Patient/proxy patient controlled analgesia: use in palliative care

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 2010; Howard et al 2008; Anderson et al 1998; Lloyd-Thomas and Howard 1994; Llewellyn 1993; Doyle et al 1993; Bray 1983).

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).

The effective use of patient controlled analgesia has been reported in palliative care practice in terminally ill adults with cancer (Baumann et al 1986), and in the domiciliary or community setting (Meuret and Jocham 1996).

More recently PCA and proxy PCA (PPCA), which is when 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).

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 naive and with limited pain experiences, 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 (Howard et al 2012; Hewitt et al 2008).

The children and young people who may derive enhanced pain management from this method of analgesic, 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 2011; Zelcer et al 2010).

Studies in several fields including oncology, and children with cognitive impairment, have demonstrated the safety of PPCA in these populations (Czarnecki et al 2011; Czarnecki et al 2008; Anghelescu 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 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 pump is programmed with a lockout interval of 10-30 minutes.

The patient may also receive a small background infusion of the analgesic solution but some patients, eg those with renal impairment, may not receive a background infusion.

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 a subcutaneous analgesic solution (the bolus dose).

The bolus dose can only be repeated after a set period of time - the lockout period. The pump is programmed with a lockout interval of 10-30 minutes. 

The use of PCA and PPCA requires a locked pump which allows for programming of drug concentration, continuous infusion rate (if required), bolus dose and lockout interval. The pump used by the palliative care team in this Trust is a TPCA pain management pump, and therefore covered by this clinical practice guideline.

TPCA pumps must only be programmed by a trained and competent member of the Great Ormond Street Hospital (GOSH) Palliative care team. All personnel who care for patients receiving PCA or PPCA must be trained and competent to do so.

Healthcare professionals and families calling in are advised by switchboard operators to call again if there is no response after 15 minutes.

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

Competent member of the Palliative care team — a doctor or nurse from the GOSH Palliative care team who has attended a CME medical training session, received training to use the TPCA, 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 must be a patient of the GOSH Palliative care team. Each child’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 CME Medical or the GOSH Palliative care team.

PCA/PPCA documentation - all documentation required for patients receiving PCA/PPCA can be found in the Palliative care office (4th floor 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 standard training session on delivery of PCA and PPCA in the community.

This will be delivered by the GOSH palliative care team consultants or clinical nurse specialists prior to jointly managing a named patient. Ongoing training will be offered twice a year at GOSH.

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 (Appendix 1).

• 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).

• 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

All patients/parents should be given a copy of the information leaflet about PCA and PPCA (Rationale 3). This can be obtained from the Palliative care team office.

A member of the GOSH Palliative care team discusses the use of PCA/PPCA with the child and family, and obtains agreement in using this technique for management of pain (Rationale 3).

• The child and family should be prepared for the PCA/PPCA.

• The technique should be explained to the child and family (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 Rationale 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 (9am to 5pm) or out of hours via switchboard on 020 7405 9200 and air calling the service.

GOSH palliative care staff 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 4).

• 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 provided.

Dosing regime

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

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

2. A child who has relatively stable background opiate analgesia requirements, but has incident or spontaneous breakthrough pain.

3. A child who is at end of life with background stable opiate analgesia and some breakthrough pain.

For all frameworks, consider PCA or PPCA, type of opiate to be used, concentration, diluents, bolus size and lockout time. 

Drugs used for PCA/PPCA

For patients in framework 1

• 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 = 50mcg/kg)

  • Patient weighs >50kg: 50mg in 20mls of 0.9 per cent sodium chloride (1ml = 2.5mg)

For patients in frameworks 2 and 3

• Calculate the previous day’s oral morphine equivalent (OME) for 24 hours using standard conversion tables (Rationale 10). Convert this to the subcutaneous opioid to be used in PCA/PPCA, using standard conversion tables. This is the subcutaneous 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 is between 10-30 minutes.  

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 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 stock 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 (Southern and Read 1994)(Rationale 11 and 12).

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 subcutaneous infusion site and changes of the pump syringes for continuing prescriptions, will be carried out by the community nursing teams at the child’s place of care, according to local syringe driver policies.

Community 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 24/7.

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 in the home.

Equipment for commencing PCA/PPCA includes:

• A TPCA pain management pump (Rationale 14). The GOSH pumps are stored in a designated area in the palliative care team office. The serial number of the pump must be recorded in the patient’s documentation. All users must check the pump maintenance date before use (Rationale 15).

• Appropriate sized luer lock syringe (Rationale 16).

• An anti-siphon, anti-reflux administration set (Rationale 11 and 12).
  

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.

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 17).

• The analgesic solution and additional drugs are prescribed (Rationale 18).

• The drug being administered corresponds with the protocol and symptom management plan (Rationale 19).

• The pump programming corresponds to the most recent entry in the PCA/PPCA documentation (Rationale 19).

• The patient is comfortable and pain is being managed appropriately with the current PCA/PPCA and adjuvant medications (Rationale 18).

• Required PCA/PPCA documentation is completed.

Syringes and administration sets must be changed every 24 hours (Rationale 20).

The sedation level of the child must be assessed and recorded on the PCA/PPCA daily assessment chart whilst the device is in progress (Rationale 21). 

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 22).

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

• Utilise non-pharmacological pain management strategies (Rationale 23).

• Discuss with GOSH Palliative care team.

The GOSH Palliative care team can be contacted on 020 7829 8678 (9am to 5pm) 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 patients protocol and symptom management plan (Rationale 24).

Increase the PCA/PPCA if:

• The patient has opiate sensitive pain which has not resolved after frequent boluses (Rationale 25).

• Other interventions have been tried and have not been effective (regular simple analgesia, repositioning etc)(Rationale 26).

Discontinue PCA/PPCA if:

• Patient/carer prefers an alternative route or type of analgesic regime (Rationale 2).

• The pain is not adequately controlled by this method despite changes to regime, dosing schedule and drug used (Rationale 27). 

• The patient dies and their death and its manner were anticipated (Rationale 28).
  

Prevention and detection of opioid related side effects

As with all palliative care patients, discuss the 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

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 (Rationale 21):

1. STOP the infusion (Rationale 29) 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 Palliative care team.

3. The Palliative care team may review and adjust the protocol and symptom management plan (Rationale 18).

4. Document actions in the child’s PCA/PPCA contact sheets (Rationale 30).

Respiratory depression

Consider rate and depth of respiration, respiratory effort and level of sedation (Rationale 31).

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 32):

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

2. Consider whether to administer naloxone.

3. The infusion may be recommenced following assessment and discussion with the palliative care team.

4. The Palliative care team may review and adjust the protocol and symptom management plan (Rationale 18).

5. Document actions in the child’s PCA/PPCA contact sheets (Rationale 30).

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 33).

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

3. The Palliative care team may review and adjust the protocol and symptom management plan (Rationale 18).

4. Document actions in the child’s PCA/PPCA contact sheets (Rationale 30).

Pruritus

The patient should be observed for pruritus (itching) daily (Rationale 34).

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 Palliative care team may consider the substitution of another opioid (Rationale 35).

Urinary retention

The GOSH Acute pain service database (Howard et al 2010) indicates there is no evidence that intravenous opioid administration causes urinary retention in children. 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 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 Palliative care team and consider admission to local hospital for assessment and catheterisation procedure if needed.
  

PCA/PPCA pump technical problems

The TCPA pump is the only pump to be used for PCA/PPCA palliative care patients being cared for in community settings.

The manufacturers provide a user’s reference guide (Appendix 2).

Each community team member trained to care for patients using the TCPA pump, will be provided with a guide during training. In addition a guide will be placed in the home of each child using the TPCA pump.

The pump has two methods of communicating a warning to users:

• Alert - during this mode the pump will continue to run and three bleeps will sound every three to four minutes. Parents or healthcare professionals should check the screen message (this will alternate with the infusion running screen) and follow next steps, as outlined by the quick reference guide or specific information provided to families by the community teams and the GOSH Palliative care team (Rationale 36).

• Alarm - during this mode the pump will stop the infusion. The LED indicator turns red and an audible alarm activates, continuing until it is silenced or the problem is rectified. Parents or healthcare professionals should check the screen message and follow the next steps, as outlined by the quick reference guide or specific information provided to families by the community teams and the GOSH Palliative care team (Rationale 36).
  

Potential pump problems

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 42).

Stopping PCA/PPCA

The PCA/PPCA must be stopped if the pump malfunctions (Rationale 42).

Consider stopping in the following situations:

• excessive sedation

• respiratory depression or respiratory arrest

The Palliative care team must be informed that the infusion has been stopped (Rationale 30 and 37).

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 44).

Criteria for stopping PCA/PPCA includes:

• 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 30 and 37).

Record:

• date and time

• total drug infused as per TPCA

• volume of infusion solution remaining in syringe (Rationale 30)  

Clean the pump with damp cloth, soap and water (Rationale 45).

Return cleaned PCA/PPCA pump to GOSH Biomedical engineering department for required checking and maintenance (Rationale 20 and 46).

Dispose remaining controlled drugs according to local community policy.

Appendix

Appendix 1 - TCPA Pain Management Pump, Quick User Guide (part 1)

Appendix 2 - TCPA Pain Management Pump, Quick User Guide (part 2)

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: To administer PCA/PPCA.
Rationale 15: All pumps should be serviced at least once a year. Stickers indicate when this service is due. Rationale 16: Pumps can hold a variety of syringe sizes up to 50ml.
Rationale 17: To adhere to hospital drug policy.
Rationale 18: To ensure effective analgesia with minimal side effects.
Rationale 19: To prevent drug errors.
Rationale 20: To adhere to hospital policy.
Rationale 21: To ensure early detection and treatment of opioid induced sedation.
Rationale 22: To provide effective and adequate pain relief.
Rationale 23: To ensure a strategy of multi-modal analgesia is being undertaken.
Rationale 24: To ensure swift action is taken if analgesia is unsatisfactory.
Rationale 25: To provide effective analgesia either when the infusion rate is inadequate or prior to activities the child wishes/needs to undertake which are likely to be painful, eg movement or going out of the home, clinical procedures.
Rationale 26: Regular administration of simple analgesics can reduce the amount of opiate the child requires. Rationale 27: To ensure optimal analgesia is provided.
Rationale 28: To enable the intrusion of the equipment to be minimised for the family as they spend time with their dead child.
Rationale 29: To allow for prompt treatment of opiate induced respiratory depression.
Rationale 30: To maintain an accurate record.
Rationale 31: Respiratory rate and pattern can vary and the child’s normal respiratory rate must be taken into consideration alongside disease process.
Rationale 32: To ensure prompt treatment of opiate induced respiratory depression.
Rationale 33: Ondansetron has been shown to be efficacious in the management of opioid induced nausea and vomiting (Zernikow et al 2009).
Rationale 34: To ensure early detection and treatment of opioid induced pruritus.
Rationale 35: Fentanyl is thought to be less likely to cause pruritus.
Rationale 36: As the patient will receive intermittent visiting by health care professionals in the community setting, family specific instructions will be provided to each family to meet their specific information needs.
Rationale 37: To minimise the risk of periods of time without analgesia.
Rationale 38: To provide effective analgesia based on the most recent assessment of the child.
Rationale 39: To prevent administration errors due to pump being incorrectly set up.
Rationale 40: To ensure delivery of analgesia and prevent irritation and pain at infusion site.
Rationale 41: To ensure patent safety, only those professionals trained in pump management and palliative care will have access to pump codes.
Rationale 42: To prevent administration errors due to faulty equipment.
Rationale 43: To determine and correct the cause of the problem.
Rationale 44: Patient safety.
Rationale 45: To prevent cross-infection.
Rationale 46: To ensure equipment is available for patients requiring them.

References

Reference 1:
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. Paediatr Anaesth 20 (2): 126-34.

Reference 2:
Howard R, Carter B, Curry J, Morton N, Rivett K, Rose M, Tyrrell J, Walker S, Williams G, Association of Paediatric Anaesthetists of Great Britain and Ireland (2008). Good practice in post-operative and procedural pain. Pediatr Anaesthesia 18: Suppl 1: 1-3.

Reference 3:
Anderson BJ, McKenzie R, Persson MA, Garden AL (1998). Safety of postoperative paediatric analgesia. Acute Pain 3(1): 14-20.

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Lloyd-Thomas AR Howard R (1994). A pain service for children. Pediatric Anasthesia 4: 3-15.

Reference 5:
Llewellyn N (1993). The use of PCA for paediatric post-operative pain management. Paediatric Nursing 5(5): 12-15.

Reference 6:
Doyle E, Harper I, Morton NS (1993). Patient-controlled analgesia with low dose background infusions after lower abdominal surgery in children. Br J Anaesth 71 (6): 818-22.

Reference 7:
Bray RJ (1983). Postoperative analgesia provided by morphine infusion in children. Anaesthesia 38 (11): 1075-8.

Reference 8:
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Schiessl C, Gravou C, Zernikow B, Sittl R, Griessinger N (2008). Use of patient-controlled analgesia for pain control in dying children. Support Care Cancer 16 (5): 531-6.

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Anderson AK, Breen M, Sebastian N, Mycroft J (2010). The use of emergency boxes for children with advanced cancer. European Journal of Palliative Care 17(2): 80-83.

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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.

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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

Reference 18:
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.

Reference 19:
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.

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Czarnecki ML, Ferrise AS, Jastrowski Mano K E,Murphy Garwoord 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.

Reference 21:
Anghelescu DL, Burgoyne LL, Oakes LL, Wallace DA (2005). The safety of patient-controlled analgesia by proxy in pediatric oncology patients. Anesth Analg 101 (6): 1623-7.

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Reference 23:
Southern DA, Read MS (1994). Overdosage of opiate from patient controlled analgesia devices. BMJ 309 (6960): 1002.

Document control information

Lead author(s)
Dr Dilini Rajapakse, Consultant, Palliative Care team

Additional authors
Tanya Boggs, Clinical Nurse Specialist, Palliative Care team

Document owner
June Helmsley, Clinical Nurse Specialist, Palliative Care team

Approved by
Clinical Practice Committee

First introduced: 1 September 2011
Date approved: 1 September 2011
Review schedule: Two years
Next review: 2 September 2013
Document version: 1.0