Palliative Care Order Set - Stratis Health

Palliative Care
Annotations Committee on Evidence-Based Practice/May 6, 2008
• Nasal oxygen 2 liters/minute via nasal cannula as needed. May titrate upwards as needed based on
patient's symptoms
• Fan
• Morphine 2.5 to 10 mg by mouth or sublingual every hour as needed
• Oxycodone 2.5 to 10 mg by mouth or sublingual every hour as needed
• Lorazepam 0.25 to 1 mg by mouth or sublingual every 2 hours as needed
• If rales present
- Furosemide 20-40 mg by mouth or sublingual once, and monitor response
• If wheezing present
- Nebulized albuterol, every 4 hours as needed
- Nebulized ipratropium, every 4 hours as needed
• Albuterol and ipratropium can be combined (e.g., Duoneb®)
(Del Fabbro, 2006 [R])
• If respiratory depression occurs with opioid use
- Close observation of the patient while the drug is metabolized may be sufficient; as the patient
clears the drug, the respiratory suppression will abate
- If rapid reversal of respiratory suppression is necessary, dilute a 0.4 mg (1 mL) ampule of
naloxone in normal saline to a total volume of 10 mL, and administer one mL every 1 to 2
minutes until the respiratory rate improves
(von Gunten, 2005a [R])
12. Fatigue Management
Fatigue may be defined as decreased vitality in physical and/or mental functioning. Patients may identify
increased tiredness, and state that rest fails to resolve the fatigue.
There are assessment tools for fatigue; some examples include the Memorial Symptom Assessment Scale,
the Edmonton Functional Assessment Tool, the Multidimensional Fatigue Symptom Inventory, and the
Profile of Mood States.
Medications that may make the patient more tired should be administered at bedtime rather than in the
morning. Conversely, stimulating agents should be administered in the morning. Due to significant
side effects, corticosteroids should be reserved for terminally ill patients who may also have nausea and
vomiting.
Causes of fatigue may include infection, hypoxemia and anemia. Sedating medications and electrolyte
abnormalities (e.g., sodium, potassium, magnesium, calcium) may be causative factors. Fatigue may
result from nutritional imbalance/impairment, cachexia and anorexia, deconditioning and weakness. Sleep
disturbance, depression and emotional or psychological distress contribute to fatigue. Uncontrolled pain,
as well as progression of the underlying disease, which may be seen in significant organ dysfunction (e.g.,
heart, liver, kidney, lung) or cancer and/or treatments may be directly linked to fatigue (Reisfield, 2007 [R];
Watson, 2005 [R]).
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