NATIONAL PALLIATIVE

CARE GUIDELINE
Table Of Contents
Contents
FOREWORD ___________________________________________________________________III

ACKNOWLEDGMENTS _________________________________________________________IV

LIST OF ACRONYMS ___________________________________________________________VI

CHAPTER ONE : INTRODUCTION ________________________________________________1

1.1 BACKGROUND_____________________________________________________________2

1.2 RATIONALE FOR THE NATIONAL GUIDELINES FOR PALLIATIVE CARE ______2

1.3 OBJECTIVES OF PC GUIDELINE ___________________________________________2

1.4 TARGET AUDIENCE _______________________________________________________3

CHAPTER TWO: PHYSICAL CARE 1- PAIN MANAGEMENT_________________________3

2.1 SECTION A: CAUSES OF PAIN, ASSESSMENT AND TREATMENT ______________3

2.2 CAUSE AND CLASSIFICATIONS OF PAIN ____________________________________4

2.3 ASSESSMENT OF PAIN _____________________________________________________7

2.4 PRINCIPLES OF CHRONIC PAIN MANAGEMENT ____________________________9

2.5 WHO 3-STEP ANALGESIC LADDER _______________________________________10

2.6 WHO ANALGESIC LADDER FOR CHILDREN _______________________________14

2.7 VARIATION FROM THE WHO PAIN MANAGEMENT PROTOCOL ____________15

2.8 ADJUVANT FOR PAIN _____________________________________________________16

CHAPTER THREE: PHYSICAL CARE II - SYMPTOM MANAGEMENT _______________18

3.1 RESPIRATORY SYMPTOMS _______________________________________________20

3.2 MANAGEMENT OF PULMONARY SECRETIONS ____________________________23

COUGH ____________________________________________________________________ 24

3.3 GASTROINTESTINAL SYMPTOMS ________________________________________25

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 3.4 POSSIBLE CAUSES OF WEIGHT LOSS AND MALNUTRITION IN CHRONIC
ILLNESSES ___________________________________________________________31

3.5 MANAGEMENT OF SYMPTOMS CAUSING WEIGHT LOSS ___________________31

3.6 URINARY SYMPTOMS ____________________________________________________ 37

3.6 SKIN CARE ______________________________________________________________42

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CHAPTER 4: NEUROPSYCHIATRIC SYMPTOMS AND THEIR PHARMACOLOGICAL

AND PSYCHOTHERAPEUTIC TREATMENT___________________________49

4.1 INTRODUCTION _________________________________________________________ 49

4.2 INSOMNIA _______________________________________________________________54

4.3 DEPRESSION _____________________________________________________________56

4.4 SUICIDE IDEATION _______________________________________________________57

4.5 SOCIAL CARE AND SUPPORT IN PALLIATIVE CARE ________________________59

4.6 SPIRITUAL CARE _________________________________________________________59

4.7 ROLE OF COMMUNICATION IN PALLIATIVE CARE ________________________ 60

4.8 CARE OF THE CARE GIVERS _____________________________________________ 60

CHAPTER FIVE: END OF LIFE CARE _____________________________________________61

5.1 BEREAVEMENT ISSUES AT THE END OF LIFE ______________________________63

5.2 AFTER DEATH: ___________________________________________________________64

5.3 GRIEF THERAPY _________________________________________________________64

CHAPTER SIX: PECULIARITIES OF PALLIATIVE CARE IN CHILDREN______________65

6.1 PEDIATRICS PAIN MANAGEMENT ________________________________________65

6.2 SPECIAL NEEDS FOR CHILDREN__________________________________________65

CHAPTER SEVEN: PROGRAM IMPLEMENTATION_________________________________66

7.1 PROVIDING PALLIATIVE CARE SERVICE USING DIFFERENT MODELS ______66

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 Acknowledgements

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 List of Acronyms

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 Physical
Pain

Emo onal
Total Psycho
-social
pain pain pain

Spiritual
pain

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PAIN

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 0 1 2 3 4 5
no hurt hurts little bit hurts little more hurts even more hurts whole lot hurts worse

0 2 4 6 8 10
No Hurts Hurts Hurts Hurts Hurts
hurt a little bit a little more even more a whole lot worst

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2.4 Principles of chronic pain management

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WHO Analgesic Ladder

Step 3
Step up if pain Step 2 Step up if pain Strong opioid
presists Weak Opioid presists
Step1
or increases or increases Severe pain
Non-opioid Moderate pain
Mild pain +/- non-opioid
+/- non-opioid
+/- adjuvant +/-adjuvant
+/-adjuvant

Consider prophylactic laxatives to avoid constipation

Non-opioids ibuprofen or other NSAID,paracetamol(acetaminophen),or aspirin

Weak opioids codeine,tramadol,or low-dose morphine
Strong opioids morphine and fentanyl
Adjuvants antidepressant,anticonvulsant,antispasmodic,muscle relaxant,bisphosphonate or
corticosteroid
Combining an opioid and non-opioid is effective,but do not combine drugs of the same class.
Time doses based on drug half-life [”dose by the clock”];do not wait for pain to recur

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 d e
t it u
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 Step 2
Strong opioid
Step up if
Step 1 pain persists Moderate or
Non-opioid or increases
severe pain
Mild pain +/- non-opioid
+/- adjuvant +/- adjuvant

consider prophylactic laxatives

to avoid constipation

Non-opioids Age>3 mos: ibuprofen or paracetamol(acetaminophen);Age<3 mos: paracetamol

morphine[medicine of choice) or fentanly.
Strong opioids
antidepressant,anticonvulsant,antispasmodic,muscle relaxant,bisphosphonate,or
Adjuvants corticosteroid
Combining an opioid and non-opioid is effective,but do not combine drugs of the same class.
Time doses based on drug half-life[”dose by the clock”];do not wait for pain to recur

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Section B: Special considerations for HIV and AIDS patients

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 Cutaneous/ Oral Visceral Somatic Neurological / Headache

. Kaposi’s . Rheumatological . HIV -related headaches

. Tumours
Sarcoma disease from encephali s,
. Gastri s
. Oral cavity pain . Back Pain meningi s etc
. Pancrea s
. Herpes zoster . Myopathies .HIV -unrelated heasaches
. Infec on
.Oral or from tension,migraine etc
. Biliary tract
oesophageal . latrogenic(AZT)
disorders
candidiasis . Peripheral neuropathy
.Neuropathies associated
with DDI,D4T toxici es
.Alcohol,nutri onal deficiencies

Section C: Non Pharmacological management of pain

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Section A: Common Symptoms

FEVER

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 do
a n
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g w
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a y
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s a
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Th
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