Medications for Dying Patients

Medications for IMMINENTLY dying patients

General recommendations:

  • At VUMC, there is a very helpful order set titled “Comfort Care Orders (Trauma, MICU, SICU, NEURO ICU, Palliative Care”
  • No order set at VA
  • Clean up orders: make sure to remove unnecessary medications, nursing text orders, etc.
  • Do make sure to order PRNs in anticipation of their need so that they become available to RN, particularly in the unit if you anticipate rapid progression of events following extubation, etc.

 

Pain:

  • Morphine 2mg IV or SQ q1h PRN
  • Hydromorphone 0.25 – 0.5mg IV or SQ q1h PRN
  • Write as PRN, as needed for pain > 2/10 or for air hunger
  • Hydromorphone is preferable to morphine in patients with renal impairment
  • If ineffective after 1 hours, increase by 50-100%
  • If given every hour for 3-4 hours, consider an infusion (given PRN dose as hourly rate)
  • Fentanyl is not a great option in ICU unless it is a continuous drip. Bolus lasts only 15 mins

 

Dyspnea/Tachypnea:

  • Assess for volume overload, considering decrease or stopping IVFs or tube feeds
  • Opioids are the treatment of choice for dyspnea
  • Consider Benzodiazepines for air hunger not controlled by opiates
  • Supplemental oxygen for comfort (do not base on O2 sat)
  • Consider use of cool air and/or fan to the face/patient
  • Diuresis, bronchodilators, steroids, other mgmt as indicated if underlying cause identified

 

Restlessness/Agitation:

  • Assess for urinary retention, constipation, pain, other modifiable factors before initiating medical therapy
  • Haloperidol (Haldol) 0.5 – 1 mg PO, IV or SQ q4h PRN
  • Lorazepam (Ativan) 0.5 – 1 mg PO or IV q4h PRN (tablet can be made into slurry if patient is experiencing dysphagia)
  • CAUTION: Benzos can worsen delirium

 

Nausea:

  • Ondansetron (Zofran) 4mg IV q4h or 8mg q8h PRN
  • Promethazine (Phenergan) 25mg PO or PR q6h PRN; caution can be very sedating
  • Prochlorperazine (Compazine) 10mg PO or IV q4h PRN
  • Haloperidol (Haldol); see dosing above
  • If felt to be obstructive in etiology, try Dexamethasone 4mg IV or SQ q8-12h with Octreotide 100-400mcg IV or SQ q8h
  • If felt to be related to anxiety, try Lorazepam; see dosing above
  • Scopolamine is highly anti-cholinergic and takes time to be effective, so would NOT use in imminently dying patients

 

Secretions:

  • Position for comfort; side lying if possible to move sections
  • Remember: the patient is NOT bothered by their own secretions, and it is often the family and caregivers who are likely disturbed, so avoid deep suctioning
  • Glycopyrrolate (Robinol) 0.2 – 0.4 mg SQ or IV q6h PRN (can schedule; but use caution as it does cause confusion or other mental status changes like many anti-sialagogues)
  • Atropine 1% Ophthalmic Solution 2 drops SL 2-4h PRN