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PALLIATIVE CARE
For End of life
(for full explanation see GERI Pearls at geriatrics.unmc.edu)
(Issues and Orders to cover)
1) Discuss & clarify with patient &/or family &/or DPOA-HC
a) goals of care
b) advance directives, (hospitalizations?)
c) anticipated sx’s of dying & plan of management
d) hospice referral
2) Involve & assure staff’s comfort with plan and orders
3) Document discussions and write orders,
(anticipate problems to avoid delay in
treatment using the following plan:)
4) AGGRESSIVE care
(mnemonic)
A NOREX-IA/ A GGITATION
(mnemonic for correctable causes)
A ches (see P ain)
N ausea (see G astrointesitnal)
O ral candidiasis
R eactive depression
E vacuation (see G astrointesitnal)
X erostomia
I atrogenic (radiation/chemotherapy)
A cid (gastritis/PUD)
b) offer food/fluids as able
c) Appetite stimulants? ;(megestrol, remeron, trazadone)
(marinol, dexamethasone)
A GGITATION (Terminal Delirium)
a) Correct “correctables”
b) Haldol 0.5 mg po/sc q 30 min prn delirium
G ASTROINTESTINAL
-CONSTIPATION:
(with opiates always start these)
a) DSS 100-250mg q.d. to b.i.d
or
b) 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? - > oxybutinin
R ESPIRATORY
DYSPNEA “B-R-E-A-T-H A-I-R”
(for correctable causes)
B ronchospasm
R ales
E ffusions
A irway obstruction
T hick secretions
H emoglobin (low?)
A nxiety
I nterpersonal issues
R eligious concerns
(For unresponsive dyspnea,
give immediate release opiates)
M.S. (write prn pain or dyspnea)
E MOTIONAL SUPPORT
(Hospice? , counselor?)
S PIRITUAL SUPPORT
(pastoral support? Hospice?)
S ECRETIONS
If cough strong - moisten
If cough weak - dry-up
(with anticholinergics)
-for Death Rattle: atropine qtts, glycopyrolate, TD scopalamine
I NFLAMATION (FEVER)
-acetaminophen &/or ASA
scheduled dose (is 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/
Inflm
+
+
+
+
-
Neuro
pathic
+
+/+
Bone
APAP*
+
NSAIDS
+
Decadron**
+
Opiates~
+
Antidepressants
Anti+
convulsants
Radiation/
+
chemo
*Acetaminophen scheduled dose and add PRN
narcotics (write p.o. or p.r.)
**dexamethasone: 4 – 10 mg per day
~Opiates
po/pr
morphine
5-7.5 mg
q 4h*
ocycodone
2.5mg q
4h.*
15mg q
12 h*
MS Contin
sc/i
v
2
mg
q2
h*
--
size
liquid
15mg
10 &
20mg/5ml
100mg/5ml
5mg
5mg/5ml
15,30,60
-100,200
mg
Oxycontin
10 mg q
-10, 20,
-12 h.*
40,80,
160 mg
Duragesic
25
-25,50,75
-patches
mcg/h.
100
q 3 d*
mcg/h*
*(these are starting doses – titrate to pain control and
tolerance)
(UPPER LIMIT determined by sedation)
Antidepressants
Nortryptyline
Anticonvulsant
Neurontin
--
dose p.o.
10-50mg q.d.
100 mg q.d.–
400 mg t.i.d.
size
10 &25 mg
100 & 300 mg
(gabapentin)
Tegretal
100mg t.i.d.
100 & 300 mg
Abdominal pain (colicky) (r/o urinary retention or impaction)
oxybutinin 5-10 mg t.i.d., or TD scopolamine (1.5 mg patch q 3 d.)
Bowel obstruction - > M.S. + anticholinergics, if severe - > Octreotide
A nxiety (pain) (counsel, reassurance, family, friends, pastor)
medication
hydroxyzine
po/im
size
liquid
10-50mg q
10 & 25
10&25mg
4h
mg
/5ml
Haldol
1-5 mg q 30
2mg/ml
min.(no IV)
lorazepam
0.5-2 mg
0.5, 1, 2
2mg/ml
t.i.d
mg
(If unable p.o.) (Give sublingual: Dissolve lorazepam in water,
give buccally q 1 hr.)
I nterpersonal/spiritual-->counseling, family, friends, pastors, hospice.
N on-acceptance---------> counseling, family, friends, pastors, hospice.
Adapted form “Primer of Palliative Care”
Porter Storey MD
For full explanation see Geri Pearls at:
geriatrics.unmc.edu evv 10-26-03