The Elizabeth Hospice Palliative Reference Cards

“Ensuring that people facing the challenges of advanced severe illnesses receive the highest quality care is at the heart of what we do.”

Sarah McSpadden, RN, MSN, MHA President & Chief Executive Officer

Our Mission To enhance the quality of life for those nearing the end of life’s journey and for those who grieve. Our Services Palliative and hospice care for adults and children of all ages, Bereavement support for families and the community, Education for all healthcare professionals. To Refer a Patient: (760) 737-2050 or (800) 797-2050 For more information, visit us at ehospice.org

NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

TABLE OF CONTENTS

Page Subject

1 Patterns of Functional Decline

33 Change in Patient Status

2 Multiple Issues Can Cause Suffering

34-35 Resuscitation Statistics, DNR

3 Total Pain

36-41 2 Roads to Death, Last Hours of Living

4-5 Palliative Care is… Hospice Care is… 42-46 Effective Communication, NURSE 6-9 Pain & Symptom Assessment, FLACC, PAINAD 47 Family Meeting to Address "Don’t Tell" 10-11 Choosing Analgesics, Dosing Principles 48-51 Decision-Making, Goals of Care 12-13 Equianalgesic Dosing 52-53 Performance Status, ECOG, Karnofsky, PPS 14 Pain Pathophysiology 54-55 Prognosis in Cancer, Metastatic Spread 15 Neuropathic Pain Management, Dosing 56-57 Prognosis in Dementia, FAST 16-19 Nausea 58 Advance Care Planning 20 Constipation 59-61 Spiritual Screening 21 Complete Malignant Bowel Obstruction 62-69 Medication Kinetics 22-23 Dyspnea 64 Actions of Antipsychotics, Benzodiazepines, Opioids 24-32 Delirium Screening & Management 66 Antipsychotic Risk of Adverse Effects

PATTERNS OF FUNCTIONAL DECLINE

Adapted from Lunney JR et al. JAMA 2003. PMID 12746362.

1 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

MULTIPLE ISSUES CAN CAUSE SUFFERING

2 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

TOTAL PAIN In 1964, Dame Cicely Saunders created the concept of “Total Pain” to encompass the many dimensions of a patient’s experience that can lead to pain and suffering.

3 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

PALLIATIVE CARE IS…

Palliative Care is the knowledge & skills to manage the experience of patients and families with an illness with any diagnosis, anytime there is need. It aims to prevent & relieve suffering, and promote quality of life, death & bereavement. It can be provided concurrent with care to manage the underlying disease, or it can be the total focus of care.

4 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

HOSPICE CARE IN THE USA IS…

Hospice care in the USA is a special insurance benefit to provide enhanced palliative care to patients living with an advanced illness with a prognosis of 6 months or less if the illness runs its normal course, and their families. It also provides bereavement care for their families for at least 13 months after the patient’s death

5 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

PAIN / SYMPTOM ASSESSMENT

HISTORY FOR EACH PAIN / SYMPTOM 1.Location 2.Description Nociceptive, e.g., aching, throbbing Neuropathic, e.g., burning, shooting, stabbing, electrical Associated radiation, numbness, allodynia, hyperalgesia Mixed 3.Change over time (Temporal Profile)

BEHAVIORAL CHANGES Activities, eating, sleeping, thinking, mood

PSYCHOLOGICAL, SOCIAL, SPIRITUAL FACTORS Anxiety, depression Family or other social stresses, burdens Meaning and value, why me?

Constant

Breakthrough

Intermittent Acute

ON EXAMINATION At rest, on movement, on palpation

4. Severity (0‒10) 5.Effect of medications, other therapies Beneficial, adverse / side effects

6 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

SEVERITY ASSESSMENT SCALES WONG-BAKER FACES PAIN RATING SCALE

WORST

NONE

None

Annoying

Uncomfortable Distressing

Horrible

Unbearable

None

Little

Little More

Even More

Whole

Worst

Bit

Lot

7 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024 FACES from Hockenberry MJ,Wilson D, Winkelstein Ml: Wong’s Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. ©, Mosby.

T O C

PEDIATRIC FLACC SCALE BEHAVIORAL OBSERVATION PAIN RATING SCALE

CATEGORIES

SCORE

No particular expression or smile; disinterested

Frequent to constant frown, clenched jaw, quivering chin

Occasional grimace or frown, withdrawn

FACE

Uneasy, restless, tense

LEGS

No position or relaxed

Kicking or legs drawn

Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense Moans or whimpers, occasional complaint Reassured by occasional touching, hugging, or talking to; Distractable

Arched, rigid or jerking

ACTIVITY

Crying steadily, screaming or sobs, frequent complaints

No crying (awake or asleep)

CRY

Difficult to console or comfort

CONSOLABILITY

Content, relaxed

TOTAL

8 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024 Merkel SI et al. Pediatric Nursing 1997. PMID 9220806. Developed by Merkel SI et al. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI. Used with Permission

T O C

PAIN ASSESSMENT IN THE COGNITIVELY IMPAIRED ( PAINAD )

ITEMS

SCORE

Breathing independent of vocalization

Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations Repeated troubled, calling out. Loud moaning or groaning. Crying.

Occasional labored breathing. Short period of hyperventilation.

None

Occasional moaning or groaning. Low level speech with a negative or disapproving quality.

Negative vocalization

None

Sad. Frightened. Frowning.

Facial Expression Smiling /

Facial grimacing.

inexpressive

Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out.

Tense. Distressed pacing. Fidgeting.

Body language

Relaxed

No need

Distracted or reassured by voice or touch.

Unable to console, distract or reassure.

Consolability

toconsole

TOTAL

9 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024 The PAINAD was developed and tested by clinicians and researchers at the New England geriatric research Education and clinical center, a Department of Veterans Affairs center of excellence with divisions at EN Rogers Memorial Veterans hospital, Bedford, MA, and VA Boston health System. Used with permission. Warden V et al. J Am Med Dir Assoc. 2003. PMID 12807591

T O C

CHOOSING ANALGESICS

WHO 3-STEP LADDER When first starting an analgesic, choose one based on the severity of the patient’s pain. Within a step, choose the analgesics most appropriate for each patient:

3 Severe (7-10) Morphine Oxycodone Hydromorphone Fentanyl

Start at Step

2 Moderate (4-6) Codeine Tramadol A / Codeine A / Hydrocodone A / Oxycodone ± Adjuvants ( Meperidine / pethidine

Severity

1‒3

Methadone ± Adjuvants

4‒6

1 Mild (1-3) A cetaminophen / Paracetamol ASA / NSAIDs ± Adjuvants ( Propoxyphene notindicated )

7‒10

& pentazocine notindicated )

A = Acetaminophen / paracetamol ASA = Acetylsalicylic Acid NSAID = Non-steroidal anti-inflammatory

10 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

DOSING‒FIRST ORDER KINETICS

Most medications to manage symptoms follow first-order kinetics, i.e., clinical effect follows the plasmaconcentration

Dose scheduled medications every t ½ Steady state is reached after 5 x t ½ Dose breakthrough medications every T max PRN Choose 10‒20 % of 24 hr dose

SC / IM

PO /PR

Cmax

Opioids t Cmax

t ½

15 min 4 hr 30 min 4 hr 60 min 4 hr

SC / IM PO / PR

T max

Half-life ( t ½ )

Time

11 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024 See Medication Kinetic Parameter cards for T max and t ½ for selected palliative medications

T O C

EQUIANALGESIC DOSING GUIDELINE FOR CHRONIC PAIN

CHANGING ROUTES OFADMINISTRATION PO / PR IV / SC / IM Epidural Intrathecal 3 : 1 : 0.1 : 0.01 CHANGING ANALGESICS Oral / rectal Dose (mg) Analgesic Parenteral SC / IV / IM Dose(mg) 150 Meperidine 50 150 Tramadol - 150 Codeine 50 15 Hydrocodone - 15 Morphine 5 10 Oxycodone - 5 Oxymorphone - 3 Hydromorphone 1 2 Levorphanol 1 Fentanyl 0.050mg* *1000 mcg = 1 mg; must convert to mg to calculate equianalgesic dose TRANSDERMAL FENTANYL Morphine 50 mg PO in 24 hr ≈ Fentanyl 25 mcg transdermal patch q72H

METHADONE

Conversion Ratios

Daily Oral Morphine Equivalent (OME) Dose (mg/24 hr PO)

Morphine PO

Methadone PO

No more than 7.5 mg oral methadone daily (e.g., 2.5 mg three times daily)

<60 OME

60-199 OME and < 65 years of age ≥ 200 OME and/or > 65 years of age

20 1 Suggest no more than 30-40 mg per day, regardless of previous opioid does :

METHADONE SC / IV DOSING For Morphine PO to Methadone SC or IV 1. Calculate the Methadone PO Dose/24 hr using the table above 2. Then ÷ 2 to convert to Methadone SC or IV Dose/24 hr For Methadone SC or IV to Methadone PO 1. Use 1 : 1.3 (parenteral : oral) ADJUST FOR INCOMPLETE CROSS TOLERANCE Poor pain control 100 % equianalgesic dose Moderate pain control 75 % equianalgesic dose Excellent pain control 50 % equianalgesic dose

12 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

EQUIANALGESIC DOSING GUIDELINE FOR CHRONIC PAIN

COMBINATION PRODUCTS Acetaminophen 325 mg + Codeine 30 mg PO ( aka Tylenol#3 )

Acetaminophen 500 mg + Hydrocodone 5 mg PO ( akaVicodin )

Acetaminophen 325 mg + Oxycodone 5 mg PO ( akaPercocet )

Morphine 4‒5 mg PO ≈

Morphine 6‒7 mgPO ≈

Morphine 8‒9 mg PO ≈

13 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024 CALCULATION FORMULA To convert from one analgesic/route of administration to another analgesic/route of administration: X mg analgesic 1 by route 1 value for analgesic 1 by route 1 from table Y mg analgesic 2 by route 2 value for analgesic 2 by route 2 from table EXAMPLE To calculate the dose of morphine PO q4H equivalent to hydromorphone 2 mg/hr IV (without adjusting for incomplete cross-tolerance): 1. Calculate the total dose of hydromorphone q24H = 2 x 24 = 48 mg q24H 2. Convert to an equianalgesic dose of morphine PO q24H: X mg morphine PO 15 for morphine PO Y mg hydromorphone IV 1 for hydromorphone IV X mg morphine PO 15 48 mg hydromorphone IV 1 X mg morphine PO = 48 x 15 = 720 mg morphine PO q24H 3. Calculate the dose q4H = 720/6 = 120 mg morphine PO q4H = = =

T O C

PAIN PATHOPHYSIOLOGY

14 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

NEUROPATHIC PAIN MANAGEMENT‒ DOSING

Listed therapeutic range Start low; titrate up slowly over weeks

SNRIs Venlafaxine 37.5‒225 mg daily PO Duloxetine 60‒120 mg daily PO LIDOCAINE Lidocaine 5 % patch: Apply 1 -3 patches daily ( local effect only ) Lidocaine IV ( 2 gm / 500 mL ) D

ANTIEPILEPTICS Ca 2+ CHANNEL BLOCKADE

Gabapentin 900‒3600 mgPO / 24 hrdiv q8H Pregabalin 200‒600 mg PO / 24 hr div q8-12H Na + CHANNEL BLOCKADE Carbamazepine D 800‒1200 mg PO/24 hr div q8-12H Na + /Ca 2+ CHANNEL BLOCKADE Lamotrigine N 200‒400 mg PO/24 hr div q12H Topiramate N 200‒400 mg PO/24 hr div q12H OTHER Levetiracetam 1000‒3000 mg PO/IV/24 hr div q12H Valproic acid D 1000‒2000 mg PO/IV daily or div q12H TRICYCLICS TERTIARY AMINE ( More sedating ) Amitriptyline 10-150 mg PO daily Imipramine 10-150 mg PO daily SECONDARY AMINE ( Less sedating, preferred ) Nortriptyline 10-100 mg PO daily ( Amitriptyline metabolite ) Desipramine 10-150 mg PO daily ( Imipramine metabolite ) N = NMDA receptor antagonism D = Monitor drug levels for toxicity div = In divided doses J. Mangham, PharmD 6/08

• Loading dose: 2 mg/kg IV over 15-20 min • Then continuous infusion at 1 mg/kg/hr • Check Lidocaine plasma level 8‒10 hr after start of infusion, target 2‒6 mcg/mL OPIOIDs Dosing is based on pain assessment and management cards. STRONG MU AGONIST STRONG KAPPA AGONIST Morphine Oxycodone Fentanyl Hydromorphone Methadone N WEAK Mu AGONIST ( with 5HT 3 / NE reuptake inhibition ) Tramadol 100‒400 mg PO / 24 hr div q6H Tramadol ER 100 - 300 mg PO daily Tramadol / acetaminophen ( 37.5mg / 325 mg ) 4‒8 tablets PO / 24 hr div q6H

15 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

NAUSEA MANAGEMENT

Assessment: Conceptualize Underlying Causes: 13 "M's" of Emesis Above Neck 1. Masses 2. Meningeal Irritation 3. Migraine / other headaches 4. Movement Below Neck 5. Motility 6. Mucositis 7. Mechanical obstruction 8. Myocardial infarction 9. Maternity Systemic 10. Mentation 11. Medications 12. Microbes 13. Metabolic

Treatment 1. Treat underlying cause 2. Treat experience of nausea

Conceptualize likely neurotransmitters. Dopamine antagonists are first choice. Titrate to effect using t Cmax . Add medications from different classes. Do not overlap mechanisms of action.

Causes Above Neck Treat Underlying Cause

Causes Below Neck Treat Underlying Cause

Treat Nausea

Treat Nausea CTZ: 1. DA antagonist 2. H 1 antagonist

5. Motility

If due to medications: •  or stop responsible medications •  motility with prokinetic medication •  opioid inhibition of bowel function with methylnaltrexone If due to gastroparesis, e.g., Diabetes: •  motility with prokinetic medication

1. Masses

CTZ: 1. Dexamethasone 2. DA antagonist 3. H 1 antagonist CTZ: 1. Dexamethasone 2. DA antagonist 3. H 1 antagonist CTZ: 1. DA antagonist 2. H 1 antagonist CTZ: 1. DA antagonist 2. H 1 antagonist

• Dexamethasone to  inflammation / edema • If tumor, treat to  mass effect • If fluid collection, drain fluid • Dexamethasone to  inflammation / edema • If tumor, treat to  mass effect

2. Meningeal Irritation

CTZ: 1. DA antagonist 2. H 1 antagonist

3. Migraine or other headaches 4. Movement, vestibular stimulation

• Treat headache to  pain, associated symptoms

CTZ: Chemo Trigger Zone Adapted from Emanuel LL et al. EPEC-Oncology, 2005. Open Access at www.P ALL M ED .us. Wood G et al. JAMA 2007. PMID: 17848654.

•  motion • Treat inner ear infections •  or stop offending medications

16 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

NAUSEA MANAGEMENT

Causes Below Neck Treat Underlying Cause

Causes Below Neck Treat Underlying Cause Treat Nausea 7. Mechanical

Treat Nausea CTZ: 1. DA antagonist 2. H 1 antagonist

If extraluminal compression, e.g., adhesions, tumor: • Dexamethasone to  inflammation / edema • If tumor, treat to  mass effect • Surgery to stent or bypass • Octreotide to  intestinal • Volume • Nitrates to  angina • Optimize oxygenation / cardiac perfusion • Opioid analgesics to  intractable pain If 1st trimester,  estrogen & progesterone   gastric emptying • Eat small, frequent low-fat meals If 3rd trimester, mass effect  mechanical obstruction of bowel • Reposition • Keep stool soft / moving with stimulant ± osmotic laxatives

6. Mucositis

If due to gastric H + ;  gastric pH with: • Liquid antacid • H 2 blocker • Proton Pump Inhibitor If due to ASA or NSAIDs (  Prostaglandin E  relative ischemia   mucous production): • Ensure well hydrated • Misoprostol (Prostaglandin E analogue) to  perfusion • Proton Pump Inhibitor to  gastric pH If due to infection, e.g., H. Pylori, Candida, CMV, Herpetic  gastric erosions: • Treat infection •  gastric pH with H 2 blocker or Proton Pump Inhibitor If intraluminal obstruction, e.g., constipation or obstipation: • Relieve impaction with enemas, disimpaction •  constipation with stimulant ± osmotic laxatives

CTZ: 1.DA antagonist 2.H 1 antagonist

Obstruction (continued)

8. Myocardial infarction

CTZ: 1.DA antagonist 2.H 1 antagonist

9. Maternity

Possibly

Ondansetron

Most other

antinausea medications are not indicated as they may be teratogenic

7. Mechanical Obstruction

CTZ: 1. DA antagonist 2. H 1 antagonist

17 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

NAUSEA MANAGEMENT

Systemic Causes

Treat Underlying Cause Supportive care to reduce anxiety, underlying stress: • Behavior modification • Guided imagery • Hypnosis If during chemotherapy • Prophylactic antinauseants • Modify dose of chemotherapy If during radiation therapy • Prophylactic antinauseants • Modify dose of radiation If other medications, e.g., opioids, anticholinergics • Prophylactic antinauseants •  or stop responsible medications If due to systemic infections / sepsis: • Treat underlying infections • Reduce fever

Treat Nausea Diffuse effect: Centrally acting medications

Treat Underlying Cause

Treat Nausea CTZ: 1.DA antagonist 2.H 1 antagonist

13.

10. Mentation, e.g., anxiety, stress

If hypercalcemia due to metastases: • Rehydrate with NaCl; diurese with furosemide • Dexamethasone • Bisphosphonates, e.g., pamidronate, zoledronic acid; if cause is treatable If hyponatremia due to dehydration: • Stop diuretics, including alcohol & caffeine, e.g. coffee, tea • Rehydrate with NaCl containing fluids: - Orally: soups, sport drinks, red vegetable juices - Parenterally: 0.9 NaCl If liver failure, reduce toxins with lactulose, rifaximin, neomycin If renal failure, dialyze to reduce toxins

Metabolic

11.

See Chemotherapy Emetogenicity Table Emetogenicity Table CTZ: 1.DA antagonist 2.H 1 antagonist See Radiation

Medications / Treatments

12. Microbes

CTZ: 1.DA antagonist 2.H 1 antagonist

18 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

T O C

NAUSEA MANAGEMENT

Non-Pharmacological Management: Acupuncture, behavior modification, hypnosis, imagery, modification of eating habits / odors Pharmacological Management DA: Dopamine Antagonists H 1 : Histamine Antagonists Central Action Haloperidol 0.5‒2 mg PO / SC / IV q12‒24H Metoclopramide 10‒20 mg PO / SC / IV q6H Diphenhydramine 25‒50 mg PO / SC / IV q6H

Dexamethasone 2‒20 mg PO / SC / IV daily Dronabinol 5‒25 mg PO / 24 hr div q2‒4H Lorazepam 0.5‒2 mg PO / SC / IV q8H

Meclizine 25‒50 mg PO q6H Hydroxyzine 25‒50 mg PO q6H Promethazine 25 mg PO / PR q6H Promethazine 12.5‒25 mg IV q6H

Prochlorperazine 10‒20 mg PO q6H Prochlorperazine 25 mg PR q12H Olanzapine 5‒10 mg PO daily 5HT 3 : Serotonin Antagonists Ondansetron 4‒8 mg PO / SC / IV q6H Granisetron 1 mg PO / IV daily or q12H Dolasetron 200 mg PO / IV daily Palonosetron 0.25 mg PO / IV daily

Ach: Acetylcholine Antagonists Inoperable Obstruction

Scopolamine patch 1‒3 TD q72H Scopolamine 0.1‒0.4 mg SC/ IV q4H

Octreotide 100‒400 mcg or more SC / IV q8H or 10‒80+ mcg/ hr SC infusion Scopolamine 0.1‒1.0+ mg/ hr SC infusion Glycopyrrolate 0.1‒1.0+ mg/ hr SC infusion

Div = in divided doses

19 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

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CONSTIPATION MANAGEMENT

Possible Causes

Stool Softeners

Bulking Agents

• Diet • Dehydration • Dysmotility • Mechanical obstruction

• Opioids • Anticholinergics

If there is no squeeze, e.g., with opioids, stool softeners lead to softer stool that still doesn't move • Docusate Na + 100‒250 mg PO bid

Not recommended with chronic opioid use • Methylcellulose 1 tbsp bid • Psyllium 1 tbsp bid

• Calcium channel blockers • 5HT 3 receptor antagonists • Ca 2+ / Al 3+ antacids

• Carcinomatosis • Hypercalcemia • Diabetes Mellitus

Stimulants

Osmotics

• Senna 2‒9 tabs or Senna tea daily • Bisacodyl 2 x 5‒10 mg PO daily • Cascara extract 50 mg PO daily • Metoclopramide 10 mg PO qid ac & hs • Erythromycin 250 mg PO tid

• Polyethylene glycol 17 gm PO daily or bid • Magnesium Hydroxide 30 ml PO bid • Magnesium Citrate ½ bottle PO bid • Lactulose 30 ml PO bid‒ tid • Sorbitol 30 ml PO bid

Management Pearls • Bowel peristalsis is stimulated by intraluminal volume • Anticipate opioid-induced constipation; treat prophylactically: - Titrate stimulant laxatives to effective doses - Add osmotic laxatives to draw water into the stool, increase its volume, and stimulate peristalsis • If obstipation occurs, before starting stimulant or osmotic laxatives ensure no impaction • If diarrhea occurs with obstipation, i.e., overflow incontinence, check for impaction, then decrease laxative doses, don't stop them • Bowels do NOT become inactive and never work again because of laxatives • Soap suds enemas are NOT recommended; they can damage bowel wall and lead to perforation

Enemas

Emollients

• Mineral or other oil, 30‒60 ml PO daily (risk of aspiration) • Glycerin suppository PR daily

• Phosphosoda (osmotic) • Mineral or other oil 50‒100 ml to soften leading edge • Tap Water 0.5‒1 L PR daily to increase volume, stimulate peristalsis

Peripheral Opioid Mu Receptor Antagonist

Before starting, ensure some stool moving, no hard leading edge Methylnaltrexone 0.15 mg/kg SC q 24 hr prn, if no bowel movement in the last 48 hr; approximated to 8 mg (if 84 to < 136 lb) or 12 mg (if~ 136 to 250 lb)

20 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

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COMPLETE MALIGNANT BOWEL OBSTRUCTION SHUT DOWN THE GUT !

Adapted from Ripamonti C et al. Support Care Cancer 2001. PMID: 11430417. Dolan EA. Am J Hosp Palliat Care. 2011 PMID: 21504999

21 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

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DYSPNEA ASSESSMENT

Medical Research Council ( MRC ) Dyspnea Scale for COPD

Respiratory Depression Uncommon Increased risk if patient has • Obesity • Sleep apnea

0 = Strenuous exercise 1 = Walking fast on level ground, or walking uphill 2 = Walking slower than others on level ground, or stop for breath walking own pace on level ground 3 = Stop for breath after 100 yds / few minutes on level ground 4 = Too breathless to leave house or dress

NON-VERBAL ASSESSMENT

Modified Borg Dyspnea Scale Self-rating of shortness of breath 0 = Nothing at all 1 = Very slight 2 = Slight 3 = Moderate 4 = Somewhat severe 5 = Severe 6 7 = Very severe 8 9 = Very very severe 10 = Maximal

Variable

0 points

1 point

2 points

Total

Heart rate / minute < 90 beats

90‒109 beats

≥ 110 beats > 30 breaths

Respiratory rate / minute Restlessness: non-purposeful movements Paradoxical breathing pattern: abdomen moves in on inspiration Accessory muscle use: rise in clavicle during inspiration Grunting at end-expiration: guttural sound Nasal flaring: involuntary movement of nares

≤ 18 breaths 19‒30 breaths

Occasional slight movements

None

Frequent movements

None

Present

None

Slight rise

Pronounced rise

None

Present

None

Present

Eyes wide open, facial muscles tense, brow furrowed, mouth open, teeth together Total:

Look of fear

None

X / 16

22 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

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DYSPNEA MANAGEMENT

Always treat underlying cause + manage patient’s report of shortness of breath (SOB), not respiratory rate Mild SOB Non-pharmacologic Moderate SOB Opioids PRN Severe SOB Opioids ER + PRN Extreme / Refractory SOB Benzodiazepines • Pulmonary rehabilitation & education

When opioids ineffective, use benzodiazepines as • Anxiolytic / sedatives • Amnestics • Skeletal muscle relaxants Start PRN dosing, titrate using ‘catchup technique’ Lorazepam 1‒2 mg PO/Buccal q1H PRN 1‒2 mg SC q30min PRN or 1‒2 mg IV q15min PRN Maintenance = 50% of total dose in 24 hours q12H (t ½ = 12 hr) Typically 2‒10 mg / 24 hr or equivalent with an alternate benzodiazepine Midazolam Loading dose 0.2 mg/kg IV/SC Maintenance dose 0.075 mg/kg/hr IV/SC

Like pain management, calculate opioid use in 24 hr and offer as Morphine or Oxycodone ER PO q8‒12h + 10‒20% of 24 hr total dose as IR PO q1H PRN Anxiety If anxious, consider adding Trazodone 50‒100 mg PO q1H PRN (especially in elderly) Clonazepam 0.25 mg PO q24H (longer acting  steady plasma levels) Lorazepam 0.5 mg PO/SL q12H

Opioids most often relieve SOB without  respiratory drive Caution, not contraindication, if obesity or sleep apnea In naïve patients, typically Morphine IR 30‒60 mg / 24 hr or equivalent Start PRN dosing, titrate using ‘catchup technique’ to relief of SOB, not respiratory rate Morphine IR 5 mg PO q1H PRN or 2 mg SC q30min PRN or 2 mg IV q15min PRN Hydromorphone IR 1 mg PO q1H PRN or 0.3 mg SC q30min PRN or 0.3 mg SC q15min PRN Oxycodone IR 5 mg PO q1H PRN

• Fan to face relieves SOB through stimulation of baroreceptors of Cranial Nerve V (facial nerve)

• Open window, cool air • Relaxation techniques • Positioning • Pursed-lip breathing • Acupuncture

Oxygen • Potent symbol of medical care, only useful when  % saturation or  pO2 • For other causes, fan to face or compressed air via nasal canula may be equally effective

23 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

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DELIRIUM TERMINOLOGY

Delirium An acute change in mental status that may fluctuate and has underlying physiological causes; not dementia. It may be hyperactive (presence) or hypoactive (absence) of psychomotor agitation, perceptual disturbances and/or changes in level of consciousness. It is often mixed when both subtypes are present currently. Associated Behaviors, Symptoms, Signs Acute onset Rapid onset of symptoms over minutes to days, even if it began or occurred in the past Fluctuation or waxing/weaning Intensity changes rapidly, symptoms may come and go Agitation On intentional, excessive, and purposeless cognitive and/or motor activity Hallucination Perception of an object or event that does not exist. May be visual, auditory, olfactory, gustatory, or tactile

Altered level of consciousness

Inattention Inability to focus for direct thinking

Clinically differentiated degrees of awareness and alertness, i.e., hypervigilant, alert, lethargic, cloudy, stuporous, or comatose

Confusion Not oriented to person, place, time, or situation

Irritable Prone to excessive impatience, annoyance or anger to get needs met

Delusion A fixed or false belief or wrong judgment that opposing evidence does not change; maybe paranoid, grandiose, somatic, or persecutory Disinhibition Unable to control an immediate impulsive response to a situation

Labile affect Rapidly changing and out of context mood symptoms

Psychosis Loss of contact with reality

Disorganized thinking

Restlessness See ‘agitation’ about left

Thoughts are confusing, vague, and/or do not logically flow; they are loosely or not connected

Irwin et al. 2013. PMID: 23480299. Used with Permission.

24 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

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DELIRIUM ASSESSMENT Establish the patient’s situation , the likely underlying cause(s) of the delirium , and whether it is potentially reversible, or not . Delirium is irreversible if 1) the patient is actively dying, 2) the patient's goals of care focus on symptom management and not treating the underlying cause(s), and 3) time-limited therapeutic trial(s) have failed to reverse the underlying cause of the delirium. Common Causes Terminal Delirium Assessment Diagnostic Workup Reversible causes found in 50% • Constipation • Urinary retention • Fluid and/or metabolic imbalance An irreversible delirium during the active dying process; a prospective diagnosis Signs of Active Dying: Cardiac Failure:

Test for impairments in: • Attention • Cognition • Consciousness • Reality, perceptions • Behavior Determine subtype: Hyperactive • Behavioral disturbances • Increased motor activity • Hallucinations

Consistent with context and goals. Look for common causes and reversibility. Start with: • History & physical • Cognitive status • Allergies, adverse reactions • Review medication history, including dosage changes over time • Alcohol and/or benzodiazepine use or withdrawal • Chemistry and hematological workup • Infection workup • Vitamin levels

• Medications, e.g., opioids, benzodiazepines, steroids, anticholinergics • Infections, e.g. urinary tract infection, pneumonia • Hepatic or renal failure • Hypoxia • Hematological disturbances, e.g., anemia

• Cyanosis, venous pooling, mottling, peripheral cooling • Oliguria, anuria Neurological Changes: • Decreasing consciousness • Changes in breathing, e.g. decreasing tidal volume, apnea, Cheyne-Stokes respirations, agonal breathing • Loss of gait, inability to swallow

• Delusions Hypoactive

• Decreased consciousness • Decreased motor activity • Often mistaken for depression

• Oral, tracheal secretions • Loss of sphincter control

Irwin et al. J Palliat Med 2013. PMID: 23480299. Used with Permission

25 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

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DELIRIUM SCREENING

CAM: Confusion Assessment Method

3) DISORGANIZED THINKING

A diagnosis of delirium is suggested if question 1 and 2 are YES with either • YES from 3 or • Anything other than alert in 4

Is the patient’s thinking disorganized or incoherent, as evidenced by rambling or relevant conversation, unclear or illogical flow of ideas, unpredictable switching from subject to subject?  Yes  No  Uncertain 4) ALTERED LEVEL OF CONSCIOUSNESS Overall, how would you rate this patient’s level of consciousness?  Alert  Vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily)  Lethargic (drowsy, easily aroused)  Stuporous (difficult to arouse)  Comatose (unarousable)  Uncertain

1) ACUTE ONSET

Is there sudden onset of mental status change?  Yes  No  Uncertain 2) INATTENTION Does the patient had difficulty focusing attention, for example, is easily distracted or has difficulty keeping track of what is being said?  Yes  No  Uncertain

Adapted from Inouye et al. 1990. PMID 2240918. Used with permission.

26 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

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CAM-ICU FLOWSHEET

27 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

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Step 1: Level of Consciousness Assessment RASS: RICHMOND AGITATION‒SEDATION SCALE

Scale

Label

Description

+ 4 + 3 + 2 + 1

COMBATIVE

Combative, violent, immediate danger to staff Pulls to remove tubes or catheters; aggressive Frequent non- purposeful movement, fights ventilator Anxious, apprehensive, movements not aggressive

VERY AGITATED

AGITATED RESTLESS

ALERT & CALM

Spontaneously pays attention to caregiver

Not fully alert, but has sustained awakening to voice (eye opening & contact > 10 seconds) Briefly awakens to voice (eyes open & contact < 10 seconds)

- 1

DROWSY

- 2 - 3

LIGHT SEDATION

MODERATE SEDATION Movement or eye opening to voice (no eye contact) If RASS is ≥ -3, proceed to CAM-ICU (is patient CAM-ICU positive or negative)

No response to voice, but movement or eye opening to physical stimulation

- 4

DEEP SEDATION

- 5

UNAROUSABLE No response to voice or physical stimulation If RASS is -4 or -5 STOP (patient unconscious), RECHECK later

Sessler et al. 2002. PMID: 12421743.

Ely et al. 2003. PMID: 12799407

28 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024

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