What medications can be continued or initiated in hospice for symptom management?

Medications for Symptom Management in Hospice Care

In hospice care, medications should focus exclusively on symptom management and comfort, with discontinuation of medications that do not directly contribute to patient comfort or quality of life. 1

Core Medications for Symptom Management

Pain Management

• Opioids: Morphine remains the gold standard for moderate to severe pain
  • Starting dose: 2.5-5 mg orally every 4 hours or 1-3 mg IV/SC every 2 hours PRN 1, 2
  • For patients already on opioids, consider increasing dose by 25% 3
  • Caution: Monitor for respiratory depression, especially within first 24-72 hours 2

Dyspnea Management

• Opioids: Same agents as for pain management but often at lower doses
  • If opioid-naïve: Morphine 2.5-10 mg PO every 2 hours PRN or 1-3 mg IV every 2 hours PRN 3
  • For fluid overload: Consider low-dose diuretics 3
• Oxygen therapy: Only for symptomatic hypoxia 3, 1
• Non-pharmacologic: Fans, cooler temperatures, positioning 1

Anxiety and Agitation

• Benzodiazepines: For anxiety associated with dyspnea or terminal agitation
  • Lorazepam 0.5-1 mg PO every 4 hours PRN 3
  • Midazolam 0.5-1 mg/h for continuous sedation when needed 3
• Avoid benzodiazepines as initial treatment for delirium in patients not already taking them 3

Delirium Management

• Antipsychotics:
  • Haloperidol for moderate to severe delirium 3
  • Levomepromazine 12.5-25 mg every 8 hours for cases with agitation 3
  • Chlorpromazine 12.5 mg every 4-12 hours IV/IM or 25-100 mg rectally 3

Secretion Management

• Anticholinergics:
  • Scopolamine 0.4 mg subcutaneous every 4 hours PRN or 1.5 mg patches (1-3 patches every 3 days) 3
  • Atropine 1% ophthalmic solution 1-2 drops SL every 4 hours PRN 3
  • Glycopyrrolate 0.2-0.4 mg IV or subcutaneous every 4 hours PRN 3

Nausea and Vomiting

• Antiemetics:
  • Metoclopramide 10 mg PO/IV/IM every 6 hours 4
  • Adjust dose for renal impairment (half dose if CrCl <40 mL/min) 4

Medications to Continue or Discontinue

Continue

• Pain medications: Opioids, neuropathic pain agents (gabapentin, pregabalin, amitriptyline) 3
• Symptom control medications: Medications for dyspnea, nausea, anxiety, delirium, and secretions 3, 1
• Medications providing immediate comfort: Any medication directly alleviating current symptoms 1

Discontinue

• Preventive medications: Medications for long-term disease prevention 1
• Chronic disease medications: Unless they provide immediate symptom relief 1
• Vitamins and supplements: All should be discontinued 1
• Acid reducers: Unless active GI symptoms are present 1
• Any medication the patient persistently fails to take or tolerate 3
• Any medication for symptoms which have resolved (e.g., pain, nausea, vertigo, pruritus) 3

Special Considerations

Medication Administration Routes

• Consider alternative routes when oral intake is compromised:
  • Sublingual, rectal, topical, or parenteral routes 5
  • Emergency medication kits often contain medications in these alternative forms 5

Antidepressants in Hospice

• Be aware that antidepressant use is often disrupted during patients' final days
• Consider tapering to avoid discontinuation syndrome 6
• 30% of hospice patients are prescribed antidepressants for symptoms including depression, anxiety, pain, sleep disturbances, and poor appetite 6

Medication Cost and Waste

• Medication waste at time of death can be significant (estimated $15,000 for 279 patients) 7
• Most commonly wasted medications: morphine solution and lorazepam 7
• Consider prescribing smaller quantities when prognosis is very limited 7

Family Support

• Encourage family presence with the patient 1
• Reassure family that medications for symptom relief are unlikely to shorten life 1
• Provide regular updates about the patient's condition and expected changes 1
• Offer guidance on how family can provide comfort (touch, talking, mouth care) 1

Common Pitfalls to Avoid

• Inappropriate medication continuation: Continuing chronic disease medications that no longer benefit the patient 1
• Inadequate symptom control: Underdosing pain or anxiety medications due to concerns about respiratory depression 1
• Delayed response to symptoms: Not having PRN medications readily available 1, 5
• Overtreatment: Continuing interventions that cause more burden than benefit 1

Emergency medication kits are commonly used by hospice programs and may help prevent emergency department visits and hospitalizations 5. These typically include medications for pain, dyspnea, nausea/vomiting, and seizures.