Palliative Standing Orders

marienm, RN, CCRN · Mar 10, 2017

I've never worked in end-of-life care (except comfort care in the hospital), so a couple of questions:

If a patient needs oxygen for comfort, does that require an order?

Does this order set need to address diet/texture orders? ("Pt may eat for comfort"/"Thickened liquids only"/"NPO & provide mouth care every 2-4 hours")

Do you need to specify cessation of other treatments/assessments (like vital signs)? (or maybe you still take them, in which case, how often?)

Are the ranges of med doses allowed by your agency? (In the hospital, I need an order for Morphine IR 5 mg (for moderate pain) OR 10 mg (for severe pain) and couldn't give a dose that was ordered as 5-10mg.)

Just curious-- do your patients and staff find the SQ route more tolerable than the PR route for pain/anxiety meds?

notanumber · Mar 12, 2017

Good questions!

We have oxygen as a standing order for 99% of our residents (2-4L via NP or mask), so it is available if needed without adding to the palliative orders as a reminder. I thought about putting it in there, but O2 seems to be overused as it is and is really rarely indicated. I don't want the casual/new nurses seeing on the Palliative Order sheet and assuming it is a common part of comfort care. Is that a rational conclusion?

Diet texture/order I will definitely add! This question comes up a lot from the care staff so having a specific order may make it clearer. We have an RD on hand to assess/write them.

We only do VS monthly and PRN unless specifically ordered by physician (e.g. BP monitoring daily x 2 weeks) or indicated by medication (e.g. digoxin, insulin). As part of practice we stop all VS monitoring during the active phase, but I know there is uncertainty among some about when this should be done specifically. I'll add for clarification - example: [ ] Discontinue all VS monitoring. Resident currently being monitored for the following:____Regular Monthly VS___QID BGL_____

Yes, ranges are common. Our current palliative order set includes them. I will ask our DOC to double check whether this is best practice according to licensing. I like them because it allows nursing staff to titrate without having to phone the physician for every sudden increase in pain or persistent dyspnea. On the other hand, I have seen some totally disregard the "start low and go slow" philosophy which would be the concern.

Initiating SQ routes happen very quickly here, because by the time our population starts receiving EOL care, they usually have severe dysphagia, or delirium, or have decreased LOC. I don't like giving PR (or did you mean PO?) because of the discomfort. The only time I ever give a medication PR at that stage is if the resident is febrile and in obvious discomfort and Tylenol is the best drug of choice.

One change I would like to see is more frequent PO use, as a quality indicator that we are improving in giving better palliative care, sooner, before the resident deteriorates and before nurses feel the more rapid SQ rout is needed to control symptoms that have become intolerable.

makeitwork, BSN, RN · Mar 12, 2017

What stands out for me is the fentanyl patch. If a patient is already taking one or more of the short-acting analgesics, a 24-hour morphine equivalent is calculated and then a fentanyl equianalgesic dose can be calculated allowing better initial pain management with the patch. The automatic 12mcg fentanyl patch may waste time getting ahead of the pain. As I think about it, I suppose the 12mcg patch may be better than nothing, but, I would want a more accurate dose initially on board. Just a thought...

marienm, RN, CCRN · Mar 13, 2017

I did mean PR...was just wondering which was worse in the end--needle sticks every 2 hours (potentially; I realize it's PRN or a potentially longer-lasting rectal dose. Most of our comfort care patients still have IV access, so I don't give a lot of pain meds by either of those routes. (If the pt lost their access, we probably would try not to start a new one, but they don't usually start out as end-of-life patients.)

I get what you mean about the oxygen! Especially if the facility already has a standing order, no need to dupicate it here and put cannulas on everyone.

What you said about the meds & vitals got me thinking, do you normally d/c all non-pain/anxiety meds at this point? I've had patients who take, say, diltiazem. Stopping it would probably cause an arrythmia which might increase SOB & anxiety. Would you keep giving this med if you had a safe route? If so, would you check vitals before giving it? I'm not trying to complicate your orders, I promise. Partly just wondering how it works...

With the pain meds, could your pts have the fentanyl patch *with* one othe the other meds for breakthrough pain? That might address makeitwork's point.

tyvin, BSN, RN · Mar 17, 2017

Don't the palliative patients transition over to a hospice?

tyvin, BSN, RN · Apr 9, 2017

Don't the palliative patients transition over to a hospice?

I guess not...

nutella, MSN, RN · Apr 9, 2017

There are several things .

You write "facility" - are you working in a longterm care facility?

I assume that is the case and you are drafting a order sheet that you can fax to the facility medical director to get orders for care and comfort?

If this is the case I would say

- take out fentanyl - this is nothing that should be just checked off without calculation and review.

- Structure the sheet into

categories

- pain - typically patients receive roxanol concentrated morphine in facilities because it is cheap and easy to administer sl. Alternatives are oxycodone as a concentrated liquid for patients who are allergic to morphine. subc morphine or dilaudid should not be the norm and if that is needed you probably also want an eval and admission to hospice to help with the management. In my experience, the vast majority of patients in longterm care can be managed with sublingual morphine when it is concentrated, given in the appropriate dose and often enough.

-dyspnea : see above plus order for oxygen 2-4 l/min for comfort per nc

-congestion: atropin drops are expensive. levsin and scopolamin are popular

-anxiety/agitation : first line is usually ativan and if not working or more severe symptoms haldol - zyprexa is also more popular because it can be given sl and injection.

-nausea/vomiting: compazine, haldol, zofran, reglan -- tough I find that compazine and haldol are cheap and effective plus compazine is also available rectally - it also has some sedative properties which can be helpful when somebody has severe nausea.

-constipation: dulcolax sup, senna if swallowing

-fever: tylenol supp or pill

-other medication

- interventions like foley for comfort

and other things that apply to everybody in facilities for longterm care who are considered for care and comfort for example

- code status DNR/DNI with POLST

- may eat and drink for comfort if able and wishes to do so (even though they may have been NPO before or trouble swallowing)

- may have alcohol for occasions

- stop all oral medication, stop oral medication when unable to swallow

I think you should always communicate with the MD about the symptom severity because otherwise how would the MD know what dose or interval to order?

notanumber · Apr 10, 2017

Don't the palliative patients transition over to a hospice?

No, we care for residents through to the end of life. Hospice is generally for patients coming from the community or acute care who are already at end of life and need short stay skilled nursing care for symptom control until they pass.

tyvin, BSN, RN · Apr 11, 2017

No, we care for residents through to the end of life. Hospice is generally for patients coming from the community or acute care who are already at end of life and need short stay skilled nursing care for symptom control until they pass.

Thank you...what type of facility do you work at?

jennkada, ADN · Nov 26, 2019

On 4/9/2017 at 8:27 AM, nutella said:
- take out fentanyl - this is nothing that should be just checked off without calculation and review.

I know this was a few years ago, but you want to keep fentanyl as an option if the patient has an opioid allergy.