MANAGEMENT OF NON-PAIN SYMPTOMS AT THE END OF LIFE

MANAGEMENT OF NON-PAIN MANAGEMENT OF NON-PAIN SYMPTOMS AT THE END OF SYMPTOMS AT THE END OF

LIFELIFE

Cornerstone HospiceCornerstone Hospice

Lucy W. Ertenberg, M.D.Lucy W. Ertenberg, M.D.Vice President/Chief Medical OfficerVice President/Chief Medical Officer

ObjectivesObjectives Recognize the range of symptoms at Recognize the range of symptoms at

the end of lifethe end of life Discuss the pharmacological Discuss the pharmacological

interventions used in relief of these interventions used in relief of these symptomssymptoms

Recognize effects and side effects of Recognize effects and side effects of medications used in end of life medications used in end of life symptom managementsymptom management

Hospice PharmaciaHospice Pharmacia

Provides enteral and topical Provides enteral and topical medications for thousands of hospice medications for thousands of hospice patientspatients

Compounds multiple medications Compounds multiple medications into suspensions, topical gels and into suspensions, topical gels and suppositoriessuppositories

PARENTERALPARENTERAL

Cornerstone Hospice does do continuous IV Cornerstone Hospice does do continuous IV and subcutaneous infusions.and subcutaneous infusions.

Cornerstone Hospice does do Patient Cornerstone Hospice does do Patient Controlled Analgesia (PCA) which is used only Controlled Analgesia (PCA) which is used only by alert patients who are able to judge their by alert patients who are able to judge their own pain needs.own pain needs.

Bolus infusions are administered by nursing Bolus infusions are administered by nursing staff or by family/caregivers educated in staff or by family/caregivers educated in recognizing the signs of pain and in the recognizing the signs of pain and in the correct use of the medication and equipment.correct use of the medication and equipment.

SUBCUTANEOUSSUBCUTANEOUS

HOSPITALS usually require that HOSPITALS usually require that equipment used in the hospital has equipment used in the hospital has been approved and inspected by the been approved and inspected by the hospital and that the staff has hospital and that the staff has received instruction on its use.received instruction on its use.

Therefore, outside equipment will be Therefore, outside equipment will be changed out to hospital equipment.changed out to hospital equipment.

BLUE PLATE SPECIALBLUE PLATE SPECIAL Morphine Sulfate (Roxanol) Morphine Sulfate (Roxanol) 20 mg/ml 20 mg/ml

Begin with 0.25 ml (5 mg) every 4 hours as needed Begin with 0.25 ml (5 mg) every 4 hours as needed for pain or dyspneafor pain or dyspnea

Lorazepam (Ativan) 0.5 mg tablet (may be dissolved (Ativan) 0.5 mg tablet (may be dissolved in 5 ml water used sublingually) or liquid 2 mg/ml in 5 ml water used sublingually) or liquid 2 mg/ml Begin with 0.5 Begin with 0.5 mg every 6 hours as needed for agitationmg every 6 hours as needed for agitation

Atropine 1% Ophthalmic Drops Atropine 1% Ophthalmic Drops Begin with 2drops SUBLINGUAL Begin with 2drops SUBLINGUAL every four hours as needed for secretionsevery four hours as needed for secretions

JCAHO FacilitiesJCAHO Facilities

Require an indication for each medicationRequire an indication for each medication Do not allow ranges for doses or times, Do not allow ranges for doses or times,

therefore write; therefore write; “Morphine sulfate 20 mg/ml 0.25 (5 mg) “Morphine sulfate 20 mg/ml 0.25 (5 mg) every 3 hours as needed for moderate every 3 hours as needed for moderate pain”pain”

“ “Morphine sulfate 20mg/ml 0.5ml (10mg) Morphine sulfate 20mg/ml 0.5ml (10mg) every 3 hours as needed for severe pain”every 3 hours as needed for severe pain”

FIRSTFIRST

Look for a treatable Look for a treatable CAUSECAUSEof the symptom and…of the symptom and…

Treat the cause!

DYSPNEADYSPNEA Subjective—Dyspnea is how the Subjective—Dyspnea is how the

patient tells you he feels. patient tells you he feels. BreathlessBreathless Short of BreathShort of Breath Hard to BreatheHard to Breathe

Objective—What you can measureObjective—What you can measure TachycardiaTachycardia TachypneaTachypnea HypoxiaHypoxia

DYSPNEADYSPNEA Opioids reduce the feelings of Opioids reduce the feelings of

breathlessness and should be breathlessness and should be considered for use in all (End of Life) considered for use in all (End of Life) patients unless otherwise patients unless otherwise contraindicated”contraindicated”

DYSPNEADYSPNEA

Check the Check the Respiratory RateRespiratory Rate

ANXIETY/AGITATIONANXIETY/AGITATION BenzodiazepinesBenzodiazepines Lorazepam—begin with 0.5 mg every 6 hours as Lorazepam—begin with 0.5 mg every 6 hours as

neededneeded Tablet 0.5 and 1mgTablet 0.5 and 1mg Liquid 2 mg/mlLiquid 2 mg/ml Gel 1 mg/mlGel 1 mg/ml Suppository 2 mgSuppository 2 mg Alprazolam (Xanax)—begin with 0.25 mg every 6 Alprazolam (Xanax)—begin with 0.25 mg every 6

hours as neededhours as needed Tablets 0.5 and 1 mgTablets 0.5 and 1 mg Liquid 1 mg/mlLiquid 1 mg/ml

CAVEATCAVEAT

Always review the medication list for Always review the medication list for the usethe use

ofof OTHER BENZODIAZEPINESOTHER BENZODIAZEPINES

AGITATION WITH AGITATION WITH HALLLUCINATIONSHALLLUCINATIONS

NeurolepticsNeuroleptics Haloperidol (Haldol) begin with 1 mg Haloperidol (Haldol) begin with 1 mg

every 6 hours as neededevery 6 hours as needed Tablets 0.5, 1, 2, 5 mgTablets 0.5, 1, 2, 5 mg Liquid 2 mg/mlLiquid 2 mg/ml Suppository 1, 2, 5 mgSuppository 1, 2, 5 mg Gel 1 mg/mlGel 1 mg/ml Injections 5 mg/mlInjections 5 mg/ml

AGITATION WITH AGITATION WITH HALLUCINATIONSHALLUCINATIONS

NeurolepticsNeuroleptics Chlorpromazine (Thorazine) begin Chlorpromazine (Thorazine) begin

with 25 mg every 6 hours as neededwith 25 mg every 6 hours as needed Tablets 25, 50,100 mgTablets 25, 50,100 mg Liquid 100 mg/mlLiquid 100 mg/ml Gel 100mg/mlGel 100mg/ml

Suppository 25, 50, 100 mgSuppository 25, 50, 100 mg

AGITATION WITH AGITATION WITH HALLUCINATIONSHALLUCINATIONS

NeurolepticsNeuroleptics Resperidone (Risperdal) begin with Resperidone (Risperdal) begin with

0.5 mg at bed time0.5 mg at bed time Tablets 0.25, 0.5, 1, 2, 3, 4 mgTablets 0.25, 0.5, 1, 2, 3, 4 mg Liquid 1mg/mlLiquid 1mg/ml

CAVEATCAVEAT

If you don’t give them enough If you don’t give them enough lorazepam, you will just make them lorazepam, you will just make them MAD!MAD!

If you don’t give them enough If you don’t give them enough haloperidol, you will just make them haloperidol, you will just make them MAD!MAD!

ANTIPSYCHOTICSANTIPSYCHOTICS Conventional (First Generation)Conventional (First Generation)

Chlorpromazine—ThorazineChlorpromazine—Thorazine Haloperidol—Haldol Haloperidol—Haldol

Atypical (Second Generation)Atypical (Second Generation) Aripiprazole—AbilifyAripiprazole—Abilify Olanzaprine—ZyprexaOlanzaprine—Zyprexa Quetiapine—Seroquel (Use with Parkinson’s Quetiapine—Seroquel (Use with Parkinson’s

Disease)Disease) Risperadone—RisperdalRisperadone—Risperdal Asenapine—Saphris Asenapine—Saphris

ANTIPSYCHOTICSANTIPSYCHOTICS NeurolepticsNeuroleptics

Suppresses spontaneous movements Suppresses spontaneous movements and complex behaviors and complex behaviors

Reduce initiative and interest in Reduce initiative and interest in environmentenvironment

Reduce manifestations of emotionsReduce manifestations of emotions

ANTIPSYCHOTICSANTIPSYCHOTICS AntipsychoticsAntipsychotics

Initially drowsy or slowedInitially drowsy or slowed Easily awakened and answer questionsEasily awakened and answer questions Intact cognitionIntact cognition Gradually fewer hallucinations and Gradually fewer hallucinations and

delusionsdelusions More coherence and organization More coherence and organization

ANTIPSYCHOTICSANTIPSYCHOTICS Side EffectsSide Effects

BradykinesiaBradykinesia RigidityRigidity TremorTremor Akathesia (Subjective Restlessness)Akathesia (Subjective Restlessness) Tardive DyskinesiaTardive Dyskinesia

ANTIPSYCHOTICSANTIPSYCHOTICS There is NO FDA approved There is NO FDA approved

antipsychotic medication for the antipsychotic medication for the treatment of dementia related treatment of dementia related psychosis.psychosis.

ANTI PSYCHOTICSANTI PSYCHOTICS Fatal ventricular arrhythmia—Fatal ventricular arrhythmia—

TorsadesTorsades

ANTIPSYCHOTICSANTIPSYCHOTICS Beer’s ListBeer’s List Chemical RestraintsChemical Restraints

CAVEATCAVEAT

Some Long Term Care Facilities may Some Long Term Care Facilities may not accept patients on …not accept patients on …

Haloperidol Haloperidol or or

ChlorpromazineChlorpromazine

SECRETIONSSECRETIONS Hyoscyamine (Levsin) Begin with 0.125 mg every 4 Hyoscyamine (Levsin) Begin with 0.125 mg every 4

hours as needed hours as needed Tablets 0.125 mg Tablets 0.125 mg

Liquid 0.125 mg/ml Liquid 0.125 mg/ml Gel 0.125 mg/ml Gel 0.125 mg/ml

Atropine 1% Ophthalmic Drops Begin with 3 drops Atropine 1% Ophthalmic Drops Begin with 3 drops every 4 hours as needed every 4 hours as needed

Atropine 1% Ophthalmic Drops—Use orally or Atropine 1% Ophthalmic Drops—Use orally or sublingually sublingually

Scopolamine Begin with one patch changed every 3 Scopolamine Begin with one patch changed every 3 days days

Trans derm-Scop Trans derm-Scop

NAUSEA NAUSEA *Target Your Therapy**Target Your Therapy*

• Abdominal Spasms Abdominal Spasms *Hyoscyamine *Hyoscyamine *Dicyclomine (Bentyl) begin with 10 *Dicyclomine (Bentyl) begin with 10 mg mg every 4 hours as needed every 4 hours as needed Tablets 10, 20 Tablets 10, 20 mg mg Liquid 10 Liquid 10 mg/mlmg/ml

NAUSEANAUSEA Delayed Gastric Emptying Delayed Gastric Emptying Metoclopramide (Reglan) Begin with Metoclopramide (Reglan) Begin with

10 mg 4 times a day OR 10 mg before 10 mg 4 times a day OR 10 mg before meals and at bedtime meals and at bedtime Tablets 10mg Tablets 10mg Liquid 5 mg/ml or 5 mg/5ml Liquid 5 mg/ml or 5 mg/5ml

Injection 10 mg/2ml (5mg/ml in 2 ml Injection 10 mg/2ml (5mg/ml in 2 ml vial)vial)

NAUSEANAUSEA

Vestibular Vestibular Scopolamine Scopolamine Meclizine (Over the Counter ‘OTC’) Meclizine (Over the Counter ‘OTC’)

Begin with 12.5 mg every 6 hours as Begin with 12.5 mg every 6 hours as neededneeded

Tablets 12.5, 25 mgTablets 12.5, 25 mg Liquid 12.5 mg/5mlLiquid 12.5 mg/5ml

NAUSEANAUSEA

Chemoreceptor Trigger Chemoreceptor Trigger Zone Zone (CTZ)(CTZ)

ZofranZofran AnzemetAnzemet KytrilKytril

NAUSEANAUSEA NON SPECIFIC CAUSENON SPECIFIC CAUSE Prochlorperazine(Compazine) Begin with 10 mg Prochlorperazine(Compazine) Begin with 10 mg

every 6 hours as neededevery 6 hours as needed Tablets 5, 10 mgTablets 5, 10 mg Liquid 10mg/mlLiquid 10mg/ml Suppositories 10, 25 mgSuppositories 10, 25 mg Gel 25mg/mlGel 25mg/ml Promethazine (Phenergan) Begin with 25 mg Promethazine (Phenergan) Begin with 25 mg

every 6 hours as neededevery 6 hours as needed Tablets 12.5, 25, 50 mgTablets 12.5, 25, 50 mg Liquid 25 mg/mlLiquid 25 mg/ml Suppositories 12.5, 25, 50 mgSuppositories 12.5, 25, 50 mg Gel 25 mg/mlGel 25 mg/ml

NAUSEANAUSEA NON SPECIFIC CAUSENON SPECIFIC CAUSE Dexamethasone (Decadron) Begin Dexamethasone (Decadron) Begin

with 2mg each morningwith 2mg each morning Tablets 0.5, 0.75, 1, 2, 4 mgTablets 0.5, 0.75, 1, 2, 4 mg Liquid 4 mg/ml, 10 mg/mlLiquid 4 mg/ml, 10 mg/ml Suppository 4, 8, 20 mgSuppository 4, 8, 20 mg Gel 4 mg/mlGel 4 mg/ml

NAUSEA NAUSEA “Shot “Shot

Gun” Gun” ABHRABHR AAtivan tivan BBenadryl enadryl HHaldol aldol RReglaneglanCapsule 0.5 12.5 0.5 10 mgCapsule 0.5 12.5 0.5 10 mgLiquid 0.5 12.5 0.5 10 mg/5mlLiquid 0.5 12.5 0.5 10 mg/5mlSupp 0.5 12.5 0.5 10Supp 0.5 12.5 0.5 10Gel 1 25 1 10 mg/mlGel 1 25 1 10 mg/ml

CAVEATCAVEATDO DO NOTNOT USE METOCLOPRAMIDE USE METOCLOPRAMIDE

(Reglan = ‘(Reglan = ‘RR’ in ABHR) ’ in ABHR) IF THERE IS ANY CHANCE OF IF THERE IS ANY CHANCE OF

BOWEL OBSTRUCTIONBOWEL OBSTRUCTION

SEIZURESSEIZURES ACUTEACUTE Lorazepam suppository 2 mgLorazepam suppository 2 mg

1. Begin with one 2mg suppository1. Begin with one 2mg suppository

2. If seizure not controlled, repeat 2 2. If seizure not controlled, repeat 2 mg suppository in 5 minutes and mg suppository in 5 minutes and then 10 minutesthen 10 minutes

SeizuresSeizures MaintenanceMaintenance Continue anti-seizure medications Continue anti-seizure medications

throughout illness whenever possiblethroughout illness whenever possible

CAVEATCAVEAT If Cornerstone Hospice home patient or If Cornerstone Hospice home patient or

ALF patient has a risk of seizures (i.e. ALF patient has a risk of seizures (i.e. possible brain metastases) or has a possible brain metastases) or has a history of seizures, a history of seizures, a SEIZURE KITSEIZURE KIT can can be ordered from Hospice Pharmacia to be ordered from Hospice Pharmacia to be kept on hand, in the refrigerator.be kept on hand, in the refrigerator.

SEIZURE KITSSEIZURE KITS Contain: Contain: LORAZEPAM SUPPOSITORIES 2mg (3)LORAZEPAM SUPPOSITORIES 2mg (3)

HICCUPSHICCUPS If due to dyspepsia or Gastro-If due to dyspepsia or Gastro-

Esophageal Reflux Disease (GERD) Esophageal Reflux Disease (GERD) Metoclopramide Begin with 10 mg Metoclopramide Begin with 10 mg

every 8 hours as neededevery 8 hours as needed

HICCUPSHICCUPS If due to tumor or central causeIf due to tumor or central cause *Baclofen begin with 10 mg every *Baclofen begin with 10 mg every

8 8 hours as neededhours as needed *Haloperidol*Haloperidol *Chlorpromazine*Chlorpromazine

SteroidsSteroids DexamethasoneDexamethasone *Anorexia*Anorexia *Bone Pain*Bone Pain *Edema Reduction Around Tumor *Edema Reduction Around Tumor

SiteSite *Mood elevation (Steroid High)*Mood elevation (Steroid High) *Wheezing*Wheezing

CAVEATCAVEAT STEROID use may lead to psychosis STEROID use may lead to psychosis

particularly in formerly psychotic particularly in formerly psychotic patients or bi-polar patientspatients or bi-polar patients

Avoid steroids in formerly psychotic, Avoid steroids in formerly psychotic, manic or schizophrenic patientsmanic or schizophrenic patients

Use steroids very cautiously Use steroids very cautiously beginning at very low doses in Bi-beginning at very low doses in Bi-polar patientspolar patients

HOSPICE PHARMACIA HOSPICE PHARMACIA COMFORT KITCOMFORT KIT

Can be ordered for all Cornerstone Can be ordered for all Cornerstone Hospice home patients.Hospice home patients.

The Comfort Kit is keptThe Comfort Kit is kept in the REFRIGERATORin the REFRIGERATOR

COMFORT KITCOMFORT KIT(CK)(CK)

Acetaminophen (Tylenol) Suppositories 6 Acetaminophen (Tylenol) Suppositories 6 650 mg 650 mg

Haloperidol Liquid 2mg/ml 15 mlHaloperidol Liquid 2mg/ml 15 ml Atropine 1% Ophthalmic Drops 2 mlAtropine 1% Ophthalmic Drops 2 ml Lorazepam Tablets 1 mg 10Lorazepam Tablets 1 mg 10 Morphine Sulfate Liquid 20mg/ml 15mlMorphine Sulfate Liquid 20mg/ml 15ml Prochloperazine Tablets 10mg 6Prochloperazine Tablets 10mg 6 Prochloperazine Suppositories 25 mg 6Prochloperazine Suppositories 25 mg 6

PALLIATIVE SEDATIONPALLIATIVE SEDATION

““Palliative Sedation” is the use of Palliative Sedation” is the use of high doses of sedatives to relieve high doses of sedatives to relieve extremes of physical and emotional extremes of physical and emotional distress in the final days of life.distress in the final days of life.

The goal is to render the patient The goal is to render the patient unconscious to relieve suffering, not unconscious to relieve suffering, not to intentionally end life.to intentionally end life.

LAST DOSE PHENOMENONLAST DOSE PHENOMENON

BIBLIOGRAPHYBIBLIOGRAPHY‘‘Atypical Antipsychotic Drugs and the Risk of Sudden Cardiac Atypical Antipsychotic Drugs and the Risk of Sudden Cardiac

Death’, Death’, New England Journal of MedicineNew England Journal of Medicine; Volume 360 #3, ; Volume 360 #3, January 15, 2009.January 15, 2009.

Depression in Later Life: A Diagnostic and Therapeutic Depression in Later Life: A Diagnostic and Therapeutic Challenge’, Challenge’, American Family PhysicianAmerican Family Physician; May 15, 2008.; May 15, 2008.

Medication Use Guidelines, Tenth EditionMedication Use Guidelines, Tenth Edition, Hospice Pharmacia,, Hospice Pharmacia, 2009.2009.

‘‘Use of Antipsychotic Drugs in Dementia: What’s All the Use of Antipsychotic Drugs in Dementia: What’s All the Agitation About?’,Agitation About?’, Palliative Medicine Matters; Palliative Medicine Matters; Volume 2, Volume 2, Number 3, Fall 2008.Number 3, Fall 2008.

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