In a hospice patient who is actively dying, is it better to give morphine (morphine) alone or morphine (morphine) plus Ativan (lorazepam) at the same time for pain and symptom management?

Management of Symptoms in Actively Dying Hospice Patients: Morphine Plus Lorazepam vs. Morphine Alone

For actively dying hospice patients, the combination of morphine plus lorazepam (Ativan) is more effective than morphine alone for managing the complex symptoms of terminal dyspnea with associated anxiety. 1

Rationale for Combination Therapy

• Symptom Complexity: Actively dying patients often experience multiple overlapping symptoms:

  • Dyspnea (effectively treated with opioids)
  • Anxiety (effectively treated with benzodiazepines)
  • These symptoms frequently co-occur and exacerbate each other 2, 1

• Complementary Mechanisms:

  • Morphine: Acts on opioid receptors to reduce respiratory drive and perception of breathlessness
  • Lorazepam: Acts on GABA receptors to reduce anxiety that often accompanies dyspnea

Dosing Recommendations

Initial Regimen

• Morphine:

  • Start with 2.5-10 mg PO every 4 hours PRN (or 1-3 mg IV/SC every 2-4 hours PRN) 1
  • For patients already on opioids: Increase regular dose by approximately 25% 1

• Lorazepam:

  • Start with 0.5-1 mg PO/SL every 4 hours PRN 2, 1
  • For elderly/debilitated patients: Consider lower starting dose of 0.25-0.5 mg 1

Route of Administration

• Oral route is preferred if patient can swallow
• Switch to subcutaneous route when oral intake is no longer possible (common in final days) 3
• Consider subcutaneous infusion via syringe driver if medications are needed frequently 1

Special Considerations

Renal Function

• Important caveat: Avoid morphine in severe renal impairment (eGFR <30 mL/min) 1
• Use oxycodone instead of morphine in patients with renal failure 1

Delirium Management

• If patient develops delirium, avoid increasing benzodiazepine doses as this may worsen confusion
• Consider adding haloperidol 0.5-2 mg for delirium management 2

Medication Administration Challenges

• Family caregivers often underutilize prescribed PRN medications, particularly with flexible dosing regimens 4
• Structured regimens with clear instructions result in better symptom control than completely flexible PRN dosing 4

Monitoring and Titration

• Assess response to initial doses within 30-60 minutes
• Titrate as needed based on symptom control:
  • For persistent dyspnea: Increase morphine dose
  • For persistent anxiety: Increase lorazepam dose
• Do not reduce opioid doses solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for symptom management 2

Non-Pharmacological Interventions

• Position patient upright if possible
• Provide cool, moving air (fan)
• Ensure calm environment
• Provide emotional support to patient and family

Key Pitfalls to Avoid

1. Undertreating symptoms due to fear of respiratory depression
2. Withholding opioids based solely on vital sign changes in dying patients
3. Failing to address anxiety that accompanies dyspnea
4. Using benzodiazepines alone for dyspnea without opioids
5. Neglecting to educate caregivers about appropriate medication administration

By using morphine plus lorazepam in actively dying hospice patients, clinicians can provide more comprehensive symptom relief than with morphine alone, addressing both the physical and psychological components of terminal distress.