What are the recommended interventions for symptom management in hospice care?

Recommended Interventions for Symptom Management in Hospice Care

The most effective interventions for symptom management in hospice care include systematic opioid administration for pain and dyspnea, benzodiazepines for anxiety, positioning and oxygen therapy for respiratory distress, and regular mouth care for thirst, all delivered through a coordinated multidisciplinary team approach. 1

Pain Management

Assessment and Pharmacological Interventions

• Use standardized pain assessment tools (0-10 Numeric Rating Scale) for communicative patients 2
• Follow WHO analgesic ladder for systematic pain management 1:
  • Mild pain (1-3/10): Acetaminophen and/or NSAIDs
  • Moderate pain (4-6/10): Weak opioids plus acetaminophen/NSAIDs
  • Severe pain (7-10/10): Strong opioids plus acetaminophen/NSAIDs

Opioid Administration

• Provide regular around-the-clock dosing with breakthrough dosing 1
• Start with low doses in elderly patients and titrate gradually 3
• Monitor for and manage side effects (particularly constipation)
• Be aware of drug interactions with benzodiazepines and other CNS depressants that can increase risk of respiratory depression 3

Dyspnea Management

Pharmacological Interventions

• Opioids are first-line treatment for unrelieved dyspnea 2, 1
  • For opioid-naive patients: morphine 2.5-10 mg PO q2h prn or 1-3 mg IV q2h prn
  • For patients on chronic opioids: consider increasing dose by 25% 2
• Benzodiazepines for dyspnea with anxiety component 2, 1
  • Lorazepam 0.5-1 mg PO q4h prn if benzodiazepine naive 2

Non-pharmacological Interventions

• Positioning (elevate head of bed)
• Use of fans for facial air flow 2
• Oxygen therapy if hypoxic and/or subjective relief is reported 2, 1
• Reduce excessive secretions with:
  • Scopolamine 0.4 mg subcut q4h prn
  • Atropine 1% ophthalmic solution 1-2 drops SL q4h prn
  • Glycopyrrolate 0.2-0.4 mg IV or subcut q4h prn 2

Anxiety and Delirium Management

Anxiety Management

• Benzodiazepines for anxiety 1
  • Lorazepam 0.5-1 mg PO q4h prn 2
  • Midazolam for terminal agitation or when rapid effect needed 1

Delirium Management

• Antipsychotics are first-line treatment 1
  • Chlorpromazine 10-25 mg q4-6h prn for severe symptoms 4
  • Lower dosages in elderly, emaciated, or debilitated patients 4

Thirst and Oral Symptoms Management

Assessment and Interventions

• Examine mouth and tongue for dryness and cracking 2
• Provide frequent mouth care
• Use water-soaked gauzes, water sprays, and ice chips when permissible 2
• Consider artificial saliva 2
• Involve family members in providing simple mouth care 2

Anorexia/Cachexia Management

Pharmacological Interventions

• Consider appetite stimulants if aligned with goals of care:
  • Megestrol acetate 400-800 mg/d
  • Olanzapine 5 mg/d
  • Dexamethasone 2-8 mg/d
  • Consider cannabinoid 2

Non-pharmacological Approaches

• Focus on patient goals and preferences
• Provide family with alternate ways of caring for the patient
• Educate family that absence of hunger and thirst is normal in dying patients 2

Multidisciplinary Team Approach

Team Coordination

• Implement systematic symptom assessment and documentation 2, 5
• Ensure regular interdisciplinary communication about symptom management 5
• Consider specialist palliative care consultation for difficult-to-manage symptoms 2

Family Involvement

• Encourage family presence and participation in care 1
• Provide guidance on how family can assist with comfort measures 2, 1
• Reassure family that medications for symptom relief are unlikely to shorten life 1
• Provide respite care options for family caregivers 2

Implementation Strategies

Quality Improvement

• Standardize assessment tools and documentation 2
• Implement regular symptom assessment during rounds 2
• Develop protocols for symptom management 2
• Provide education to all team members on symptom management 2

Common Pitfalls to Avoid

• Inadequate symptom assessment, particularly in non-communicative patients 2
• Delayed response to symptoms 1
• Inappropriate medication continuation 1
• Undertreatment of symptoms due to fear of side effects 1
• Lack of coordination between team members 5
• Insufficient attention to psychological distress that can amplify physical symptoms 5
• Failure to address family understanding and expectations about symptom management 5

By implementing these evidence-based interventions through a coordinated multidisciplinary approach, hospice care can effectively manage symptoms and improve quality of life for patients with advanced illness.