What medication can be prescribed to a terminally ill female patient with depression, anxiety, nausea, vomiting, and pain, who is currently on hospice care?

Medication Management for Hospice Patient with Depression, Suicidality, Nausea, Vomiting, and Pain

For this terminally ill hospice patient with severe depression, suicidality, and refractory nausea/vomiting, I recommend mirtazapine 7.5-15 mg at bedtime as your primary intervention, which uniquely addresses depression, anxiety, nausea, and can augment pain control while improving appetite and sleep. 1, 2

Primary Recommendation: Mirtazapine

Mirtazapine is the optimal single agent for this patient because it simultaneously treats multiple symptoms:

• Addresses depression and suicidality with antidepressant effects 2
• Reduces nausea and vomiting through antihistamine and 5-HT3 antagonist properties 1
• Improves appetite in cachexic hospice patients 1
• Enhances sleep quality with sedating effects at lower doses 1
• May provide adjunctive analgesic benefit in chronic pain 1

Dosing: Start with 7.5-15 mg orally at bedtime, can increase to 30 mg if needed for depression 1, 2. The lower dose (7.5-15 mg) provides more sedation and antiemetic effect, while higher doses (30 mg) provide stronger antidepressant action 1.

Additional Antiemetic Management

For breakthrough nausea/vomiting despite mirtazapine, add:

• Haloperidol 0.5-2 mg PO/IV every 4-6 hours as first-line dopamine antagonist for nausea with additional benefit for agitation 1, 3
• Olanzapine 2.5-5 mg at bedtime as alternative antipsychotic with antiemetic, anxiolytic, and appetite-stimulating properties 1, 3
• Ondansetron 4-8 mg PO 2-3 times daily if nausea persists despite dopamine antagonists 1, 3, 4

Managing Depression and Suicidality in Hospice Context

Critical considerations for this patient:

• Monitor suicidality closely during the first weeks of mirtazapine treatment, as antidepressants can increase suicidal thoughts in some patients, though this risk is primarily documented in younger patients 2
• Benzodiazepines for acute anxiety/agitation: Lorazepam 0.5-1 mg PO every 4-6 hours as needed for breakthrough anxiety or distress 1, 3
• Avoid benzodiazepines as monotherapy for depression, as they can worsen underlying depressive symptoms and do not treat the core depressive illness 1

Pain Management Coordination

Ensure adequate opioid therapy continues:

• Continue baseline opioids for pain control, as mirtazapine does not replace analgesics 1
• Mirtazapine may enhance opioid effectiveness and reduce opioid-induced nausea 1
• Monitor for opioid-induced constipation and treat prophylactically with stimulant laxatives (senna, bisacodyl) 1

Refractory Symptom Management

If symptoms remain intractable despite above interventions:

• Levomepromazine 12.5-25 mg every 8 hours provides antipsychotic, antiemetic, and analgesic effects with rapid onset 1
• Chlorpromazine 25-50 mg PO at bedtime for refractory insomnia and agitation with antiemetic benefit 1
• Continuous subcutaneous infusion of antiemetics (haloperidol, metoclopramide) if oral route becomes unfeasible 1
• Palliative sedation with midazolam (starting 0.5-1 mg/hour continuous infusion) as last resort for truly refractory suffering 1

Important Caveats

Avoid these common pitfalls:

• Do not use benzodiazepines alone for depression, as they lack antidepressant efficacy and may worsen depressive symptoms 1
• Do not abruptly discontinue mirtazapine if started, as withdrawal can cause serious side effects 2
• Screen for delirium before treating with benzodiazepines, as benzodiazepines can worsen delirium; use haloperidol or olanzapine instead 1
• Monitor for orthostatic hypotension with antipsychotics, especially in bed-bound hospice patients 1
• Ensure family understands that treating depression and suffering does not hasten death and is appropriate palliative care 1

Timeline Expectations

Therapeutic response timeline:

• Antiemetic effects from mirtazapine: 1-3 days 1
• Sleep improvement: 1-3 days 1
• Antidepressant effects: 2-4 weeks for full response 2
• Appetite stimulation: 1-2 weeks 1

Given hospice status, prioritize rapid symptom relief with immediate antiemetic and anxiolytic interventions while allowing time for mirtazapine's antidepressant effects to develop 1.