Stepwise Protocols for Crisis Symptom Management

Read: American Thoracic Society Sudden Breathlessness COMFORT protocol

Step 1: Call for Help and Stay Calm
Alert family, caregiver, or emergency contact using your phone, bell, or hand signal. Encourage calm, slow speech, and steady movements.

If no relief, then…

Step 2: Observe and Support Breathing
Notice signs of distress—fast breathing, neck muscle strain, or fearful expression. Use pursed-lip breathing, count breaths, and focus on slow exhalations.

If no relief, then…

Step 3: Medications
Use prescribed inhaler, nebulizer, or steroids.

If no relief, then…

Step 4: Fan and Oxygen
Use a handheld fan or open window for air across the face.
Use supplemental oxygen if prescribed. Clear secretions or use CPAP/BiPAP as directed by your care team.

If no relief, then…

Step 5: Reassure, Relax, and Take Your Time
Slow down, sit upright, and create a calm environment—soft music, prayer, or guided imagery. Avoid talking until breathing eases.

If no relief, then…

Step 6: Emergency Services

Call emergency services for uncontrolled breathlessness

Step 7: 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