Palliative Care Order Set - Stratis Health

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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. Institute for Clinical Systems Improvement www.icsi.org 21
Palliative Care Annotations Committee on Evidence-Based Practice/May 6, 2008 Medications • Serotonin-specific reuptake inhibitors (Doses may be titrated upward as needed, usually no more frequently than once a week.) - Escitalopram, 5-10 mg by mouth daily - Citalopram, 10-40 mg by mouth daily - Sertraline, 25-50 mg by mouth daily • Psychostimulant - Methylphenidate, 5 mg by mouth 30 to 60 minutes before breakfast and lunch • Other - Mirtazapine, 7.5-15 mg by mouth daily may be helpful in patients with poor appetite. Doses may be titrated upward as needed, usually no more frequently than once a week (Theobold, 2002 [D]) The Food and Drug Administration (FDA) has requested manufacturer's of antidepressants include a warning statement regarding antidepressants increasing the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders. The full warning statement can be found at: http://www.fda.gov/ cder/drug/antidepressants/default.htm 9. Diarrhea Management Diarrhea can have a significant impact on quality of life and result in dehyrdration and electrolyte abnormalities. The primary treatment of diarrhea should be to treat the underlying cause. Causes of diarrhea may include: drugs (such as laxatives, antibiotics, chemotherapy, antacids, magnesium supplements), malignancy, fistula, ileal resection, gastrectomy or colectomy, and other diseases (such as inflammatory bowel disease, AIDS). Diarrhea due to Clostridium difficile must be excluded. The presense of diarrrhea does not exclude the possibility of bowel impaction as the effect of gut flora on fecal material can cause liquefaction and subsequent passage of loose stool. Symptomatic relief may be achieved with loperamide. If opioid therapy is going to be initiated, caution should be exercised when also adding in antidiarrheal therapy so constipation does not occur. Consider consultation if intractable diarrhea is present. Orders Cholestryamine 4 grams by mouth 3 to 4 times daily Loperamide 4 mg initially, then 2 mg after each loose stool (maximum daily dose is 16 mg) (Alderman, 2003 [R]; Fallon, 1997 [R]) www.icsi.org Institute for Clinical Systems Improvement 22
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
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Page 39 and 40: Institute for Clinical Systems Impr
Page 41 and 42: Brief Description of Evidence Gradi
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Page 47 and 48: Priority Aims and Suggested Measure
Page 49: Resources Available Palliative Care

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