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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98206-en.cckm

201712341

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

IP - ED - End of Life Sustaining Measures in ED and ICU Patient - Adult - Supplemental [3429]

IP - ED - End of Life Sustaining Measures in ED and ICU Patient - Adult - Supplemental [3429] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - ED - End of Life Sustaining Measures in ED and ICU Patient - Adult -
Supplemental [3429]
Intended for Adult Patients in ED or ICU Only
Do NOT use on patients with paralytics or high-dose sedatives/barbiturates actively present at the
time this protocol is enacted.
A note must be written that documents the rationale for comfort care, discussions with attending
and discussion with family in order to proceed with this order set.
Educate family regarding tachypnea not being equal to dyspnea, secretion build-up in airways and
snoring, changes in skin color, bowel/bladder control, unpredictability in the timing of death, etc.
Post-mortem examination must be requested per hospital Policy.
Patient Care Orders
Order to Initiate Withdrawl of Life Sustaining Measures [103939]
Initiate Withdrawl of Life Sustaining Measures
[NURCOM0058]
All active orders prior to this ordering session (with a
few exceptions) will be discontinued when this order is
signed.
Vital Signs [102158]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
As needed.
Respiratory [102160]
the terminal patients with a confirmatory brain death note in the chart, please skip For
ventilator wean.
Page 1 of 7
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Terminal Ventilator Wean [RT0073] CONTINUOUS, Starting today, Routine, VERIFY
THAT FAMILY IS READY FOR EXTUBATION PRIOR
TO INITIATION OF TERMINAL VENTILATOR WEAN.
IF UNCLEAR, PLEASE CALL ADMITTING SERVICE
ON CALL.
1. If a confirmatory brain death note by the physician
is in the medical record, please do not perform the
terminal wean.
2. If patient experiences discomfort during any of the
following reductions in ventilation, resume higher
settings and adjust the medication for comfort prior to
further ventilator changes.
3. Adjust all alarms on ventilator as possible to
minimize noise.
4. On current vent mode wean FIO2 by 20% O2 as
tolerated to room air. May accelerate FIO2 wean as
tolerated if respiratory rate does not increase by more
than 5 breaths per minute and heart rate does not
increase by more than 10%.
5. When on 21% FiO2, adjust PEEP to 0 cm H2O by 3
cm of water increments as tolerated. May accelerate
PEEP wean as tolerated if respiratory rate does not
increase by more than 5 breaths per minute and heart
rate does not increase by more than 10%.
6. Change to pressure support (PS) such that Tidal
Volume is approximately same as on current
ventilation mode. Call MD if patient not
spontaneously breathing prior to proceeding with
ventilator wean.
7. Wean PS by 5cm H2O as tolerated after FIO2 at
room air and PEEP as 0. May accelerate PS wean as
tolerated if respiratory rate does not increase by more
than 5 breaths per minute and heart rate does not
increase by more than 10%.
8. Disconnect the ventilator when PS at 5/0.
Respiratory rate should be less than 30 breaths per
minute.
Extubation [RT0073] CONTINUOUS, Starting today, Routine, 1. Do not
extubate until terminal ventilator wean is complete.
2. Extubate if family wishes to have the endotracheal
tube removed otherwise disconnect ventilator and
leave endotracheal tube in place.
3. Pt should be breathing less than 30 breaths per
minute prior to extubation.
4. Suction retropharnyx and endotracheal tube prior to
removing endotracheal tube.
5. Extubate when PS 5/0.
Code Status [103356]
Code Status (Single Response) [232996]
No CPR: The patient does not want CPR in the
setting of cardiac arrest (Single Response)
[232972]
May intubate for medical management of non-
arrest situations (e.g. pneumonia). (Single
Response) [232973]
Page 2 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:14:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

No CPR/May Intubate [CDSTS0001] Patient Location:
Does not want intubation under any
circumstance, even for a treatable problem (e.g.,
pneumonia). (Single Response) [232975]
No CPR/No Intubation [CDSTS0005] Purple wristband option to communicate No CPR
status? Yes
Full Code [CDSTS0003] Details
Non-Categorized Patient Care Orders [102159]
Adjust Alarms as Appropriate to Minimize Noise
[NURCOM0022]
CONTINUOUS, Starting today
No Supplemental Oxygen Via Nasal Cannula or
Mask Unless there is a Clear Comfort Related
Need [NURCOM0022]
CONTINUOUS, Starting today
Leave All Lines and Catheters Provided They Are
Not Causing Discomfort for the Patient
[NURCOM0022]
CONTINUOUS, Starting today
Pacemaker / ICD Reprogramming [CARD0015] ONCE, Starting today For 1 Occurrences, Routine,
Consults are performed Monday-Friday 0700-1700.
For after hours, weekends and holidays, contact the
Cardiology Fellow on call.
Reason for consult: Other (Comment (Withdrawing
care, end of life)
Specify programming changes (if needed): Please turn
device off
Type of device: Unknown
Device company: Unknown
Withdrawing care, end of life
Please turn device off
Contingency Parameters [102162]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: If not responding to RN interventions or
medications.
Intravenous Therapy
IV Fluids [102099]
sodium chloride 0.9% infusion [64367] at 10 mL/hr, Intravenous, CONTINUOUS
Medications
Secretion Management [102098]
Page 3 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:14:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

atropine 1% ophthalmic soln [34849] 1 drop, Sublingual, PRN - NOTIFY PHARMACY
WHEN NEEDED, secretions
Administer sublingually. First line for secretions.
scopolamine (TRANSDERM-SCOP) 1
MG/3DAYS 72hr patch [166671]
1 patch, Transdermal, PRN - NOTIFY PHARMACY
WHEN NEEDED, secretion
Administration Instructions to read: Administer for
excessive secretions unresponsive to at least 6 doses
of atropine solution. Apply to dry, hairless area behind
ear. Remove old patch when applying new one.
Pain Management (Single Response) [149310]
MORPHine - Early Infusion Protocol [208271]
MORPHine 60 mg in sodium chloride 0.9% 60
mL infusion syringe [755102]
1-20 mg/hr, Intravenous, CONTINUOUS
Initiate at 0.1 mg/kg/hr (Maximum initial dose 10
mg/hour or current rate). Increase infusion rate by
20% every 4 hours if patient exhibits signs or
symptoms of discomfort and has a CPOT score of
>2. May bolus additional morphine up to 50% of
current infusion rate every 30 minutes if patient
exhibits signs or symptoms of discomfort. Contact
MD with any questions
MORPHine PF injection [800122] 0.1 mg/kg, Intravenous, ONCE For 1 Doses
Do NOT administer if patient has running narcotic
infusion
MORPHine - Early Infusion Protocol [208272]
MORPHine 60 mg in sodium chloride 0.9% 60
mL infusion syringe [755102]
1-20 mg/hr, Intravenous, CONTINUOUS
Initiate at 0.1 mg/kg/hr (Maximum initial dose 10
mg/hour or current rate). Increase infusion rate by
20% every 4 hours if patient exhibits signs or
symptoms of discomfort and has a CPOT score of
>2. May bolus additional morphine up to 50% of
current infusion rate every 30 minutes if patient
exhibits signs or symptoms of discomfort. Contact
MD with any questions
MORPHine PF injection [800122] 10 mg, Intravenous, ONCE For 1 Doses
Do NOT administer if patient has running narcotic
infusion
MORPhine - As Needed Boluses with Continuous
Infusion Option [208273]
MORPHine 60 mg in sodium chloride 0.9% 60
mL infusion syringe [755102]
1-20 mg/hr, Intravenous, CONTINUOUS
Initiate at 0.1 mg/kg/hr (Maximum initial dose 10
mg/hour or current rate). Increase infusion rate by
20% every 4 hours if patient exhibits signs or
symptoms of discomfort and has a CPOT score of
>2. May bolus additional morphine up to 50% of
current infusion rate every 30 minutes if patient
exhibits signs or symptoms of discomfort. Contact
MD with any questions
MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, EVERY 15 MINUTES PRN,
other
If patient has persistant pain symptoms after 3 doses
in 1 hour, start a continuous infusion.
for 4 Minutes
FENTanyl - Early Infusion Protocol [208274]
Page 4 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:14:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

FENTanyl (50 mcg/mL) infusion [800264] 12.5-200 mcg/hr, Intravenous, CONTINUOUS
Initiate at 25 mcg/hr (Maximum initial dose 50
mcg/hour or current rate). May increase infusion rate
by 20% every hour if patient exhibits signs or
symptoms of discomfort and has a CPOT score of >
2. May bolus additional fentanyl up to 25% of current
infusion rate every 10 minutes if patient exhibits
signs or symptoms of discomfort. Contact MD with
any questions
FENTanyl PF injection [800187] 2 mcg/kg, Intravenous, ONCE For 1 Doses
Do NOT administer if patient has running narcotic
infusion
FENTanyl - Early Infusion Protocol [208275]
FENTanyl (50 mcg/mL) infusion [800264] 12.5-200 mcg/hr, Intravenous, CONTINUOUS
Initiate at 25 mcg/hr (Maximum initial dose 50
mcg/hour or current rate). May increase infusion rate
by 20% every hour if patient exhibits signs or
symptoms of discomfort and has a CPOT score of >
2. May bolus additional fentanyl up to 25% of current
infusion rate every 10 minutes if patient exhibits
signs or symptoms of discomfort. Contact MD with
any questions
FENTanyl PF injection [800187] 100 mcg, Intravenous, ONCE For 1 Doses
Do NOT administer if patient has running narcotic
infusion
FENTanyl - As Needed Boluses with Continuous
Infusion Option [208276]
FENTanyl (50 mcg/mL) infusion [800264] 12.5-200 mcg/hr, Intravenous, CONTINUOUS
Initiate at 25 mcg/hr (Maximum initial dose 50
mcg/hour or current rate). May increase infusion rate
by 20% every hour if patient exhibits signs or
symptoms of discomfort and has a CPOT score of >
2. May bolus additional fentanyl up to 25% of current
infusion rate every 10 minutes if patient exhibits
signs or symptoms of discomfort. Contact MD with
any questions
FENTanyl PF injection RANGE [750047] 25-100 mcg, Intravenous, EVERY 15 MINUTES
PRN, pain
If patient has persistant pain symptoms after 3 doses
in 1 hour, start a continuous infusion.
for 1 Minutes
Sedatives (Single Response) [102107]
Midazolam - Early Infusion Protocol [235364]
midazolam (VERSED) 50 mg in dextrose 5 % 50
mL infusion [700236]
1-10 mg/hr, Intravenous, CONTINUOUS
Initiate at 0.1 mg/kg/hr (Maximum initial dose 10
mg/hour or current rate). Titrate rate by 20% of
current rate every 4 hours to maintain a RASS
sedation score of 0. Bolus by dose equal to current
hourly infusion rate every 2 hours if patient exhibits
signs or symptoms of discomfort. Contact MD with
any questions
midazolam (VERSED) injection [800197] 0.05 mg/kg, Intravenous, ONCE For 1 Doses
NOTE: Initial Bolus - Do NOT order if patient has
running midazolam infusion
Midazolam - Early Infusion Protocol [235366]
Page 5 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:14:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

midazolam (VERSED) 50 mg in dextrose 5 % 50
mL infusion [700236]
1-10 mg/hr, Intravenous, CONTINUOUS
Initiate at 0.1 mg/kg/hr (Maximum initial dose 10
mg/hour or current rate). Titrate rate by 20% of
current rate every 4 hours to maintain a RASS
sedation score of 0. Bolus by dose equal to current
hourly infusion rate every 2 hours if patient exhibits
signs or symptoms of discomfort. Contact MD with
any questions
midazolam (VERSED) injection [800197] 10 mg, Intravenous, ONCE For 1 Doses
NOTE: Initial Bolus - Do NOT order if patient has
running midazolam infusio
Midazolam - As Needed Boluses with Continuous
Infusion Option [235368]
midazolam (VERSED) 50 mg in dextrose 5 % 50
mL infusion [700236]
1-10 mg/hr, Intravenous, CONTINUOUS
Initiate at 0.1 mg/kg/hr (Maximum initial dose 10
mg/hour or current rate). Titrate rate by 20% of
current rate every 4 hours to maintain a RASS
sedation score of 0. Bolus by dose equal to current
hourly infusion rate every 2 hours if patient exhibits
signs or symptoms of discomfort. Contact MD with
any questions.
midazolam (VERSED) injection RANGE [750056] 0.5-2 mg, Intravenous, EVERY 15 MINUTES PRN,
sedation, Comfort/Sedation
If patient has persistant RASS score of > 0 after 3
doses in 1 hour, start a continuous infusion.
Lorazepam - Early Infusion Protocol [235370]
lorazepam (ATIVAN) 120 mg/60 mL infusion
syringe [785157]
0.5-5 mg/hr, Intravenous, CONTINUOUS
Initiate at 0.025 mg/kg/hr (Maximum initial dose 2.5
mg/hour or current rate). Titrate rate by 20% of
current rate every 4 hours to maintain RASS
sedation score of 0. Bolus by dose equal to current
hourly infusion rate every 2 hours if patient exhibits
signs or symptoms of discomfort. Contact MD with
any questions.
lorazepam (ATIVAN) injection - Maximum Dose =
2 mg [800053]
0.02 mg/kg, Intravenous, ONCE For 1 Doses
NOTE: Initial Bolus - Do NOT order if patient has
running lorazepam infusion.
Lorazepam - Early Infusion Protocol [235372]
lorazepam (ATIVAN) 120 mg/60 mL infusion
syringe [785157]
0.5-5 mg/hr, Intravenous, CONTINUOUS
Initiate at 0.025 mg/kg/hr (Maximum initial dose 2.5
mg/hour or current rate). Titrate rate by 20% of
current rate every 4 hours to maintain RASS
sedation score of 0. Bolus by dose equal to current
hourly infusion rate every 2 hours if patient exhibits
signs or symptoms of discomfort. Contact MD with
any questions.
lorazepam (ATIVAN) injection - Maximum Dose =
4 mg [800053]
4 mg, Intravenous, ONCE For 1 Doses
NOTE: Initial Bolus - Do NOT order if patient has
running lorazepam infusion.
Lorazepam - As Needed Boluses with
Continuous Infusion Option [221520]
Page 6 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:14:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

lorazepam (ATIVAN) 120 mg/60 mL infusion
syringe [785157]
0.5-5 mg/hr, Intravenous, CONTINUOUS
Initiate at 0.025 mg/kg/hr (Maximum initial dose 2.5
mg/hour or current rate). Titrate rate by 20% of
current rate every 4 hours to maintain RASS
sedation score of 0. Bolus by dose equal to current
hourly infusion rate every 2 hours if patient exhibits
signs or symptoms of discomfort. Contact MD with
any questions.
lorazepam (ATIVAN) injection RANGE [750075] 0.25-1 mg, Intravenous, EVERY 15 MINUTES PRN,
Comfort/Sedation
If patient has persistent RASS score of > 0 after 3
doses in 1 hour, start a continuous infusion.
General [102141]
Note: Contact MD for all medication orders that
are not routinely necessary for comfort [950018]
CONTINUOUS
Consults
Consults [102161]
Consult Spiritual Care (Inpatient) [CON0056] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: End of Life Sustaining Measures
Consult Palliative Care (Inpatient) [CON0055] ONCE, Starting today For 1 Occurrences, Routine
Reason For Consult: End of Life Care/Comfort Care
Page 7 of 7
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:14:19 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org