Palliative Care Order Set - Stratis Health

Palliative Care
Annotations Committee on Evidence-Based Practice/May 6, 2008
There are no specific tests, but evaluation should include review of all medications; general physical evaluation,
including vital signs, hydration status and oxygenation; pain and recent alcohol or drug use. Particularly
in elders, delirium may be the only harbinger of serious illness or complications.
Haloperidol remains the first drug of choice, with the best evidence base supporting effectiveness. Lower
doses are recommended in the elderly. There is little evidence supporting the use of other antipsychotic
agents. Benzodiazepines are not recommended for monotherapy because of the risk of paradoxical stimulation,
oversedation and prolongation of delirium. No good evidence exists for the use of other psychotropic
drugs for delirium (Weissman, 2005 [R]).
The safety of antipsychotic medications, both older agents and newer "atypical" drugs, has been the subject
of increasing debate. Most studies describe an increased risk of mortality associated with the introduction
of these drugs in patients with dementia. As with all interventions, the clinician must weigh the potential
risks against possible benefits, in the context of the patient's overall status and goals of care (Barnett, 2006
[B]; Gill, 2007 [B]; Schneider, 2005 [M]).
Treatments
• Underlying cause(s)
• Calm fears, reduce noise and unfamiliar surroundings
• Reorientation of routine and environment – include family
• Medications
- Haloperidol, initial dose of 0.5 mg with titration from 0.5-5.0 mg every hour until a total daily
requirement is established, which is then administered in 2-3 divided doses per day. Intravenous
haloperidol may cause less extrapyramidal symptoms than oral haloperidol. Maximum
30 mg/day.
The U.S. Food and Drug Administration (FDA) informed health care professionals that the WARNINGS
section of the prescribing information for haloperidol has been revised to include a new cardiovascular
subsection regarding cases of sudden death, QT prolongation and torsades de pointes (TdP) in patients treated
with haloperidol, especially when given intravenously, or at doses higher than recommended.
(Elsayem, 2000 [R]; Inouye, 2006 [R]; Quijada, 2002 [R]; Watson, 2005 [R]; Weissman, 2005 [R])
8. Depression Management
Seriously ill patients may already have many of the vegetative symptoms of depression, e.g., fatigue, anorexia
and sleep disturbance. Sadness, anhedonia, guilt, irritability and hopelessness are examples of affective
symptoms that can be present in depression. When physical symptoms fail to improve despite optimal
interventions, consider coexisting depression requiring additional treatment.
Optimal treatment for depression generally involves a combination of modalities, including medications and
non-pharmacologic approaches. The patient's expected clinical course will influence choice of modalities
in general and specific drugs in particular. Many antidepressant medications can take weeks to achieve
full therapeutic effect. A psychostimulant, such as methylphenidate, may provide improvement of mood
and appetite within days. If a psychostimulant produces a good result, add an antidepressant, unless the
patient is expected to die within days to weeks. Serotonin-specific reuptake inhibitors are generally well
tolerated. Choice of a specific agent depends on provider preference and formulary limitations. Tricyclic
antidepressants generally have more side effects, especially anticholinergic, and may be difficult to use in
patients with cardiac problems. In general, use lower starting doses in elderly patients.
Consider referral to a counselor or therapist.
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