuprofen: 10mg/kg/dose q6-8h caution if bleeding/GI issues
  • Morphine
    • PO: 0.2-0.5 mg/kg/dose q4-6h
    • SL/IV/SC: 0.05-0.2 mg/kg/dose q4-6h
    • Infusion/CADD: 10-30 mcg/kg/hr titrate to response
  • HYDROmorphone
    • PO: 0.03-0.08 mg/kg/dose q4h
    • IV/SC: 0.01-0.02 mg/kg/dose q2-4h
    • Infusion/CADD: 0.003-0.005 mg/kg/hr (or 3-8 micrograms/kg/hr) titrate to response
  • Fentanyl
    • Transdermal patch: best used as an alternate route for pain already controlled on another opioid; should not be used to treat acute uncontrolled pain. Rule of thumb is 2mg PO morphine = 1mcg/hr fentanyl – thus a child needs to be on ~30mg of PO morphine daily before switching to patch.
    • SL/IV/SC: 1-2 micrograms/kg/dose q30-60 min
    • Infusion/CADD: 0.5-2 micrograms/kg/hr titrate to response
  • Methadone (under the direction of a PPC specialist)

Adjuvants:

  • Radiotherapy (in consultation with a radiation oncologist)
  • Dexamethasone: 0.1-0.25 mg/kg/dose IV/PO/SC (max 8mg)
  • Gabapentin: for neuropathic pain
    • 5mg/kg/dose, start qhs and increase by 5mg/kg/day q3-4 days until effective or 60mg/kg/day
  • TCAs: for neuropathic pain
    • Amitriptyline: 0.2mg/kg PO qhs (10mg max), increase by 0.2mg/kg/day q4 days until effective or 1mg/kg/day or sedated
  • Ketamine (under direction of PPC specialist)
  • Topical lidocaine or capsaicin
  • Bisphosphanates

Pruritus

Can be a side effect of opioids due to their histamine releasing properties: usually resolves within a few days of treatment initiation or increased dosage. Some opioids result in less pruritus than others; may respond to opioid rotation (hydromorphone, fentanyl).

  • Diphenhydramine: 1mg/kg q6h
  • Hydroxyzine: 0.5mg/kg/dose PO QID
  • Ondansetron: PO/SL/IV/SC: 0.15 mg/kg/dose q8h (weak evidence)
  • Naloxone: Only effective for opioid-induced pruritus. 0.5-1mcg/kg/hr infusion. May reduce analgesic effects. Recommend consulting with a PPCspecialist prior to use. Only effective for opioid-induced pruritus.

 

Secretion Control

If child is too weak to clear own secretions, reposition on side for postural drainage.   Give frequent mouth care. 

Suctioning can cause irritation and increased secretions, and should be avoided if possible.

Most effective treatment, with fewest side effects, is to reduce total fluid intake (via enteral tube, IV). Titrate to comfort and urine output.

  • 1% ophthalmic Atropine: 1-3 drops q4h SL prn
  • Glycopyrrolate:
    • PO: 40-100 mcg/kg/dose q6-8h
    • IV/SC: 4-10 micrograms/kg/dose q3-4h
  • Scopolamine:
    • IV/SC: 5-10 micrograms/kg q4-8h
    • Transdermal patch: available in 1.5mg patches, can apply up to 3 at a time q72h

*Consider side effects: thickened, difficult to clear secretions, dry mouth and drowsiness

Seizures

Seizures at end-of-life can be very distressing, and aggressive management is most often appropriate.

Management strategy: benzoà benzo à phenobarbital (if intractable)

  • Lorazepam:
    • SL/buccal: 0.05-0.1 mg/kg/dose
    • IV/SC: 0.1mg/kg/dose
  • Midazolam:
    • SL: 0.2-0.5 mg/kg/dose (5-10mg max)
    • IV/SC: 0.1-0.2 mg/kg/dose
  • Phenobarbital: 20mg/kg IV load, followed by maintenance dose of 5mg/kg IV/PO OD. Can be given SC, but many children find it uncomfortable.

Urinary Retention

Consider looking for reversible causes (high dose opiods; spinal metastases/primary amenable to radiation).

 Having a warm bath and encouraging the child to pass urine in the water is often the most effective treatment for opioid induced retention. Consider opioid rotation.

Catheterization may be necessary to relieve the discomfort of a full bladder.

It is recommended with the use of drugs at end of life that may cause urinary retention to have catheterization supplies in the event the child is unable to void and cause is not reversible.

References

  1. Chen, J. and Lau, E. (Ed). Sick Kids Drug Handbook and Formulary. The Hospital for Sick Children: Toronto, ON. 2013 & 2014
  2. Dipchand, A. and Friedman, J. (Ed.). The Hospital of Sick Children Handbook of Pediatrics. 11th  2009.
  3. Goldman, Hann, Liben. Oxford Textbook of Palliative Care for Children, 2nd  Oxford University Press, 2012.
  4. Hain, R. and Jassal, S. Paediatric Palliative Medicine, Oxford Specialist Handbooks in Paediatrics. 
  5. Levine, D., Lam, C., et al. Best Practices for Pediatric Palliaitve Cancer Care:  A Primer for clinical Providers.  Journal of Supportive Oncology 2013; 11: 114-125.
  6. POGO/PCMCH Provincial Pediatric Palliative Care Steering Committee. Symptom Management Guide for Children Near/End-of-Life.
  7. Rainbow Children’s Hospice Basic Symptom Control in Paediatric Palliative Care – 11th Edition Accessed June 3, 2014. [Available online]
  8. Shaw, T. Pediatric Palliative Pain and Symptom Management. Pediatric Annals, 2012. 41(8): 329-334
  9. Waterloo Wellington Symptom Response Kit Clinical Guidelines and Order Form. Revised 2014.

Primary authors Dr. Stacey Marjerrison, McMaster Children’s Hospital, Hamilton Health Sciences, Hamilton and Patti Bambury, Grand River Hospital, Kitchener. Reviewed by the POGO Satellite Manual Palliative Care Working Group, 2016.

5.5 End of Life
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In this Section

  • 1.1 History and Overview
  • 1.2 Acknowledgements
  • 1.3 Committees and Working Groups
  • 1.4 POGO Satellite Manual Disclaimer
  • 2.1 Principles of POGO Satellite Clinic Care
  • 2.2 Eligible Patients
    • 2.2.1 Children Eligible for Chemotherapy Administration in a POGO Satellite Clinic
    • 2.2.2 Children Eligible for the Management of Complications in a POGO Satellite Clinic
    • 2.2.3 Children Eligible for Supportive Care in a POGO Satellite Clinic
  • 2.3 Scope of POGO Satellite Clinic Practice
  • 2.4 Expanded POGO Satellite Clinic Practice
  • 3.1 Safe Handling, Administration and Disposal of Chemotherapy Agents
    • 3.1.1 Personal Protective Equipment
    • 3.1.2 Preparation, Transport and Storage
    • 3.1.3 Administration of IV Hazardous Drugs
    • 3.1.4 Administration of Oral Hazardous Drugs
    • 3.1.5 Disposal of Equipment/Personal Protective Equipment used to Administer Hazardous Drugs
    • 3.1.6 Safe Handling for Pharmacy
    • 3.1.7 References
  • 3.2 Accidental Exposure/Spills
  • 3.3 Extravasation Management
    • 3.3.1 Prevention and Management of Extravasations
    • 3.3.2 Antidotes and Treatments for Extravasation
    • 3.3.3 Sample Extravasation Documenting Tool
    • 3.3.4 References
  • 3.4 Injecting SC Medication Via an Insuflon
  • 3.5 Chemotherapy Administration Reference List
  • 3.6 Central Venous Catheter Care
  • 3.7 Chemotherapy Quick Reference
    • 3.7.1 Rapid Hydration
    • 3.7.2 Provider Guide: Prevention and Management of Irinotecan-Induced Diarrhea
    • 3.7.3 Capizzi Methotrexate
    • 3.7.4 Erwinia Asparaginase
  • 4.1 Management of Fever and Neutropenia
    • 4.1.1 Routine Order Sample Sheet
    • 4.1.2 Sample Fever Cards
    • 4.1.3 Criteria for low-risk designation. Risk categorization refers to risk of bacteremia and serious complications, including mortality.
  • 4.2 Pentamidine Administration
    • 4.2.1 Inhaled Pentamidine
    • 4.2.2 Intravenous Pentamidine
  • 4.3 Antiemetics
  • 4.4 Treatment of Varicella-Zoster Infections
  • 4.5 Immunization of Children with Cancer
  • 4.6 Transfusion
  • 4.7 Clinical Circumstances that Warrant Consultation with the Specialized Childhood Cancer Program
  • 5.1 Palliative Care Overview
  • 5.2 Communication
  • 5.3 Settings of Care
  • 5.4 Symptom Management
  • 5.5 End of Life
  • 5.6 When a Child Dies at the POGO Satellite Clinic
  • 5.7 Appendix: Sample Bereavement Materials
    • 5.7.1 Reconciling Your Grief
    • 5.7.2 Funeral Arrangement Checklist
    • 5.7.3 Helping Children Who Grieve
    • 5.7.4 Coping with the Holidays
    • 5.7.5 The Grief Experience
  • 5.8 References
  • 6.1 Goals and Objectives
  • 6.2 Participant Site Selection
    • 6.2.1 Tertiary Hospital Site Selection
    • 6.2.2 Community Hospital Site Selection
  • 6.3 POGO’s Roles
    • 6.3.1 PHIPA, Privacy and Research
  • 6.4 Funding
    • 6.4.1 Funding Support for Tertiary Hospital Activity
    • 6.4.2 Funding Support for Community Hospital Activity
  • 6.5 Infrastructure and Formal Requirements
    • 6.5.1 Specialized Childhood Cancer Program Partners’ Role in the POGO Satellite Program
    • 6.5.2 POGO Satellite Clinic Partners’ Role in the POGO Satellite Program
  • 7.1 Preamble
  • 7.2 Investigator Responsibilities
  • 7.3 Training Requirements
    • 7.3.1 General Training for Conduct of Research
    • 7.3.2 Protocol-Specific Training
  • 7.4 Research Activities That May Be Completed in POGO Satellite Clinics Under Supervision of DSI
  • 7.5 Research Activities to be Completed in Specialized Childhood Cancer Programs Only
  • 7.6 Recognition and Reporting of Adverse Events (AEs)
  • 7.7 Data Transfer
  • 7.8 Pharmacy Drug Accountability
  • 7.9 Site Inspections and Quality Assurance
  • 8.1 Pediatric Oncology Shared Care Initial Data Transfer Sheet
  • 9.1 POGO Satellite Clinic Preparedness Checklist
  • 9.2 POGO Satellite Clinic Quality Assurance Checklist
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