What is a recommended palliative care order set for a patient?

Palliative Care Order Set

A comprehensive palliative care order set should include morphine for pain and dyspnea, midazolam for anxiety and agitation, haloperidol for delirium and nausea, antimuscarinic agents for secretions, antiemetics, laxatives, and advance care planning documentation including POLST/MOLST forms. 1, 2

Core Medication Orders

Pain Management

• Morphine sulfate is the first-line opioid for moderate to severe pain 1

  • Starting dose: 2.5-10 mg PO every 2 hours PRN or 1-3 mg IV every 2 hours PRN 1
  • For patients already on chronic opioids, increase doses by approximately 25% 1
  • Titrate to effect, with no maximum ceiling dose 3
  • Common pitfall: Underdosing in opioid-naive patients or failing to provide adequate breakthrough dosing 1

• Adjuvant analgesics 2

  • NSAIDs for inflammatory pain
  • Bisphosphonates for bone pain in breast cancer and myeloma 2

Dyspnea Management

• Morphine for unrelieved dyspnea 2, 1

  • Same dosing as for pain: 2.5-10 mg PO every 2 hours PRN 1
  • More aggressive titration may be required for acute progressive dyspnea 2

• Oxygen therapy for symptomatic hypoxemia 2, 1

  • Short-term relief only; role diminishes as life expectancy decreases 2

• Benzodiazepines for dyspnea with anxiety component 1

  • Lorazepam 0.5-2 mg PO/SL/IV every 2-4 hours PRN
  • Common pitfall: Using opioids alone when anxiety is a significant component 1

Anxiety and Agitation

• Midazolam as first-line benzodiazepine 1
  • Starting dose: 0.5-1 mg/hour continuous infusion or 1-5 mg PRN 1
  • For refractory agitation: combine with neuroleptics 2

Delirium Management

• Haloperidol as first-line antipsychotic 1, 2
  • Starting dose: 0.5-2 mg PO/IV/SC every 4-6 hours PRN
  • Titrate to symptom control 2
  • Add lorazepam for agitation refractory to high-dose neuroleptics 2
  • Critical pitfall: Distinguishing delirium from anxiety—benzodiazepines worsen delirium 1

Respiratory Secretions

• Antimuscarinic agents 1, 2
  • Scopolamine 1-3 patches every 72 hours
  • Atropine 1% ophthalmic solution 1-2 drops SL every 4 hours PRN
  • Glycopyrrolate 0.2-0.4 mg IV/SC every 4 hours PRN

Nausea and Vomiting

• Antiemetics 1
  • Metoclopramide 10 mg PO/IV every 6 hours 4
  • Ondansetron 4-8 mg PO/IV every 8 hours
  • Haloperidol 0.5-2 mg for nausea related to opioids or metabolic causes 1

Bowel Management

• Prophylactic laxatives for all patients on opioids 1
  • Senna with docusate 2 tablets PO twice daily
  • Bisacodyl 10 mg PO/PR daily PRN
  • Methylnaltrexone 8-12 mg SC every other day for opioid-induced constipation refractory to other laxatives 1
  • Critical: Constipation may be more difficult to control than pain if not carefully monitored 2

Sleep Disturbances

• Sleep aids 1
  • Trazodone 25-50 mg PO at bedtime
  • Mirtazapine 7.5-15 mg PO at bedtime
  • Zolpidem 5-10 mg PO at bedtime

Route of Administration Considerations

Transition Planning

• Oral route preferred initially 5

  • 89% of patients use oral route at admission 5

• Subcutaneous route becomes primary as death approaches 5

  • 94% of patients use subcutaneous route at day of death 5
  • Adjust route based on patient's ability to swallow and absorb medications 1

• Provide for breakthrough symptom management regardless of route 1

Advance Care Planning Documentation

Life Expectancy: Years

• Initiate discussion of personal values and preferences for end-of-life care 2
• Document advance directives including:
  • Healthcare proxy/medical power of attorney 2
  • Resuscitation preferences 2
  • Mechanical ventilation preferences 2
  • Artificial nutrition/hydration preferences 2
• Complete POLST/MOLST forms 2
  • These medical orders are more effective than traditional advance directives alone 2
  • Provide explicit direction about code status and desired interventions 2

Life Expectancy: Months to Weeks

• Confirm patient values and decisions in light of status changes 2
• Determine preferred location of death 2
• Ensure complete documentation accessible across all care settings 2
• Address family concerns and resolve conflicts between patient and family goals 2
• Consider palliative care specialist consultation for conflict resolution 2

Life Expectancy: Weeks to Days

• Clarify and confirm code status 2
• Explore organ donation and autopsy preferences 2
• Implement and ensure compliance with advance care plan 2
• Withhold/withdraw mechanical ventilation as indicated based on patient preferences, prognosis, and reversibility 2

Symptom Assessment Orders

Regular Monitoring

• Assess pain, dyspnea, and depression at every encounter 2, 6
• Monitor for delirium using DSM-IV criteria 2
• Reassess symptom control to determine if strategy changes are warranted 2

Acceptable Outcomes

• Adequate pain and symptom management 2
• Reduction of patient and family distress 2
• Acceptable sense of control 2
• Relief of caregiver burden 2
• Strengthened relationships 2

Medication Management Principles

Continuation and Discontinuation

• Continue medications for symptom palliation unless ineffective or causing distressing side effects 1
• Discontinue medications inconsistent with comfort goals 1
  • Consider discontinuing fluid support or using low-dose diuretics if fluid overload contributes to dyspnea 2
  • Remove unnecessary medications and tubes in dying patients 2

Dose Adjustments

• Titrate all symptom control medications to optimal relief 2
• Increase doses and/or change routes as needed for adequate symptom control 2
• Consider opioid rotation if delirium is believed caused by neurotoxicity of current opioid 2

Special Considerations for Dying Patients (Days to Hours)

Ventilation Decisions

• Critically evaluate invasive ventilation in patients with advanced disease 2
• NIV may be used for symptom reduction but should not prolong dying process 2
• Provide sedation as needed 2
• Give anticipatory guidance to family regarding dying of respiratory failure 2

Intensification of Care

• Consider sedation for intractable symptoms 2
• Provide emotional and spiritual support 2
• Support and educate caregivers about anticipated disease progression and dying process 2

Common Pitfalls to Avoid

• Failing to prescribe prophylactic laxatives with opioid initiation 1
• Inadequate breakthrough dosing for pain and other symptoms 1
• Abrupt discontinuation of opioids or benzodiazepines 1, 3
• Delaying advance care planning until acute crisis 2, 6
• Using benzodiazepines for delirium instead of antipsychotics 1
• Undertreatment of dyspnea due to unfounded concerns about respiratory depression 6
• Failing to adjust medication routes as patient condition deteriorates 5