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CAPC Palliative Care Discussion Forum
General Operational Topics
Palliative Sedation PoliciesAuthor: szaglifa
Date: Jun 11, 2009 3:50 pm
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All guidelines apply for I.V. and intramuscular injections. When used for Moderate or Deep
Sedation see separate IV guideline and the Mount Carmel Administrative Policy for definitions
and monitoring guidelines.
A. The patient must be in a Critical Care Unit for a continuous infusion
B. Give IV push doses over at least 2 minutes. Wait at least an additional 2 minutes to fully
evaluate effect.
C. Monitoring: Continuous infusion: Monitor BP every 5 minutes for 1 hour upon initiation of
infusion and after any rate change.
IV Push: Guidelines apply for R.N. or physician administration for uses other than
moderate/deep sedation. Maximum Dose without physician present = 35 micrograms/kg
(0.035 mg/kg). Bolus dosing under the direct supervision of a physician.
1. Continuous pulse oximetry required.
2. Continuous EKG monitoring or intermittent BP monitoring: Monitor BP every 5 minutes
x 4 after the initial dose then every 15 min until patient reaches baseline Aldrete score.
D. For Critical Care sedated patient: Daily sedation interruption (DSI) every 24 hours or as
ordered by physician; Wean down in increments of 1 mg/hour every 2 hours s unless
otherwise specified. DSI should be terminated for certain criteria. See DSI Standard.
E. Concomitant use of narcotics and other CNS depressants may increase the risk of
underventilation or apnea and may contribute to profound and prolonged drug effects.
Midazolam and narcotics both depress ventilatory response to carbon dioxide stimulation.
Continue monitoring for at least 30 minutes after the last IV dose.
F. Standard Concentration: 1 mg/ml
Maximum concentration: 2 mg/ml
G. Because Flumazenil (Romazicon®) does not, uniformly reverse the respiratory depression
effects of benzodiazepines, the monitoring guidelines still must be followed.
H. Do not transport using pneumatic tube system.
I. Must be given under constant supervision for IV push, or for continuous infusion use a locked
device when available.
J. Patients receiving supportive Midazolam may be transferred to any non-monitored bed for
palliative care when the following criteria are met:
1. Patients who are DNR/Comfort Care – Arrest or DNR/Comfort care.
2. Midazolam is no longer being actively titrated or being tapered off.
3. These guidelines do not permit the initiation of Midazolam on non-monitored units except
as listed in guideline above.
K. Contraindications: Acute narrow angle or untreated open-angle glaucoma
References: AHFS 2008
Micromedex 2008
Hope this is helpful. Sharol Herr, RN, BSN, MSEd, CHPN; Nurse Clinician/Education Coordinator; Mount Carmel Health Palliative Care Leadership Center; Columbus, Ohio.
Also, does anybody have a consent form for palliative sedation they are using?