Managing symptoms and End-of-Life (EOL) is essential in the hospice and palliative care setting. Many patients experience exacerbating symptoms in the last hours to days of life. Alleviating burdensome symptoms is important to not only promote comfort for the patient, but also to decrease feelings of helplessness for caregivers.  Most hospices choose to provide patients with “Emergency Kits”, also referred to as E-Kits or Comfort Kits, which contains several doses of some of the commonly used medications to treat EOL symptoms such as pain, breathlessness, anxiety/agitation, nausea/vomiting, and terminal secretions.

PAIN

Unless the patient has a documented allergic reaction, morphine remains the gold standard for EOL pain.  Morphine is available in various forms and can be easily titrated to meet the needs of the dying patient.  A common form of Morphine used at EOL is liquid oral concentrated solution of 20mg/ml.  Starting dose of 5mg q 2 hours can be titrated up to 20mg to achieve adequate pain control. Acetaminophen oral or suppository can be an effective adjuvant therapy for pain (Harman & Walling, 2023)

BREATHLESSNESS

Morphine is also an effective choice for the treatment of breathlessness/dyspnea. Opiates may alter perception of anxiety and decrease respiratory effort, thus slowing respiratory distress (Mahler, 2013).  Lorazepam and other benzodiazepines are good options as well.  Morphine dosing is the same as with pain and Lorazepam can be started at 1mg q 4 hours and titrated to 2mg as needed.  These medications are often used together for maximum effectiveness (Mahler, 2013).

ANXIETY/AGITATION

Often referred to as terminal agitation or terminal delirium, this symptom is characterized by an acute change in mentation which may present as hyperactive/agitated state, hypoactive or a mixture of the two.  Although there are many excellent options for treating anxiety and agitation, and EOL, haloperidol is a frequently used medication.  Haloperidol is a first-generation antipsychotic that can be initiated at 0.5-5mg.  Lorazepam and other benzodiazepines are also an effective option.

NAUSEA/VOMITING

The etiology of nausea and vomiting at EOL is often difficult to isolate, therefore multiple medications may need to be utilized in the management.  Ondansetron 4-8mg q 6-8 hours is commonly used, however, promethazine, prochlorperazine and haloperidol are also effective treatment options.  In patients with dementia and Parkinson’s, ondansetron is the preferred option due the lack of effects on the dopamine receptors.  Promethazine and prochlorperazine and frequently used in suppository form for the patient who is experiencing excessive vomiting. 

TERMINAL SECRETIONS

Most hospices have a preferred treatment of terminal secretions based on what has worked well in the past.  Atropine 1% ophthalmic solution administered PO is a common treatment modality.  Two to four drops every 2-4 hours is recommended starting dose.  Scopolamine transdermal patch is a good option, however, as with most transdermal delivery, the onset is not immediate. Hyoscyamine and glycopyrrolate are also effective choices. (Protus, Grauer, & Kimbrel, 2013).

PAIN

Morphine: 5-20mg q 2-4 hours

Acetaminophen suppository: 325-650mg q 4-6 hours

BREATHLESSNESS

Morphine: 5-20mg q 2-4 hours

Lorazepam: 1-2mg q 4 hours

ANXIETY/AGITATON

Lorazepam: 1-2mg q 4 hours

Haloperidol: 1-10mg q 4-6 hours (max dose 100mg/day)

NAUSEA/VOMITING

Promethazine: 12.5-25mg q 4 hours

Ondansetron: 4-8mg q 8 hours

Prochlorperazine: 5-10mg q 6/8 hours

Haloperidol: 0.5-2mg q 6-8 hours

TERMINAL SECRETIONS/ “DEATH RATTLE”

Atropine 1%: 2-4gtt q 2-4 hours

Hyoscyamine: 0.125-0.25mg q 4-8 hour

Scopolamine transdermal: 1mg q 72 hours

References

Harman, S. M., Walling, A. M. (2023) Palliative Care: The last hours and days of life.  Retrieved  August 26, 2023 from https://www.uptodate.com/contents/palliative-care-the-last-hours-and-days-of-life?search=morphine%20for%20end%20of%20life%20pain&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=2#H1024055721

Mahler DA. Opioids for refractory dyspnea. Expert Rev Respir Med. 2013;7:123–134.

Protus BM, Grauer PA, Kimbrel JM. Evaluation of atropine 1% ophthalmic solution administered sublingually for the management of terminal respiratory secretions. Am J Hosp Palliative Care. 2013;30(4):388-392. doi: 10.1177/1049909112453641. [PubMed 22833553]

Mindi Henry MSN, APRN-CNP, ACHPN
Director of Clinical Services | PDC Rx

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