Transcript Guidelines and procedure for the use of the BRAD

Managing Symptoms at the End of Life
When the Oral route Fails
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1. What is an RMAD?
2. Indications for the Use of the RMAD
3. Benefits of RMAD Placement
4. Making an RMAD
5. Placing an RMAD
6. Administering Medications via the RMAD
7. Documentation
A RMAD is a device which allows
for easy and comfortable administration of
fluids or medications that are in solution or
suspension into the rectum.
A balloon inflation port which inflates
a 10ml balloon inside the rectum
Small holes at the end of the
tube to disperse the
medication onto the rectal
mucosa
A tube to carry the medication into
the rectum
A medication port
Placement of the RMAD in the
distal 1/3 of the rectum.
RMAD placement showing easy access to ports.
Indications
•The patient is in the last days to week of life, no
longer able to swallow, and:
•Oral doses of liquid pain medications > 1.5ml
•Symptoms spiraling out of control
•Family is overwhelmed
•Patient is severely Agitated
•Multiple oral medications for comfort
•Copious oral secretions or vomiting
•Bowel obstruction
•Seizures
Benefits of RMAD placement
1. Quick control of severe symptoms
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(Pain, Agitation, SOB, Seizures < 1HR)
2. The patient no longer has to be
repositioned for medications
3. Medication administration is painless
4. All current comfort medications can be
continued
Benefits of RMAD placement
4. Highly cost effective
5. More reliable/quicker acting than
transdermal gels
6. Families can give all medications
easily by one route
7. Decreased chance of aspiration of
medications
The RMAD Kit
1 Large Zip-lock bag
1 RMAD
1 Package water soluble lubricant
1 Mortar and Pestle
2 -10ml syringes
1-3ml syringe
1-specimen container
1- Catheter securing device
2-Clean barrier pads
1 pair- non-sterile gloves
2- Medication and Instruction Sheets
1- RMAD Quick Reference Sheet
Making an RMAD
Step 1: Open one 14fr and one 16fr-5cc Foley catheter,
but do not remove the 16fr catheter from its package.
Making an RMAD
Step 2: Cut the valve off of the 14fr catheter
Making an RMAD
Step 3: Place the cut valve (green) onto the drainage
end of the16fr catheter.
Making an RMAD
Step 4: Place tape (cloth-paper tape works well) around
the drainage end and valve.
Making an RMAD
Step 5: Leave the finished RMAD in the package.
Assessment Guidelines Prior to
Placement
•Assess rectal opening for wounds, abscesses, or
drainage
•Assess for diarrhea or hard stool
•Assess for allergy to latex, if present, use nonlatex catheters to make RMAD.
Six general guidelines for administering
medications via the RMAD.
1. Use cool tap water (not refrigerated).
2. Suspend solid medications as follows:
For a small sized tablet (e.g., Valium) add 1ml water
For a medium sized tablet (e.g., Phenobarbital) add
1.5ml water
For a large sized tablet (e.g., Vicodin) add 2 ml water
3. Total amount should not exceed 13ml (including flush).
4. Instill over 5 to 10 seconds.
5. Tip syringe back and forth.
6. Always flush the RMAD with 3ml water after every dose.
Medications that can be given via RMAD
•Liquid Morphine
•Benzodiazepines (Ativan, Diazepam, etc.)
•Barbiturates (Nembutal, Phenobarbital)
•NSAID’s (excluding salicylates)
•Oral steroids
•Most anti-seizure Medications (not Dilantin)
•Anti-nausea Medications
•Resperidal and Haloperidol
Medications that cannot be given via RMAD.
•Dilantin
•Any “Do not Crush” Medications*
•Switch to short acting given ATC
•ASA and related Medication (Salicilates)
•Switch to Indocin
Sample Orders for RMAD
Placement and Medications.
Placement:
“RN to place Rectal Medication Administration Device 3
inches into rectum. Inflate balloon to 10ml.”
Medications:
Phenobarbital
Give Phenobarbital 400mg every 12 hours rectally
via RMAD.
Morphine (Scheduled)
Give Liquid morphine (20mg/ml) -4ml every
4 hours rectally around the clock via RMAD.