Hi, everyone. We are getting ready to roll out our new protocols here in Delaware on November 1st. Here's probably the biggest "hot button" protocol for this year's update. I just wanted to get some opinions on this one, and I was wondering if anyone has anything similar.
Please excuse the formatting as I copied and pasted it from a PDF.
COMFORT CARE/END OF LIFE CARE
INDICATIONS: An adult patient has a life limiting/terminal illness, prefers focus of treatment to be comfort and has a valid DMOST form specifying “Treatment of Symptoms Only/Comfort Measures,” or the patient is confirmed to be enrolled in hospice care.
Exclusion: patients who are FULL CODE.
Patients or family may choose to exit this protocol at any time.
The goal of comfort care is to reduce patient’s symptoms and distress and maintain patient dignity by aligning their care with their stated end-of-life preferences. All interventions should be minimally invasive with the goal of keeping the patient comfortable and reducing pain. If the patient is enrolled in hospice care, contact the hospice care agency.
Discuss with the patient and/or caregiver the reason for calling 911 and their goals of care. Review home management versus transport options and engage in shared decision-making. If clinically appropriate, consider treatment on scene. If the patient cannot be safely or comfortably managed at home, arrange transport to the hospital.
If there are any unresolvable issues regarding an appropriate treatment plan, contact medical control.
Do not administer Naloxone.
Ensure patient is warm, clean, dry, and comfortable. Use supplemental oxygen as needed for patient comfort. Suction the airway as needed for patient comfort.
Administer Ondansetron (Zofran) 8mg ODT, IM or IV for any nausea. For refractory nausea/vomiting, after 10 minutes, administer 1.25 mg Droperidol IM or slow IV push.
Treat for pain based on patient’s subjectively reported symptoms. Acetaminophen, Ketorolac, and Fentanyl may be given concurrently. Hypotension is not a contraindication for Fentanyl during Comfort Care.
Acetaminophen (Tylenol): Give 975-1000 mg of Tylenol PO if patient can tolerate PO.
Ketorolac (Toradol): Give 15 mg IM or IV.
Fentanyl: Give 100 mcg of Fentanyl IM or IV. Can be re-dosed after 5 minutes for persistent pain. Maximum total of 400mcg permitted. Contact medical control for additional doses.
Contact Medical Control for consideration of Ketamine to treat refractory pain.
Treat anxiety based on patient’s subjectively reported symptoms. During Comfort Care it is acceptable to administer Fentanyl and Midazolam concurrently. Hypotension is not a contraindication for Midazolam during Comfort Care.
Midazolam (Versed): Give 2mg IV or 5mg IM. Contact medical control for additional doses.
For hypersecretion, administer 0.5mg Ipratropium Bromide (Atrovent) by nebulizer.
May assist family with utilization of hospice provided comfort pack.
Patient disposition may include:
• Transfer of care to hospice.
• Transport if necessary.
• Refusal of transport. o To include release of care to family. Contact medical control if interventions have been performed for refusal.
• Telemetric pronouncement of death.