Antiemetic Regimen in Hospice
For hospice patients with nausea and vomiting, initiate dopamine receptor antagonists (haloperidol, metoclopramide, or prochlorperazine) as first-line therapy, with scheduled dosing around-the-clock rather than as-needed, and escalate systematically by adding agents from different drug classes if symptoms persist. 1
Initial First-Line Approach
Start with dopamine receptor antagonists as the foundation:
- Haloperidol 1-2 mg PO/IV every 4-6 hours is preferred for non-specific nausea in hospice patients 1, 2
- Metoclopramide 10-40 mg PO/IV every 4-6 hours is equally effective, particularly when gastric stasis is suspected 1, 2, 3
- Prochlorperazine 10 mg PO every 6 hours or 25 mg suppository every 12 hours is an alternative option 1, 2
Critical principle: Use around-the-clock scheduled dosing rather than PRN once nausea develops, as this provides more consistent symptom control 1
Systematic Escalation Algorithm
Step 1: Optimize Dopamine Antagonist
Titrate your chosen dopamine receptor antagonist to maximum tolerated dose before adding additional agents 1
Step 2: Add Adjunctive Agents from Different Classes
If nausea persists after optimizing Step 1, add one or more of the following:
- 5-HT3 antagonist (ondansetron 8-16 mg PO/IV daily) 1, 2
- Anticholinergic agent (scopolamine 1.5 mg transdermal patch every 72 hours) 1
- Antihistamine (meclizine) 1
- Cannabinoid (dronabinol 5-10 mg PO every 4-6 hours or nabilone 1-2 mg PO BID) 1
Step 3: Add Corticosteroid
If symptoms remain uncontrolled:
- Dexamethasone 4-8 mg PO BID (can use up to 12 mg daily) 1, 2
- Olanzapine 2.5-5 mg PO BID if not already tried (particularly effective but use cautiously in elderly due to increased mortality risk in dementia patients) 1, 2
Step 4: Continuous Infusion
For intractable nausea and vomiting:
- Consider continuous IV or subcutaneous infusion of antiemetics 1
- A studied hospice regimen includes metoclopramide 10 mg + diphenhydramine 25 mg + dexamethasone 4 mg IV every 6 hours, which achieved 90% response rate within 2 days 4
- Alternative: metoclopramide 60-120 mg/day continuous subcutaneous infusion plus dexamethasone 3
Anxiety-Related Component
If anxiety contributes to nausea:
- Lorazepam 0.5-1 mg PO every 4-6 hours 1
- Consider lorazepam 1 mg at bedtime the night before and morning of anticipated triggers 1
Specific Etiologies in Hospice
Gastric Outlet Obstruction
- Corticosteroids + proton pump inhibitor + metoclopramide 1
- Note: Metoclopramide is contraindicated in complete mechanical obstruction 1
Bowel Obstruction
- Avoid metoclopramide (contraindicated in mechanical obstruction) 3
- Consider octreotide and anticholinergics instead 1
Opioid-Induced Nausea
- Consider opioid rotation if nausea persists despite antiemetics 1
- Methylnaltrexone 0.15 mg/kg subcutaneously every other day for opioid-induced constipation contributing to nausea (contraindicated in mechanical obstruction) 1
Critical Monitoring and Pitfalls
Monitor for extrapyramidal symptoms (dystonic reactions, akathisia) with metoclopramide and prochlorperazine:
- Have diphenhydramine 25-50 mg PO/IV every 4-6 hours readily available for treatment 1, 2
- Continuous infusion metoclopramide has lower rates of dystonic reactions than intermittent bolus dosing 5
Olanzapine precautions:
- Black box warning for increased mortality in elderly patients with dementia-related psychosis 1, 2
- Monitor for excessive sedation, particularly in elderly patients 1
- Consider 2.5-5 mg dose in elderly or oversedated patients rather than standard 5-10 mg 1, 2
Promethazine caution:
- Risk of vascular damage with IV administration; use central line only if IV route necessary 1
- More sedating than alternatives 6
Dying Patient (Days to Weeks)
For patients in the active dying phase: