This document provides a guide for managing common symptoms in seriously ill pediatric patients, with a focus on end-of-life care. It outlines the social and medical aspects of accepting palliative care over curative treatment, maintaining comfort through active medical care, and managing a home or hospital death. The document also provides guidance on treating pain, nausea, anxiety, and other symptoms through pharmacological and non-pharmacological means.

6. Curative / Life-Prolonging Therapy Relieve Suffering - “Palliative” Care Presentation Death A Better Viewpoint

11. Oncologic Emergencies Immediate Intervention Required Common Less Common Pain Fever with Neutropenia or Splenectomy Airway Compression Spinal Cord Compression Brain Herniation Hyperleukocytosis

17. WHO 3-Step Ladder Step 1 - Mild Step 2 - Moderate Step 3 - Severe Aspirin Acetaminophen NSAIDs Codeine Hydrocodone Oxycodone Tramadol Morphine Hydromorphone Methadone Levorphanol Fentanyl Always consider adding an adjuvant Rx

19. Level II and III Medications Pain Control Using Narcotics

24. Equianalgesic Narcotic Dosing Source : McCaffery M, Pasero C. PAIN : Clinical Manual, 2nd Edition, Harcort Health Sciences Website, 2000. www.harcourthealth.com/PAIN/index.html Oral/Rectal Dose (mg) Analgesic Parenteral Dose (mg) 3 Morphine 1 20 Codeine 12 3 Hydrocodone -- 0.75 Hydromorphone 0.15-(0.3 w/ PCA) 2 Oxycodone -- 2 Methadone 1 25 mcg/hr Fentanyl Patch = 1 mg/hr IV MSO 4 -- Fentanyl 10-20 mcg 30 Meperidine 7.5

25. Common Uncommon Constipation Bad dreams / hallucinations Dry mouth Dysphoria / delirium Nausea / vomiting Myoclonus / seizures Sedation Pruritus / urticaria Sweats Respiratory depression Urinary retention Opioid Side Effects Demerol is not recommended due to its side effects Addiction is NOT a side effect

36. NIH Consensus Statement 21 “ The introduction of acupuncture into the choice of treatment modalities that are readily available to the public is in its early stages. Issues of training, licensure, and reimbursement remain to be clarified. There is sufficient evidence, however, of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value.”

38. Use of the ShotBlocker “ In my office, using the ShotBlocker on over 100 patients, ages ranging from 4-18 years, I have noticed a significant reduction in the perceived pain from my patients receiving minor injections and immunizations. Although anecdotal, the response has been striking.” -- James Hunter, MD, PhD

39. Scientific Results Ordering Information Bionix Medical Technologies Phone: 1-800-551-7096 Fax: 800-455-5678 Web: www.bionix.com Pricing 25 per box ……………………………. $23.75 100 per box ………………………… $85.00

60. Management of pain must be considered an important component of the health care provided to all neonates, regardless of their gestational age or severity of illness . Conclusion

63. Pain Scales

64. Analgesic Medications

77. Two Paths to Death Usual Difficult Sleepy Lethargic Obtunded Comatose Death Restless Confused Tremulous Hallucinations Delirium Seizures Myoclonic Jerks

78. Thanks for listening

81. Thanks for Listening Gary Allegretta, M.D. Kennebunk Pediatric Center Phone: 207-985-6770 E-Mail: [email_address] Fax: (206) 338-2426 Web: www.jasonprogram.org Break Time!