Palliative Care Order Set - Stratis Health

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Palliative Care Annotations Committee on Evidence-Based Practice/May 6, 2008 Metoclopramide 10 to 20 mg by mouth or IV 4 times daily 30 minutes before meals and at bedtime Lorazepam 0.25 to 2 mg by mouth, sublingual or IV every 4 hours as needed Dexamethasone 1 to 20 mg by mouth daily; may be in divided doses (Baines, 1997 [R]; Hallenbeck, 2000 [R]; Kris, 2006 [R]) * 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. 16. Oral Care Management There are many causes of dry and sore mouth, and most are easily treatable. Dental issues may require immediate attention. Numerous medications, and infection, as well as decreased intake, are often culprits of this uncomfortable symptom (Henson, 2004 [R]). Treatments • Refer to dentist for oral health assessment, cleaning and specific dental treatment as indicated (Wiseman, 2006 [R]) • Oral hygiene: avoid lemon glycerin, use soft toothbrush, no strong mouth rinses or toothpastes, and well-fitted dentures/prostheses. Clean daily, remove dentures/prostheses at bedtime (Finnish Medical Society Duodecim, 2005 [R]; Henson, 2005 [R]) • Mouth moisturizer gel as needed • Lip balm as needed • Sore throat spray or throat lozenges as needed • Artificial saliva every hour as needed • Food preparation: lukewarm; nothing very cold or hot; mildly spiced, soft foods • Medications Topical viscous lidocaine 2% – 5 mL every 4 hours, by mouth, swish and spit as needed Magic mouthwash/hematology mouthwash (viscous lidocaine 2%-60 mL, diphenhydramine elixir 60 mL, aluminum hydroxide/magnesium hydroxide 60 mL) 1 to 2 tsp, by mouth, swish and swallow or swish and spit 3 to 4x/day as needed (Center for Advancement of Palliative Care, 2007a [R]; Finnish Medical Society Duodecim, 2005 [R]). Salt solution (1 tsp of salt in 240 mL/1 cup of water) swish and spit 4 times a day as needed (Henson, 2004 [R]; Kaye, 1990 [R]) Treatments of candida • Clotrimazole 10 mg troche, dissolve in mouth, 5 times a day x 14 days • Nystatin suspension 100,000 units/mL 5 mL, swish and swallow 4 times a day for 7 days • Fluconazole 200 mg initially, then 100 mg by mouth daily for 7 days (Center for Advancement of Palliative Care, 2007b [R]; Finnish Medical Society Duodecim, 2005 [R]; www.icsi.org Institute for Clinical Systems Improvement 27
Palliative Care Annotations Committee on Evidence-Based Practice/May 6, 2008 Palliative Care Pocket Consultant, 2001 [R]; Rosielle, 2005 [R]; Watson, 2005 [R]) 17. Pain Management Pain is usually the first symptom that comes to mind when thinking about palliative care. While good pain management is a priority for many patients, it is important to establish with the patient the relative importance of complete pain control at the possible expense of mental clarity. The following is a brief overview of pain management. The reader is referred to the ICSI Assessment and Management of Acute Pain guideline and Assessment and Management of Chronic Pain guideline for more indepth discussion about treatment of pain. The approach to initial pain management consists of two parts. During the initial assessment, the clinician should determine if the pain is visceral, somatic or neuropathic. At the same time, the clinician should be evaluating the location and intensity of the pain, along with aggravating/alleviating factors, and duration of pain. Pain is what the patient says it is; it is subjective. It is important to accept what the patient says the pain is, and to treat it, and continually reassess treatment and goals of therapy in conjunction with the patient. Barriers to good pain management in palliative care include discounting a patient's subjective measure of pain, difficulty in assessment of the cognitively impaired, myths believed by both practitioners and patients about opioid therapy, and fears of addiction and hastening death. Patients need to be educated about medication compliance, addiction, tolerance, side effects and appropriate dosing of analgesics. Many patients, as well as family members, believe the use of opioids will create "addicts" and so are reluctant to use opioids for analgesia. All opioids will result in physical dependence, and sudden discontinuation of the opioid may result in symptoms of withdrawal. Physical dependence is not addiction. Addiction, as defined by the Federation of State Medical Boards of the United States, is "a primary, chronic neurobiologic disease … characterized by behaviors that include the following: impaired control over drug use, craving, compulsive use, and continued use despite harm." Pseudoaddiction may occur when analgesics are prescribed inadequately. When the interval between doses of opioids is too long, a patient's pain relief may wane, resulting in the need to ask for more medication. This request, sometimes perceived as "drug-seeking behavior," is actually a consequence of poor prescribing habits. If the pain is mild (score of 1 to 3 on a 0 to 10 scale), acetaminophen may be initiated. Acetaminophen is well tolerated, especially by elderly patients. If the pain appears chronic in nature, scheduled acetaminophen may be all that is needed. Non-steroidal anti-inflammatory drugs (NSAIDs) can be considered but must be used with caution in elderly patients as well as patients, with renal dysfunction or history of gastrointestinal bleeding. If the pain is moderate (score of 4 to 6 on a 0 to 10 scale), add an opioid to the scheduled acetaminophen or NSAID, such as morphine, hydromorphone or oxycodone. If the patient is on no analgesics, combination products of hydrocodone/acetaminophen or oxycodone/acetaminophen may be prescribed, however, the maximum total daily dose of acetaminophen of 4,000 mg should not be exceeded. If the patient is requiring multiple doses in a day, scheduled doses of long-acting opioids may result in less fluctuation in blood levels and may be more convenient for patients and caregivers. Severe pain (score greater than 6 on a 0 to 10 scale) requires use of higher doses of opioids, such as morphine, hydromorphone, oxycodone, or fentanyl. Once the pain is controlled and stable and at the patient's pain goal, long-acting dosage forms of morphine, oxycodone, methadone or fentanyl may be initiated. Since the onset of analgesia for fentanyl patches is 12 hours, fentanyl patches should only be used for stable pain management. They can be useful in patients who cannot swallow or when there are concerns regarding adherence to the prescribed regimen. When pain control is achieved, convert the patient to long-acting opioids. For oral morphine and oxycodone, www.icsi.org Institute for Clinical Systems Improvement 28
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 and 20: Palliative Care Annotations Committ
Page 27: 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
Page 45 and 46: Palliative Care References Committe
Page 47 and 48: Priority Aims and Suggested Measure
Page 49: Resources Available Palliative Care

Palliative Care Order Set - Stratis Health

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