What are the primary recommendations for comfort medications in hospice patients?

From the Guidelines

The primary comfort medications recommended for hospice patients include opioids, anxiolytics, anticholinergics, and antiemetics, with morphine being the first-line opioid for pain and dyspnea, as supported by the most recent guidelines 1. When managing symptoms in hospice patients, it's essential to consider the individual's response to medications and titrate accordingly.

• Opioids, such as morphine, are effective for pain and dyspnea management, with a starting dose of 2.5-5mg orally every 4 hours or 1-2mg IV/SC as needed.
• Anxiolytics like lorazepam (0.5-1mg orally or sublingually every 4-6 hours) help manage anxiety and agitation.
• Anticholinergics, including glycopyrrolate (0.2-0.4mg SC/IV every 4-6 hours) or scopolamine patches (1.5mg behind the ear every 72 hours), are effective for secretion management.
• Antiemetics, such as haloperidol (0.5-1mg orally or SC every 4-6 hours) and metoclopramide (10mg orally or SC every 6 hours), address nausea, vomiting, and terminal agitation. These medications should be used in conjunction with a bowel regimen, including stool softeners and laxatives, to prevent constipation, as recommended by recent guidelines 1. Palliative sedation can be considered for refractory pain after consultation with pain management/palliative care specialists, as noted in the most recent guidelines 1. It's crucial to regularly reassess symptoms and adjust medication regimens accordingly, ensuring that patients receive optimal comfort and relief during end-of-life care, as emphasized by recent studies 1.

From the FDA Drug Label

While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of morphine sulfate tablets, the risk is greatest during the initiation of therapy or following a dosage increase. To reduce the risk of respiratory depression, proper dosing and titration of morphine sulfate tablets are essential [see Dosage and Administration (2.2. 3)].

The primary recommendations for comfort medications in hospice patients are not directly addressed in the provided drug label. Morphine is often used for pain management in hospice care, but the label primarily discusses the risks associated with its use, such as respiratory depression.

• The label emphasizes the importance of proper dosing and titration to minimize risks.
• It also highlights the need for close monitoring of patients, especially during the initiation of therapy or following dosage increases.
• Alternative treatments, such as non-opioid analgesics, may be considered for certain patients, like the elderly, cachectic, or debilitated. 2

From the Research

Comfort Medications in Hospice Care

The primary recommendations for comfort medications in hospice patients include:

• Opioid and nonopioid analgesics for pain management 3
• Anxiolytics, such as lorazepam, for anxiety and agitation 3, 4
• Anticholinergics, such as atropine, for symptom management 3
• Antipsychotics, such as haloperidol, for delirium and agitation 3, 4

Commonly Prescribed Medications

Commonly prescribed medications in hospice care include:

• Acetaminophen for pain management 3
• Morphine for pain management 3
• Haloperidol for delirium and agitation 3, 4
• Lorazepam for anxiety and agitation 3, 4
• Prochlorperazine for nausea and vomiting 3
• Atropine for symptom management 3

Medication Kits for Symptomatic Emergencies

Medication kits for managing symptomatic emergencies in the home typically contain:

• Medications for pain and dyspnea 5
• Medications for nausea and vomiting 5
• Medications for seizures 5
• Oral, sublingual, and rectal routes of administration are common, as well as topical preparations of combination medications 5

Effectiveness of Lorazepam and Haloperidol

The combination of lorazepam and haloperidol has been shown to be effective in reducing agitation in patients with advanced cancer and delirium 4

• Lorazepam + haloperidol resulted in a significantly greater reduction in Richmond Agitation-Sedation Scale (RASS) score at 8 hours compared to placebo + haloperidol 4
• The lorazepam + haloperidol group required less rescue neuroleptics and was perceived to be more comfortable by caregivers and nurses 4