Transcript MANAGEMENT OF NONPAIN SYMPTOMS AT THE END OF LIFE

MANAGEMENT OF NON-PAIN
SYMPTOMS AT THE END OF
LIFE
Cornerstone Hospice
Lucy W. Ertenberg, M.D.
Vice President/Chief Medical Officer
Objectives
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Recognize the range of symptoms at the
end of life
Discuss the pharmacological interventions
used in relief of these symptoms
Recognize effects and side effects of
medications used in end of life symptom
management
Hospice Pharmacia
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Provides enteral and topical medications
for thousands of hospice patients
Compounds multiple medications into
suspensions, topical gels and suppositories
PARENTERAL
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Cornerstone Hospice does do continuous IV and
subcutaneous infusions.
Cornerstone Hospice does do Patient Controlled
Analgesia (PCA) which is used only by alert
patients who are able to judge their own pain
needs.
Bolus infusions are administered by nursing staff
or by family/caregivers educated in recognizing
the signs of pain and in the correct use of the
medication and equipment.
SUBCUTANEOUS
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HOSPITALS usually require that equipment
used in the hospital has been approved
and inspected by the hospital and that the
staff has received instruction on its use.
Therefore, outside equipment will be
changed out to hospital equipment.
BLUE PLATE SPECIAL
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Morphine Sulfate (Roxanol) 20 mg/ml
Begin with 0.25 ml (5 mg) every 4 hours as needed
for pain or dyspnea
Lorazepam (Ativan) 0.5 mg tablet (may be
dissolved in 5 ml water used sublingually) or liquid
2 mg/ml
Begin with 0.5 mg every 6 hours as needed for
agitation
Atropine 1% Ophthalmic Drops
Begin with 2drops SUBLINGUAL every four hours
as needed for secretions
JCAHO Facilities
Require an indication for each medication
 Do not allow ranges for doses or times,
therefore write;
“Morphine sulfate 20 mg/ml 0.25 (5 mg)
every 3 hours as needed for moderate
pain”
“Morphine sulfate 20mg/ml 0.5ml (10mg)
every 3 hours as needed for severe pain”
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FIRST
Look for a treatable CAUSE
of the symptom and…
Treat the cause!
DYSPNEA
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Subjective—Dyspnea is how the patient
tells you he feels.
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Breathless
Short of Breath
Hard to Breathe
Objective—What you can measure
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Tachycardia
Tachypnea
Hypoxia
DYSPNEA
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Opioids reduce the feelings of
breathlessness and should be considered
for use in all (End of Life) patients unless
otherwise contraindicated”
DYSPNEA
Check the
Respiratory Rate
ANXIETY/AGITATION
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Benzodiazepines
Lorazepam—begin with 0.5 mg every 6 hours as needed
Tablet 0.5 and 1mg
Liquid 2 mg/ml
Gel 1 mg/ml
Suppository 2 mg
Alprazolam (Xanax)—begin with 0.25 mg every 6 hours
as needed
Tablets 0.5 and 1 mg
Liquid 1 mg/ml
CAVEAT
Always review the medication list for the use
of
OTHER BENZODIAZEPINES
AGITATION WITH
HALLLUCINATIONS
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Neuroleptics
Haloperidol (Haldol) begin with 1 mg
every 6 hours as needed
Tablets 0.5, 1, 2, 5 mg
Liquid 2 mg/ml
Suppository 1, 2, 5 mg
Gel 1 mg/ml
Injections 5 mg/ml
AGITATION WITH
HALLUCINATIONS
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Neuroleptics
Chlorpromazine (Thorazine) begin with 25
mg every 6 hours as needed
Tablets 25, 50,100 mg
Liquid 100 mg/ml
Gel 100mg/ml
Suppository 25, 50, 100 mg
AGITATION WITH
HALLUCINATIONS
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Neuroleptics
Resperidone (Risperdal) begin with 0.5
mg at bed time
Tablets 0.25, 0.5, 1, 2, 3, 4 mg
Liquid 1mg/ml
CAVEAT
If you don’t give them enough lorazepam,
you will just make them MAD!
If you don’t give them enough haloperidol,
you will just make them MAD!
ANTIPSYCHOTICS
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Conventional (First Generation)
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Chlorpromazine—Thorazine
Haloperidol—Haldol
Atypical (Second Generation)
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Aripiprazole—Abilify
Olanzaprine—Zyprexa
Quetiapine—Seroquel (Use with Parkinson’s Disease)
Risperadone—Risperdal
Asenapine—Saphris
ANTIPSYCHOTICS
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Neuroleptics
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Suppresses spontaneous movements and
complex behaviors
Reduce initiative and interest in environment
Reduce manifestations of emotions
ANTIPSYCHOTICS
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Antipsychotics
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Initially drowsy or slowed
Easily awakened and answer questions
Intact cognition
Gradually fewer hallucinations and delusions
More coherence and organization
ANTIPSYCHOTICS
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Side Effects
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Bradykinesia
Rigidity
Tremor
Akathesia (Subjective Restlessness)
Tardive Dyskinesia
ANTIPSYCHOTICS
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There is NO FDA approved antipsychotic
medication for the treatment of dementia
related psychosis.
ANTI PSYCHOTICS
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Fatal ventricular arrhythmia—Torsades
ANTIPSYCHOTICS
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Beer’s List
Chemical Restraints
CAVEAT
Some Long Term Care Facilities may not
accept patients on …
Haloperidol
or
Chlorpromazine
SECRETIONS
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Hyoscyamine (Levsin) Begin with 0.125 mg every
4 hours as needed
Tablets 0.125 mg
Liquid 0.125 mg/ml
Gel 0.125 mg/ml
Atropine 1% Ophthalmic Drops Begin with 3 drops
every 4 hours as needed
Atropine 1% Ophthalmic Drops—Use orally or
sublingually
Scopolamine Begin with one patch changed every
3 days
Trans derm-Scop
NAUSEA
*Target Your Therapy*
•
Abdominal Spasms
*Hyoscyamine
*Dicyclomine (Bentyl) begin with 10 mg
every 4 hours as needed
Tablets 10, 20 mg
Liquid 10 mg/ml
NAUSEA
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Delayed Gastric Emptying
Metoclopramide (Reglan) Begin with 10
mg 4 times a day OR 10 mg before meals
and at bedtime
Tablets 10mg
Liquid 5 mg/ml or 5 mg/5ml
Injection 10 mg/2ml (5mg/ml in 2 ml vial)
NAUSEA
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Vestibular
Scopolamine
Meclizine (Over the Counter ‘OTC’) Begin
with 12.5 mg every 6 hours as needed
Tablets 12.5, 25 mg
Liquid 12.5 mg/5ml
NAUSEA
 Chemoreceptor
Trigger Zone
(CTZ)
Zofran
Anzemet
Kytril
NAUSEA
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NON SPECIFIC CAUSE
Prochlorperazine(Compazine) Begin with 10 mg
every 6 hours as needed
Tablets 5, 10 mg
Liquid 10mg/ml
Suppositories 10, 25 mg
Gel 25mg/ml
Promethazine (Phenergan) Begin with 25 mg
every 6 hours as needed
Tablets 12.5, 25, 50 mg
Liquid 25 mg/ml
Suppositories 12.5, 25, 50 mg
Gel 25 mg/ml
NAUSEA
NON SPECIFIC CAUSE
Dexamethasone (Decadron) Begin with
2mg each morning
Tablets 0.5, 0.75, 1, 2, 4 mg
Liquid 4 mg/ml, 10 mg/ml
Suppository 4, 8, 20 mg
Gel 4 mg/ml
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NAUSEA
“Shot Gun”
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ABHR
Ativan
Capsule 0.5
Liquid 0.5
Supp
0.5
Gel
1
Benadryl
12.5
12.5
12.5
25
Haldol Reglan
0.5
10
mg
0.5
10 mg/5ml
0.5
10
1
10 mg/ml
CAVEAT
DO NOT USE METOCLOPRAMIDE
(Reglan = ‘R’ in ABHR)
IF THERE IS ANY CHANCE OF
BOWEL OBSTRUCTION
SEIZURES
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ACUTE
Lorazepam suppository 2 mg
1. Begin with one 2mg suppository
2. If seizure not controlled, repeat 2 mg
suppository in 5 minutes and then 10
minutes
Seizures
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Maintenance
Continue anti-seizure medications
throughout illness whenever possible
CAVEAT
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If Cornerstone Hospice home patient or
ALF patient has a risk of seizures (i.e.
possible brain metastases) or has a history
of seizures, a SEIZURE KIT can be
ordered from Hospice Pharmacia to be
kept on hand, in the refrigerator.
SEIZURE KITS Contain:
LORAZEPAM SUPPOSITORIES 2mg (3)
HICCUPS
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If due to dyspepsia or Gastro-Esophageal
Reflux Disease (GERD)
Metoclopramide Begin with 10 mg
every 8 hours as needed
HICCUPS
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If due to tumor or central cause
*Baclofen begin with 10 mg every 8
hours as needed
*Haloperidol
*Chlorpromazine
Steroids
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Dexamethasone
*Anorexia
*Bone Pain
*Edema Reduction Around Tumor Site
*Mood elevation (Steroid High)
*Wheezing
CAVEAT
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STEROID use may lead to psychosis
particularly in formerly psychotic patients
or bi-polar patients
Avoid steroids in formerly psychotic, manic
or schizophrenic patients
Use steroids very cautiously beginning at
very low doses in Bi-polar patients
HOSPICE PHARMACIA
COMFORT KIT
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Can be ordered for all Cornerstone Hospice
home patients.
The Comfort Kit is kept
in the REFRIGERATOR
COMFORT KIT
(CK)
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Acetaminophen (Tylenol) Suppositories 6
650 mg
Haloperidol Liquid 2mg/ml
15 ml
Atropine 1% Ophthalmic Drops
2 ml
Lorazepam Tablets 1 mg
10
Morphine Sulfate Liquid 20mg/ml
15ml
Prochloperazine Tablets 10mg
6
Prochloperazine Suppositories 25 mg
6
PALLIATIVE SEDATION
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“Palliative Sedation” is the use of high
doses of sedatives to relieve extremes of
physical and emotional distress in the final
days of life.
The goal is to render the patient
unconscious to relieve suffering, not to
intentionally end life.
LAST DOSE PHENOMENON
BIBLIOGRAPHY
‘Atypical Antipsychotic Drugs and the Risk of Sudden Cardiac Death’,
New England Journal of Medicine; Volume 360 #3, January 15,
2009.
Depression in Later Life: A Diagnostic and Therapeutic Challenge’,
American Family Physician; May 15, 2008.
Medication Use Guidelines, Tenth Edition, Hospice Pharmacia, 2009.
‘Use of Antipsychotic Drugs in Dementia: What’s All the Agitation
About?’, Palliative Medicine Matters; Volume 2, Number 3, Fall 2008.
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