Palliative Care Order Set - Stratis Health

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]).
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