Palliative medicine - Revision history

Danbot: Add References

2026-03-22T09:38:10Z

Add References

← Older revision		Revision as of 09:38, 22 March 2026
Line 159:		Line 159:
	==See Also==		==See Also==
	*[[Pain control]]		*[[Pain control]]

			==References==
			<references/>

	[[Category:Misc/General]]		[[Category:Misc/General]]
	[[Category:Palliative Medicine]]		[[Category:Palliative Medicine]]

Jonrako: /* Agitation/Restlessness/Confusion */

2021-08-14T22:46:47Z

Agitation/Restlessness/Confusion

← Older revision		Revision as of 22:46, 14 August 2021
Line 55:		Line 55:
	#Review medication list and delete all non-essential medication to reduce anticholinergic burden: American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults		#Review medication list and delete all non-essential medication to reduce anticholinergic burden: American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults
	#Pain is a leading cause of delirium (see Acute Pain protocol). If not effective then…		#Pain is a leading cause of delirium (see Acute Pain protocol). If not effective then…
	#Haloperidol (Haldol). ~~If not effective then…~~		#Haloperidol (Haldol).
	#Lorazepam~~. If not effective then…~~		##Haloperidol has the best data in treating agitation or delirium in this patient population.
	#~~Referral~~ to Palliative Care		##Haloperidol 1mg IVP q1 hour PRN
			#Benzodiazepines
			##Caution needed with benzodiazepines because they can cause paradoxical agitation in elderly patients.
			##Lorazepam 1mg PO or SQ q 1 hour PRN
			#Delirium refractory to initial medications then referral to Palliative Care

	==Nausea/Vomiting==		==Nausea/Vomiting==

Jonrako: /* Dyspnea/Cough */

2021-08-14T22:37:14Z

Dyspnea/Cough

← Older revision		Revision as of 22:37, 14 August 2021
Line 30:		Line 30:


	==~~Dyspnea~~/~~Cough~~==		==Secretions<ref>Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.</ref>==
	~~#Optimize underlying disease treatment~~. ~~If no relief then…~~		*"Death Rattle"
	~~#Check oxygen saturation – supplement if below 90%~~. ~~If no relief then…~~		**Refers to the sound that is made when air passes through a dying patient's pooled secretions within the posterior oropharynx
	~~#Start opioid (Introduce laxative: see constipation protocol)~~. ~~If no relief then…~~		**Not harmful but distressing symptoms to the family.
	~~#Referral~~ to ~~Palliative Care~~		*Proper positioning
			*Aggressive suctioning should be avoided, as comfort of the patient is the goal.
			*Glycopyrrolate 0.1mg IV or 0.2mg PO
			**Prevents new secretions & reduces respiratory gurgling.
			**Does not cross blood-brain barrier & therefore does not contribute to terminal delirium

	==Acute Pain<ref>Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.</ref>==		==Acute Pain<ref>Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.</ref>==

Jonrako: /* Acute PainVertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6. */

2021-08-14T22:29:48Z

Acute PainVertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.

← Older revision		Revision as of 22:29, 14 August 2021
Line 45:		Line 45:
	*If pain is unrelieved for 30 minutes, increase bolus dose by 50-100%		*If pain is unrelieved for 30 minutes, increase bolus dose by 50-100%
	*If not opioid-naive, give up to 20% of total daily opioid dose.		*If not opioid-naive, give up to 20% of total daily opioid dose.
	#Referral to Palliative Care		*Referral to Palliative Care for refractory to pain control despite appropriate medications.

	==Agitation/Restlessness/Confusion==		==Agitation/Restlessness/Confusion==

Jonrako: /* Acute Pain */

2021-08-14T22:28:33Z

Acute Pain

← Older revision		Revision as of 22:28, 14 August 2021
Line 36:		Line 36:
	#Referral to Palliative Care		#Referral to Palliative Care

	==Acute Pain==		==Acute Pain<ref>Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.</ref>==
	*Opioids are the principle treatment for pain in terminally ill patients.		*Opioids are the principle treatment for pain in terminally ill patients.
	*Be cautious with morphine in terminally ill patients who have renal impairment as this can lead to opioid induce neurotoxicity.		*Be cautious with morphine in terminally ill patients who have renal impairment as this can lead to opioid induce neurotoxicity.
	**Use hydromorphone or fentanyl.~~<ref>Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.</ref>~~		**Use hydromorphone or fentanyl.
	Morphine: 4mg IV x 1 and IV folus q 15 minutes PRN		*Morphine: 4mg IV x 1 and IV folus q 15 minutes PRN
	Hydromorphone: 1mg IV x 1 and 1 mg IV bolus q 15 minutes PRN		*Hydromorphone: 1mg IV x 1 and 1 mg IV bolus q 15 minutes PRN
	Fentanyl: 25mcg iv x 1 and 25 mcg IV bolus q 15 minutes PRN		*Fentanyl: 25mcg IV x 1 and 25 mcg IV bolus q 15 minutes PRN
			*If pain is unrelieved for 30 minutes, increase bolus dose by 50-100%
			*If not opioid-naive, give up to 20% of total daily opioid dose.
	#Referral to Palliative Care		#Referral to Palliative Care

Jonrako: /* Acute Pain */

2021-08-14T22:07:35Z

Acute Pain

← Older revision		Revision as of 22:07, 14 August 2021
Line 37:		Line 37:

	==Acute Pain==		==Acute Pain==
	~~#Non-opioid pharmacological therapy~~		*Opioids are the principle treatment for pain in terminally ill patients.
	#*~~Acetaminophen 500mg by mouth every 6 hours prn (avoid~~ in ~~liver disease)~~		*Be cautious with morphine in terminally ill patients who have renal impairment as this can lead to opioid induce neurotoxicity.
	#**~~NSAIDS contraindicated~~ in ~~COVID19: https://www~~.~~bmj~~.~~com~~/~~content/368/bmj.m1086~~		**Use hydromorphone or fentanyl.<ref>Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.</ref>
	#:~~Start opioid (If acetaminophen not effective)~~		Morphine: 4mg IV x 1 and IV folus q 15 minutes PRN
			Hydromorphone: 1mg IV x 1 and 1 mg IV bolus q 15 minutes PRN
			Fentanyl: 25mcg iv x 1 and 25 mcg IV bolus q 15 minutes PRN
	#Referral to Palliative Care		#Referral to Palliative Care

Jonrako: /* Dyspnea */

2021-08-14T21:33:19Z

Dyspnea

← Older revision		Revision as of 21:33, 14 August 2021
Line 15:		Line 15:
	*Reassurance is key to family		*Reassurance is key to family
	*[[O2]], [[biPAP\|NIPPV]]		*[[O2]], [[biPAP\|NIPPV]]
	*Bedside Fan		*Bedside Fan
	*[[Morphine]];
	~~start "low and go slow", 1-2mg IVP Q10-15min until desired effect~~
	**If opioid tolerant, in addition to standing use - 10% of 24 hour opioid regimen Q10min; or 25% of 4 hour opioid regimen Q10min

	==[[Dehydration]]==		==[[Dehydration]]==

Jonrako: /* Dyspnea */

2021-08-14T21:32:22Z

Dyspnea

← Older revision		Revision as of 21:32, 14 August 2021
Line 8:		Line 8:

	==[[Dyspnea]]==		==[[Dyspnea]]==
			*Opioids are the first-line treatment for palliation of dyspnea.
			**Opioids decrease the chemoreceptor response to hypercapnia, thereby depressing the central respiratory drive and mitigating anxiety<ref>Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.</ref>
			*In Patients who are already taking opioids regularly, administer 5% of their total daily morphine dose to manage dyspnea.<ref>Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.</ref>
			*Admit to hospital or hospice inpatient when a a patient is experiencing refractory dyspnea despite initial palliative resuscitation
	*Not a time to reclarify goals of care		*Not a time to reclarify goals of care
	*Reassurance is key to family		*Reassurance is key to family
	*[[O2]], [[biPAP\|NIPPV]]		*[[O2]], [[biPAP\|NIPPV]]
	*Bedside Fan		*Bedside Fan
	*[[Morphine]]; start "low and go slow", 1-2mg IVP Q10-15min until desired effect		*[[Morphine]];
	**If opioid tolerant, in addition to standing use - 10% of 24 hour opioid regimen Q10min; or 25% of 4 hour opioid regimen Q10min		start "low and go slow", 1-2mg IVP Q10-15min until desired effect
			**If opioid tolerant, in addition to standing use - 10% of 24 hour opioid regimen Q10min; or 25% of 4 hour opioid regimen Q10min

	==[[Dehydration]]==		==[[Dehydration]]==

Rossdonaldson1: /* Rescue Medications for Symptom Distress */

2021-01-06T16:34:08Z

Rescue Medications for Symptom Distress

← Older revision		Revision as of 16:34, 6 January 2021
Line 110:		Line 110:
	\|-		\|-
	\| Ondansetron\|\|		\| Ondansetron\|\|
	*Nausea/Vomiting\|\|		*Nausea/Vomiting
			\|\|
	*Oral		*Oral
	*IV		*IV

Rossdonaldson1: /* Rescue Medications for Symptom Distress */

2021-01-06T16:33:47Z

Rescue Medications for Symptom Distress

← Older revision		Revision as of 16:33, 6 January 2021
Line 127:		Line 127:
	**Introduce laxative		**Introduce laxative
	\|-		\|-
	\| Morphine Sulfate\|\|		\| Morphine Sulfate
			\|\|
	*Pain		*Pain
	*Dyspnea\|\|		*Dyspnea
	*IV\|\|2-4 mg\|\|		\|\|
			*IV
			\|\|2-4 mg\|\|
	*Every 3-4 hours.		*Every 3-4 hours.
	**Increase dose by 50% for pain unrelieved by starting dose at 1 hour for oral and 15 minutes for IV dose.		**Increase dose by 50% for pain unrelieved by starting dose at 1 hour for oral and 15 minutes for IV dose.