Analgesia: use of patient/proxy patient controlled analgesia in palliative care

The aim of this guideline is to provide guidance on patient/proxy patient controlled analgesia and its use in palliative care at Great Ormond Street Hospital (GOSH).

Background

The use of patient controlled analgesia (PCA) and nurse controlled analgesia (NCA) has been shown to provide a safe and effective technique for the administration of intravenous or subcutaneous opiates for the relief of pain (Howard et al 2012Howard et al 2010).

These techniques are most commonly used following surgery (Franson 2010; Howard et al 2010), but can also be effective for the management of non-surgical pain such as sickle crisis, pancreatitis and cancer related pain (Friedrichsdorf et al 2007 Melzer-Lange et al 2004).

More recently PCA and proxy PCA (PPCA), where analgesia is controlled by a parent or carer, has been reported to be effective in hospital and in the community setting in terminally ill children (Zernikow et al 2009; Schiessl et al 2008, Mherekumombe and Collins 2015; Anghelescu et al 2015).

The utilisation of PPCA has been restricted by historical concerns in relation to patient safety, with parental participation limited to assessment and reporting of their child’s pain to health care professionals, rather than being trained to take on the responsibility for administration of bolus doses of analgesia. Although this is entirely appropriate in a patient population who are opiate naïve and with limited pain experience, such as the majority of post-operative patients.

The palliative care population who will be considered for PCA and PPCA have different characteristics.

In this population, patients and parents/carers are experienced in both pain assessment and management of pain, utilising oral, buccal and transdermal analgesic preparations including opioids in many cases (Hewitt et al 2008).

The children and young people who may derive enhanced pain management from this method of analgesic, delivery are recognised to both have experience of opiates during their illness trajectory, and be more likely to require assistance in initiating bolus analgesia as a result of their disease or its progression (Malcolm et al 2011Zelcer et al 2010).

Studies in several fields including children with cancer and children with cognitive impairment, have demonstrated the safety of PPCA in these populations (Czarnecki et al 2011Czarnecki et al 2008Anghelescu et al 2005).

Morphine is considered to be the gold standard for intravenous analgesia and is therefore usually the opioid of choice ( Lloyd-Thomas and Howard 1994). The use of other opioids is only considered when morphine is contra-indicated or no longer effective.

Abbreviations and definitions used in this guideline

The term analgesic solution will be used to refer to the specific drug or drugs prescribed in solution.

The term patient controlled analgesia (PCA) refers to a method of pain control, which allows the patient to press a button to self-administer a pre-programmed amount of a subcutaneous or intravenous analgesic solution (the bolus dose).

The pump programming will determine the time before another bolus dose can be administered  this is the lockout period. The patient may also receive a background infusion pre-programmed hourly rate of analgesic solution. The term proxy patient controlled analgesia (PPCA) refers to a technique by which the PPCA may be activated by someone else, ie parents or carers, who may press a button to give the patient a pre-programmed amount of analgesic solution (the bolus dose).

The use of PCA and PPCA requires a specially designed locked pump which allows for programming of drug concentration, continuous infusion rate (if required), and a bolus dose and lockout interval. All personnel who care for patients receiving PCA or PPCA must be trained and competent to do so. PCA and PPCA pumps must only be programmed by competent personnel who will have received specific training.

TPCA – Ambulatory PCA pump manufactured by CME medical which uses 50ml syringes for drug delivery.

CADD Solis – Ambulatory PCA pump manufactured by Smith & Nephew which uses cassettes for drug delivery.

mcg = micrograms, mg = milligrams, ml = millilitres, kg = kilograms

Competent personnel – a doctor or nurse who has attended a device-specific training session, and has knowledge of the GOSH clinical practice guideline for commencing the use of PCA or PPCA in the care of a child or young person receiving palliative care.

The child or young person must be a patient of the GOSH Palliative Care team. Each child or young person’s symptom management plan and protocol for PCA or PPCA, must be agreed and signed by a GOSH palliative care consultant.

Competent community medical and nursing staff  staff who have received the training package for PCA and PPCA, either delivered by the GOSH Palliative Care team or the company who supplied the device being used.

PCA/PPCA documentation – all documentation required for patients receiving PCA/PPCA can be found in the Palliative Care office (Level 4 Main Nurses Home, GOSH). This documentation will be utilised by GOSH Palliative Care team staff and be available in the community setting where the patient is cared for.

Prescriber – professional who will issue a prescription for the drug required for the PCA/PPCA for the use of a specific patient.

Protocol for PCA/PPCA – the required drug, dosage regime and programming plan as requested by the GOSH palliative care consultant for the use of a specific patient.

Community care training

All paediatric community medical and nursing staff involved in jointly managing patients who will be using a PCA or PPCA, must receive a training session on delivery of PCA and PPCA in the community. This may be delivered by the company who supply the device being used or by the GOSH Palliative Care team prior to jointly managing a names patient.

Children and young people who are going to utilise PCA will be trained (using age and developmentally appropriate techniques) in the use of the equipment, how to assess their pain and the potential side effects of opiates.

In addition, their parents/carers will also be trained in order to support the child/young person in managing the technique. Face-to-face training will be supported by written instructions provided to meet the specific needs of the family.

Children and young people who are assessed as requiring PPCA, will have a least one parent/carer trained in the technique of PPCA, how to assess pain and the potential side effects of opiates. Face-to-face training will be supported by written instructions provided to meet the specific needs of the family.

Assessment for PCA/PPCA

Prior to setting up the infusion, the GOSH Palliative Care team will consider:

  • The suitability of PCA/PPCA for each individual patient.

  • The competency of staff involved in service delivery of PCA/PPCA for the individual patient, including anticipated changes in place of care (eg emergency admission to hospital; transfer from hospital to hospice or home; or patients on day release / home leave).

  • The suitability of the proposed place of care and supervision available.

  • The anticipated effectiveness of PCA/PPCA for the type and nature of pain, disease profile and pathway (Rationale 1 and 2).

If the patient is going to use PCA they must:

  • be able to understand the technique
  • be willing to use it
  • be physically able to press the button on the handset (Rationale 2)

If the parent or carer is going to use PPCA they must:

  • be able to understand the technique

  • be willing to use it

  • be able to follow written instructions on a symptom management plan

  • be able to access telephone advice 24/7 from the GOSH Palliative Care team

  • be physically able to press the button on the handset

Preparation for PCA/PPCA administration

A member of the GOSH Palliative Care team will discuss the use of PCA/PPCA with the child and family, and obtain agreement in using this technique for management of pain (Rationale 3). Risk assessment to be carried out by the GOSH Palliative Care team or the community nursing team (see appendix 1)

  • The child and family should be prepared for the PCA/PPCA, including explanation of the technique (Rationale 4 and 5).

  • Parents should be advised in a sensitive manner that they are not permitted to administer a bolus by pressing the button for PCA (Rationale 6 and 7).
  • The family should be made aware that if the child is unable to use PCA, the pump programming can be changed to PPCA (Rationale 8).
  • PPCA may be changed to PCA if the child is able and willing to press the button and understands the concept (Rationale 8).
  • If the family have any questions they should contact the GOSH Palliative Care team.

The GOSH Palliative Care team can be contacted on 020 7829 8678 (Monday to Friday 8am to 6pm) or out of hours via switchboard on 020 7405 9200 and air calling the service.

GOSH Palliative Care team should also ensure that an age appropriate pain assessment tool, PCA/PPCA documentation including pain and symptom diary, and an up-to-date symptom management plan, is available at the child’s place of care and circulated to all MDT members (Rationale 3 and 4).

Pain Assessment 

  • Self-report is the gold standard for pain assessment and should be used whenever possible.

  • Determine the pain assessment tool that the child is confident in using ( Rationale 9).

  • For children unfamiliar with pain assessment tools, work with the child and parents/carer to explain and select an appropriate assessment tool to be used during the use of PCA/PPCA ( Rationale 9).

  • Words that the child uses for pain and the child’s usual pain related behaviour, should be recorded.

  • For infants, patients who are cognitively impaired and those unable to communicate, an appropriate observational tool should be used and the parents/carers should be involved as much as possible.

  • Healthcare professionals to use a PCA/PPCA contact recording sheet for each assessment (telephone or direct contact).

  • Encourage patients/carers to record pain episodes and action taken using pain and symptom diary.

Dosing regime

Patients will be categorised into one of three frameworks as follows:

  1. A child with rapidly escalating pain, who is opiate naive or only requiring a small amount of opiate analgesia by another route of administration.

  2. A child who has background opiate analgesia requirements, and has frequent incident pain or breakthrough pain.

  3. A child who is at the end of life and no longer able to take analgesia via another route.

For patients in framework 1

  • Opiate naive patients.
  • Drug: morphine sulphate.
  • Action: binds with receptors in the brain and spinal cord to block the transmission of impulses along the nerve axon.
  • Available in ampoules of: 1mg/ml, 5mg/ml, 10mg/ml, 30mg/ml. Use caution to ensure that correct ampoules are selected.
  • Subcutaneous:
    • Patient weighs <50kg: 1mg/kg in 20mls of 0.9 per cent sodium chloride (1ml = 50micrograms/kg).
    • Patient weighs >50kg: 50mg in 20mls of 0.9 per cent sodium chloride (1ml = 2.5mg).
  • Intravenous:
    • Patient weighs <50kg: 1mg/kg in 50mls of 0.9 per cent sodium chloride (1ml= 20micrograms/kg).
    • Patient weighs >50kg: 50mg in 50mls of 0.9 per cent sodium chloride (1ml=1mg).

For patients in frameworks 2 and 3

Some palliative care patients may already be receiving large doses of morphine sulphate or other opiate by a different route for treatment of breakthrough pain or incident pain but may wish to switch to a PCA or PPCA method of administration. For these patients larger doses of morphine sulphate may be prescribed and therefore the concentrations of drug made up in the devices by both intravenous and subcutaneous routes may need to be altered. This should be discussed with the Palliative Care team consultant prescribing the PCA/PPCA.

  • Calculate the previous day’s oral morphine equivalent (OME) for 24 hours using standard conversion tables (Rationale 10). Convert this to the subcutaneous/intravenous opioid to be used in PCA/PPCA, using standard conversion tables. This is the background opiate infusion over 24 hours for the PCA/PPCA.
  • To calculate initial bolus sizes divide the background opiate infusion by 24.

For all frameworks, the lockout times for both PCA and PPCA are between 10-30 minutes.

Addition of other drugs to the PCA/PPCA

Consideration of combining other drugs in the PCA/PPCA in addition to morphine sulphate or equivalent opioid, for the management of analgesia and/or agitation MUST be discussed with the Palliative Care team consultant and a clear rationale for this should documented in the individual patient’s records.

In these circumstances, consider concurrent and expected symptoms that may need to be managed (eg nausia and vomiting, agitation), dosing regimens, drug compatibility and availability of medication in the care setting and training of personnel (patient/proxy and staff) involved in administration.

Medication for use in the community setting

Patients who are being cared for in the community setting will require medications to be prescribed and dispensed by community staff (general practitioners or appropriately experienced non-medical prescribers).

These prescriptions will follow the protocol for PCA/PPCA provided by the GOSH Palliative Care team consultant and detailed in the child’s own symptom management plan.

The GOSH Palliative Care team will ensure that this information is available in the community setting to enable medications to be obtained before the PCA/PPCA is required to commence (Rationale 11).

Ordering disposables

The community team will supply appropriate disposables for patient use. The GOSH Palliative Care team will provide information on how to obtain suitable disposables. For reasons of patient safety, all administration sets used for PCA/PPCA should contain an anti-siphon/anti-reflux valve as recommended by the device manufacturer (Southern and Read 1994)(.  Rationale 12 and 13).

Setting up infusions

The GOSH Palliative Care team will provide a protocol for the set up and continued use of all PCA/PPCA pumps. All programming changes will be made by the Palliative Care team, or by staff trained in the management of PCA/PPCA in the community setting.

Management of the infusion and changes to the medication delivery system for continuing prescriptions, will be carried out by the nursing teams at the child’s place of care, according to local syringe driver policies.

Nursing teams are requested to include a copy of their syringe driver management policy in the patient’s documentation.

The GOSH Palliative Care team are available for telephone advice 24 hours a day, seven days a week.

It is particularly important to ensure that other medications, including adjuvant analgesia, has been prescribed correctly before the PCA/PPCA is set up, and all necessary documentation is available with the patient.

Pumps used for PCA/PPCA analgesia include: 

  • TPCA – Ambulatory PCA pump manufactured by CME medical which uses 50ml syringes for drug delivery.
  • CADD Solis – Ambulatory PCA pump manufactured by Smith & Nephew which uses cassettes for drug delivery.

PCA/PPCA pumps are stored in the Palliative Care team office, (Level 4, Main Nurses Home). These pumps should not be removed from the Palliative Care team office without first liaising with the Palliative Care team. The type and serial number of the pump must be recorded on the Palliative Care team database (Rationale 14). All users must check the pump maintenance date before use. Out of date pumps must be serviced before use (Rationale 15

Care of patient while receiving PCA/PPCA analgesia

All children receiving opioids must be supervised by an adult parent/carer. The professionals supporting the patient and family will include the GOSH Palliative Care team and community palliative care services (including children's hospices), community children's nursing teams, and local hospital teams.

Staff overseeing PCA/PPCA should review the patient at least once daily and check the following:

  • The patient’s PCA/PPCA protocol has been completed correctly (Rationale 16).

  • The analgesic solution and additional drugs are prescribed (Rationale 17).

  • The drug being administered corresponds with the protocol and symptom management plan (Rationale 18).

  • The pump programming corresponds to the most recent entry in the PCA/PPCA documentation (Rationale 18).

  • The patient is comfortable and pain is being managed appropriately with the current PCA/PPCA and adjuvant medications (Rationale 17).

  • Required PCA/PPCA documentation is completed.

  • If subcutaneous administration, check infusion site daily for signs of infusion reaction (Rationale 17)

  • Administration sets and other disposables must be changed as per hospital policy (Rationale 19).

If the patient is in pain:

  • Complete and document pain and symptom assessment:

  • For PCA: encourage the patient to give a bolus and evaluate effectiveness after 10-15 minutes (Rationale 20).

  • For PPCA: administer a bolus and evaluate effectiveness after 10-15 minutes.

  • Utilise non-pharmacological pain management strategies (Rationale 21).

  • Discuss with GOSH Palliative Care team.

The GOSH Palliative Care team can be contacted on 020 7829 8678 (Monday to Friday 8am to 6pm) or out of hours via switchboard on 020 7405 9200 and air calling the service.

The GOSH Palliative Care team will review all patient assessment data on a daily basis, and will make appropriate adjustment to the patient's protocol and symptom management plan (Rationale 22).

Prevention and detection of opioid-related side effects

As with all Palliative Care patients, discuss the expected end of life observable events due to the disease (breathing changes, skin colour changes, depressed level of consciousness and decreased responsiveness) at an appropriate time and in a sensitive manner with family. Complete an emergency care plan when appropriate.

The PCA/PPCA will not be discontinued when changes (breathing, colour, level of consciousness and responsiveness) associated with a natural death due to the underlying disease process occurs.

Sedation level

Daily assessment and recording of sedation level should be undertaken (Rationale 23).

If the patient has a change of sedation score, which is unusual for the child and not thought to relate to the underlying disease process, and therefore may be due to the PCA/PPCA:

  1. STOP the infusion (Rationale 24) and ensure the child is well supervised.

  2. Contact the GOSH Palliative Care team. The infusion may be recommenced following assessment and discussion with the GOSH Palliative Care team.

  3. The GOSH Palliative Care team may review and adjust the protocol and symptom management plan (Rationale 17).

  4. Document actions in the child’s PCA/PPCA contact sheets (Rationale 25).

Respiratory depression

Consider rate and depth of respiration, respiratory effort and level of sedation (Rationale 26).

If the patient has a change which is unusual for the child and not thought to relate to the underlying disease process, and therefore may be due to the PCA/PPCA (Rationale 27):

  1. STOP the infusion and contact the GOSH Palliative care team.

  2. The infusion may be recommenced following assessment and discussion with the GOSH Palliative Care team.

  3. The GOSH Palliative Care team may review and adjust the protocol and symptom management plan (Rationale 17).

  4. Document actions in the child’s PCA/PPCA contact sheets (Rationale 25).

Nausea and vomiting

If the patient complains of nausea or has been vomiting, it may be due to the disease process or the PCA/PPCA infusion medication.

Consider aspirating a nasogastric or gastrostomy tube and:

  1. Administer an anti-emetic as per symptom management plan ( Zernikow et al 2009) ( Rationale 28).

  2. If nausea/vomiting continues, contact the GOSH Palliative Care team.

  3. The GOSH Palliative Care team may review and adjust the protocol and symptom management plan (Rationale 17).

  4. Document actions in the child’s PCA/PPCA contact sheets (Rationale 25).

Pruritus

The patient should be observed for pruritus (itching) daily (Rationale 29).

If the patient complains of pruritus it may be due to the disease process or the PCA/PPCA infusion medication.

Contact the GOSH Palliative Care team. The GOSH Palliative Care team may consider the substitution of another opioid (Rationale 30).

Urinary retention

The GOSH Acute Pain service database indicates that the incidence of urinary retention in patients receiving intravenous opioids via NCA or PCA is very low (Peters et al 2013). For this reason, retention in children on PCA/PCCA should be treated as for any other child under similar circumstances.

  • If the patient has not passed urine in the previous day, examine for a palpable bladder and ask about whether there is any discomfort. If no discomfort, discuss with GOSH Palliative Care team and decide on a plan of observation for the day. This degree of urinary infrequency may be a normal event for a child with this disease process.

  • If there is discomfort and urinary retention is suspected, discuss with the GOSH Palliative Care team and consider admission to local hospital for assessment and catheterisation procedure if needed.

Stopping PCA/PPCA

The PCA/PPCA must be stopped if the pump malfunctions (Rationale 31).

Consider stopping in the following situations:

  • excessive sedation
  • respiratory depression or respiratory arrest

The GOSH Palliative Care team must be informed that the infusion has been stopped (Rationale 25 and 32).

Discontinuing PCA/PPCA

The PCA/PPCA may be discontinued by a member of the GOSH Palliative Care team, or community palliative care services who are trained to do so (Rationale 33).

Criteria for stopping PCA/PPCA include:

  • The patient is able or chooses to take analgesia via an alternative route and this is prescribed.
  • The patient has died.

The GOSH Palliative Care team must be informed that the PCA/PPCA has been discontinued.

Discontinuation must be recorded in the child’s PCA/PPCA documentation (Rationale 25).

Record:

  • date and time
  • total drug infused
  • volume of infusion solution remaining (Rationale 25)

Once the use of the PCA/PPCA has discontinued, clean the pump with sanitising cloth, for example Clinell wipes (Rationale 34).

Return cleaned PCA/PPCA pump to Palliative Care office (level 4, Main Nurses Home, when not required (Rationale 35).

If the PCA/PPCA pump has been used out of the hospital the Palliative Care team will take the pump to GOSH Biomedical Engineering department for required checking and maintenance (Rationale 19

Dispose of remaining controlled drugs according to local community policy.

PCA/PPCA pump technical problems

The pumps currently used for PCA/PPCA palliative care patients are either the TPCA or the CADD Solis (see appendix 3)

Palliative Care team staff must ensure that faulty pumps are returned to Biomedical Engineering with the problem accurately described. Any pump which has been dropped or damaged must be taken out of service until checked by Biomedical Engineering (Rationale 31).

Rationale

Rationale 1: To ensure that the benefits are balanced against potential risks.
Rationale 2: To ensure that the most appropriate technique is used for the patient.
Rationale 3: To provide information.
Rationale 4: To meet information needs.
Rationale 5: To reduce anxiety.
Rationale 6: In order to ensure patient safety, only children and young people trained in the use of the PCA technique (and aware of the potential side effects of opioids) may administer boluses.
Rationale 7: In PCA excessive opioid demands initiate sedation: the child falls asleep and allows the opioid level to decrease.
Rationale 8: PCA and PPCA programming differs.
Rationale 9: To ensure the child understands and can use the tool prior to the painful experience.
Rationale 10: To ensure that there is no loss of analgesia during conversion.
Rationale 11: To ensure that there is an adequate supply for the patient in the place of care.
Rationale 12: To prevent siphonage (Southern and Read 1994).
Rationale 13: To prevent siphonage and reflux.
Rationale 14: Patient safety and audit trail of equipment used.
Rationale 15: All PCA/PPCA pumps should be deep cleaned and serviced at least once a year. Orange stickers indicate when this service is due.
Rationale 16: To adhere to hospital drug policy.
Rationale 17: To ensure effective analgesia with minimal side effects.
Rationale 18: To prevent drug errors.
Rationale 19: To adhere to hospital policy.
Rationale 20: To provide effective and adequate pain relief.
Rationale 21: To ensure a strategy of multi-modal analgesia is being undertaken.
Rationale 22: To ensure swift action is taken if analgesia is unsatisfactory.
Rationale 23: To ensure early detection and treatment of opioid induced sedation.
Rationale 24: To allow for prompt treatment of opiate induced sedation.
Rationale 25: To maintain an accurate record.
Rationale 26: Respiratory rate and pattern can vary and the child's normal respiratory rate must be taken into consideration alongside disease process.
Rationale 27: To ensure prompt treatment of opiate induced respiratory depression.
Rationale 28: Ondansetron has been shown to be efficacious in the management of opioid induced nausea and vomiting (Zernikow et al 2009).
Rationale 29: To ensure early detection and treatment of opioid induced pruritus.
Rationale 30: Fentanyl is thought to be less likely to cause pruritus.
Rationale 31: To prevent administration errors due to faulty equipment. 
Rationale 32: To minimise the risk of periods of time without analgesia.
Rationale 33: Patient safety.
Rationale 34: To prevent cross infection.
Rationale 35: To ensure equipment is available for patients requiring them.

References

Anghelescu DL, Burgoyne LL, Oakes LL, Wallace DA (2005). The safety of patient-controlled analgesia by proxy in pediatric oncology patients. Anesthesia and Analgesia 101 (6): 1623-7. [Last accessed 28.07.2017]

Anghelescu DL, Snaman JM, Trujillo L, Sykes AD, Yuan Y, Baker JN (2015). Patient-controlled analgesia at the end of life at a pediatric oncology institution. Pediatric Blood Cancer 62 (7): 1237-44. 

Czarnecki ML, Ferrise AS, Jastrowski Mano KE, Murphy Garwood M, Sharp M, Davies H, Weisman SJ (2008). Parent/Nurse controlled analgesia for children with developmental delay. Clinical Journal of Pain 24(9): 817-824. http://[Last accessed 28.07.2017]

Czarnecki ML, Salamon KS, Jastrowski KE, Ferrise AS, Sharp M, Wiseman SJ (2011). A preliminary report of Parent/Nurse-controlled analgesia (PCNA) in infants and pre-schoolers. Clinical Journal of Pain 27(2): 102-107. [Last accessed 28.07.2017]

Franson HE (2010). Post operative patient-controlled analgesia in the pediatric population: a literature review. American Association of Nurse Anesthetists 78(5): 347-378. [Last accessed 28.07.2017]

Friedrichsdorf SJ, Finney D, Bergin M, Stevens M, Collins JJ (2007). Breakthrough pain in children with cancer. Journal of Pain and Symptom Management 34 (2): 209-16. [Last accessed 28.07.2017]

Hewitt M, Goldman A, Collins G, Childs M, Hain R (2008). Opioid use in the palliative care of children and young people with cancer. The Journal of Pediatrics 152: 39-44. [Last accessed 28.07.2017]

Howard RF, Carter B, Curry J, Jain A, Liossi C, Morton N, Rivett K, Rose M, Tyrrell J, Walker S, Williams G, Association of Paediatric Anaesthetists of Great Britain and Ireland (2012) Good practice in postoperative and procedural pain management

Howard RF, Lloyd-Thomas A, Thomas M, Williams DG, Saul R, Bruce E, Peters J (2010) Nurse-controlled analgesia (NCA) following major surgery in 10,000 patients in a children's hospital. Pediatric Anesthesia 20 (2): 126-34. [Last accessed 28.07.2017]

Lloyd-Thomas AR, Howard RF (1994). A pain service for children.  Pediatric Anesthesia 4 (1): 3-15.

Malcolm C, Adams S, Anderson G, Gibson F, Hain R, Morley A, Forbat L (2011). The symptom profile and experience of children with rare life-limiting conditions: The perspectives of families and key health professionals. Research report for Cancer Care Research Centre. Sterling, University of Sterling

Melzer-Lange MD, Walsh-Kelly CM, Lea G, Hillery CA, Scott JP (2004). Patient-controlled analgesia for sickle cell pain crisis in a pediatric emergency department. Pediatric Emergency Care 20 (1): 2-4. [Last accessed 28.07.2017]

Mherekumombe MF, Collins JJ (2015). Patient-controlled analgesia for children at home. Journal of Pain and Symptom Management 49 (5): 923-7. [Last accessed 28.07.2017]

Peters J, Campbell F, Middleton J, Keen K, Howard R (2013). The incidence of urinary retention in children receiving opioid analgesia by means of PCA or NCA [poster]. International Symposium on Paediatric Pain, Mexico.

Schiessl C, Gravou C, Zernikow B, Sittl R, Griessinger N (2008). Use of patient-controlled analgesia for pain control in dying children. Supportive Care in Cancer 16 (5): 531-6. [Last accessed 28.07.2017]

Southern DA, Read MS (1994). Overdosage of opiate from patient controlled analgesia devices. BMJ 309 (6960): 1002. [Last accessed 28.07.2017]

Zelcer S, Cataudella D, Cairney AEL, Bannister SL (2010). Palliative care of children with brain tumours. Archives of Paediatrics and Adolescent Medicine 164(3): 225-230. [Last accessed 28.07.2017]

Zernikow B, Erik M, Craig F, Anderson B (2009). Pediatric palliative care: use of opioids for the management of pain. Pediatric Drugs 11(2): 129-151. [Last accessed 28.07.2017]

Document control information

Lead Author(s)

Tanya Boggs, Clinical Nurse Specialist, Palliative Care team

Additional Author(s)

Dr Dilini Rajapakse, Consultant, Palliative Care team
June Hemsley, Clinical Nurse Specialist Team Lead, Palliative Care team

Document owner(s)

June Hemsley, Clinical Nurse Specialist Team Lead, Palliative Care team

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
01 September 2011
Date approved: 
06 July 2017
Review schedule: 
Three years
Next review: 
06 July 2020
Document version: 
3.0
Previous version: 
2.0