Symptom Response Kit Instructions for UseStep 1

Patient Identifiers

Ensure that all required patient identifiers are included on the prescription form. Mandatory identifiers are:

Patient Name

Delivery Address

Date of birth

Health Card #

Step 2

Patient Meets Criteria for SRK

To have a SRK delivered, the patient must be a LHIN patient.

Patients for whom SRKs are typically delivered include:

PPS less than 50%

May require unanticipated symptom management

A patient whose disease process is nearing end stage AND an end of life plan is in place

Step 4

Kit Content

The Kit Includes: Atropine Opth. Drops Haldoperidol (Haldol) Lorazepam (Ativan) Methotrimeprazine (Nozinan) Morphine OR Hydromorphone as per direction provided by MD on Prescription form

All non-controlled medications (denoted by •) will be dispensed unless the MD crosses out the medication and initials the change.

Controlled medications (denoted by □) will only be dispensed if the box is checked indicating the MD’s medication preference and intent to order the controlled medication.

If you would like to have a narcotic dispensed but wish to be contacted for orders, check off the narcotic that you would like dispensed but leave the dosing blank. 24/7 physician availability must be available if choosing this option.

Step 5 Other Medications

Additional medication may be added to the kit. Use the areas on the bottom of the Prescription form to add, as appropriate.

Step 6 Exceptional Access Medications

All of the standard medications in the kit are covered by Ontario Drug Benefit (ODB), however you may prefer certain medications for anticipated symptoms. In this case, order these medications separately. The Physician must arrange for Exceptional Access by calling 1-866-811-9893.

Examples of commonly used exceptional access medications: Midazolam, scopolamine, glycopyrrolate, injectable lorazepam

Step 7 Complete prescription form and fax to pharmacy for your geography.

Completed SRK Prescription form is to be faxed to :

Yurek Pharmacy Fax #: 1-888-637-3690 (For Oxford, Elgin, London/Middlesex, Perth)

Brown’s Pharmacy Fax #: 519-881-1369 (For Grey, Bruce and Huron Counties)

Regular delivery is within 24 hours. If urgent

delivery is required, contact the Pharmacist:

Yurek: 1-888-631-6502

Brown: 1-844-474-7577

Symptom

Response Kit

Prescription

Name:

HCN:

Phone #:

Delivery Address:

DOB:

1. The following are Physician orders to be implemented by a Registered Nurse when symptoms require urgent intervention tofacilitate a comfortable death at home.

2. The MRP is to be notified as soon as possible regarding a change in condition necessitating the initiation of these orders

3. Completed Prescription is to be faxed to Yurek’s or Brown’s (Grey-Bruce only)Pharmacy

Allergies:

Indicates that medication will be dispensed. Physician to cross out and initial to cancel order

Anxiety

LORazepam (1 mg tab) ____ tabs SL q ____ h PRNSeizures

LORazepam (1 mg tab) ____ tabs SL q ____ min PRN

May crush and dissolve in water to put under tongue

Twenty four (24) 1 mg tabs

Delirium

Haloperidol ____ mg SC q_____hr PLUS ____ mg q____h PRNNausea

Haloperidol ____ mg SC q____h PRN

Three (3) injectable 5 mg/mL (1 mL amp)

Delirium or Nausea

Methotrimeprazine ____ mg q____h PLUS _____mg SC q ____hr PRN Five (5) 25mg/mL (1 mL amp)

Excess Pulmonary Secretions

Atropine 1% eye drops ____ drops SL or buccal q ____ h PRN One (1) 5 mL bottle of 1%

MD must check to dispense. If you wish to be called for orders – leave the dosing information blank

Pain and/or Shortness of Breath - Choose one of:

Hydromorphone ____mg SC q___h AND ____mg SC q ___h PRN Five (5) 2 mg/mL (1 mL amp)

OR

Hydromorphone ____mg SC q___h AND ____mg SC q ___h PRN

Three (3) 10 mg/mL (1mL amps)

OR

Morphine ____mg SC q___h AND ____mg SC q ___h PRN

Three (3) 15 mg/mL (1 mL amps)

If on PO Dexamethasone consider adding to the kit:

Dexamethasone ____ mg SC q____h Two (2) 4 mg/1mL (5 mL amp)

At risk for Terminal Bleed:

Midazolam ____ mg SC X1. May repeat in 10 min X1 if needed. Two (2) 5mg/mL (2 mL amps)

Not covered by ODB. MD or delegate to arrange for Exceptional Access 1-866-811-9893

Additional SRK Orders:

Physician Signature Print Physician Name CPSO#

Office Pager Cell Fax These orders are for initiation of the SRK medications only when urgent intervention is required. Prescriptions for ongoing

medications need to be sent to the patient’s home pharmacy as needed.

Medication Anxiety/Shortness of Breath - LORAZEPAM

• LORazepam (1mg tab) 1 tab PO/SL q1h PRNSeizures – LORAZEPAM

• LORazepam (1 mg tab) 2 tabs PO/SL q15 min. PRNMay crush and dissolve in water to put under the tongue

Delirium - HALDOL Mild: • Haldol 1 mg PO/SC q8-12 hr. PLUS I mg PO/SC q1hr PRN

Moderate:• Haldol 2-2.5 mg PO/SC q8-12 hr. PLUS 2-2.5 PO/SC q1hr PRN

Severe:• Haldol 2.5-5 mg SC Stat. Repeat q20-30 min., up to 3 or 4 times. Once controlled, continue with 2.5-5 mg SC /PO q 18-12 hr.

Delirium – METHOTRIMEPRAZINE Mild: • 5-12.5 mg PO/SC q12hr. AND 5-12.5 mg PO/SC q1hr. PRN

Moderate:• 12. 5 mg PO/SC q8-12 hr. AND 12.5 mg PO/SC q1hr. PRN

Severe:• 25 mg SC Stat. Repeat q30 min. up to 3 or 4 times. Once controlled, continue with 25 mg SC/PO q6-8 hr. AND 25 MG SC/ PO q1hr.

PRNNausea - HALDOL

• Haldol 0.5-1mg PO OD or BID. If ineffective, increase dose to 2 mg BID or TID• Haldol 0.5-2mg SC q4-6 h PRN

Nausea - METHOTRIMEPRAZINE • Methotrimeprazine 2 mg PO/SC BID or TID. May be titrated up to 5mg to 12.5 mg PO/SC BID or TID

Excessive Pulmonary Secretions – ATROPINE • Atropine eye drops 2 DROPS SL or buccal q4-6 hr. PRN

Excessive Pulmonary Secretions – GLYCOPYROLATE • 0.2-0.4 mg SC q2-4 hr. PRN. May also consider continuous infusion

The Nursing Delirium Screening Scale (NuDESC)

Features and Description Symptom Rating (0-2) 0 1 2

1. DisorientationVerbal or behavioral manifestation of not being oriented to time or place or misperceivingpersons in the environment2. Inappropriate behavior

Behavior inappropriate to place and/or for the person (eg attempting to get out of bed whenit is contraindicated, pulling at tubes)

3. Inappropriate CommunicationCommunication inappropriate to place and/or for the person (e.g. incoherence, non-communicative, unintelligible speech)

4. Illusions/HallucinationsSeeing or hearing things that are not there; distortions of visual objectives

5. Psychomotor retardationDelayed responsiveness, few or no spontaneous actions/words; e.g. patient is difficult toarouse

Overall Score: /15

Scoring: Symptoms Absent= 0, Occasional or Mild= 1, Moderate to Severe= 2

Patient Rating: Severe 10-15: Moderate 5-10:

Mild 1-5:

(Pallium Palliative Pocketbook. First Edition, Third Printing. July 2013)