Medication Management With Palliative Care

Pain management and palliative care issues and concepts word cloud illustration.

For our residents with life-limiting illnesses, the focus of medication management shifts from curative medications to palliative care medications. The focus of palliative care is on managing symptoms such as pain, anxiety or respiratory distress, while keeping other chronic conditions (such as High blood pressure, Diabetes, GERD) as stable as possible. Concerns over addictive properties of medications is decreased, while concern over safety remain.

Common categories of palliative medications:

    • Pain

A major focus in managing a resident with a terminal condition is ensuring that their pain is controlled; we may not be able to eliminate pain entirely but our goal is always to achieve maximum comfort while limiting side effects and safety risks. Most pain medications used are narcotics and increase the risk of constipation; bowel regimen should always accompany use of narcotics and bowel movements monitored. Family/loved ones often have concerns over pain meds and may need education and support to better understand medications used and their reasoning. Methadone and roxanol are common pain medications used. Methadone is a long acting opiod narcotic, Schedule II controlled substance. It is used to treat pain and relieve respiratory distress. Roxanol or morphine sulphate is a short acting opiod narcotic, Schedule II controlled substance. It is used to treat “breakthrough” pain and shortness of breath.

    • Respiratory distress/shortness of breath

For those patients with severe/frequent episodes of SOB, we recommend giving the following medications together at the onset of attack: 1 Ativan tablet, 1 pre-filled syringe of Roxanol, and 1 duo-neb via nebulizer. We call this combination an “Emergency “Breathing Kit.””

    • Anxiety

Lorazepam (Ativan) and Alprazolam (Xanax) are most commonly used, benzodiazepines, Schedule IV controlled substance.These medications are effective in providing relief from both anxiety and shortness of breath, especially for those with respiratory issues (CODP) where we see a cycle of SOB leading to increased anxiety, which leads to increased SOB and increasing anxiety. Medications work by relaxing the entire body, including the respiratory muscles, allowing the breaths they take to be more effective and help to break the cycle. Lorazepam is quicker acting, usually within 15 min/wears off quicker. Alprazolam may take up to 45 min to be effective, but results last longer. Both medications can increase drowsiness and increase fall risk.

    • Agitation/hallucinations

The most common medications used are Haldol and Risperdone, both are antipsychotic drugs. Haldol has a more immediate effect, often used to treat physical agitation, screaming, hitting not responsive to other interventions, happens without regard to time of day; usually scheduled but can be used as needed. Risperdone is used more for “sundowning” behaviors commonly occurring at the same time daily. Both medications have the side effects of sedation and increased fall risk.

    • Insomnia

Trazadone and temazepam are commonly used to treat insomnia. Trazadone is an antidepressant that causes drowsiness and is used for sleep initiation or maintenance disorders; takes approx 45 min to work, can be given at same time as Lorazepam or Roxanol if needed (since those are short acting). Temazepam (Restoril) is a benzodiazepine, Schedule IV controlled susbstance; causes dizziness, sleepiness, increases fall risk. Not usually recommended for older adults.

    • Nausea

We commonly use Promethazine (Phenergan), an antiemetic. It prevents and controls motion sickness, nausea, vomiting, and dizziness.It has a sedative effect, can lessen pain and anxiety. Available in both oral and suppository form. Common cause of nausea can be constipation – check to see when last bowel movement occurred.

    • Constipation

Senna S is a natural laxative, usually scheduled daily. Milk of Magnesia is a laxative/antacid given as needed, 30ml daily for no BM for 2 days. Dulcolax (Bisacodyl) suppository is a stimulant laxative given as needed for no BM for 3 days. Ok to hold Senna S for loose stools, and resume the next day. These medications are all over-the-counter medications.

Common as patient nears end of life, no longer able to swallow, saliva and fluids collect in mouth and throat causing the “rattle” sound. This can be very upsetting to family/ loved ones. We use Atropine drops an anticholinergic medication that lowers and dissolves the amount of body fluids in mouth and throat, for this. They are usually given as 2 drops every 2 hours as needed for secretions. An effective non-med intervention is to change positions – turn resident onto their side, may eliminate this. CompassionCare Hospice knows just how important palliative care can be.