Microsoft word - tool 14 palliative care orders final.doc

Tool 14 – Standing Orders for
Palliative Care

Influenza Care Center – Palliative Care Orders INTRO: These orders define the care to be provided to patients (adults and children 10 years and older) admitted to an Influenza Care Center who are no longer benefiting from medical interventions offered at the ICC, are too sick to be transferred to an acute care hospital, and for whom the supervising physician has determined palliative care is appropriate after discussion with any available family members. a. Admit or transfer to standard cot or bed in the palliative care area of the a. No vital signs will be taken b. Call physician if patient is not breathing, has no palpable pulse, and has a. Make comfortable in bed. Patient may do as much activity as they wish a. Assist patient with toileting and bathing a. Goal is to make patient comfortable. Patients unlikely to be able to eat or drink. May offer sips of liquids or ice chips as patient wishes. a. Provide air/oxygen as resources permit to promote patient comfort: i. If oxygen is available in palliative care section and it promotes patient’s comfort, offer oxygen at 2 – 4 liters/minute by nasal cannula. ii. If no oxygen available, provide room air blow-by via nasal cannula at 2 liters/minute, if it promotes comfort for patient. iii. If no air delivery source available, provide small standing fan positioned to blow air toward patient’s head/face and upper body. b. If patient is dypneic, see below. c. If patient has excessive respiratory secretions: i. Hyoscomine (Levsin) 0.125 mg SL q 4 hrs prn, OR ii. Atropine 1% ophthalmic drops 2gtt q 4 hrs SL prn. i. For mild pain use acetaminophen per the table below. ii. For moderate to severe pain or SOB if patient can take oral 1. Start morphine sulfate (MSIR, Roxanol) 10 mg po or SL q 2. Assess level of pain/dyspnea, and if not adequately relieved, may increase by 5 mg q 1 hr (e.g. start with 10 mg po q 4 hrs, reassess in 1 hour, increase to 15 mg p.o. if still experiencing pain, then if still inadequate relief, increase to 20 mg 1 hour later, etc). Once adequate dose determined, provide that dose q 4 hours over the first 24 hours. 3. Once adequate pain control has been reached, calculate total dose needed over 24 hrs and convert to controlled release. 4. For example, Morphine sulfate 20 mg po q 4hrs = 180 mg/24 hrs. This is equivalent to Morphine sulfate controlled release (MS contin, Oramorph) 90 mg po q12 hr. iii. If patient cannot take oral medications: morphine sulphate-IR tabs, or oral morphine solution 20mg/ml, 15mg PR q 4 hrs, and adjust as above, OR morphine sulfate 3mg SQ/IV q 1 hr. Titrate up q 30 mins to patient comfort. No ceiling for morphine dose. iv If Morphine does not relieve dyspnea\SOB, add: Lorazepam (Ativan) 2mg po/SL/SQ/IV q4 hrs prn. (suggest a lower dose for elderly) b. Fever: If fever is causing discomfort, may give Acetominophen as needed. (Offer PR or liquid as an option), 24 hrs dose not
Dose Route
Frequency
to exceed
160mg/5ml
i. 10 – 17 yrs: physician must evaluate and prescribe Promethazine 25 mg po prn nausea. May repeat q 4 – 6 hrs prn nausea. If patient cannot tolerate oral medications, may give PR or IM. iii. If ineffective after 24 hours, change to prochlorperazine (Compazine) 10mg POQ 6 hrs prn nausea or vomiting. If patient cannot tolerate oral medications, may give 25 mg suppositories PR q 12 hrs prn nausea or vomiting. d. Cough: Hydrocodone 5 mg with homatropine 1.5 mg/5ml (Hycodan, e. Diarrhea: Loperamide (Imodium) 2 mg tabs; 4mg (2 tabs) 1st dose, then 2 mg=1tab after each loose stool, Not to exceed 8 tabs/day. agitation/restlessness: If ineffective 2 hours after the 1st dose, give 1 mg and then 1 mg q 6hrs prn.

Source: http://ccdimager.net/familypracticesource/Orders/Palliative%20care%20Orders.pdf