Directions for Use of PCAD Pathway

	Download the PCAD Pathway Form
	Treatments/Interventions/Assessments
	Pain Management
	Tests/Procedures
	Medications
	Fluids/Nutrition
	Activity
	Consults
	Psychosocial Needs
	Spiritual Needs
	Patient/Family Education
	Discharge Planning

These are the instructions for completing the PCAD Pathway form:

The PCAD Pathway is used to provide guidelines for the interdisciplinary management of the imminently dying inpatient. When a primary healthcare provider orders PCAD, the Pathway is filled out and included in the Care Plan section of the patient chart. The start date is filled in for that day, and the elements of care are repeated each day that the patient remains on the PCAD Pathway. The Pre-Admission Consideration/Admission Criteria section is completed when the PCAD is initiated and the Discharge Outcomes section is completed when the patient dies or is discharged.

Suggestions for the management of advanced disease include:

Treatments/Interventions/Assessments

Clarify the Goals of Care of Palliative Care for Advanced Disease (PCAD) with the Patient and/or Family

	The attending physician and/or member of the health care team most familiar with the patient should clarify the goals of care with the patient and/or family
	Family refers to either actual relatives or other key people designated by the patient

Facilitate Discussion and Documentation of Advance Directives

	Provide necessary information for patient and family in making informed advance directive decisions
	Advance directives, if declined by patient and family, are not necessary for continuation of PCAD
	Document discussions

Initiate/Review MD Order Sheet

	Attending physician must write the order for the initiation of the PCAD
	Attending physician or designated house staff should complete the MD Order Sheet and review as patient status necessitates

The major aspects of comfort assessment include:

Interventions

Suggested non-pharmacological comfort interventions include:
Feverish/Diaphoresis
	Cool compresses
	Tepid sponges
	Frequent linen change
Eye Care
	Moisten conjunctiva with ophthalmic lubricating gel or artificial tears or physiological saline solution to avoid painful, dry eyes
Mouth/Lip Care
	Moisten and clean oral mucosa with baking soda mouthwash or artificial saliva preparation
	Coat lips with thin layer of petroleum jelly
	Avoid perfumed lip balms and lemon/glycerine swabs which can be desiccating or irritating
	Obtain order to treat candidiasis
Dyspnea
	Fan to gently circulate air near patient's face
	Encourage relaxation breathing techniques
	Use energy conservation measures/pacing
Skin Care
	Turn every two hours (determine by patient comfort)
	Bathe with mild soap and rinse well
	Moisturize skin at least twice a day by gentle application of skin lotion of the patient's choice
	Assess for redness and apply Opsite™ and/or Duoderm™ on these areas
	Assess need for specialty bed
	Offer gentle massage
	As the patient approaches death, the need for turning lessens as the risk of skin breakdown becomes less important and the goal of comfort is more important
Elimination
	Consider Foley catheters for patient comfort and convenience
	Consider use of condom catheters and adult diapers for incontinence in collaboration with patient and/or family
	Consider non-pharmacological interventions in determining bowel management (e.g., disimpaction, enemas). Intervene only if this is or will be problematic to the patient
Psychosocial/Spiritual
	Support verbalization and anticipatory grieving
	Encourage family caring activities per family preferences when appropriate
	Facilitate verbal and tactile communication, e.g., handholding, touch
	Assist family as needed with nutrition, transportation, childcare, financial, and funeral issues
	Provide opportunity for expression of beliefs, fears, and hopes
	Provide access to religious resources
	Facilitate religious practices
	Integrate complementary modalities such as music, massage

Pain Management

	For Opioid-Naïve Patient: Morphine sulfate 15 mg po or 5 mg SQ/IV. Repeat q 1 hr until pain relief is adequate. Begin morphine sulfate 30 mg po or 10 mg SQ/IV q 4 hr ATC or begin IV morphine sulfate infusion at 2 mg per hour, plus morphine sulfate 15 mg po or 5 mg SQ/IV q 1 hr prn
	For Opioid-Treated Patient: If pain remains uncontrolled, increase fixed schedule dose by 50%. Many non-opioid analgesics are available and should be considered after opioid therapy has been optimized. If pain remains uncontrolled, consider a pain and/or palliative care specialist consult

Tests/Procedures - NONE unless necessary for patient/family comfort

	Labs - Whenever possible, all lab work should be discontinued and only ordered if results would guide treatments geared to comfort
	Diagnostic Tests
	-	Consider necessity based on goals of care
	-	Restrict interventions to patient's history, visual assessment, and physical exam only

Medications

Medication regimens focus on the relief of distressing symptoms. Only treat symptoms if distressing to patient. Suggestions for:
	Dyspnea
	-	For Opioid-Naïve Patient: Morphine sulfate 5 – 15 mg po or 2 – 5 mg SQ/IV. Repeat q 1 hr, if needed. When symptom is improved, begin morphine sulfate 30 mg po or 10 mg SQ/IV q 4 hr ATC; or begin morphine sulfate infusion at 2 mg per hour, plus morphine sulfate 15 mg po or 5 mg SQ/IV q 1 hr prn
	-	For Opioid-Treated Patient: If dyspnea is not controlled, increase fixed schedule dose by 50%. If breathlessness continues, add Lorazepam 0.5mg po or SQ/IV prn. Repeat q 60 minutes if needed until symptom intensity declines, then begin 1 mg po/SQ/IV q 3 hr Additional therapies may include: Dexamethasone 16 mg po/IV, followed by 4 mg po/IV q 6 hr Albuterol 2.5 mg via nebulization q 4 hr prn if wheezing present
	IV Hydration Consider decreasing IV rate to 0.5 – 1 liter/24 hr (1 liter = 41ml/hr)
	Anxiety & Insomnia Lorazepam 0.5 mg po/SQ/IV BID-TID and q HS for anxiety Temazepam 10 – 30 mg po q HS for anxiety/ insomnia Clonazepam 0.5 – 2 mg po BID for anxiety/myoclonus
	Confusion/Agitation Haloperidol 0.5 mg po/SQ/IV. Repeat q 30 minutes until symptom intensity declines. Haloperidol 0.5 – 5 mg po/SQ/IV q 4 hr prn
	Constipation Lactulose 30 ml po q 2 hr prn until constipation relieved. When symptom improves, begin Lactulose 30 ml po q 12 hr Warm Fleets Enema TIW prn To prevent constipation: Senokot 1 – 2 tabs po BID and Colace 1 – 2 tabs po BID
	Diarrhea Loperamide 4 mg po q 4 hr prn
	Fever Acetaminophen 650 mg po/PR q 4 hr prn, and/or Dexamethasone 1.0 mg po/SQ/IV q 12 hr prn
	Hiccups Chlorpromazine 10 – 25 mg po/IM TID prn Haloperidol 0.5 – 2 mg po/SQ/IV TID – QID
	Nausea/Vomiting Metoclopromide 10 mg po/IV q 4 hr prn or, Prochlorperazine 10 mg po/IV q 4 hr or 25 mg PR q 8 hr prn with or without Dexamethasone 4 mg po/IVPB q 6 hr
	Pruritis Diphenhydramine 25 – 50 mg po/IV q 12 hr Hydrocortisone 1% cream to affected areas q 6 hr Dexamethasone 1.0 mg po daily alone or in combination with above
	Stomatitis Viscous Lidocaine 2% to painful areas prn Clotrimazole 10 mg troche 5 times daily Nystatin S & S q 6 hr prn Magic mouthwash prn
	Tracheal Secretions (Noisy Respirations) Scopolamine patches 1.5 – 3 mg 72 hr, or Scopolamine 0.4 mg SQ q 4 – 6 hr

Fluids/Nutrition

	Diet: No restrictions Most patients lose their appetite and reduce food intake long before they reach the last hours of their lives. Loss of appetite is normal. The patient is not hungry and food may not be appealing or may be nauseating. Studies demonstrate that parenteral or enteral feeding of patients neither improves symptom control nor lengthens life and that anorexia may be protective, as ketosis can lead to a greater sense of well-being and diminish pain. There may be an increased risk of aspiration as the patient gets weaker and finds swallowing, particularly of fluids, more difficult
	-	Nutrition to be guided by patient's choice of time, place, quantities and type of food desired
	-	Diet should be guided by the patient's choice of time, place, quantities and type of nutrition desired. Family may provide food
	-	Educate family in nutritional needs of dying patient
	-	Diet Plan:
		-	Eliminate any dietary restrictions (e.g. low sodium, etc.) if possible
		-	A "NO FOOD" request written for any patient will be honored and the dietitian can discuss the appropriateness of the diet plan with the family
		-	Nutrition for Family: Food and beverages can be ordered for family when patient on PCAD (e.g., coffee, tea, guest snacks, or guest trays)
		-	Consider a Nutritional Consult as needed
	IVs for symptom management only
	Most patients reduce their fluid intake, or stop drinking entirely, long before the last hours of their lives. Most experts in the field feel, from direct observation, that dehydration in the last hours of life does not cause distress. Parenteral fluids are sometimes considered to reverse delirium. Their use, however, can lead to fluid overload with consequent excessive edema, worsened breathlessness, cough, and orotracheobronchial secretions, particularly if there is significant hypoalbuminemia. Parenteral fluids can be difficult to maintain if venous access is difficult, and have the potential to prolong the dying process. Consider need for ongoing hydration. Individualize orders. Consideration needs to be given to the necessity for additives. D/C any non-essential additives. If IV fluids are indicated and IV access is difficult for the patient, consider the use of hypodermoclysis. Consider referral to a pain and/or palliative care specialist
	Transfusions for symptom relief only
	-	Orders are to be individualized
	-	Consider need for RBC's and platelets based on goals of care patient response vs. discomfort (e.g., transfusion reaction) and cost
	-	Alternative comfort measures may be available if transfusions are being implemented solely for comfort. Consider alternative treatments for dyspnea, fatigue, etc. Contact a pain and/or palliative care specialist as needed
	I and O
	Consider goals of care before ordering
	Weight
	Consider the risks/benefits relative to patient's level of debilitation and discomfort incurred to obtain a weight. Question how the patient would be weighed before ordering (e.g., bedscale, chair scale)

	Activity determined by patient's preferences and ability. Patient determines participation in ADLs, e.g., turning and positioning, bathing, transfers
	Activity should be reassessed continually and adjusted to meet the needs and ability of the patient. Encourage OOB to chair for bedridden patients. Involve family in taking patient out of room for diversion and stimulation
	Weakness and fatigue frequently increase as death approaches; consider patient safety needs vs. comfort and independence needs
	At the end of life, fatigue need not be resisted and most treatment to alleviate it can be discontinued. Consider passive movement of joints for joint position fatigue

Consults

	Assess for psychological and spiritual distress of both the patient and family. Initiate referrals to institutional specialists to optimize comfort and quality of life in all domains (physical, psychological, cultural, and spiritual). Consider the benefit of a consult by a pain or palliative care specialist for assistance in the management of issues within all these domains throughout the dying process
	Initiate referrals to institutional specialists to optimize comfort and enhance quality of life (QOL)

Psychosocial Needs

Psychosocial Comfort Assessment
	Patient: Assess mental status, cognition, mood, coping skills, fears/concerns/goals, cultural practices, depression, suicidal ideation
	Primary Caregiver/Family: Assess distress, coping skills, communication with patient, personal health, financial concerns, dependents, concurrent crisis
	Grieving Process – Patient & Family: Assess awareness/acceptance of impending loss, anticipatory grieving process, risk factors for complicated mourning
Psychosocial Support - Referral to Social Work
	Entry onto PCAD triggers an automatic notification to Social Work
	Provide comprehensive psychosocial support for patient and family by optimizing involvement of existing and previously involved supports (e.g., Social Work, Chaplaincy, Pain and Palliative Care Service, Psychiatry, etc.). Consider complementary modalities, such as music or massage therapy. Minimize distress and normalize feelings:
	-	Offer emotional support and support expressions of feelings, fears, concerns, and wishes
	-	Support verbalization and the grieving process before, during, and after death with families
	-	Encourage family caring activities as appropriate/individualized to family situation and culture
	-	Facilitate verbal and tactile communication
	-	Respect patient's cultural needs and rituals
	Assist family with nutrition, transportation, child care, financial, funeral issues
	Educate family regarding bereavement process and resources
	Be aware of risk factors for complicated mourning including:
	-	Death of a spouse or a child
	-	Death of a parent (particularly in early childhood or adolescence)
	-	Sudden, unexpected, and untimely deaths (particularly if associated with horrific circumstances)
	-	Multiple deaths
	-	Deaths by suicide
	-	Survivors with low esteem, low trust in others, previous psychiatric disorders, previous suicidal threats or attempts, or absent or unhelpful family
	-	Survivors with an ambivalent attachment to deceased person, dependent or interdependent attachment to deceased person, or insecure attachment to parents in childhood (particularly learned fear and learned helplessness)

Spiritual Needs

	Spiritual comfort assessment of religious denomination, prayer/scriptural resources, religious/spiritual life, rituals, religious/spiritual practices, spiritual distress
	Spiritual support: Referral to Chaplain Entry onto PCAD triggers an automatic notification to Chaplaincy
	-	Provide opportunity for expression of beliefs, fears, and hopes
	-	Provide opportunity for patient and family to utilize spiritual, religious and philosophical beliefs and actualize practices

Patient/Family Education

Assess needs and provide education regarding:

	Goals of Palliative Care for Advanced Disease Pathway
	Physical and Psychosocial Needs During the Dying Process
	Nutrition/Hydration
	Physical Comfort – Symptom Management
	Grieving Process
	Coping Techniques/Relaxation Techniques/ Imagery/Meditation/Massage
	Bereavement Process and Resources

Discharge Planning

	For discharge to community: refer to pain and palliative care specialists/hospice/home care/social work as needed
	At time of death provide:
	-	Post mortem care observing cultural and religious practices and preferences
	-	Care of the patient's possessions as per family wishes
	-	Bereavement support for family
	-	Debriefing session for staff
	-	Send condolence card with bereavement resources about local community groups

For More Information about PCAD please contact:

Marilyn Bookbinder, RN, PhD
Director of Nursing
Dept of Pain Medicine and Palliative Care
Beth Israel Medical Center
First Avenue at 16th Street
New York, NY 10003
Fax: (212) 844-1503
Phone: (212) 844-1462

Acknowledgment

This Pathway Manual would not have been possible without the expertise, diligence and coordinating efforts of Elizabeth Arney, RN, MS and the BIMC Quality Improvement End-of-Life Care Team.