Palliative Care Order Set - Stratis Health

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Palliative Care Annotations Committee on Evidence-Based Practice/May 6, 2008 resources should be utilized. Non-pharmacologic approaches may include guided-imagery and relaxation, music, prayer and massage. Frank discussions of fears may help alleviate anxiety. Well-designed studies of medications used in the palliative treatment of anxiety are not available. Benzodiazepines are often helpful in the treatment of anxiety. A significant minority of individuals manifest a paradoxical reaction to benzodiazepines, becoming more agitated. Chronic anxiety frequently responds to the use of serotonin-specific or serotonin-norepinephrine re-uptake inhibitors. (Barraclough, 1997 [R]) Orders Lorazepam 0.25-2 mg by mouth, sublingual or IV every 4 hours as needed for anxiety or restlessness Alprazolam 0.25-0.5 mg 3 times daily by mouth as needed for anxiety or restlessness Sertraline 25-50 mg daily by mouth daily Citalopram 10-40 mg daily by mouth daily 5. Constipation Management Constipation is the infrequent, difficult passage of hard stool. Constipation may be associated with pain, discomfort and flatulence, and may result in anorexia, nausea and vomiting, confusion and urinary dysfunction. Assessment of constipation should be contrasted against what was the normal pattern of bowel movements. Limited mobility and lack of privacy may exacerbate constipation. Other causes of constipation may include hypercalcemia, poor nutrition, poor fluid intake, drugs (opioids, anticholinergic agents, aluminum-containing drugs) and other diseases (anal fissure, hemorrhoids, tumor). Pain due to severe constipation secondary to opioids will be exacerbated by additional opioid therapy; evacuation of the rectum/colon may result in significant relief. Constipation may also be a signal of impending spinal cord compression. Bulk forming laxatives should be avoided in patients on opioids because they can cause significant flatulence, bloating and discomfort, which may result in noncompliance with a necessary bowel program (Fallon, 1997 [R]). If scheduled opioids are started, a bowel program should be started, as well. All opioids will result in constipation. A stool softener by itself is insufficient; a stimulant laxative should be added. Non-pharmacologic orders Prunes Hydration Pharmacologic orders • Hard stools: stool softener - Docusate 100-400 mg by mouth twice daily - Glycerin suppositories 1 daily • Stimulants: - Senna 1-4 tablets by mouth twice daily - Bisacodyl 5-10 mg by mouth daily, as needed - Magnesium hydroxide (Milk of Magnesia®) 30 mL by mouth daily - 70% Sorbitol 15-30 mL by mouth daily (Hallenbeck, 2005 [R]) Institute for Clinical Systems Improvement www.icsi.org 19
Palliative Care Annotations Committee on Evidence-Based Practice/May 6, 2008 6. Cough Management Identify the cause, when possible. Pain may prevent the patient from coughing effectively. Poorly controlled congestive heart failure and chronic obstructive pulmonary disease can cause or aggravate cough. Gastroesophageal reflux disease, postnasal drainage from chronic sinusitis and aspiration of liquids from dysphagia are other conditions that can produce or worsen cough. Treat underlying conditions to the extent possible, considering goals of care and comorbidities (Estfan, 2004 [R]). Orders • Guaifenesin with dextromethorphan (100 mg/10 mg per 5 mL), 5 to 10 mL by mouth every 2 hours as needed • Guaifenesin with codeine (100 mg/10 mg per 5 mL), 5 to 10 mL by mouth every 2 hours as needed • Benzonatate 200 mg by mouth 3 times a day • Lidocaine 20 mg in 2 mL (premixed), nebulized, every 4 hours as needed cough (avoid administration within 2 hours of eating to decrease risk of aspiration) 7. Delirium Management Delirium is an acute confusional state. The incidence rises with age. While it occurs in other settings, including long-term care facilities and end-of-life settings, it is a common problem in patients, occurring in up to 50% of individuals during the hospitalization. Some settings present an even greater risk, including postoperatively and in the intensive care unit (Inouye, 2006 [R]). Delirium is a clinical syndrome, not a disease in itself. Its etiology is usually multi-factorial and includes central nervous system lesions, drugs, fluid and electrolyte abnormalities, hypoxia and other metabolic abnormalities. Functional dependence, polypharmacy, sensory impairments and the existence of chronic health problems are factors increasing the risk for delirium. Patients with dementia are particularly susceptible to delirium. The extent of the evaluation will depend on multiple factors, including the overall goals of care, as well as patient and family preference. Generally the causes of delirium are multifactorial. Although the onset of delirium is rapid, full clearance of symptoms can take weeks or longer. Delirium is a poor prognostic factor. Manifestations of delirium include poor concentration, misinterpretations, rambling incoherent speech, impaired consciousness, and impaired short-term memory. Paranoid ideas, restlessness, disorientation and hallucinations may also be observed. Patients with noisy and/or aggressive behavior may also be exhibiting signs of delirium. Delirium may also present as lethargy or diminished sensorium. This may not require any specific treatment for the patient's comfort, but the presence of hypoactive delirium also warrants evaluation to identify treatable problems. Causes of delirium include hypercalcemia, hypoglycemia, hyponatremia and renal failure. Drug-related sources include opioids, corticosteriods with withdrawal, alcohol withdrawal, benzodiazepine with withdrawal, SSRI withdrawal, nicotine withdrawal, digoxin and lithium. Cerebral tumor, stroke or transient ischemic attack may be contributing factors, as well as anxiety and depression. Other treatable conditions causing delirium include infection, hypoxia, pain, constipation and dehydration. Patients with underlying disorientation with preexisting dementia, thiamine (vitamin B1) deficiency, non-convulsive status epilepticus or multi-system organ failure may show signs of delirium, as well (Palliative Care Pocket Consultant, 2001 [R]). www.icsi.org Institute for Clinical Systems Improvement 20
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 17 and 18: Annotations Palliative Care Committ
Page 19: Palliative Care Annotations Committ
Page 23 and 24: 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
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Page 47 and 48: Priority Aims and Suggested Measure
Page 49: Resources Available Palliative Care

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