What medications are commonly used for symptom management in end-of-life patients?

Medications for End-of-Life Symptom Management

Opioids are the cornerstone of end-of-life symptom management, particularly for pain and dyspnea, and should be prescribed for all patients experiencing these symptoms at the end of life. 1

Pain Management

Pain is one of the most common and distressing symptoms at the end of life. Effective management includes:

First-line medications:

• Opioids: Morphine is the gold standard for severe pain
  • Start with 2.5-10 mg PO every 2 hours as needed (if opioid-naive)
  • For patients already on opioids, consider increasing dose by 25% 1
  • Alternative opioids include oxycodone, hydromorphone, and fentanyl (transdermal for stable pain)

For neuropathic pain:

• Anticonvulsants (gabapentin, pregabalin)
• Antidepressants (tricyclic antidepressants, SSRIs) 1
• Consider tramadol, oxycodone, hydromorphone, or fentanyl for refractory neuropathic pain 1

Dyspnea Management

Dyspnea affects most patients with advanced illness, particularly those with cancer or cardiopulmonary disease:

Pharmacological approach:

• Opioids: First-line treatment for unrelieved dyspnea
  • Morphine 2.5-10 mg PO every 2 hours as needed (if opioid-naive) 1
• Benzodiazepines: Add for anxiety-associated dyspnea
  • Lorazepam 0.5-1 mg PO every 4 hours as needed 1
• Oxygen: Only for hypoxemic patients 1
• For excessive secretions: Scopolamine 0.4 mg subcutaneous every 4 hours, glycopyrrolate 0.2-0.4 mg IV/subcutaneous every 4 hours, or atropine 1% ophthalmic solution 1-2 drops sublingually every 4 hours 1

Delirium Management

Delirium is common and distressing at the end of life:

Pharmacological management:

• Antipsychotics:
  • Moderate delirium: Oral haloperidol, risperidone, olanzapine, or quetiapine 1
  • Severe delirium with agitation: Haloperidol, olanzapine, or chlorpromazine 1
  • For refractory agitation: Add lorazepam to neuroleptics 1

Important considerations:

• Reduce or eliminate delirium-inducing medications (steroids, anticholinergics)
• Avoid benzodiazepines as initial treatment for delirium 1
• Consider opioid rotation if delirium is suspected to be opioid-induced

Nausea and Vomiting

Pharmacological management:

• Antiemetics:
  • Metoclopramide (caution with prolonged QT and extrapyramidal symptoms) 1, 2
  • Promethazine, prochlorperazine, ondansetron 1
  • For anxiety-related nausea: Benzodiazepines 1
• Dopamine receptor antagonists for nonspecific nausea 1

Anorexia/Cachexia

Pharmacological management:

• Appetite stimulants:
  • Megestrol acetate
  • Medroprogesterone acetate
  • Corticosteroids 1

Constipation (especially with opioid use)

Pharmacological management:

• Laxatives
• Stool softeners
• Methylnaltrexone for opioid-induced constipation
• Osmotic agents 1

Anxiety and Depression

Pharmacological management:

• Depression: Tricyclic antidepressants, SSRIs 1
• Anxiety: Benzodiazepines (lorazepam, diazepam)

Palliative Sedation for Refractory Symptoms

For intractable symptoms that cannot be adequately controlled:

• Consider palliative sedation after consultation with palliative care specialist 1
• Most commonly used for refractory pain, dyspnea, agitated delirium, and convulsions 1

Route of Administration Considerations

As patients approach death:

• Oral route becomes less viable (decreases from 85.5% to 49.1% of medications) 3
• Subcutaneous route becomes increasingly important
• Transdermal options (like fentanyl) may be appropriate for stable symptoms 4
• PRN medications increase significantly at end of life (from average 1.34 to 3.26 medications) 3

Common Pitfalls and Caveats

1. Fear of opioid addiction: This should not be a concern in end-of-life care. Undertreating pain due to addiction concerns is inappropriate 5

2. Inappropriate polypharmacy: Deprescribe medications for chronic conditions that no longer contribute to comfort (antihypertensives, statins, antidiabetics) 3

3. Inadequate dosing: Titrate symptom management medications to optimal relief; don't hesitate to increase doses for refractory symptoms 1

4. Neglecting PRN medications: Always prescribe breakthrough medications for symptom flares 3

5. Route of administration: Plan ahead for alternative routes as oral intake diminishes 3

6. Overlooking non-pain symptoms: Dyspnea, delirium, and nausea can be as distressing as pain but are often undertreated 5

By focusing on these key medication strategies for symptom management, healthcare providers can significantly improve quality of life and provide comfort for patients at the end of life.