PLACE LABEL HERE
COMFORT CARE
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Diagnosis/Reason for Comfort Care: _________________________________________________________
1.
Consults:
Palliative Care Nurse
Chaplain Services
 Social Work Services for Hospice referral
 Pain Management Center
2.
Code Status: DNR/AND (Allow Natural Death): In the event of cardiac or respiratory failure/arrest, CPR
will NOT be performed. Cardioversion/defibrillation, intubation, ventilation, and emergency medications
used exclusively for resuscitation will NOT be utilized.
3.
Scope of Treatment: This defines the plan of care until the moment of arrest or pulseless rhythm
Check only those treatments that will be withheld/withdrawn.
If none are checked, all possible interventions may be used.
Do not treat arrhythmias
DC/do not initiate ALL antibiotics
 DC/do not initiate non-invasive ventilation (BiPap/CPap)
DC/do not initiate TPN, Albumin
DC/do not initiate vasopressors
DC/do not initiate tube feedings
No tracheostomy
DC/do not initiate dialysis
No blood products
Other:_____________________
4.
5.
6.
7.
8.
9.
10.
11.
Discontinue pulse ox (unless ventilated or on BiPap/CPap), lab tests, and radiology exams
Oxygen as needed for comfort
 Discontinue telemetry/monitoring
Vital signs BID
Diet:  Regular diet as tolerated  Discontinue tube feedings
Activity: Ad lib
Discontinue IV lines not needed for medications or fluids
 Pet visitation/animal assisted therapy
MEDICATIONS: (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)
12.
 Discontinue IV fluids but continue IV access. Do NOT restart IV if access lost
 Continue IV fluids ________________at ______ml/hr IV
13.
Increased work of breathing with cough/gag reflex:
 Atrovent (ipratropium) 0.5 mg per nebulizer q 8 hrs prn
 Albuterol 2.5 mg/3 ml per nebulizer q 8 hrs prn
Fluid Volume control:  Lasix (furosemide) 20mg IV q 8 hrs prn
Secretion control:  Isopto atropine (eye drops) 1%: 3 drops sublingual or po q 4 hrs prn
 Scopalomine transderm patch, apply behind ear q 72 hrs prn. Discontinue
Atropine drops 18 hrs after initiation of patch
14.
15.
*3-3127*
FORM 3-3127 REV. 10/2011
Send copy to pharmacy __________
(initials)
Page 1 of 2
PLACE LABEL HERE
COMFORT CARE ORDERS
*3-3127*
FORM 3-3127 REV. 03/2010
Send copy to pharmacy __________ (initials)
PLACE LABEL HERE
COMFORT CARE
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
19.
Chest Pain:  Nitroglycerin 0.4 mg sublingual q 5 min x 3 doses prn
 Dexamethasone 4 mg po at 8 am and 12 pm to improve asthenia, depression, dyspnea and/or pain
Moderate to Severe Pain, Dyspnea or Respiratory Rate > 25/min
Morphine 10 mg/5 ml solution, 4 mg po or sublingual q 1 hr prn
Morphine 1-4 mg IV q 1 hr prn
 Morphine continuous 0.5 mg/ml IV
Bolus: 2-4 mg q 1 hr prn
Begin infusion at _____mg/hr (consider initial rate: 1-10 mg/hr based on patient’s
previous 24 hr average dose)
If titration upward is necessary, give bolus dose and increase rate by 1 mg/hr, q hr as
needed to control or prevent pain and respiratory discomfort
OR
 Dilaudid (HYDROmorphone) 2-4 mg po q 3 hrs prn
 Dilaudid (HYDROmorphone) 0.5-1 mg IV q 3 hrs prn
 Dilaudid (HYDROmorphone) continuous 0.5 mg/ml
Bolus: 0.5 – 1 mg IV q 1 hr prn
Begin infusion at ______mg/hr (consider initial rate: 0.5-2 mg q hr based on patient’s
previous 24 hr average dose)
If titration upward is necessary, give bolus dose and increase rate by 0.5 mg/hr, q hr as
needed to control or prevent pain and respiratory discomfort
Mild Pain, Temp >100.5F, HA:
Tylenol (acetaminophen) 650 mg po or per rectum q 4 hrs
20.
Anxiety/Agitation:
16.
17.
18.
21.
22.
23.
24.
25.
26.
27.
Ibuprofen 600 mg po q 6 hrs prn
Xanax (alprazolam) 0.5-1 mg po q 8 hrs prn


Ativan (lorazepam) 0.5-2 mg po or IV q 4 hrs prn


Diastat (diazepam) Gel 10 mg per rectum q 4 hrs prn
Psychosis/hallucinations/delirium: Haldol (haloperidol) liquid 2 mg/ml, 2 mg po q 4 hrs prn
Seizure Control:
 Ativan (lorazepam) 2 mg IV q 5 min x 3 doses prn
Nausea and Vomiting:
 Reglan (metoclopramide) 10mg IV q 6 hrs prn (5 mg if age > 65 y/o)
 Zofran (ondansetron) 4 mg IV q 6 hrs prn
Phenergan (promethazine) 12.5 – 25 mg po or per rectum q 6 hrs prn
Compazine (prochlorperazine) 10 mg suppository per rectum q 8 hrs prn
Constipation Prevention:  Dulcolax (bisacodyl) 10 mg suppository per rectum q day prn
Intractable hiccups:
 Thorazine (chlorpromazine) 25 mg IV q 8 hrs prn
Itching:
 Benadryl (diphenhydramine) 25 mg po or IV q 6 hrs prn
Wound care: _______________________________________________________________________
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
FORM 3-3127 REV. 10/2011
___________________
Time
_________________________________
Physician Signature
__________
PID Number
Send copy to pharmacy __________ (initials)
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