Palliative Care Order Set - Stratis Health

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Palliative Care Order Set Committee on Evidence-Based Practice/May 6, 2008 Pain Management (Annotation #17) (Titrate for comfort except where noted) Mild pain medication options: Acetaminophen* Ibuprofen* Naproxen* Tramadol Malignant bone pain medication options: Ibuprofen* Naproxen* Dexamethasone* Combination medication options: Hydrocodone/Acetaminophen Oxycodone/Acetaminophen Opioid medication options: Fentanyl Hydromorphone* Morphine* Oxycodone* Neuropathic pain medication options: Amitriptyline Desipramine Gabapentin Nortriptyline Lidocaine patch Pregabalin Opioid reversing agent Naloxone* *See multi-symptom medications for specific orders Tramadol ____ mg (25-100 mg) by mouth 4 times daily as needed for pain (Reduce dose in patients with renal dysfunction. Caution: May cause delirium. Maximum dose is 400 mg/day.) Combination Medications (In addition to acetaminophen for mild pain, add the following): Hydrocodone 5 mg/acetaminophen 500 mg 1-2 tablets by mouth every 4 hours as needed for moderate pain (Consider if acetaminophen is prescribed for fever control; maximum dose is 4,000 mg per day.) Oxycodone 5 mg/acetaminophen 325 mg ____(1-2 tablets) by mouth every 4 hours as needed for moderate pain (Consider if acetaminophen is prescribed for fever control; maximum dose is 4,000 mg per day.) Obtain orders for constipation management/bowel care if opioids are prescribed Opioid Medications Fentanyl 20 mcg IV every 15 minutes as needed for severe pain. Evaluate after each dose Obtain orders for constipation management/bowel care if opioids are prescribed Neuropathic Pain Medications Amitriptyline ____mg (10-25 mg) by mouth daily at bedtime as needed for neuropathic pain (Avoid use in elderly patients.) Nortriptyline ____mg (10-25 mg) by mouth daily at bedtime as needed for neuropathic pain (Avoid use in elderly patients.) Desipramine ____mg (10-25 mg) by mouth daily at bedtime as needed for neuropathic pain (Avoid use in elderly patients.) Gabapentin (Reduce dose in patients with renal dysfunction.) For elderly patients, 100 mg by mouth daily at bedtime. Titrate up to 100 mg twice daily and then 100 mg 3 times a day as needed for comfort For non-elderly patient, 100 mg by mouth daily at bedtime. Titrate up to 300 mg twice daily and then 300 mg 3 times a day as needed for comfort Pregabalin 50 mg by mouth 3 times daily for neuropathic pain. Evaluate in 7 days. (Reduce dose in patients with renal dysfunction.) Transdermal lidocaine patch (1-3 patches) for neuropathic pain. Apply for 12 hours, remove for 12 hours Institute for Clinical Systems Improvement www.icsi.org 11
Palliative Care Order Set Committee on Evidence-Based Practice/May 6, 2008 Secretion Management (Annotation #18) Atropine Scopolamine Glycopyrolate Guaifenesin* Hyoscyamine *See multi-symptom medications for specific orders Atropine (1% ophthalmic drops) 1-4 drops sublingual every 2 hours as needed for excessive secretions Glycopyrolate ___mg (1-2 mg) by mouth sublingual every 8 hours as needed for secretions Hyoscyamine ____mg (0.125-0.25 mg) sublingual every 6 hours as needed for excessive secretions Scopolamine 1.5 mg transdermal patch behind the ear every 72 hours as needed. May increase up to 3 patches in 72 hours for secretions. Seizure Management (Annotation #19) Lorazepam* Diazepam *See multi-symptom medications for specific orders Diazepam ____ mg (5-10 mg) IV every 10-15 minutes up to 30 mg as needed for seizures Diazepam 0.2 mg/kg rectally as needed for seizures. May repeat once in 4 hours as needed to stop seizure (maximum is one treatment course every 5 days) Skin and Wound Care Management (Annotation #20) To control pain: Pruritus: Hydromorphone* Hydroxyzine Morphine* Doxepin Oxycodone* Paroxetine To control odor: Camphor/menthol lotion Metronidazole Hydrocortisone Silver sulfadiazine cream Triamcinolone Diphenhydramine Dexamethasone* Cholestyramine* *See multi-symptom medications for specific orders Metronidazole (0.75% cream) applied to wound daily for odors. Discontinue after 7 days, and assess wound Metronidazole 500 mg by mouth 3 times a day for odors. Discontinue after 7 days, and assess wound Metronidazole 500 mg crushed and sprinkled directly on wound daily for odors. Discontinue after 7 days, and assess wound Silver sulfadiazine cream (1%) applied to wound surface daily to control odor. Reassess wound in 7 days Pruritus Hydroxyzine____ mg (10-25 mg) by mouth every 6 hours as needed for irritation Doxepin ____ mg (10-25 mg) by mouth at bedtime for pruritus. Use daily for 7 days, then evaluate Paroxetine ____mg (10-20 mg) by mouth daily for pruritus Diphenhydramine 25 mg by mouth every 4 hours as needed for itching. Avoid in elderly (Maximum dose is 300 mg/day.) Camphor/menthol lotion (Sarna®) applied as needed for irritation Hydrocortisone 1% cream or lotion applied 2-3 times per day as needed for irritation Triamcinolone 0.1% cream applied 2-3 times per day as needed for irritation www.icsi.org Institute for Clinical Systems Improvement 12
Page 1 and 2: I CSI Health Care Order Set: Pallia
Page 3 and 4: Palliative Care Committee on Eviden
Page 5 and 6: Palliative Care Foreword Committee
Page 7 and 8: Palliative Care Order Set Committee
Page 11: Palliative Care Order Set Committee
Page 17 and 18: Annotations Palliative Care Committ
Page 19 and 20: Palliative Care Annotations Committ
Page 39 and 40: Institute for Clinical Systems Impr
Page 41 and 42: Brief Description of Evidence Gradi
Page 43 and 44: Palliative Care References Committe
Page 45 and 46: Palliative Care References Committe
Page 47 and 48: Priority Aims and Suggested Measure
Page 49: Resources Available Palliative Care

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