Stepwise Protocols for Crisis Symptom Management

Step 1: Optimize underlying disease treatment
If no relief, then...

Step 2: Check oxygen saturation – supplement if below 90%
If no relief, then...

Step 3: Start opioid (and introduce laxative – see Constipation protocol)

• ORAL or SL: Morphine Sulfate: 15 mg ½-1 tablet every 4 hours AROUND THE CLOCK.
• IV or SQ: Morphine 5 mg IV or SQ every 3 hours around the clock. Increase by 50% for pain unrelieved by starting dose.

If no relief, then…

Step 4: Referral to palliative care

Step 1: Non-opioid pharmacological therapy
Acetaminophen 500mg by mouth every 6 hours prn (avoid in liver disease)
[Read: NSAIDS contraindicated in COVID-19]

If acetaminophen not effective, then…

Step 2: Start opioid (and introduce laxative – see Constipation protocol)

• ORAL or SUBLINGUAL: Morphine Sulfate: 15 mg ½-1 tablet every 4 hours AROUND THE CLOCK (once we know what the average daily total requirement is to keep pain or dyspnea below a 5 out of 10, switch to a long-acting pain medicine).
• IV or SQ: Morphine 5 mg IV or SQ every 3 hours around the clock.

Increase by 50% for pain unrelieved by starting dose.
If not effective, then…

Step 3: Referral to palliative care

Step 1: Full examination – look for sources of pain/distress including constipation, urinary retention, pressure ulcers

Step 2: Review medication list - delete all non-essential medication to reduce anticholinergic burden
Read: American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults

Step 3: Pain is a leading cause of delirium – try non-opioid pharmacological therapy
Acetaminophen 500mg by mouth every 6 hours prn (avoid in liver disease)
Read: NSAIDS contraindicated in COVID-19

If acetaminophen not effective, then…

Step 4: Start opioid (and introduce laxative – see Constipation protocol)

• ORAL or SL: Morphine Sulfate: 15 mg ½-1 tablet every 4 hours AROUND THE CLOCK.
• IV or SQ: Morphine 5 mg IV or SQ every 3 hours around the clock.

Increase by 50% for pain unrelieved by starting dose.
If not effective, then…

Step 5: Haloperidol (Haldol)

• ORAL or SUBLINGUAL:
  • Haloperidol liquid (Haldol): 2 mg per ml, Give ¼ ml to ½ ml by mouth or under tongue every hour until relief or calm.
  • Haloperidol tablets: 1 mg tablet, give half tablet every 1 hour until calm, increase to full tablet if no relief from starting dosage.
• IV or SQ: Haloperidol 2 mg/ml ¼ ml every hour until relief, increase to ½ ml if no relief from starting dosage.

If haloperidol not effective, then…

Step 6: Lorazepam

• ORAL or SUBLINGUAL:
  • Lorazepam liquid (Ativan): 2 mg per ml, give ¼ to ½ ml by mouth or under tongue every hour until relaxed/calm. Increase to 1ml if no relief from starting dosage.
  • Lorazepam tablets: 1 mg tablet, give ½ tablet every hour until calm, increase to 1 tablet if no relief.
• IV or SQ: Lorazepam 1 mg/ml, give ½ ml every hour until relief, increase to 1 ml if no relief from starting dose.

If lorazepam not effective, then…

Step 7: Referral to palliative care

Step 1: Reverse underlying cause if possible (GI obstruction, vertigo, constipation)

Step 2: Treat empirically with metaclopramide (Reglan) or ondansetron (Zofran)

• ORAL or SUBLINGUAL: Metoclopramide: 10 mg every 6 hours around the clock OR Ondansetron: 4 mg every 8 hours, increase to 8 mg if no relief from starting dosage.
• IV or SQ: Metoclopramide: 5 mg/ml, give 1 ml every 6 hours around the clock. OR Ondansetron: 0.15 mg/kg IV every 8 hours.

If using either drug for opioid-induced nausea, give 30 minutes before morphine to prevent nausea. This should only be necessary for 3-4 days as nausea wears off with time.
If not effective, then…

Step 3: Haloperidol (Haldol)

• ORAL or SUBLINGUAL:
  • Haloperidol liquid (Haldol): 2 mg/mL, give ¼ to ½ ml by mouth or under tongue every hour until calm.
  • Haloperidol tablets: 1 mg tablet, give 1/2 tablet every hour until calm, increase to full tablet if no relief.
• IV or SQ: Haloperidol: 2 mg/ml ¼ ml every hour until relief, increase to ½ ml if no relief from starting dosage.

If not effective, then…

Step 4: Lorazepam

• ORAL or SUB LINGUAL:
  • Lorazepam liquid (Ativan): 2 mg per ml, give ¼ to ½ ml by mouth or under tongue every hour until relaxed/calm, increase to 1ml if no relief from starting dosage.
  • Lorazepam tablets: 1 mg tablet, give ½ tablet every hour until calm, increase to 1 tablet if no relief.
• IV or SQ: Lorazepam: 1 mg/ml, give ½ ml every hour until relief, increase to 1 ml if no relief from starting dose.

If not effective, then…

Step 5: Referral to palliative care

Step 1: Rule out impaction/obstruction

Step 2: Add polyethylene glycol (Miralax) powder: 1-2 capfuls in water or juice or any liquid you like every day. If no daily bowel movement, increase to 3 capfuls, in divided doses. Over the counter.
If not effective after 48 hours, then…

Step 3: Dulcolax suppository: 1 or 2 per rectum every morning after breakfast. Over the counter.
If not effective after 48 hours, then…

Step 4: Enema – warm tap water, repeat until results (DO NOT use Fleets because of risk of hyperphosphatemia, hypocalcemia, arrhythmia).
If no effect, then…

Step 5: Referral to palliative care