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MANAGEMENT OF NON-PAIN 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. Recognize the range of symptoms at the end of life Discuss the pharmacological interventions used in relief of these symptoms

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MANAGEMENT OF NON-PAIN SYMPTOMS AT THE END OF LIFE

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  1. MANAGEMENT OF NON-PAIN SYMPTOMS AT THE END OF LIFE Cornerstone Hospice Lucy W. Ertenberg, M.D. Vice President/Chief Medical Officer

  2. 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

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

  4. 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.

  5. 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.

  6. 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

  7. 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”

  8. FIRST Look for a treatable CAUSE of the symptom and… Treat the cause!

  9. DYSPNEA • Subjective—Dyspnea is how the patient tells you he feels. • Breathless • Short of Breath • Hard to Breathe • Objective—What you can measure • Tachycardia • Tachypnea • Hypoxia

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

  11. DYSPNEACheck the Respiratory Rate

  12. ANXIETY/AGITATION • 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

  13. CAVEAT Always review the medication list for the use of OTHER BENZODIAZEPINES

  14. 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

  15. 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

  16. 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

  17. 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!

  18. ANTIPSYCHOTICS • Conventional (First Generation) • Chlorpromazine—Thorazine • Haloperidol—Haldol • Atypical (Second Generation) • Aripiprazole—Abilify • Olanzaprine—Zyprexa • Quetiapine—Seroquel (Use with Parkinson’s Disease) • Risperadone—Risperdal • Asenapine—Saphris

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

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

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

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

  23. ANTI PSYCHOTICS • Fatal ventricular arrhythmia—Torsades

  24. ANTIPSYCHOTICS • Beer’s List • Chemical Restraints

  25. CAVEAT Some Long Term Care Facilities may not accept patients on … Haloperidol or Chlorpromazine

  26. 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 Drops—Use orally or sublingually • Scopolamine Begin with one patch changed every 3 days Trans derm-Scop

  27. 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

  28. 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)

  29. 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

  30. NAUSEA • Chemoreceptor Trigger Zone (CTZ) Zofran Anzemet Kytril

  31. 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

  32. 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

  33. 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

  34. CAVEAT DO NOT USE METOCLOPRAMIDE (Reglan = ‘R’ in ABHR) IF THERE IS ANY CHANCE OF BOWEL OBSTRUCTION

  35. 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

  36. Seizures • Maintenance Continue anti-seizure medications throughout illness whenever possible

  37. 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)

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

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

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

  41. 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

  42. HOSPICE PHARMACIA COMFORT KIT • Can be ordered for all Cornerstone Hospice home patients. • The Comfort Kit is kept in the REFRIGERATOR

  43. 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

  44. 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.

  45. LAST DOSE PHENOMENON

  46. 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. www.accessmedicine.com.ezproxy.lib.ucf.edu

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