PALLIATIVE CARE

For End of life  

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Updated 7/31/11

(Issues and Orders to cover)

1) Discussion and clarify with patient &/o family &/o DPOA-HC

  1. goals of care

  2. advance directives (hospitalizations?, antibiotics?)  

  3. anticipated sx's of dying & plan of management

  4. hospice referral

2) Involve & assure staff's comfort with plan and orders

3) Document discussions and orders

4) give AGGRESSIVE  COMFORT (mnemonic)
         a)
 A NOREX-IA/ A GITATION
             (mnemonic for correctable causes)

A ches  E vacuation problems
N ausea    X erostomia
O ral candidiasis   atrogenic (radiation/chemo)
R eactive depression   A  cid (gastritis/PUD)

          b) offer food/fluids as able

c) Appetite stimulants: (megestrol, remeron, trazodone)  
                                (marinol, dexamethasone)
 

A GITATION (Terminal Delirium)
-Fix the "correctable"
-Haldol 0.5mg p.o./sc q 30 min prn delirium
-lorazepam 0/5 mg po/sl/sc q 30 min prn delirium

G  ASTROINTESTINAL

-CONSTIPATION (with opiates always start:)
 Senna 1-6 tabs q.d.

-NAUSEA: Compazine or Haldol or TD Scopolamine or Reglan or Zofran

G ENITOURINARY      

-BLADDER: discuss incontinence management
 -catheter?  If spasms?
oxybutynin

R  ESPIRATORY                       

           -DYSPNEA   "B-R-E-A-T-H    A-I-R" (for correctable causes)          

  B ronchospasm A nxiety  
  R  ales I nterpersonal issues
  E ffusions  R   eligious concerns
  A  irway obstruction    
  T  hick secretions    
  H emoglobin
(low?)
   

 (For unresponsive dyspnea give immediate release opiates)

E  MOTIONAL SUPPORT
S  PIRITUAL SUPPORT
S  ECRETIONS  If cough strong
moisten
    
                     If cough weak dry-up (anticholinergics)

 
-Death Rattle: atropine gtts, glycopyrrolate, TD scopolamine

I   NFLAMMATION (FEVER)
     -acetaminophen &/or ASA scheduled dose (best) or PRN         

V OLUME (review with family, dehydration has no pain)                       

E  MPATHY (secure your emotional support)  

PAIN (P-A-I-N)   (Mnemonic for evaluation)  

  P hysical
  A nxiety
  I interpersonal/social problems
  N on-acceptance/spiritual distress

 P hysical  
(
Pain) - make sure of diagnosis (when you can)

Drug

Mech/
Inflammatory
vs.
neuropathic  vs. bone

Acetaminophen*

+

+

+

NSAIDS

+

--

+

Dexamethasone**

+

--

+

Opaites~

+

+/-

+

Anti-depressants

--

+

--

Anti-convulsants

--

+

--

Radiation/Chemo

--

--

+

          + = effective       -- = not effective  
   *Acetaminophen scheduled dose and add PRN narcotics
     (write p.o. or p.r.)
 **dexamethasone: 4-10 mg per day
 

~Opiates

po/pr*

sc/iv

size

liquid

morphine

5- 7.5mg q 4h*.

2mg q 2h

15mg

10,20 mg/5ml
100mg/5ml

oxycodone

2.5mg q 4h.*

---

5mg

5 mg/5 ml.

MS Contin

15mg q 12 h*

---

15,30,60,100,200 mg

 

OxyContin

10 mg q 12 h.*

---

10, 20, 40, 80, 160 mg

 

Duragesic p.start

12 mcg/h. q 3 d*

---

12,25,50,75,100mcg/h 

 

 Tramadol(Ultram)

25-100mg q 6 hr

---

  50, 100 mg

Tramadol ER

start 100 mg q d

---

100,200,300 mg  

* (these are starting doses - titrate to pain control and tolerance)
(NO UPPER LIMITS)

Antidepressants

dose  p.o.

size

Bupropion 37.5 mg q d to 100 mg SR q d max 300 mg SR 100 & 150 mg SR

duloxetine

20 mg start, max 60 mg q d

20, 30, 60 mg

Anticonvulsant Neurontin (gabapentin)


100 mg q.d.- 400 mg t.i.d.


100 & 300 mg

lamotrigine

25 mg q d, increase by 25-50 mg q 2 wks
max 400 mg q d

25 & 100 mg

Abdominal pain (colicky) (r/o urinary retention or impaction)
oxybutynin  5 - 10 mg t.i.d., or TD scopolamine (1.5 mg patch q 3d.)                            
Bowel obstruction → M.S. + anticholinergics, if severe → Octreotide

A nxiety (pain) (counsel, reassurance, family, friends, pastor)
(choose med based on additional benefits (e.g. hydroxyzine for secretions)

Medication

po

im/iv

size

liquid

hydroxyzine  

10-50mg q 4h

10-50 mg q 4h

10 & 25 mg

10 & 25mg/5ml.

Haldol

1-5 mg q 4h

1-2 mg q 4h (not iv) 

2mg/ml

Lorazepam

0.5-2 mg t.i.d.

0.5-2 mg q 4h

0.5 & 1 mg

 

(If unable p.o.: Give sublingual: Dissolve Lorazepam  in water, give buccally q 1 hr.)

I nterpersonal/spiritual-->counseling, family, friends, pastors              

N on-acceptance----------->counseling, family, friends, pastors

For more explanation see website: geriatrics.unmc.edu visit GERI Pearls
Adapted From "Primer of Palliative Care" Porter Storey MD
  

 

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