What is the recommended approach for managing symptoms in patients requiring hospice palliative care?

Symptom Management in Hospice Palliative Care

The recommended approach for managing symptoms in hospice palliative care is a structured, medication-based protocol focused on addressing refractory symptoms, with midazolam, levomepromazine, and morphine as first-line agents for sedation, delirium, and pain respectively, while providing comprehensive family support. 1

Core Principles of Symptom Management

Assessment and Medication Selection

• Identify the specific refractory symptoms requiring management:

  • Pain → Opioids (continue pre-existing regimens)
  • Agitation/anxiety → Benzodiazepines
  • Delirium → Neuroleptics/antipsychotics
  • Refractory symptoms requiring sedation → Structured protocol based on symptom severity

• Determine patient's proximity to death:

  • Imminently dying patients: Focus solely on comfort parameters
  • Non-imminently dying patients: Consider physiological stability and temporary respite therapy

First-Line Medications by Symptom

For Sedation in Refractory Symptoms

• Midazolam 1:
  • Starting dose: 0.5-1 mg/h or 1-5 mg as needed
  • Usual effective dose: 1-20 mg/h
  • Administration: Continuous infusion (IV/SC)
  • Advantages: Rapid onset, can be co-administered with morphine or haloperidol

For Delirium/Agitation

• Levomepromazine 1:
  • Starting dose: 12.5-25 mg
  • Usual effective dose: 12.5-25 mg every 8h and every 1h PRN
  • Administration: IV, SC, IM
  • Alternative: Chlorpromazine (12.5 mg every 4-12h IV/IM)

For Pain Management

• Morphine 1, 2:
  • Continue pre-existing pain medications unless adverse effects occur
  • Adjust dose to balance pain control and adverse effects
  • For patients unable to swallow: Consider subcutaneous route 3

Administration Routes

• Route selection based on disease progression 1, 3:
  • At admission: 89% oral route
  • Near death: 94% subcutaneous route
  • Consider IV, IM, rectal, or via stoma/gastrostomy when appropriate

Special Considerations

Palliative Sedation Protocol

For patients with refractory symptoms despite optimal management:

1. Initial sedation:

   • Start with midazolam (first-line)
   • Titrate to the least level necessary for adequate relief 1

2. If inadequate response:

   • Consider levomepromazine (for delirium)
   • Consider phenobarbital (1-3 mg/kg SC/IV bolus, then 0.5 mg/kg/h) 1
   • Consider propofol for rapid sedation (20 mg loading dose, then 50-70 mg/h) 1

3. Monitoring parameters 1:

   • For imminently dying patients: Monitor only for comfort, not vital signs
   • For non-imminently dying patients: Monitor sedation level and physiological parameters

Hydration and Nutrition

• Decisions about hydration/nutrition are independent of sedation decisions 1
• Consider reducing or withdrawing if they exacerbate suffering
• Base decisions on patient's best interests when no clear direction is given

Family Support

Critical elements of family support include 1:

• Encourage family presence with the patient
• Provide reassurance about treatment decisions
• Keep family informed about patient condition and what to expect
• Offer post-death meeting to address grief and concerns

Interdisciplinary Approach

• Establish an interdisciplinary team for complex pain management 1
• Consult palliative care specialists for symptom management and goals of care 1
• Consider non-pharmacological approaches alongside medications:
  • Cognitive behavioral therapy
  • Physical and occupational therapy 1

Medication Tapering and Discontinuation

For patients on long-term opioids who require dose reduction:

• Never abruptly discontinue opioids in physically dependent patients 2
• Taper gradually (10-25% of total daily dose)
• Monitor for withdrawal symptoms
• Adjust taper speed based on patient response 2

Common Pitfalls to Avoid

1. Mismanaging delirium: Administering opioids or benzodiazepines as initial treatment can worsen delirium; use antipsychotics first 1

2. Abrupt opioid discontinuation: Can lead to withdrawal, uncontrolled pain, and suicide risk 2

3. Overlooking route of administration changes: As patients approach death, transition from oral to subcutaneous route is typically necessary 3

4. Failing to continue baseline pain medications: Pre-sedation symptom medications should be continued unless ineffective or causing distress 1

5. Inadequate family communication: Families need regular updates and reassurance about the care plan 1

By following this structured approach to symptom management in hospice palliative care, clinicians can effectively address patient suffering while providing appropriate support to families during this difficult time.