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PLEASE REVIEW. LINE OUT AND INITIAL ANY UNWANTED ORDERS.
PATIENT NAME:
DATE OF BIRTH:
GENERAL ORDERS
May hold medications/treatments if death is imminent
Oral Suction: May use oral suction as needed
Retention Catheter:
Insert as needed.
Replace as needed.
Irrigate with 50ml of sterile normal saline as needed. Dispense 1 bottle
Reference: FHS Policy 967.00
Artificial Tears: 2 drops as needed for dry eyes, every 1 hour Dispense 1 bottle
Artificial Saliva: 2 sprays, every 2 hours as needed for dry mouth, Dispense 1 bottle
Triple Antibiotic Ointment: Apply topically 2 times daily to minor skin scratches and/or abrasions Dispense 1 tube
Thick-It: Slowly mix the recommended amount with liquids to form nectar, honey, or pudding consistency as needed
for difficulty swallowing. Dispense 1 tub
Feeding tube: Replace as needed
Release Body: Permission to release the body to funeral home after death
PAIN – Pain Level 1- 4 and/or As Adjuvant to Opioid Therapy (Contact Attending provider If Pain over 4)
Oral Medication
1 Acetaminophen (Tylenol):
a. Administer 325 mg tablets, two orally every 4 hours as needed for pain. Dispense 30 tablets or 5
suppositories
b. If unable to take orally, use 650 mg suppository, one rectally, every 4 hours as needed for pain.
c. Not to exceed total dose of 3000 mg per day.
d. If ineffective or not tolerated go to # 2.
2. Ibuprofen (Motrin): 400 mg orally every 4 hours as needed for pain. Dispense 30 tablets. Maximum total dose of
2400mg per day.
Topical Medication (For Patient Unable To Take Oral Anti-Inflammatories)
1. Ketoprofen 10% Pluronic-Lecithin Oil Gel (PLO): Apply 1 ml topically to inner wrist every 6 hours. Rub in well.
Dispense 30 ml If ineffective or not tolerated go to # 2.
2. Ketoprofen 10%/Prednisone 1.25% Pluronic-Lecithin Oil Gel (PLO): Apply 1 ml topically to inner wrist every 6
hours. Rub in well. Dispense 30 ml
ANXIETY / TERMINAL RESTLESSNESS
Lorazepam (Ativan): Administer 0.5 mg, 1 tablet orally or sublingually every hour as needed for anxiety. Dispense 30
tablets
o DO NOT exceed 2 mg in 4 hours.
o If not comfortable after 2 doses, notify attending provider.
DELIRIUM
Haloperidol (Haldol): 1 mg orally, may repeat in 1 hour, then every 4 hours as needed for delirium. Dispense 15
tablets
o If ineffective or not tolerated, notify attending provider
FEVER – Greater Than 102 Fahrenheit (39 Celsius)
Oral Medication
1. Acetaminophen (Tylenol): Administer 325 mg tablets, two orally every 4 hours as needed for fever greater than
102 degrees Fahrenheit (39 degrees Celsius). Dispense 30 tablets
1. If unable to take orally, use 650 mg suppository, one rectally, every 4 hours as needed for fever greater than
102 degrees Fahrenheit (39 degrees Celsius). Dispense 5 suppositories
2. Not to exceed total dose of 3000 mg per day.
3. If ineffective or not tolerated go to #2.
2. Ibuprofen (Motrin):
1. 400 mg orally every 6 hours as needed for fever greater than 102 degrees Fahrenheit (39 degrees Celsius).
Dispense 30 tablets
2. Max dose of 2400mg/day.
3. Topical Medication (For patient unable to take oral antipyretic)
Ketoprofen 10% PLO: Apply 1 ml topically to inner wrist every 6 hours. Rub in well. Dispense 30 ml
Physician initial:
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(03/31/2017)
Revision N
PHYSICIAN ORDERS
FRANCISCAN HOSPICE
(NOT FOR HOSPITAL USE)
PATIENT NAME:
DATE OF BIRTH:
OXYGEN THERAPY
o Obtain pulse oximetry to assess need for oxygen.
o If 89% or less, apply oxygen, 2 liters per minute, continuously via nasal cannula.
o May increase to 3 liters per minute continuously for unimproved oxygen saturation of 89% or less or unrelieved
dyspnea.
o If oxygen saturation remains 89% or lower or dyspnea remains unrelieved, increase to 4 liters per minute
continuously.
o Patient may use oxygen intermittently.
SECRETIONS: ORAL/PHARYNGEAL
Excess Secretions:
1. Atropine Sulfate 1% ophthalmic solution:
a. Instill 2 drops sublingually every 4 hours as needed for excess secretions. Dispense 1 bottle If ineffective or
not tolerated go to # 2 or call attending provider.
2. Glycopyrrolate (Robinul) For Hospice House ONLY:
a. Administer 0.4 mg subcutaneously or intravenously every 4 hours as needed for excess secretions
Dispense 6 doses
Thick Secretions
1. Guaifenesin (Robitussin):
a. 400 mg tablet (or 100 mg/5 ml solution) orally every 4 hours as needed for thick secretions. Dispense 15 tablets
b. If unable to take tablets, 100mg/5ml solution give 20ml orally every 4 hours as needed. Dispense 8 ounces
c. If ineffective or not tolerated go to # 2 or notify attending provider.
2. Guaifenesin (Mucinex):
a. 1200 mg sustained release, 1 tablet orally every 12 hours. Dispense 30 tablets
b. If ineffective after 48 hours or not tolerated go to # 3.
3. 0.9% sodium chloride (Normal Saline):
a. 3 ml in a small volume nebulizer every 4 hours as needed for thick secretions. Dispense 30 vials
4. If no relief after 72 hours, contact attending provider
DYSPNEA- Nebulizer
1. Albuterol Unit Dose (2.5 mg/3ml) SVN Treatment Every 4 hours as needed for dyspnea. Dispense 1 box
a. If ineffective or not tolerated go to # 2.
2. Duoneb (ipratropium bromide (Atrovent) and Albuterol Sulfate) SVN Treatment: Inhale contents of 1 unit
dose (3 ml) via SVN every 4 hours as needed for dyspnea. Dispense 1 box
RESPIRATORY DISTRESS with lung crackles
Furosemide (Lasix):
o Administer 40 mg by mouth daily x 3 days. Dispense3
o Assess effectiveness daily and report to provider on or before day 4.
COUGH
1. Dextromethorphan/Guaifenesin (Robitussin DM) (100 mg/10 mg/5 ml): Administer 10 ml orally every 4 hours as
needed for cough. Dispense 8 ounces
a. If ineffective or not tolerated go to # 2.
2. Benzonatate (Tessalon Perles): Administer 100 mg orally three times daily. Dispense 30 capsules
If ineffective or not tolerated, notify attending provider.
SLEEP DISTURBANCE
Temazepam (Restoril): Administer 15 mg orally at bedtime as needed for sleep disturbance. Dispense 15
capsules. If ineffective or not tolerated contact attending provider.
NAUSEA AND VOMITING
1. Prochlorperazine (Compazine):
a. Administer 10 mg orally every 6 hours as needed for nausea and/or vomiting. Dispense15 tabs or
b. If unable to tolerate oral medications give 25 mg suppository per rectum every 12 hours as needed. Dispense 5
suppositories
c. If ineffective or not tolerated go to # 2.
2. Haloperidol (Haldol): Administer 0.5 mg orally, two times daily if needed for nausea. Dispense 15 If ineffective or
not tolerated, contact attending provider.
Physician initial:
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(03/31/2017)
Revision M
PHYSICIAN ORDERS
FRANCISCAN HOSPICE
(NOT FOR HOSPITAL USE)
PATIENT NAME:
DATE OF BIRTH:
HICCUPS:
1. Chlorpromazine (Thorazine): Administer 25 mg orally every 6 hours as needed for hiccups. Dispense 15 tabs
a. If ineffective or not tolerated go to # 2.
2. Baclofen: Administer 5 mg orally, three times daily as needed for hiccups. Dispense 15 tablets or
a. If unable to tolerate oral medications use Baclofen PLO 10 mg topically, three times daily as needed for
hiccups. Dispense30 ml of PLO gel If ineffective or not tolerated, contact attending provider
STOMATITIS:
Diphenhydramine (Benadryl), Viscous Lidocaine, and Formulary Antacid (with or without simethicone) in a
1:1:1 Solution Swish and swallow 5 ml every 4 hours as needed for stomatitis. Dispense 120 ml bottle DO NOT
exceed 5 doses per day.
CANDIDIASIS:
Oral: Nystatin suspension: Swish and swallow 5 ml (500,000 units) 4 times daily for 7 days Dispense 140 ml bottle
Cutaneous: Clotrimazole 1% cream: Apply 1ml topically to affected area 2 times daily for 7 days Dispense 1 tube
Vaginal: Clotrimazole 1% cream: Insert 1 applicator full vaginally each night at bedtime for 7 nights Dispense 1 tube
PRURITIS
1. Men-Phor Lotion, or equivalent: Apply topically 2 times daily to affected area. Dispense 1 bottle
a. If ineffective or not tolerated go to #2.
2. Hydroxyzine (Vistaril): Administer 25 mg orally 3 times daily as needed for itching. Dispense 15 tablets
a. Not for use in patients age 65 and over.
3. May use Men-Phor lotion, or equivalent, in combination with hydroxyzine (Vistaril)
SKIN IRRITATION
Remedy Calazime ointment, or equivalent: Apply 2ml topically 2 to 4 times daily as needed to affected area after
incontinent episode Dispense 1 tube
BOWEL REGIMEN (if no other regimen is in place) PRN with initiation of opioids or constipation
1. Begin with gentle laxative: Senna (Senokot) 8.6 mg orally, 1-4 tablets 2 times daily as below: Dispense 60 tablets
 Administer 8.6 mg orally:
o Give1 tablet per 4 mg of hydromorphone (Dilaudid),
o 1 tablet per 30 mg morphine, or 30 mg oxycodone,
o or 1 tablet per 50 mcg fentanyl (Duragesic)
2. If no bowel movement in any 48 hour period, add:
a Milk of Magnesia (MOM) 60 ml two times daily. Dispense 1 bottle
 If ineffective after 2 days or not tolerated go to # B.
b Miralax: Mix 1 capful (17 grams) of powder in 4-8 ounces of fluid and take by mouth every day. Dispense 1
container
 If ineffective after 2 days or not tolerated go to #C.
c Bisacodyl (Dulcolax): 10 mg per rectum. Dispense 5 suppositories Insert one suppository rectally, once daily
after following steps 1, 2A and 2B
BOWEL IMPACTION
1. If stool is soft enough, manually disimpact patient. If ineffective or not tolerated go to # 2.
2. Soften with a Mineral oil retention enema, I unit dose per rectum, then manually disimpact patient. Dispense 1
enema
DIARRHEA
1. Loperamide (Imodium): Administer 2 capsules (4 mg) as needed after each loose stool. Dispense 30 capsules
Can take up to 8 capsules in 24 hours.
If ineffective go to step # 2.
2. Diphenoxylate 2.5 mg/Atropine 0.025 mg (Lomotil): Administer 2 tablets orally every 6 hours as needed after
each diarrhea stool. Dispense 30 tablets DO NOT exceed 8 tablets per day.
INDIGESTION
1. Formulary Antacid: Administer 30 ml orally every hour as needed for nausea/indigestion. Dispense 1 bottle
Maximum total dose of 7 doses (210 ml/24 hours).
If ineffective or not tolerated go to # 2.
2. Simethicone Administer 80 mg orally four times daily as needed for indigestion and/or gas, after meals and at
bedtime
Dispense 15 tablets
Physician initial:
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(03/31/2017)
Revision M
PHYSICIAN ORDERS
FRANCISCAN HOSPICE
(NOT FOR HOSPITAL USE)
PATIENT NAME:
DATE OF BIRTH:
INTRAVENOUS CATHETER CARE
. PICC or Midline Catheter (includes Power PICC)
 IN USE – Flush each lumen with 10 ml Normal Saline every 8 hours and after additional medications. Dispense
Quantity 10 – 10 ml refilled syringe
 NOT IN USE – Flush each lumen with 10 ml Normal Saline every 7 days. Dispense Quantity 1 – 10 ml prefilled
syringe
Portacath (includes Power Ports)
 IN USE – Flush with 10ml Normal Saline every 8 hours and after additional medications. Dispense 10 -10
ml prefilled syringes.
 DE-ACCESS – Flush with 5 ml 100 units/ml Heparin. Dispense 1 – 10 ml prefilled syringe.
 NOT IN USE – Flush monthly with 5 ml 100 units/ml Heparin. Dispense 1 – 10 ml prefilled syringe.
These orders will be obtained from the Medical Director for each Hospice Patient. Pre-printed orders can be
activated to address symptom changes based on a thorough clinical assessment by the Licensed Nurse. On
activation, the attending physician/ARNP if any will be notified of the symptoms, order, and response. Further
orders will be obtained from the attending physician/ARNP if any.
If the intervention(s) above are not effective the Licensed Nurse will contact the attending provider for further
orders. Should the attending be unavailable for follow-up for any reason, the Hospice Medical Director will be
contacted for ongoing orders.
If, for any order listed above, upon a thorough clinical assessment the Licensed Nurse determines the greater
dose is necessary to adequately manage the patient’s condition, the medication may be administered in the
higher dose either initially or for subsequent doses.
.
___________________________________________
Franciscan Hospice Medical Director
_________________________
Date
Hospice Medical Director:
o
o
o
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Revision M
Marilyn Pattison MD
Juan Irequi MD
Arun Vijay MD
PHYSICIAN ORDERS
FRANCISCAN HOSPICE
(NOT FOR HOSPITAL USE)