MANAGEMENT OF NON-PAIN SYMPTOMS AT THE END OF LIFE

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MANAGEMENT OF NON-PAIN SYMPTOMS AT THE END OF LIFE

• Cornerstone Hospice
• Lucy W. Ertenberg, M.D.
• Vice President/Chief Medical Officer

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Objectives

• 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

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Hospice Pharmacia

• Provides enteral and topical medications for
  thousands of hospice patients
• Compounds multiple medications into suspensions,
  topical gels and suppositories

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PARENTERAL

• 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.

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SUBCUTANEOUS

• 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.

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BLUE PLATE SPECIAL

• 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

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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!
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DYSPNEA

• SubjectiveDyspnea is how the patient tells you
  he feels.
• Breathless
• Short of Breath
• Hard to Breathe
• ObjectiveWhat you can measure
• Tachycardia
• Tachypnea
• Hypoxia

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DYSPNEA

• Opioids reduce the feelings of breathlessness and
  should be considered for use in all (End of Life)
  patients unless otherwise contraindicated

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DYSPNEACheck the Respiratory Rate
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ANXIETY/AGITATION

• Benzodiazepines
• Lorazepambegin 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

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CAVEAT

• Always review the medication list for the use
• of
• OTHER BENZODIAZEPINES

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AGITATION WITH HALLLUCINATIONS

• 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

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AGITATION WITH HALLUCINATIONS

• 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

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AGITATION WITH HALLUCINATIONS

• Neuroleptics
• Resperidone (Risperdal) begin with 0.5 mg at
  bed time
• Tablets 0.25, 0.5, 1, 2, 3, 4 mg
• Liquid 1mg/ml

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CAVEAT

• If you dont give them enough lorazepam, you
  will just make them MAD!
• If you dont give them enough haloperidol, you
  will just make them MAD!

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ANTIPSYCHOTICS

• Conventional (First Generation)
• ChlorpromazineThorazine
• HaloperidolHaldol
• Atypical (Second Generation)
• AripiprazoleAbilify
• OlanzaprineZyprexa
• QuetiapineSeroquel (Use with Parkinsons
  Disease)
• RisperadoneRisperdal
• AsenapineSaphris

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ANTIPSYCHOTICS

• Neuroleptics
• Suppresses spontaneous movements and complex
  behaviors
• Reduce initiative and interest in environment
• Reduce manifestations of emotions

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ANTIPSYCHOTICS

• Antipsychotics
• Initially drowsy or slowed
• Easily awakened and answer questions
• Intact cognition
• Gradually fewer hallucinations and delusions
• More coherence and organization

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ANTIPSYCHOTICS

• Side Effects
• Bradykinesia
• Rigidity
• Tremor
• Akathesia (Subjective Restlessness)
• Tardive Dyskinesia

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ANTIPSYCHOTICS

• There is NO FDA approved antipsychotic medication
  for the treatment of dementia related psychosis.

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ANTI PSYCHOTICS

• Fatal ventricular arrhythmiaTorsades

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ANTIPSYCHOTICS

• Beers List
• Chemical Restraints

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CAVEAT

• Some Long Term Care Facilities may not accept
  patients on
• Haloperidol
• or
• Chlorpromazine

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SECRETIONS

• 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 DropsUse orally or
  sublingually
• Scopolamine Begin with one patch changed every 3
  days
• Trans derm-Scop

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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

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NAUSEA

• 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)

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NAUSEA

• 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

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NAUSEA

• Chemoreceptor Trigger Zone (CTZ)
• Zofran
• Anzemet
• Kytril

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NAUSEA

• 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

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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

• ABHR
• Ativan Benadryl Haldol Reglan
• Capsule 0.5 12.5 0.5 10 mg
• Liquid 0.5 12.5 0.5 10 mg/5ml
• Supp 0.5 12.5 0.5 10
• Gel 1 25 1 10 mg/ml

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CAVEAT

• DO NOT USE METOCLOPRAMIDE
• (Reglan R in ABHR)
• IF THERE IS ANY CHANCE OF
• BOWEL OBSTRUCTION

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SEIZURES

• 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

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Seizures

• Maintenance
• Continue anti-seizure medications throughout
  illness whenever possible

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CAVEAT

• 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)

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HICCUPS

• If due to dyspepsia or Gastro-Esophageal Reflux
  Disease (GERD)
• Metoclopramide Begin with 10 mg every 8
  hours as needed

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HICCUPS

• If due to tumor or central cause
• Baclofen begin with 10 mg every 8
  hours as needed
• Haloperidol
• Chlorpromazine

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Steroids

• Dexamethasone
• Anorexia
• Bone Pain
• Edema Reduction Around Tumor Site
• Mood elevation (Steroid High)
• Wheezing

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CAVEAT

• 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

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HOSPICE PHARMACIA COMFORT KIT

• Can be ordered for all Cornerstone Hospice home
  patients.
• The Comfort Kit is kept
• in the REFRIGERATOR

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COMFORT KIT(CK)

• 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

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PALLIATIVE SEDATION

• 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.

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LAST DOSE PHENOMENON
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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 Whats
  All the Agitation About?, Palliative Medicine
  Matters Volume 2, Number 3, Fall 2008.
• www.accessmedicine.com.ezproxy.lib.ucf.edu

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