. 2020 Apr 8;60(1):e27–e30. doi: 10.1016/j.jpainsymman.2020.03.030

Table 1.

Recommendations for Conservative and Palliative Care Management of COVID-19 Patients (3D-TiCoS)

Phase of Illness	Monitoring (Nursing)	Drugs for Symptom Control
Stable: EWS¹: ≤7 RR: ≤25/minute O₂ Sat: >88% (with Venturi mask up to 60%)	• 3D assessment and vital signs once per shift • Evaluate pressure areas & need for pressure relieving mattress • Intensify communication with the family and prepare that sick enough to die	Dyspnea/pain: Morphine PO 2–5 mg, 4 hourly with rescue doses (10%–20% of the total daily dose) or PRN Anxiety: Lorazepam sublingual 1–2.5 mg, 8 hourly or PRN or Levomepromazine PO 5–10 mg, 6 hourly or PRN Fever: Paracetamol PO 1 g, 6 hourly or PRN Shivers: Morphine 2–5 mg IV/SC PRN or Pethidine 25–50 mg SC PRN Prescribing opioids in renal insufficiency: choose Hydromorphone (accordingly to palliative care consultation) Temporary de-prescribing of usual drugs
Unstable: EWS¹ >7 RR: >25/minute O₂ Sat: <88%	• 3D assessment twice per shift and stop vital signs measurement • O₂ delivery maximum 4 L • Observe respiratory effort • Inform the family that patient now unstable and propose visit	Dyspnea/pain: Morphine IV/SC 5 mg, 2–4 hourly with rescue doses (10%–20% of the total daily dose) or PRN Anxiety/delirium/distress: Diazepam 2.5–5 mg IV or rectal 10 mg 8–12 hourly with rescue doses PRN or chlorpromazine 12.5–25 mg IV PRN or levomepromazione 6.25–25 mg SC PRN Fever: Diclofenac 75 mg IV with rescue doses PRN or paracetamol rectal 600 mg, 6 hourly Shivers: Morphine 5 mg IV/SC PRN or pethidine 25–50 mg SC PRN Hydration maximum 250 mL/day Suspend futile treatments
End-of-Life: ARDS O₂ Sat: <70%	• 3D assessment twice per shift if patient alert • Assess ABDT₂ twice per shift if patient does not communicate • Stop O₂ • Inform the family and re-evaluate for family visits • Basic care and mouth care	Terminal dyspnea–Respiratory distress: • Morphine IV/SC 5 mg (up to every hour) with rescue doses (10%–20% of the total daily dose) or PRN. Evaluate continuous infusion with palliative care team • Diazepam 2.5–5 mg IV or rectal 10 mg 8–12 hourly with rescue doses PRN Hyperactive delirium: • Diazepam 2.5–5 mg IV or rectal 10 mg 8–12 hourly with rescue doses PRN • Chlorpromazine 12.5–50 mg IV PRN or levomepromazione 12.5–50 mg SC PRN Fever: Diclofenac 75 mg IV with rescue doses PRN or paracetamol rectal 600 mg, 6 hourly Shivers: Morphine 5 mg IV/SC PRN or pethidine 25–50 mg SC PRN

Phase of Illness

Monitoring (Nursing)

Drugs for Symptom Control

Stable:

EWS¹: ≤7
RR: ≤25/minute
O₂ Sat: >88% (with Venturi mask up to 60%)

•
3D assessment and vital signs once per shift
•
Evaluate pressure areas & need for pressure relieving mattress
•
Intensify communication with the family and prepare that sick enough to die

Dyspnea/pain: Morphine PO 2–5 mg, 4 hourly with rescue doses (10%–20% of the total daily dose) or PRN
Anxiety: Lorazepam sublingual 1–2.5 mg, 8 hourly or PRN or Levomepromazine PO 5–10 mg, 6 hourly or PRN
Fever: Paracetamol PO 1 g, 6 hourly or PRN
Shivers: Morphine 2–5 mg IV/SC PRN or Pethidine 25–50 mg SC PRN
Prescribing opioids in renal insufficiency: choose Hydromorphone (accordingly to palliative care consultation) Temporary de-prescribing of usual drugs

Unstable:

EWS¹ >7
RR: >25/minute
O₂ Sat: <88%

•
3D assessment twice per shift and stop vital signs measurement
•
O₂ delivery maximum 4 L
•
Observe respiratory effort
•
Inform the family that patient now unstable and propose visit

Dyspnea/pain: Morphine IV/SC 5 mg, 2–4 hourly with rescue doses (10%–20% of the total daily dose) or PRN
Anxiety/delirium/distress: Diazepam 2.5–5 mg IV or rectal 10 mg 8–12 hourly with rescue doses PRN or chlorpromazine 12.5–25 mg IV PRN or levomepromazione 6.25–25 mg SC PRN
Fever: Diclofenac 75 mg IV with rescue doses PRN or paracetamol rectal 600 mg, 6 hourly
Shivers: Morphine 5 mg IV/SC PRN or pethidine 25–50 mg SC PRN
Hydration maximum 250 mL/day
Suspend futile treatments

End-of-Life:

ARDS
O₂ Sat: <70%

•
3D assessment twice per shift if patient alert
•
Assess ABDT₂ twice per shift if patient does not communicate
•
Stop O₂
•
Inform the family and re-evaluate for family visits
•
Basic care and mouth care

Terminal dyspnea–Respiratory distress:

•
Morphine IV/SC 5 mg (up to every hour) with rescue doses (10%–20% of the total daily dose) or PRN. Evaluate continuous infusion with palliative care team
•
Diazepam 2.5–5 mg IV or rectal 10 mg 8–12 hourly with rescue doses PRN

Hyperactive delirium:

•
Diazepam 2.5–5 mg IV or rectal 10 mg 8–12 hourly with rescue doses PRN
•
Chlorpromazine 12.5–50 mg IV PRN or levomepromazione 12.5–50 mg SC PRN

Fever: Diclofenac 75 mg IV with rescue doses PRN or paracetamol rectal 600 mg, 6 hourly
Shivers: Morphine 5 mg IV/SC PRN or pethidine 25–50 mg SC PRN

COVID-19 = coronavirus disease 2019; 3D-TiCoS = 3D-Ticino 2019-nCov Score; EWS¹ = Early Warning Score and rules for 2019-novel coronavirus-infected patients; RR = respiratory rate; O₂ sat = oxygen saturation; 3D = dyspnea, distress, and discomfort/pain (from Italian: Dispnea, Distress, and Dolori); Vital signs = blood pressure, oxygen saturation, pulse, and body temperature; PRN = pro re nata (as needed); PO = per os (by mouth); SC = subcutaneously; IV = intravenous; ARDS = acute respiratory distress syndrome; ABDT₂ = agitation, shivering (hyperthermia), distress, tachycardia, and tachypnea (from Italian: Agitazione, Brividi (ipertermia), Distress, Tachicardia e Tachipnea).