Oak Crossing Advanced Care Orders

Resident:______MRC:______

In my judgment, the resident has a diagnosis or combination of clinical conditions that have advanced (or will continue to deteriorate to a point that the average resident with that level of illness would not be expected to survive more than 6 months. Please check all that apply:

Advanced Cardiac DiseaseCancerAdvanced Neurological DisorderAdvanced Pulmonary DiseaseAdvanced Dementia

Advanced Liver DiseaseStrokeAdvanced Renal DiseaseOther:______

Polst on file? Y/N Last updated?______Advanced Directives on file? Y/N . If no, expressed wishes:______

Orders: Advanced Care Team:  Consultation.  Assessment and treat. Assume Care

Diet: As tolerated. May provide supplements.May hold all oral food and fluids if unable to swallow. Wishes to withhold regular meals and snacks will be respected.

Activity:As tolerated.Reposition for comfort every 2 hours unless Resident/family request otherwise. Namaste program for comfort – family/loved ones may participate

Clinical Monitoring: Routine Vital Signs may be held unless requested from Resident/familyRoutine Weights may be held unless requested by Resident/family. Routine BG monitoring may be held unless requested from Resident/Family. Routine Oxygen SATS may be held unless requested from Resident/family. Routine Labs may be held unless requested by Resident/family

Symptom Management:  Subcutaneous Medications may be given using subcutaneous butterfly. Generic medications may be used, crush and give with liquid/food if able to tolerate.  If unable to swallow discontinue any oral supplements, medications, food and fluids.

Shortness of Breath:Oxygen per nasal canula 2-5 L PRN. Morphine Sulphate 2.5 mg bucc every 1 hours prn 20mg/ml. #30 ml’s no refill

Lorazepam 2mg/ml 0.25mg buccal every 4 hours pRN #30ml no refill

Secretions:Oral Sunction as needed. Atropine 1 gtt subl every 4 hours PRN #1bottle 15ml, no refills

Nausea: Compazine 5 mg po tid as needed for nausea

Pain: (Mild) Pain Scale 1-3:Use Acetaminophen per standing orders.

(Moderate) Pain Scale 4-6:Hydrocodone/Acetaminophen 5/325mg 1 tab pO every 4 hours PRN. #10, no refills

(Severe) Pain Scale 7-10:Morphine Sulfate 2.5mg buccal every 1 hour PRN 20mg/ml #30 ml’s, no refill

Anxiety/agitation/restlessness: Lorazepam 2mg/ml 0.25mg buccal every 4 hours PRN #30ml, no refill*Terminal restlessness – consult provider

Physician SignatureDEA#Date

______

*Print POLST and Advanced Directives for provider review.

*Transcribe the following orders into the Resident chart.

*Scan this document into EMR and file under Physician Orders titled: Comfort Care Orders