My 54 Yr old Pt wiht ES Liver Mass: What can I expect?

[RNDYN2CU]

Hello Hospice Nurses! It's been a while since I've posted... I am looking for advice on how I can anticipate the needs of my patient with Liver Ca. He only recently entered a convelecent hospital i work out of, he has a hx of dependency (oxycodone) so his pain meds wear off quickly. He was started on ms contin 90 mg Q 12 with roxanol 5 mg sl q 4 for BTP. We increased to 120 mg q 12, same roxanol 12 days later. He's on lactulose tid, has ativan 0.5 mg q 6 prn. His ascites has increased 5 cm in only 6 days, poor guy, and he is cognitive of his plight. The nurses at the skilled nsg facility are aghast at his morphine dose and schedule, and I have educated them.

Yes, I have a wonderful medical director to guide me, but it is through my interpretations of my patients symptoms that she is cued. Any advice on what to watch for and what he may need and what i am in for if you have ever had a pt with this diagnosis? Thanks

[KellieNurse06]

That's sad....why are the nurses bent out of shape over the morphine???? Because of addiction???? I'd tell them who cares...the person is dying for pete's sake.....what's the big deal??? Are they going to come back after they are gone as a druggie & hunt them down for more medication???? lol!

I say let the patient have whatever they want if the doc will allow......I have found from several nurses I know with years & years of experience that once the morphine starts that's usually the end is close be it days, hours etc.

I'd remind those nurses that it's not about them or what they think....let the patient have as little pain as possible & enjoy their last days......... jmpo......let us know how things are going....hope your patient can live as close to pain free as possible when they transition....

[TonyaKayRN]

Have you ever given Methadone a try? I had used it once before with a cancer pt with addiction problems and it worked really well. There is a conversion out there to convert from MSO4 to Methadone and Methadone is given q8.

[petra]

ditto, give methadone a try and maybe up the ativan the roxanol prn doses.

[doodlemom]

The roxanol dose of 5 mg is not near enough with a long acting dose of 240 mg/day. His BT dose should probably be somewhere in the range of 60 - 80 mg or more. I agree with the methadone suggestion - but not because he has a hx of dependency. It just works better from what I've seen.

What you can expect to see in this patient is decreasing responsiveness and agitation from the liver failure. His ativan dosage will more than likely need to be increased. .5 mg q 6 hrs is not very much.

[RNDYN2CU]

The roxanol dose of 5 mg is not near enough with a long acting dose of 240 mg/day. His BT dose should probably be somewhere in the range of 60 - 80 mg or more. I agree with the methadone suggestion - but not because he has a hx of dependency. It just works better from what I've seen.

What you can expect to see in this patient is decreasing responsiveness and agitation from the liver failure. His ativan dosage will more than likely need to be increased. .5 mg q 6 hrs is not very much.

Thanks doodlemom... You know, I had him on Ativan 1mg q 4 but he had 2 falls last week so we are in that limbo of sedation and relief -vs- falls... I have him in the room closest to the nurses station and front door where he ambulates with the walker I got him ( I am so proud, he did not resist the walker, what a trooper!) to go outside to smoke. I am trying to keep him ambulatory as long as possible and explained to him that he may have to settle for some discomfort in order to ambulate and when the "time" comes, he will be in bed probobly on the cadd pump.

Is the btp dose you refer to for the whole day? So like 10mg q 4? I want to bring the ativan dose back to 1 mg q 4 because he had much better relief with this but also the falls... Thanks for the advice.

[aimeee, BSN, RN]

"A common way to calculate the amount of medication to give for breakthrough pain is to add the total amount of oral opioid given in 24 hours to control the pain adequately and give 10-15% of that dose every 2-3 hours." ~ http://www.pain.com/sections/professional/expert_interviews/interview.cfm?id=16

So, 10% of 240 is 24 mg every 2 hours. That would be the MINIMUM amount for breakthrough dosing and thats an odd amount so round UP to the next logical dosing point. If you are using the 20mg/ml concentration roxanol it might make sense to do 25 mg q2h (1.25 ml). But since he has a history of tolerance to opioids, I would go with the more generous amount and jump to 40 mg q2h (2 full ml)

[doodlemom]

Thanks doodlemom... You know, I had him on Ativan 1mg q 4 but he had 2 falls last week so we are in that limbo of sedation and relief -vs- falls... I have him in the room closest to the nurses station and front door where he ambulates with the walker I got him ( I am so proud, he did not resist the walker, what a trooper!) to go outside to smoke. I am trying to keep him ambulatory as long as possible and explained to him that he may have to settle for some discomfort in order to ambulate and when the "time" comes, he will be in bed probobly on the cadd pump.

Is the btp dose you refer to for the whole day? So like 10mg q 4? I want to bring the ativan dose back to 1 mg q 4 because he had much better relief with this but also the falls... Thanks for the advice.

No I was speaking of each dose. We usually go for about 15% of the daily dose for BTP. When I wrote this before, it was very early in the morning and I wasn't quite awake!.