Because M.P. is to be enrolled into a hospice program, her care should not be
focused on curative treatments, but rather on the management of discomforting
symptoms and on improving her quality of life in the time remaining. M.P.’s
medications should be analyzed with the goal of simplification. Unnecessary
medications should be discontinued and alternatives added to manage two or more
symptoms concurrently. The following changes should be considered:
Acetaminophen. This analgesic is often helpful in relieving mild pain,
particularly in immobile elderly patients. A trial of around-the-clock acetaminophen
Albuterol/ipratropium combination. The hospice program is required to pay for
medications related to M.P.’s aspiration pneumonia and COPD because the hospice
medical director determined that these conditions are related to her terminal
prognosis. This combination inhalation formulation should be continued if she is able
to participate in her nebulizer treatments and it improves her breathing. (See Chapter
19, Chronic Obstructive Pulmonary Disease.)
Alendronate. This bisphosphonate drug can be discontinued because the treatment
of osteoporosis is not an important consideration at this terminal stage of her life nor
remain upright after taking the medication to decrease the risk of alendronate-induced
esophageal irritation (see Chapter 110, Osteoporosis). Pain that she may experience
from osteoporosis can be treated with analgesics.
Palliative Performance Score (PPS) Version 2
100 Full Normal activity and work
90 Full Normal activity and work
80 Full Normal activity with effort
70 Reduced Unable to do normal job/work
60 Reduced Unable to do hobby/housework
50 Mainly sit/lie Unable to do any work
40 Mainly in bed Unable to do most activity
Total care Minimal to sips Full or drowsy
column is determined. Thus, “leftward” columns take precedence over “rightward” columns.
1952 Bay Street, Victoria, BC, V8R 1J8, Canada www.victoriahospice.org edu.hospice@viha.ca
Aspirin. The low-dose aspirin is intended to decrease the risk of cardiovascular
clotting. The aspirin will not increase M.P.’s comfort or quality of life. Although the
aspirin would not be covered by her Medicare Hospice Benefit, it can be continued
unless her primary-care provider prefers its discontinuation.
Beclomethasone. This patient is not functioning well cognitively (i.e., not
oriented to time, person, or place) and would be unable to effectively time the
inhalation of a breath to the actuation of her metered-dose inhaler. A systemic
corticosteroid (e.g., prednisone) might improve her COPD symptoms and also
improve her appetite and sense of well-being. The potential for adverse effects is
modest with short-term corticosteroid use.
Bisacodyl, milk of magnesia. Constipation in patients with terminal illnesses is
common, occurring in as many as 94% because of decreased gastrointestinal motility
with advanced age, metabolic disturbances, decreased physical activity, lack of
adequate fiber and fluid intake, and use of constipating medications (e.g., opioids,
anticholinergics, psychotropic agents).
40–43 The milk of magnesia, with an occasional
bisacodyl suppository, has been an adequate laxative regimen for this patient. If an
opioid is later prescribed for M.P., a mild stimulant laxative (e.g., senna) can be
added. Osmotic agents such as polyethylene glycol (PEG), oral sorbitol, or lactulose
can be prescribed if needed. Mineral oil 30 mL daily is an option if the stool is hard;
however, mineral oil should not be considered for M.P. because of her risk of
aspiration. Bulk-forming laxatives should also be avoided in this population as they
may not ingest adequate water to prevent a fecal impaction. In cases of refractory
constipation, the use of methylnaltrexone bromide, an injectable opioid antagonist,
can reverse opioid-induced constipation by antagonizing opioid effects within the
gastrointestinal tract without affecting systemic analgesia.
derivative of naltrexone does not cross the blood–brain barrier. Dosing is weight
based; it is given subcutaneously as either 8 mg for patients weighing 38 to 62 kg
(84–136 pounds) or 12 mg for patients weighing 62 to 114 kg (136–251 pounds)
once a day. The most common adverse events are abdominal pain, flatulence, nausea,
Esomeprazole. This proton-pump inhibitor would probably be unnecessary
because alendronate-induced esophageal or gastrointestinal irritation would not be
an issue subsequent to its discontinuation. However, if a proton-pump inhibitor is
needed, nonprescription generic omeprazole or lansoprazole is preferred because
If a patient such as M.P. cannot swallow intact tablets,
a capsule formulation can be opened with the contents mixed with soft food and
Levothyroxine. This thyroid medication should be continued until M.P. is no
longer able to swallow. This medication, however, would not be covered under her
Medicare Hospice Benefit, which is based on her Alzheimer disease, and was
deemed not related to the terminal prognosis.
Lovastatin. Cholesterol-lowering agents are not necessary during the last 6
months of life and should be discontinued. Lovastatin would not improve the quality
of life of M.P. at this stage of her terminal illness and would not be covered by her
Megestrol. The progesterone derivative, megestrol, in doses of 400 to 800 mg
daily, can substantially stimulate appetite.
If an undernourished hospice patient
desires to eat more, the hospice may choose to provide an appetite stimulant. It is
unclear whether stimulation of appetite in a cognitively impaired patient will result
in weight gain or improved nutritional status. Because the benefits in this situation
are unclear, the potential of adverse effects (e.g., venous thrombosis) of megestrol
needs to be considered, especially in M.P., who is not ambulatory and had been
taking low-dose aspirin for prevention of cardiovascular clotting.
Memantine. Because the N-methyl-D-aspartate antagonist, memantine, has been
modestly effective in improving performance in patients with moderate to severe
51,52 but with decreasing effectiveness over time,
limited utility for M.P. (See Chapter 108, Geriatric Neurocognitive Disorders.) It
would be reasonable to discontinue M.P.’s memantine subsequent to discussion with
appropriate hospice team members and M.P.’s family.
Multivitamins. Multivitamins and other nutritional supplements are unlikely to
improve M.P.’s comfort or quality of life. The discontinuation of these drugs would
simplify medication administration, decrease the potential for medication errors, and
Olanzapine. An antipsychotic (e.g., olanzapine, haloperidol, chlorpromazine) is
often prescribed off-label to manage the agitation and confusion encountered by
patients with dementia. Behavioral modifications can be tried (see Chapter 108,
Geriatric Neurocognitive Disorders), but paranoid or delusional behavior may
require drug therapy. At the time of admission to hospice, patients may be receiving
atypical agents (e.g., olanzapine). Small doses of the first-generation antipsychotics,
such as haloperidol and chlorpromazine, may offer a dual effect and be very useful in
treating opioid-induced nausea and vomiting, although randomized clinical trials
demonstrating efficacy are lacking.
54 They would be covered by M.P.’s Medicare
Hospice Benefit. Chlorpromazine would be preferable when more sedation is
The American College of Physicians has developed clinical guidelines, based on a
systematic review of evidence and on a report by the Agency for Healthcare
Research and Quality, to improve palliative care at the end of life. These guidelines
provide strong recommendations for the regular assessment of patients at the end of
life for symptoms of pain, dyspnea, and depression, and for therapies of proven
effectiveness for these symptoms. For patients with cancer, these include the use of
opioids, nonsteroidal anti-inflammatory drugs, and bisphosphonates for pain;
tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial
interventions for depression; and opioids for unrelieved dyspnea and oxygen for
short-term relief of hypoxemia. The guidelines do not address other variables of
palliative care at the end of life or the management of other matters (e.g., nutritional
support) because the quality of evidence is limited rather than because other issues or
55 The National Consensus Project for Quality Palliative
Care recommends the measurement and documentation of pain and other symptoms
using available scales with timely assessment and symptom management acceptable
to both the patients and their families as a preferred practice.
CASE 6-1, QUESTION 3: As soon as the hospice admission and assessment is completed, the nurse in
are the components of this kit, and why is it useful?
Some hospices use a general comfort kit that contains specific medications to
manage symptoms commonly encountered by most hospice patients, or they order
medications to treat anticipated symptoms for a specific patient. These medications
are placed in the home or facility where the patient resides. This facilitates the
availability of medications to patients who encounter anticipated symptoms and is
convenient when caregivers are instructed by the patient’s primary-care provider to
provide the medication to the patient. Patients living with cancer can encounter as
many as 27 symptoms (median, 11), many of which occur together.
patients (n = 176) experienced an average of 6.6 to 6.8 distressing symptoms during
In general, the prevalence of each symptom is difficult to
measure and demonstrates a high degree of variability. Pain (34%–96%), fatigue
(32%–90%), and breathlessness (10%–95%) appear to be the most common in
patients with a variety of terminal conditions, with the prevalence of pain in cancer
patients reported as 35% to 96%.
58 Patients with terminal illnesses, including
dementia as in M.P., also experience depression (3%–82%), anxiety (8%–79%),
confusion (6%–93%), insomnia (9%–74%), nausea (6%–68%), constipation (23%–
70%), diarrhea (3%–90%), and anorexia (21%–92%).
prevalence may be attributed to a host of variables (e.g., study design, patient
population, underlying disease, inconsistent definitions, and where care was
provided). The occurrence of symptoms, however, can vary significantly, even
within the last week of life, and the need for frequent assessment of patients cannot
be overemphasized. Morphine, lorazepam, haloperidol, prochlorperazine
suppositories, and an anticholinergic agent are commonly ordered for hospice
patients. Drugs that can palliate more than one symptom, such as morphine for pain or
dyspnea, or haloperidol for agitation or nausea, are particularly suited to inclusion in
Morphine. Every hospice patient should have a short-acting opioid available for
the palliation of unrelieved dyspnea and pain. Although morphine can cause
respiratory depression, small doses are very effective in controlling dyspnea by
multiple mechanisms: vasodilation, reduced peripheral vascular resistance,
inhibition of baroreceptor responses, reduction of brainstem responsiveness to
carbon dioxide (the primary mechanism of opioid-induced respiratory depression),
and lessened reflex vasoconstriction caused by increased blood PCO2
can also reduce the anxiety associated with dyspnea and might also act directly on
opioid receptors present in the airways (Table 6-3).
Hospice patients generally do not have IV access (i.e., an IV catheter) into which
medications can be easily administered. As a result, medications are primarily
administered orally and, occasionally, by sublingual, buccal, transdermal, rectal, or
subcutaneous (if an infusion is warranted) routes of administration. When patients
lose the ability to swallow near the end of life (or have a condition that precludes
swallowing), the sublingual or buccal routes of administration are the most useful,
especially if drugs are lipophilic. The use of orally disintegrating tablets (ODTs)
may also be useful at this time. Morphine is hydrophilic, and although some of it
might be absorbed across the mucous membranes, the primary clinical effect
probably results from gastrointestinal absorption after the drug has trickled down the
Treatment of Dyspnea at End of Life
Use of a fan or open window to circulate air over the face
Long-acting agents can be added to supplement the routine use of short-acting opioids
nebulized opioids provide greater benefit than nebulized saline
Agents: morphine 2.5–10 mg in 2 mL of 0.9% saline; hydromorphone 0.25–1 mg in 2 mL of 0.9% saline;
fentanyl 25 mcg in 2 mL of 0.9% saline
Generally given every 2–4 hours as needed for breathlessness
Benzodiazepines are useful for the anxiety associated with breathlessness
Oral morphine sulfate, in a concentration of 20 mg/mL, is commonly packaged in a
30-mL bottle at the beginning of hospice care. This bottle of morphine can provide
sixty 10-mg doses, and at this concentration, only 0.5 mL of morphine needs to be
administered. Oxycodone or hydromorphone, in comparable adjusted doses, can be
substituted for morphine when needed. There is no evidence demonstrating the
superiority of any of these over the others in severe cancer pain.
Lorazepam. A short-acting benzodiazepine (e.g., lorazepam 0.5 mg every 4 hours
as needed) is useful for the treatment of anxiety. Patients, especially those with
respiratory symptoms, can experience episodes of extreme anxiety near the end of
life. Caution should be used to not overuse these drugs in the elderly because they
can increase the risk of falling or cause paradoxical reactions and worsen delirium
Haloperidol. Small doses of haloperidol (e.g., 0.5–1 mg) are useful for the
treatment of restlessness, delirium, or nausea and vomiting.
Prochlorperazine. When patients cannot take oral medications to manage nausea
and vomiting, rectal suppositories of prochlorperazine are often effective. Although it
is necessary to consider the etiology of the nausea and vomiting, prochlorperazine is
generally a good initial agent.
Anticholinergic agent. As death approaches, patients can have difficulty in
clearing pharyngeal secretions and, as a result, generate a sound commonly known as
66 Although patients are often unconscious at this point, this sound can
be very distressing to those nearby. An anticholinergic agent (e.g., glycopyrrolate,
hyoscyamine, scopolamine, atropine) can be administered in an attempt to prevent
these pharyngeal secretions from forming. Patient positioning and gentle suctioning
can remove secretions already present. This treatment modality is usually initiated
after the patient has become obtunded; if begun too early, patients might develop
problems with thickened bronchial or pulmonary secretions, tachycardia, delirium,
dry mouth, urinary retention, or other adverse anticholinergic effects. However,
efficacy is best if these agents are started earlier in the active dying process.
Glycopyrrolate, available in a tablet, injectable formulation and oral solution, is a
good choice for an anticholinergic agent because it minimally crosses the blood–
brain barrier. The 1-mg tablets could be crushed and placed under the tongue every 8
hours. Hyoscyamine is available as oral tablets, ODT, oral sustained-release tablets,
sublingual tablets, oral liquid, oral solution, and injection. Either the ODT,
sublingual tablets, or oral solution of hyoscyamine can be given in a 0.125- to 0.25-
mg dose sublingually every 4 hours as needed. Scopolamine transdermal patches
have a slow onset of action (blood levels are detected 4 hours after application)
and are of limited utility in this situation. The oral or sublingual administration of
atropine ophthalmic solution 1% is convenient to administer. Recent shortages and
price increases have made it less cost-effective. Assuming that 20 drops is
approximately equivalent to 1 mL, patients can be given 0.5 to 1 mg (1–2 drops) of
the atropine ophthalmic solution orally or sublingually every 4 hours as needed.
Families and caregivers must be instructed not to use this in the eye.
difficult to obtain, and how should the nurse manage this problem?
Providing relief for pain or other symptoms with opioids is often difficult owing to
numerous barriers. Patients and caregivers are often fearful of opioids, or mistakenly
believe these medications will cause addiction or hasten death.
create barriers by not having opioids in the pharmacy, sometimes because of the fear
of robbery, fear of investigation by drug regulatory agencies, or insufficient
appreciation of the usefulness of opioids in pain management and palliative care.
Pharmacists who are inexperienced in providing service to hospice patients might not
be knowledgeable about federal regulations governing the provision of controlled
substances to hospice patients. Federal statutes, as well as most state statutes, permit
prescriptions for Schedule II controlled substances for hospice patients to be faxed.
According to the Code of Federal Regulations (21 CFR 1306.11) paragraph (g): “A
prescription prepared in accordance with 1306.05 written for a Schedule II narcotic
substance for a patient enrolled in a hospice care program certified and/or paid for
by Medicare under Title XVIII or a hospice program which is licensed by the state
may be transmitted by the practitioner or the practitioner’s agent to the dispensing
pharmacy by facsimile. The practitioner or the practitioner’s agent will note on the
prescription that the patient is a hospice patient. The facsimile serves as the original
written prescription for purposes of this paragraph (g) and it shall be maintained in
The process of ordering controlled substances for use by hospice patients at home
can take many hours, and sometimes as much as an entire day. Hospice providers
should anticipate possible difficulties when placing orders for Schedule II controlled
substance medications. M.P.’s nurse should take the time to address any concerns
M.P.’s caregivers and family may have about these medications (i.e., how they may
affect her, any worries about addiction, side effects) and allow ample time to order
them so that symptoms can be managed as they develop.
every 4 hours as needed for nausea and anxiety. What is the most accurate assessment of her pain
G.G. is currently using two long-acting opioids (i.e., fentanyl transdermal,
sustained-release morphine which is being dosed too frequently), but is still unable
to achieve relief of her pain, which is probably neuropathic pain (described as
burning and twisting). It is estimated that up to 39% of patients with cancer pain have
72–74 This may be caused by tumor growth around nerves,
postoperative nerve damage, chemotherapy-induced neuropathy or following
radiation therapy. Opioids alone may be of limited value or may require higher than
72 The addition of adjuvant analgesics such as antidepressants,
anticonvulsants, and local anesthetics play an important role in treating neuropathic
pain (see Chapter 55, Pain and Its Management).
The use of two long-acting agents is duplicative and should be replaced with one
opioid. Methadone may be a better long-acting agent for G.G. because it has activity
against neuropathic pain (see Chapter 55, Pain and Its Management) and can reduce
the amount of medication she uses. Methadone affects the reuptake of serotonin and
norepinephrine, and blocks the NMDA receptor.
75 Studies, however, do not show
methadone to be superior to other opioids.
active metabolites, and lower cost. Methadone liquid is long-acting which may be
useful when patients lose the ability to swallow as death approaches. Disadvantages
in using methadone are its long and variable elimination half-life, drug–drug
interactions, prolongation of the QTc interval, and the variability of dosing
equivalence with other opioids. Dosing methadone is complex and should be
undertaken by experienced clinicians.
When converting fentanyl and morphine to methadone, the following should be
considered: (a) patient adherence and ability to follow prescription directions, (b)
use of an appropriate conversion formula, (c) converting a transdermal formulation
of fentanyl to an oral opioid formulation, and (d) a supplemental opioid for
Because of its long and variable elimination half-life, the dose of methadone
should generally be adjusted only once every 4 to 6 days, and patients must be able
and willing to precisely follow directions for its use. The methadone prescribing
information should be used for the conversion, with a general rule of thumb being that
the initial methadone dose should not exceed 30 mg (Table 6-4).
New safety guidelines recommend electrocardiographic monitoring prior to and
the need for this is terminally ill patients should be balanced
by life expectancy and goals of care. Caution should be used in patients with
electrolyte abnormalities (hypokalemia or hypomagnesemia), impaired liver function,
heart disease, prolonged QT syndrome, or the use of other QTc-prolonging drugs
(e.g., amiodarone, azithromycin, citalopram, fluconazole, haloperidol,
Once the conversion is made, the calculated dose is adjusted and the dosing
interval is set at every 12, 8, or 6 hours, based on patient age, previous use of
opioids, and current clinical status. Clinical judgment is vital in individualizing a
regimen for each patient based on his or her needs.
Before calculating the conversion to methadone for G.G., an important
consideration in patients using transdermal fentanyl is an assessment of its
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