What is the recommended dosage of lorazepam (Ativan) and morphine for symptom management in hospice patients?

Recommended Dosage of Lorazepam and Morphine for Symptom Management in Hospice Patients

For hospice patients with dyspnea and anxiety, the recommended starting doses are morphine 2.5-10 mg PO every 4 hours PRN (or 1-3 mg IV every 2-4 hours PRN) for dyspnea, and lorazepam 0.5-1 mg PO/SL every 4 hours PRN for anxiety. 1

Morphine Dosing Guidelines

For Opioid-Naïve Patients:

• Starting dose: 2.5-10 mg PO every 4 hours PRN 1
• IV alternative: 1-3 mg IV every 2-4 hours PRN 1
• For acute progressive dyspnea: More aggressive titration may be required 1

For Patients Already on Opioids:

• Increase regular opioid dose by approximately 25% 1
• Or add 1/6 of the daily opioid intake as supplemental dosing 1

Special Considerations for Morphine:

• If eGFR <30 mL/min, use oxycodone instead of morphine 1
• Consider subcutaneous infusion via syringe driver if needed frequently (more than twice daily), starting with morphine sulfate 10 mg over 24 hours 1
• Always initiate a stimulant laxative (e.g., senna) and consider an antiemetic when starting opioids 1

Lorazepam Dosing Guidelines

For Anxiety/Agitation:

• Starting dose: 0.5-1 mg PO/SL every 4 hours PRN 1
• Maximum daily dose: 4 mg in 24 hours 2
• For elderly/debilitated patients: 0.25-0.5 mg PO/SL every 4 hours PRN (maximum 2 mg/24 hours) 1

For Patients Unable to Swallow:

• Consider midazolam 2.5-5 mg subcutaneously every 2-4 hours PRN 1
• If needed frequently, consider subcutaneous infusion via syringe driver starting with midazolam 10 mg over 24 hours 1

Combination Therapy Considerations

• The combination of morphine and lorazepam is particularly effective for managing dyspnea with anxiety in hospice patients 1
• Lorazepam can be added when dyspnea is not relieved by opioids alone and is associated with anxiety 1
• Combined regimens (scheduled plus PRN) of lorazepam show higher administration rates (91.2%) on the day of death compared to PRN-only regimens (40.4%) 3

Life Expectancy-Based Approach

Years to Months Remaining:

• Focus on comfort while treating underlying conditions
• Use opioids for dyspnea/cough/air hunger
• Add benzodiazepines for anxiety/agitation
• Consider non-pharmacological approaches (fans, cooler temperatures)

Weeks to Days (Dying Patient):

• Withhold/withdraw interventions not focused on comfort
• Intensify palliative care
• Consider sedation for intractable symptoms
• Provide emotional support to patient and family

Common Pitfalls to Avoid

1. Undertreatment: Research shows low administration rates of prescribed medications - only 30.68% of maximum prescribed morphine 4 and 27% of prescribed lorazepam 3 are typically administered on the day of death.

2. Overly flexible regimens: More structured regimens result in higher administration rates (39.52%) compared to flexible prescriptions (21.84%) 4.

3. Inadequate caregiver support: Caregivers often struggle with decision-making regarding PRN medications. Consider combined regimens (scheduled plus PRN) for better symptom control 3.

4. Renal impairment: Avoid morphine in severe renal failure; use oxycodone instead 1.

5. Neglecting non-pharmacological interventions: Fans, positioning, oxygen therapy (if hypoxic), and emotional support remain important adjuncts to medication 1.

By following these evidence-based guidelines for lorazepam and morphine dosing, healthcare providers can effectively manage symptoms and optimize quality of life for hospice patients.