Is it appropriate to administer Ativan (lorazepam) SL tablets dissolved in liquid morphine for a slurry to a patient nearing the end of life (EOL) with impaired swallowing, and what are the considerations for dosing and potential interactions?

Sublingual Ativan Dissolved in Liquid Morphine for End-of-Life Care

Yes, it is appropriate to co-administer sublingual lorazepam (Ativan) with liquid morphine as a slurry for patients nearing end of life, as both medications are commonly used together in palliative care settings to manage refractory symptoms including pain, dyspnea, and agitation. 1

Rationale for Combined Administration

The combination of lorazepam and morphine is well-established in end-of-life care:

• Both medications are recommended for emergency sedation to provide urgent relief of overwhelming symptoms in dying patients, including severe terminal dyspnea, overwhelming pain crisis, and terminal restlessness 1, 2
• Research demonstrates that adding morphine to lorazepam significantly improves sedation and relief of anxiety compared to lorazepam alone 3
• As swallowing function diminishes in the dying process, medications are typically administered sublingually, transdermally, or via rectal suppository 4

Practical Administration Considerations

When creating a slurry for sublingual administration:

• The sublingual route is appropriate as patients lose swallowing ability near end of life 4
• Lorazepam tablets can be crushed and mixed with liquid morphine for combined administration 5
• This approach allows for simultaneous delivery of both anxiolytic/sedative and analgesic effects

Dosing Framework

For end-of-life symptom management:

• Standard lorazepam dosing ranges from 1-2 mg for elderly or debilitated patients, adjustable as needed 6
• Morphine dosing should target adequate pain and dyspnea control 4
• The lowest effective dose should be used to provide adequate comfort while monitoring for distress 1

Synergistic Benefits

The combination offers multiple therapeutic advantages:

• Morphine provides control of pain and dyspnea, which are common symptoms in the dying process 4
• Lorazepam addresses anxiety, agitation, and terminal restlessness 2, 7
• Combined therapy enhances sedation and anxiety relief beyond either agent alone 3

Important Caveats

Monitor for potential complications:

• The combination may cause additive respiratory depression, though comfort remains the primary goal in end-of-life care 1
• Restlessness can occur in 3-15% of patients receiving lorazepam, independent of morphine addition 3
• For patients at home at risk of catastrophic events, sedating medications should be prepared in advance with a clear emergency administration plan 1

Clinical Decision-Making

The intent and goals must be clearly established:

• The primary goal is relief of suffering while preserving dignity, not hastening death 2
• Sedation should be titrated to the least level necessary to provide adequate relief 2
• All participating staff and family members need to understand the rationale for combined sedation and goals of care 1