Download Crisis Management in Hospice Patients

Objectives
Crisis Management in
Hospice Patients
Ellen Fulp, PharmD, CGP
VAHPC Annual Conference
Richmond, VA
May 15, 2015
• Identify common symptoms & crises seen in
hospice and palliative care patients and how to
treat them both non-pharmacologically and with
drug therapy
• Review patient cases
• Questions & Answers
Symptoms and Crisis Situations
• Pain
• Dyspnea
• Terminal Secretions
• Intractable Nausea
• Agitation
• Anxiety
• Hallucinations
• Restlessness
• Seizures
• Bleeding
Cause of Pain
• As your patient declines, they may no longer be able
to tolerate current pain regimens
• Dysphagia (difficulty swallowing)
• Odynophagia (pain with swallowing)
• Patients with rapid decline in functional status and
weight loss may no longer experience the full benefit
of their transdermal analgesic patches
Pain
• Most common and most feared end of life symptom
• Subjective
• Pain Crisis: severe, uncontrolled pain
• Distressing to both the patient and caregivers
• Severe pain is considered > 7/10 on the pain scale
• Can be described as >10
• A pain crisis requires immediate intervention and
palliative measures
Pain Plan
• Consider the use of a fast acting opioid
• Morphine (Roxanol®, MS IR)
• Oxycodone (Oxyfast®)
• These opioids should begin relieving the patient’s
pain within 30-45 minutes with a peak at 1 hour after
administration and a duration of 4-6 hours
• Determine if the patient is opioid-naïve or tolerant
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Pain: Opioid Naïve
• Opioid naïve patients are:
• Not currently receiving opioid therapy
• Not receiving at least 60mg of morphine daily for at least a week
• When starting a patient on morphine, be sure to
discuss the therapy with patient and caregivers
• Address concerns that opioids will hasten a loved one’s death
• Assure caregivers that opioid therapy will manage symptoms and
provide comfort
• If the patient requires extended use of a new opioid,
be sure to initiate constipation prophylaxis
Pain: Opioid Naïve (Subcutaneous)
Pain: Opioid Naïve (PO)
Begin with: 5mg of morphine PO
No improvement after 1 hour: give a second dose
Depending on severity, may double dose
Repeat doses hourly until pain has resolved
Depending on severity, may continue to double dose
Maximum dose of 30mg PO
If pain persists, contact prescriber
Pain: Opioid Naïve (IV)
Begin with: 2mg of morphine subcutaneously
Begin with: 2mg of morphine IV
No improvement after 30 minutes: give a second dose
Depending on severity, may double dose
No improvement after 15 minutes: give a second dose
Depending on severity, may double dose
Repeat doses every 30 minutes until pain has resolved
Depending on severity, may double dose
Repeat doses every 15 minutes until pain has resolved
Depending on severity, may double dose
Maximum dose of 15mg SQ
Maximum of dose of 15mg IV
If pain persists, contact prescriber
If pain persists, contact prescriber
Pain: Opioid Tolerant
Pain Management
Administer current short-acting opioid at DOUBLE the current
oral dose OR administer the opioid via subcutaneous injection
or IV route
• If the patient experiences
dysphagia or odynophagia,
consider using a liquid or IR
tablet
• Liquid morphine (Roxanol®) is
available in a 20mg/mL
concentration
• Using a dropper may allow a
caregiver to administer a
dose orally or buccally
If your patient is still experiencing moderate pain after:
1 hour (PO) / 30 minutes (Subcutaneous) / 15 minutes (IV)
may increase dose by an additional 50%
If your patient is still experiencing severe pain:
may increase dose by an additional 100%
Repeat Step #2 until pain is controlled
• Dose may be swallowed
passively
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Dyspnea
Dyspnea Management
• Sensation of difficulty breathing
• Calm the patient and adjust to a semi-reclined or seated
position
• Subjective
• Dyspnea Crisis: a sudden worsening of dyspnea with an
uncomfortable awareness of breathing during which the
patient cannot manage to catch their breath
• Apply a cool compress to the cheek and encourage
breathing with a pursed-lip technique
• Symptoms: chest tightness, breathlessness, wheezing, and
pain upon inhalation
• Ensure air supply: open window, fan, oxygen
• Possible Causes: tumor, COPD, CHF, pneumonia, fluid
accumulation, anemia, aspiration, electrolyte imbalance,
fatigue, anxiety
• May not be reflective of respiratory rate or oxygen saturation
Dyspnea Management
• Opioid Naïve
• 5mg Morphine or Oxycodone PO hourly
• If no effect, may double dose based on severity
• If dyspnea persists after 30mg PO or 15mg subcutaneously
(morphine), contact prescriber for further instructions
• Opioid Tolerant
• Administer DOUBLE current PRN oral dose every hour
or regular oral dose of PRN opioid subcutaneously every 15
minutes.
• Assess hourly and increase dose 50% for moderate dyspnea or
100% for severe dyspnea until symptoms are controlled
Dyspnea Management
• Initiate opioid therapy
• Morphine, Oxycodone
• If necessary, add benzodiazepine therapy
Dyspnea Management
• Liquid morphine is a good option for patients with
dysphagia or odynophagia.
• Nebulized Morphine
• Not been shown to be more beneficial than oral or
parenteral morphine
• Minimal systemic absorption
• May start with 4mg of intravenous morphine mixed with
normal saline to a total volume of 3mL, inhaled via
nebulizer every 4 hours. Each additional dose may be
increased by 2mg until symptoms resolve.
Terminal Secretions
• Dyspnea can cause anxiety which may increase
shortness of breath
• Patients may lose the ability to swallow saliva,
causing it to pool in the throat
• Benzodiazepine Adjunct Therapy
• Breathing may become noisy and sound rattled
• Diazepam (Valium®) 5-10mg PO hourly until settled, then
Q6-8H as needed to maintain even breathing
• Lorazepam (Ativan®) 0.5-2mg PO hourly until settled,
then Q4-6H as needed to maintain even
breathing; depending on the magnitude of your
patient’s crisis, consider 0.025mg/kg IV
• This condition is commonly referred to as the “death
rattle”
• To prevent or manage the accumulation of
secretions, position your patient with their head
elevated to assist with the drainage and open the
airway
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Terminal Secretions
• Uncontrolled secretions may distress caregivers
• Fear of “drowning”
• Prompt treatment of accumulated secretions is in order
• Suctioning
• Often causes discomfort and distress
• May not be effective: secretions usually pool below the
larynx and are thus inaccessible
• Should be considered for: mucous, blood, or visible
secretions that are not responding to anti-cholinergic
agents
Nausea
• Approximately 60% of hospice patients will
experience nausea/vomiting near end of life
• Possible causes: constipation, metastasis to
liver/brain/bowel, opioid medications, and
psychological distress
Managing Terminal Secretions
• Anticholinergics:
• Atropine
• 0.4 - 0.8 mg subcutaneously every hour as needed
• 1% Ophthalmic Solution sublingually at 1-2 drops
hourly until controlled and then Q4-6H PRN.
• Hyoscyamine
• 0.125-0.25mg SL Q6-8H PRN, MDD: 12 tabs
• Scopolamine
• 0.4mg subcutaneously every hour as needed
• 1.5mg transdermal patch placed behind the ear
Q72H
• Glycopyrrolate (Robinul®)
• 1-2mg PO Q8H PRN
Nausea
• Consider the source
• End of life nausea responds well to the following therapies:
• Haloperidol (Haldol®): 1-4mg PO Q4H
• Prochlorperazine (Compazine®, Compro®): 5-10mg PO TIDQID or 25mg rectal suppository up to twice daily
• Ondansetron (Zofran®): 8mg ODT PO Q8H
• Benzodiazepines, Metoclopramide, Promethazine
• When nausea becomes intractable and significantly
affects the patient’s quality of life, it is considered a
“crisis,” and must be treated immediately
Agitation
• Agitation is a state of anxiety and nervous
excitement, but may present differently depending
on the patient
• It is important to treat agitation as soon as it is
identified to avoid escalation
• Agitation Crisis: escalated agitation severely
distressing to the patient and caregivers
• May endanger the patient or others
Agitation
• Haloperidol (Haldol®)
• 1-10mg STAT. May double the dose hourly until symptoms are
controlled, then Q4-6H (maximum daily dose of 30mg)
• Tablet, solution, and injection
• Less sedating than benzodiazepines
• Most effective medication for the treatment of agitation
• Lorazepam (Ativan®)
• 0.5-2mg PO, SL, or subcutaneously every hour until symptoms are
controlled, then Q4-6 hours PRN
• Adjunct treatment for agitation
• Paradoxical effect: opposite than desired effect
• Consider discontinuation
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Anxiety
• Anxiety is a feeling of worry or nervousness; may be
related to a particular event or uncertain outcome
• May exacerbate: dyspnea, loss of appetite, nausea,
insomnia, and agitation.
• Anxiety may be relieved by calming music and
reassurance.
• Anxiety Crisis: anxiety that exacerbates underlying
conditions and is disrupting to quality of life
Hallucinations
• A hallucination is the perception of a sight, sound,
smell, taste, or touch that is not real
• Hallucinations may be induced by: fever, delirium,
medications, and progressing illness
• Hallucinations may be comforting to a patient;
should be treated as a crisis when they distress the
patient
Terminal Restlessness
• Combination of agitation, anxiety, and hallucinations
• Often observed in patients during their last days of
life
Anxiety
• Treatment:
• Lorazepam (Ativan®) 0.5-2mg PO, SL, or subcutaneously
every hour until symptoms resolved, then every 4-6
hours as needed
• Haloperidol (Haldol®) 0.5-1mg PO or SL Q4-6 as needed
• If your patient’s anxiety does not respond to
benzodiazepines or haloperidol, consider a more
sedating option:
• Chlorpromazine (Thorazine®)
• Phenobarbital (Luminal®)
Hallucinations
• Treatment
• Haloperidol (Haldol®) 0.5-10mg STAT
• 1mg PO, SL or subcutaneously every hour until
resolved
• Established maintenance dose given PO, SL or
subcutaneously Q4-6 PRN
• Maximum daily dose of 30mg.
• Tablet, solution, and injection.
Terminal Restlessness
• Treatment Options Include:
• Midazolam (Versed®) 0.5-5mg IV push over 3-5 minutes and titrate up
to 1-10mg/hr. Fast onset < 5 minutes
• Lorazepam (Ativan®) 0.5-2mg PO, SL, or subcutaneously every 1-2 hours
• Monitor for a paradoxical effect
• Possible causes: UTI, pain, dyspnea, constipation,
organ failure, or metabolic abnormalities
• Speak to the patient in a reassuring manner and
keep the environment calm and routine
• Haloperidol (Haldol®) 0.5-5mg PO or subcutaneously every 2-4 hours
• Not all treatments are appropriate for all patients
• Dependent on terminal prognosis and disease states
• It is crucial to individualize your patient’s therapy!
• Identify the patient’s primary symptom and treat it
with the therapies previously described
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Terminal Restlessness
Seizures
• Any seizure that causes a loss of consciousness is considered
a crisis
• Causes: cancer mets to the brain, stroke, metabolic causes,
pre-existing conditions
• If your patient has experienced a seizure, continue
prophylactic medication for as long as possible
• Consider subcutaneous or PR options if swallowing is compromised
• If the potential for seizure is suspected, consider keeping an
emergency seizure kit on hand
Palliative sedation may be necessary if your patient’s symptoms are not
responsive to low doses of benzodiazepines and antipsychotics.
Seizures
• If your patient experiences a seizure, think about
drugs!
• Drug-induced seizures can be caused by many medications
including: TCAs, MAOIs, SSRIs, tramadol (Ultram®),
metoclopramide (Reglan®), and meperidine (Demerol®)
• Always consider tapering medications before
discontinuing them
• Benzodiazepines
• Barbiturates
• Bupropion
Seizure Treatment
• Benzodiazepines are the drugs of choice (acute
seizure)
• First line therapies (fast onset):
• Diazepam (Diastat®) Rectal Gel
• 0.2mg/kg PR, round down to reduce ataxia or over
sedation
• A second dose may be given 4-12 hours following the initial
dose
• Should not be used more than once every 5 days
• Diazepam (Valium®) Solution (5mg/mL)
• Administer 10-20mg rectally with a syringe
• Midazolam (Versed®)
• 10mg IM injection
• You may roll your patient onto one side when
delivering a medication rectally
• This kit should include a benzodiazepine in a non-oral formulation
Seizure Treatment
• In the event of a seizure:
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Remain calm
Provide the patient with space
Protect the patient’s head
Loosen any tight clothing
Turn the patient’s head gently to the side if they vomit
Never try to restrain movements
Never put anything in the mouth
• If you have an emergency seizure kit, administer the
anti-epileptic medication as directed
Bleeding
• Bleeding Crisis: a sudden hemorrhage that may
cause loss of life
• Bleeding may be secondary to cancer
• Unfortunately a major bleed at the end of life is not
always manageable
• Swift death
• Resuscitation not effective
• Hospice or palliative care nurse’s priority is
comforting the patient and caregivers
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Bleeding
• Superficial bleeds: apply a dressing soaked in a
vasoconstrictive liquid
• Epinephrine (1:1,000 solution)
• Oxymetazoline (Afrin®) may help to slow and stop bleeding
• Rapid acting benzodiazepines may be used to reduce anxiety
• Midazolam (Versed®) 10mg
• Lorazepam (Ativan®) 1-2mg
• Minimize visual distress
• Consider using dark colored towels
• Opaque trash bags
Palliative Sedation
• Discuss palliative sedation with the family/caregiver
• It is important to explain that palliative sedation is
not euthanasia
• Will not shorten a life
• Relieves uncontrolled pain, dyspnea, nausea, or agitation
• Provides comfort in the last days of life
• Palliative sedation may be achieved with higher
doses of benzodiazepines, barbiturates, or
antipsychotics.
Crisis Case #1
• You plan to make a follow-up visit with JB to transition
him to oral morphine and to discuss an antiinflammatory
• Before you arrive, JB’s wife calls your after hours service
to report severe pain that JB rates as a 12 out of 10
• What do you do now?
Palliative Sedation
• Not all patients will respond to crisis management
• Palliative sedation decreases a patient’s
consciousness with medications to decrease the
awareness of suffering
• Reserved for intolerable symptoms that are unrelieved
by palliative interventions
• Palliative sedation should only be initiated after the
clinicians and family agree that the patient’s
symptoms are not responding to optimal therapy
• Last line therapy
Crisis Case #1
• JB is a 72-year-old male with a primary diagnosis of lung
cancer
• Mobility and appetite significantly decreased over the last
month
• Weight loss of 40 pounds since start of care
• Primary complaint during today’s visit is pain (Pain 8 of 10)
• Current regimen:
• Fentanyl 50mcg 1 patch Q72
• MS IR 15mg 1 tablet PO Q4 PRN Pain
Crisis Case #2
• JL is a 57 year old female with end stage COPD
• Pain is controlled with morphine IR 15mg ½ tablet PO Q 4-6
hours PRN
• She presents with worsening dyspnea and is increasingly
distressed secondary to air hunger
• You direct a fan towards JL and instruct her to use a pursed-lip
breathing technique
• What drug therapy would be appropriate?
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Crisis Case #2
• You double her dose of immediate release morphine
sulfate and initiate 1mg of lorazepam hourly
• Her crisis resolves
• A few days later you notice JL is still anxious about
her dyspnea attacks and occasionally struggles with
air hunger and anxiety
• You talk with JL’s physician and she is started on
maintenance therapy of lorazepam 1mg orally every
4-6 hours as needed
Crisis Case #3
• Benzodiazepines are the drug of choice for an active
seizure
• You reassure SP’s family and encourage them to give SP
space
• His wife brings over his emergency seizure kit and you
administer diazepam rectal gel
• Soon SP’s seizure ends and he is very confused
• Explain the situation calmly and encourage him to rest
Crisis Case #3
• SP’s emergency medication kit contains haloperidol 1mg
tablets
• Haloperidol 1mg po hourly until symptoms are controlled
• Administer established dose Q4 PRN agitation, restlessness
or nausea
Crisis Case #3
• SP is a 49 year old male with pancreatic cancer and
mets to the brain
• Pain is controlled with Methadone and he has MS IR
for breakthrough
• Vital signs are normal during your nursing visit
• SP begins shielding his eyes and asks that you stop
fiddling with the light switch; you note that the lights
are off and the window is open allowing in sunlight
• SP experiences a seizure. What do you do?
Crisis Case #3
• In the weeks following his seizure, SP has become more
agitated
• Regularly restless
• Occasionally attempts to strike caregivers
• You were called to the home by SP’s wife who is frustrated
• Reports insomnia and hallucinations involved a deceased
loved one
• On physical exam, SP is pale and appears distressed
• Barking out orders
• Dry heaving
Crisis Case #4
• MP is a 78 year old female with a primary diagnosis of end
stage dementia
• Swallowing is difficult and painful
• MP’s husband is increasingly concerned that MP is
“drowning in her saliva”
• Upon examination, MP has saliva pooling in her oral
cavity
• MP’s husband insists on suctioning the secretions
• You explain that this may distress MP and may not reach
the secretions in MP’s throat
• What medication would be appropriate?
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Crisis Case #4
• Atropine or Hyoscyamine are considered first line
therapy for secretions
• You initiate 2 drops of atropine 1% ophthalmic solution
every hour until secretions are improved
• Continue Atropine 1% ophthalmic drops Q2-4 PRN
excess secretions
Crisis Management
Crisis
Management
Agitation
Haloperidol , Lorazepam
Dyspnea
Morphine, Lorazepam
Bleeding
Epinephrine/Afrin®
Seizures
Diazepam, Midazolam
Intractable Nausea
Haloperidol, Prochlorperazine, Ondansetron
Anxiety/Restlessness
Lorazepam, Chlorpromazine
Pain Crisis
Morphine, Oxycodone
References
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