What are the essential medications and doses for end of life palliative care?

Essential Medications for End of Life Palliative Care

The essential medications for end of life palliative care include morphine, midazolam, haloperidol, and an antimuscarinic agent, which should be available in all settings caring for dying patients to effectively manage common symptoms such as pain, anxiety, delirium, and respiratory secretions. 1

Core Essential Medications and Dosing

Opioids for Pain and Dyspnea

• Morphine is the first-line opioid for moderate to severe pain and dyspnea 2
  • Starting dose for opioid-naïve patients with dyspnea: 2.5-5 mg PO every 4 hours or 1-2.5 mg SC every 4 hours 3
  • For patients already on opioids: increase dose by 25-50% of the daily opioid intake 3, 2
• Hydromorphone is an alternative opioid 3
  • Starting dose for dyspnea: 1.3 mg PO every 4 hours or 0.2-0.5 mg SC every 4 hours 3

Benzodiazepines for Anxiety and Sedation

• Midazolam is the first-line benzodiazepine for anxiety, agitation, and palliative sedation 3, 2
  • Starting dose: 0.5-1 mg/hour continuous infusion or 1-5 mg as needed 3
  • Usual effective dose: 1-20 mg/hour 3
  • Can be co-administered with morphine or haloperidol 3
• Lorazepam is an alternative for dyspnea with anxiety 3
  • Dosage: 0.5-1.0 mg every 6-8 hours PO or sublingual 3

Antipsychotics for Delirium and Nausea

• Haloperidol is the first-line antipsychotic for delirium and nausea 2
  • For moderate symptoms: 0.5-2 mg 2-3 times daily 4
  • For severe symptoms: 3-5 mg 2-3 times daily 4
  • Adjust dosage for geriatric or debilitated patients: 0.5-2 mg 2-3 times daily 4
• Levomepromazine (methotrimeprazine) is an alternative antipsychotic 3
  • Starting dose: 12.5-25 mg or 50-75 mg continuous infusion 3
  • Usual effective dose: 12.5 or 25 mg every 8 hours and every 1 hour as needed for breakthrough agitation, or up to 300 mg/day continuous infusion 3

Antimuscarinics for Respiratory Secretions

• Antimuscarinic agents are essential for managing respiratory tract secretions ("death rattle") 2, 1
  • Options include scopolamine, atropine, or glycopyrrolate 2
  • Glycopyrronium bromide can be used to reduce secretions in dying patients 3

Medication Management by Symptom

Pain Management

• Continue pain medications used before sedation unless adverse effects occur 3
• If symptoms of opioid overdose are observed, reduce doses but do not rapidly withdraw due to risk of withdrawal syndrome 3
• For breakthrough pain, provide emergency bolus therapy 3

Dyspnea Management

• Opioids are first-line treatment for dyspnea 3
• For dyspnea with anxiety, add benzodiazepines 3
• In the dying patient, consider terminal sedation with benzodiazepines in addition to opioids if treatment is insufficient 3

Delirium Management

• Distinguish between anxiety and delirium, as benzodiazepines can worsen delirium 3, 2
• Neuroleptics (haloperidol, levomepromazine) are effective when patients show signs of delirium 3

Terminal Sedation

• For refractory symptoms requiring palliative sedation, use:
  • Benzodiazepines (midazolam) as first-line 3
  • Neuroleptics when delirium is present 3
  • Barbiturates (phenobarbital) or propofol for patients with extreme tolerance to opioids and benzodiazepines 3
    • Phenobarbital: 1-3 mg/kg SC or IV bolus, followed by 0.5 mg/kg/hour infusion 3
    • Usual maintenance dose: 50-100 mg/hour 3

Route of Administration

• At admission to palliative care, the oral route is predominantly used (89% of patients) 5
• As death approaches, switch to subcutaneous route (used in 94% of patients at day of death) 5
• Ensure provision for emergency bolus therapy to manage breakthrough symptoms 3

Common Pitfalls to Avoid

• Failing to distinguish between anxiety and delirium, as benzodiazepines can worsen delirium 2
• Using opioids alone for dyspnea when anxiety is a significant component 2
• Inadequate breakthrough dosing for pain and other symptoms 2
• Abrupt discontinuation of medications, especially opioids and benzodiazepines 2
• Using morphine in patients with severe renal insufficiency (consider alternative opioids) 3
• Prescribing liquid opioids in milliliters instead of milligrams when multiple concentrations are available 6

Medication Adjustments Near Death

• Continue medications for symptom palliation unless ineffective or causing distressing side effects 3
• Discontinue medications that are inconsistent with or irrelevant to the goal of patient comfort 3
• Doses of morphine, midazolam, and haloperidol are often significantly higher at the day of death compared to admission 5