What is the approach to titrating Levophed (norepinephrine) in a patient with a terminal illness and hypotension when transitioning to hospice care?

Titrating Levophed When Transitioning to Hospice Care

When transitioning a terminally ill patient with hypotension on norepinephrine to hospice care, the vasopressor should be gradually withdrawn rather than abruptly discontinued, as medications inconsistent with comfort-focused goals should be discontinued while those providing symptom palliation should be continued. 1

Core Principle: Align Medications with Comfort Goals

The fundamental approach to any medication in hospice—including vasopressors—is determining whether it serves the goal of patient comfort or merely prolongs the dying process 1:

• Medications that provide symptom palliation should be continued unless they cause distressing side effects or become ineffective 1
• Medications inconsistent with or irrelevant to patient comfort should be discontinued 1
• Norepinephrine maintains blood pressure but does not directly relieve symptoms like pain, dyspnea, or agitation that cause suffering at end of life 2

Practical Approach to Norepinephrine Withdrawal

Setting and Monitoring Considerations

• Norepinephrine withdrawal in hospice settings is feasible but presents logistical challenges, as documented in case reports of successful withdrawal outside intensive care 3
• For imminently dying patients, routine vital sign monitoring (pulse, blood pressure, temperature) should not be performed—only parameters pertaining to comfort matter 1
• Gradual deterioration of physiological parameters is expected as patients near death and should not constitute reason to reverse the withdrawal 1

Withdrawal Protocol

Gradual tapering is essential to avoid rebound effects and allow physiological adaptation 1:

• Reduce the infusion rate incrementally (e.g., decrease by 25-50% every 30-60 minutes, or slower if patient remains stable)
• Avoid abrupt discontinuation, as the FDA label warns that "infusions of LEVOPHED should be reduced gradually, avoiding abrupt withdrawal" 2
• Monitor only for comfort-related parameters: respiratory distress, agitation, pain—not blood pressure targets 1

Managing Symptoms During Withdrawal

As norepinephrine is withdrawn and blood pressure falls, anticipate and manage potential comfort issues:

For agitation or distress:

• Midazolam is first-line: start 0.5-1 mg/h continuous infusion, titrate to 1-20 mg/h as needed 1
• Can be administered subcutaneously if IV access becomes problematic 1

For delirium if present:

• Levomepromazine 12.5-25 mg, up to 300 mg/day continuous infusion 1
• Note: causes orthostatic hypotension, which is not a concern when withdrawing pressors 1

For pain:

• Continue or initiate opioids as needed for comfort 1
• Profound hypotension may compromise subcutaneous medication absorption—consider IV route if available 3

Critical Pitfalls to Avoid

• Do not continue norepinephrine simply because the patient is hypotensive—hypotension itself does not cause suffering unless it produces symptoms 1
• Do not perform aggressive monitoring that shifts focus away from comfort (e.g., frequent blood pressure checks, attempting to maintain specific MAP targets) 1
• Do not abruptly stop the infusion without gradual tapering 2
• Do not assume subcutaneous medications will be adequately absorbed in profoundly hypotensive patients—IV route may be necessary initially 3

Logistical Considerations

• Central venous access is required for norepinephrine administration, which may be maintained during withdrawal or removed once infusion is discontinued 2, 3
• Hospice settings may lack intensive monitoring equipment—this is appropriate, as comfort parameters (not hemodynamics) guide care 1, 3
• Family education is essential: explain that blood pressure numbers are not the focus, and that gradual physiological decline is expected and does not indicate suffering 1

Timeline Expectations

• Withdrawal can typically be completed over several hours with appropriate symptom management 3
• Some patients may require days if withdrawal precipitates distressing symptoms requiring aggressive palliative interventions 1
• Death may occur during or shortly after withdrawal, which should be anticipated and discussed with family beforehand 1