Comfort Care Order Set

Comfort care orders:

Discontinue all previous orders for VS monitoring, medication orders, enteral/parenteral feeding, IV fluid infusions, diagnostic testing procedures, Xrays and laboratory testing, and replace as ordered below.

Disable ICD and/or PPM (contact cardiology)

No IV Fluids

Analgesic / antipyretic:  acetaminophen 650mg PO/PR q4h PRN for pain or fever

Analgesic:

  • Opioid-naive
    • morphine 2-4mg IV q15m PRN for pain or dyspnea
    • morphine oral concentrate solution 20mg/mL 5-15mg PO/SL q1h PRN for pain or dyspnea (sublingual preferred)
    • hydromorphone 0.25-1mg IV q15m PRN for pain or dyspnea
  • Opioid-tolerant
    • morphine ?mg IV q15m PRN for pain or dyspnea
    • morphine oral concentrate solution 20mg/mL ?mg PO/SL q1h PRN for pain or dyspnea (sublingual preferred)
    • hydromorphone ?mg IV q15m PRN for pain or dyspnea
    • fentanyl ?mcg IV q15m PRN for pain or dyspnea

Continuous IV infusion analgesia:

  • morphine drip ? mg/hr to relieve pain and/or dyspnea
  • hydromorphone drip ?mg/hr to relieve pain and/or dyspnea
  • fentanyl drip ?mcg/hr to relieve pain and/or dyspnea

Bowel regimen:  senna 8.6mg/docusate 50mg 1 tab BID and bisacodyl 10mg suppository OD PRN constipation

Sedation:  ativan 0.5-2mg SL/PO/IV qh PRN for anxiety, dyspnea or restlessness (SL preferred)

Delirium:  haldol 0.5-2mg PO/IV q4h PRN for delirium (PO preferred)

Secretion Inhibitor:

  • scopolamine 1.5mg/72h transdermal patch, change every 3 days
  • Atropine 1% ophthalmic solution 2 drops SL q2h PRN for excessive secretions

Antiemetic

  • prochlorperazine 10mg PO/IV q6h PRN for nausea (PO preferred)
  • prochlorperazine 25mg PR q12h PRN for nausea
  • promethazine 6.25mg PO/IV q10m PRN for nausea (max 25 in 4 hours) (PO preferred)
  • metoclopramide 10mg PO/IV q6h PRN for nausea (PO preferred)
  • dexamethasone ?mg PO/IV q?h (PO preferred)

Respiratory Care:

  • titrate supplemental oxygen to relieve dyspnea
  • morphine 2.5mg in 2.5ml 0.9%NaCl (starting dose for opioid-naive) nebulized every 1-4 hours PRN for dyspnea

Diet: <specify>

Activity: <specify>

Consults: Palliative care service

 

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Plan:

NEURO:  discontinue all neurochecks / VS monitoring., discontinue all diagnostic testing and laboratory testing.

Sedation:  ativan 0.5-2mg SL/PO/IV qh PRN for anxiety, dyspnea, restlessness (SL preferred)

Analgesia:  acetaminophen 650mg PO/PR q4h PRN for pain or fever

Analgesic:

  • Opioid-naive
    • morphine 2-4mg IV q15m PRN for pain or dyspnea
    • morphine oral concentrate solution 20mg/mL 5-15mg PO/SL q1h PRN for pain or dyspnea (sublingual preferred)
    • hydromorphone 0.25-1mg IV q15m PRN for pain or dyspnea
  • Opioid-tolerant
    • morphine ?mg IV q15m PRN for pain or dyspnea
    • morphine oral concentrate solution 20mg/mL ?mg PO/SL q1h PRN for pain or dyspnea (sublingual preferred)
    • hydromorphone ?mg IV q15m PRN for pain or dyspnea
    • fentanyl ?mcg IV q15m PRN for pain or dyspnea

Continuous IV infusion analgesia:

  • morphine drip ? mg/hr to relieve pain and/or dyspnea
  • hydromorphone drip ?mg/hr to relieve pain and/or dyspnea
  • fentanyl drip ?mcg/hr to relieve pain and/or dyspnea

Delirium:  haldol 0.5-2mg PO/IV q4h PRN for delirium (PO preferred)

Rehab:  discontinue all rehab orders.  Activity: <specify>

Pulmo: titrate supplemental oxygen to relieve dyspnea; morphine 2.5mg in 2.5ml 0.9%NaCl (starting dose for opioid-naive) nebulized every 1-4 hours PRN for dyspnea

Cardio: Disable ICD and/or PPM (contact cardiology)

Endo: discontinue all fingersticks

Renal: discontinue all IV fluid infusions

GI:  senna 8.6mg/docusate 50mg 1 tab BID and bisacodyl 10mg suppository OD PRN constipation

Secretion Inhibitor:

  • Scopolamine 1.5mg/72h transdermal patch, change every 3 days
  • Atropine 1% ophthalmic solution 2 drops SL q2h PRN for excessive secretions

Antiemetic

  • prochlorperazine 10mg PO/IV q6h PRN for nausea (PO preferred)
  • prochlorperazine 25mg PR q12h PRN for nausea
  • promethazine 6.25mg PO/IV q10m PRN for nausea (max 25 in 4 hours) (PO preferred)
  • metoclopramide 10mg PO/IV q6h PRN for nausea (PO preferred)
  • dexamethasone ?mg PO/IV q?h (PO preferred)

DIET: discontinue all PO/IV feeding

Hem/onc: no further blood draws

Social:  Consult: Palliative care service / chaplain

 

Reference:

Jarabek, B. et al. “Use Of A Palliative Care Order Set To Improve Resident Comfort With Symptom Management In Palliative Care”. Palliative Medicine 22.4 (2008): 343-349.

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