What is the appropriate dosing of lorazepam (Ativan) for hospice patients?

Lorazepam Dosing in Hospice Care

For hospice patients requiring lorazepam, start with 0.5-1 mg orally or sublingually every 4-6 hours as needed (maximum 4 mg/24 hours), reducing to 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg/24 hours). 1, 2

Oral/Sublingual Liquid Formulation

• Lorazepam oral concentrate must be mixed with liquid (water, juice, soda) or semi-solid food (applesauce, pudding) immediately before administration 3
• Use only the calibrated dropper provided with the product to draw the prescribed dose 3
• Squeeze the dropper contents into liquid or semi-solid food and stir gently for a few seconds 3
• The entire mixture must be consumed immediately and cannot be stored for future use 3
• Oral tablets can be used sublingually (off-label) if liquid formulation is unavailable 2

Standard Dosing Protocols by Route

Oral/Sublingual Route (Preferred)

• Starting dose: 0.5-1 mg every 4-6 hours as needed 4, 1, 5
• Maximum daily dose: 4 mg in 24 hours for most patients 1, 5, 6
• Elderly/debilitated patients: 0.25-0.5 mg every 4-6 hours as needed, maximum 2 mg/24 hours 1, 2, 5

IV/Subcutaneous Route (When Unable to Swallow)

• Starting dose: 0.5-1 mg IV every 4-6 hours as needed 1
• Maximum: 4 mg in 24 hours for most patients, 2 mg in 24 hours for elderly/debilitated 1
• Alternative: 1-2 mg subcutaneously, up to 2 mg maximum 5
• Peak effect occurs at 3-5 minutes after IV administration 1

Clinical Indications in Hospice

• Primary indications: anxiety, agitation, dyspnea (especially when associated with anxiety), and insomnia 4, 5
• For dyspnea management, add lorazepam only if opioids alone are insufficient and anxiety is present 4, 5
• Do NOT use lorazepam as monotherapy for delirium—use haloperidol or other neuroleptics first-line 1, 2

Titration and Escalation

• If requiring more than 2 breakthrough doses daily, consider switching to scheduled dosing 2
• For refractory agitation despite initial benzodiazepine dosing, add haloperidol 0.5-2 mg every 1 hour as needed 1
• For severe delirium with refractory agitation, combine lorazepam 0.5-2 mg every 4-6 hours with haloperidol 1
• When higher dosing is needed, increase the evening dose before daytime doses 6, 3

Critical Safety Monitoring

• Monitor oxygen saturation continuously, as benzodiazepines carry increased risk of apnea 1
• Have respiratory support equipment immediately available and be prepared to provide artificial ventilation 1
• Assess for signs of sedation, respiratory depression, and paradoxical agitation (occurs in ~10% of patients) 5
• Track time of administration, response within 3-5 minutes for IV route, breakthrough agitation, respiratory rate, oxygen saturation, and level of consciousness 1

Common Clinical Pitfalls

• Avoid confusing anxiety with delirium—benzodiazepines can worsen delirium if given as initial treatment 1, 2
• Ensure reversible causes are addressed first: pain, urinary retention, constipation, hypoxia 2
• Use caution in patients with severe pulmonary insufficiency or COPD—use lower doses 5
• Regular use leads to tolerance, requiring dose escalation, and carries risk of addiction, depression, and cognitive impairment 2, 5
• Elderly patients have increased risk of falls and cognitive impairment 5

End-of-Life Considerations

• In the dying patient (weeks to days), focus shifts to pharmacological treatment including terminal sedation with benzodiazepines in addition to opioids if treatment is insufficient 4
• Research shows 96.1% of hospice patients do not receive their scheduled medications on the day of death, and 61.8% do not receive them during the last 3 days of life 7
• Discontinuation commonly occurs due to difficulty swallowing, minimal consciousness, confusion, nausea, or patient refusal 7
• Consider switching to midazolam 2.5-5 mg subcutaneously every 2-4 hours or continuous infusion (10-30 mg/24 hours) for patients unable to swallow 4, 2

Alternative Benzodiazepine for Continuous Infusion

• Midazolam is preferred over lorazepam for continuous subcutaneous or IV infusion, starting at 0.5-1 mg/hour 4
• Midazolam has advantages of rapid onset and compatibility with morphine or haloperidol in continuous infusions 4

Practical Administration Notes

• PRN regimens are most common in hospice (92.8% on day of death), requiring informal caregivers to make decisions about when to administer 8
• Research shows low overall administration rates (17% on admission, 27% on day of death) with PRN-only regimens 8
• Highest administration rates (91.2%) occur with combined scheduled plus PRN regimens 8
• This suggests scheduled dosing may be more effective than PRN-only approaches for consistent symptom control 8