At our community teaching hospital, orders for end of life often lacked instructions to titrate opioids based on evidence-based principles and failed to address nonpain symptoms. An order set and a nursing-driven opioid titration protocol were implemented in August 2016 after extensive education. The purpose of this retrospective preintervention and postintervention study was to evaluate the impact of this intervention on the quality of end-of-life orders. We evaluated 69 patients with terminal illness receiving morphine infusions. After implementation, more morphine infusion orders included an as-needed bolus dose with an objective indication and appropriate instructions on when and how to titrate the infusion compared with before the intervention (94.6% vs 18.8%, P < .0001). Morphine infusion orders were also significantly more likely to include a maximum dose (P = .041) and an initial bolus dose (P < .0001). In addition, prescribers were more likely to order additional medications to manage nausea/vomiting, constipation, anxiety, or pain using a nonopioid (P < .05 for all). In this study, implementation of a standardized opioid titration protocol and symptom management order set led to an improvement in the quality of morphine infusion orders for pain management at the end of life and increased the use of medications to manage nonpain symptoms in dying patients.

Data were analyzed using descriptive statistical techniques and content analysis of open-ended responses. Results. Obtained 385 responses from 44 states and nine countries. 77% female, 23% male ranging in age from 24-76 years and with 1-50 years in practice. Respondents included physicians, advanced practice nurses, RNs, SWs, and chaplains. The majority had a working knowledge of PTSD, less for PTSD at end of life. 62% routinely screen for PTSD. 53% use medications to manage PTSD, the most common being sertraline. Therapy/counseling often delivered by SWs are commonly used non-pharmaceutical interventions. Open-ended comments discussed under-recognition, challenges, knowledge limits, and care of Veterans.