Appropriate Dose of Ativan (Lorazepam) in the Oregon Protocol for End-of-Life Care
The appropriate dose of Ativan (lorazepam) for anxiolysis in end-of-life care under the Oregon protocol is 0.5 mg. This dosing recommendation is based on established clinical practice guidelines for palliative sedation in end-of-life care 1.
Dosing Recommendations for Lorazepam in End-of-Life Care
Initial Dosing
- Starting dose: 0.5 mg lorazepam 1
- Administration routes: Can be given orally, intravenously, or subcutaneously
- Frequency: As needed for breakthrough anxiety or as scheduled dosing
Dose Titration
- May be increased to 1-5 mg as needed for symptom control 1
- For continuous infusion: 0.5-1 mg/hour is the recommended starting rate 1
- Maximum recommended continuous infusion: 1-20 mg/hour based on patient response 1
Clinical Considerations for Lorazepam Use in End-of-Life Care
Patient-Specific Factors
- For elderly or debilitated patients: Lower initial dose of 0.25-0.5 mg is recommended 2, 3
- Renal impairment: Avoid increasing lorazepam dose in patients with eGFR <30 mL/min 2
- Consider shorter half-life benzodiazepines (like midazolam) if rapid onset is needed 2
Monitoring Parameters
- Assess for respiratory depression, particularly when combined with opioids
- Watch for paradoxical agitation, especially in elderly patients 2
- Monitor for excessive sedation that may interfere with meaningful interaction
- Be alert for withdrawal symptoms if dose is rapidly reduced after continuous infusion 1
Combination Therapy
- Lorazepam can be co-administered with morphine or haloperidol for enhanced symptom control 1
- If 0.5 mg lorazepam is ineffective, consider adding an antipsychotic rather than substantially increasing the lorazepam dose 2
- For refractory symptoms, consider adding phenobarbital or propofol per palliative care protocols 1
Important Cautions and Considerations
Potential Adverse Effects
- Respiratory depression (especially when combined with opioids)
- Paradoxical agitation (particularly in elderly patients)
- Withdrawal symptoms if discontinued abruptly after prolonged use
- Memory impairment and confusion 4
Family Support
- Ensure family members understand the goals of therapy
- Provide reassurance that sedation is for comfort and is unlikely to shorten life 1
- Allow family to be present with the patient and offer guidance on how they can provide comfort 1
Lorazepam 0.5 mg represents an appropriate starting dose that balances anxiolysis with minimizing adverse effects in the end-of-life setting. This dose can be titrated based on individual response while monitoring for effectiveness and side effects.