Considerations for a comfort care order set: Devices, procedures, and medications
| Indication | Order examples | Considerations |
|---|---|---|
| Devices and procedures | ||
| Pacemaker | Consider cardiology consultation if changing settings will provide comfort | Pacemakers will discontinue pacing when the body dies; consider leaving activated for comfort |
| Internal cardiac defibrillator (ICD) | Please consult cardiology for deactivation of ICD in setting of goals of comfort care | If emergent deactivation is required before cardiology is available, a specialized magnet can be placed externally to deactivate ICD |
| Endotracheal tube (ETT) | Consult respiratory therapy for extubation to comfort care Extubate to face mask, nasal cannula, or room air depending on projected clinical trajectory and goals | Consider if family and friends would like to be present Consider premedication for dyspnea and anxiety Consider what level of oxygenation support will bring the patient comfort after removal of ETT, such as nasal cannula, face mask, or noninvasive ventilation support |
| Medications for symptom control (all as needed)ab | ||
| Breakthrough pain or dyspnea | Morphine concentrated liquid 5–15 mg orally or sublingually every 3–4 hours | Can be used when patient loses ability to take oral medications |
| Terminal fever or pain | Acetaminophen 325–650 mg orally or rectally every 4–6 hours | Pills can be used orally or rectally |
| Nausea and vomiting | Ondansetron 4–8 mg orally, sublingually, or intravenously every 8–12 hours Promethazine 12.5–25 mg orally or rectally every 8 hours Olanzapine 2.5–5 mg orally or sublingually every 12–24 hours | Consider whether single medications can be used for multiple symptoms, such as olanzapine for both nausea and agitation |
| Constipation prevention | Assess for daily bowel movement | While bowel movements may slow, worsening constipation may add to agitation at end of life Suppositories are recommended when patient loses ability to swallow |
| Anxiety, terminal agitation | Lorazepam 0.5–2 mg orally or intravenously every 6–8 hours Haloperidol 0.5–5 mg orally, intravenously, or intramuscularly every 8–12 hours Olanzapine 2.5–5 mg orally or sublingually every 12–24 hours | These medications are useful for spectrum of symptoms in terminal phase |
| Terminal secretions (“death rattle”) | Atropine 1% 1–2 drops sublingually every 1–2 hours | Coach family and nursing team on repositioning as well |
↵aFor all initial medication dosing: if a patient has already been chronically on a medication, consider using the previously prescribed dose as an initial dose.
↵bConsider an approximately 50% dose reduction for all patients > 65 years or with severe renal or liver dysfunction.
Based on information from references 10–12.