AMSA Presentations Depression, Anxiety

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AMSA PresentationsDepression, Anxiety
DeliriumGU SymptomsAnorexia FatigueThe Last
Days of Life

• Jeffrey M. Behrens, MD, FACP, CMD
• Medical Director,
• VITAS Innovative Hospice of Palm Beach County

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Depression, Anxiety Delirium
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Depression
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Objectives

• Understand how to diagnose depression
• Review risk factors for depression
• Review risk factors for suicide
• Understand management of depression

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Definition of depression

• Dysphoric mood or loss of interest or pleasure in
  all or almost all usual activities m past-times.
• Word to describe include
• Depressed
• Sad
• Blue
• Hopeless
• Low
• Down in the dumps
• Irritable

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Diagnosis of depression

• At least four of the following symptoms have been
  present nearly every day for a period of at least
  2 weeks
• Poor or incresed appetite
• Weight gain or loss
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Loss of interest or pleasure in usual activities
  or decreased sexual drive
• Loss of energy or fatigue
• Feelings of worthlessness, or excessive or
  inappropriate guilt
• Diminished ability to think or concentrate
• Recurrent thoughts of death or suicide or actual
  attempts

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Risk Factors

• Pain
• Progressive physical impairment
• Advanced disease

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Risk Factors

• Advanced age gt70 (1 in 6 of people over age 65)
• Admission to a nursing home
• Psychosocial (isolation, loss of dignity,
  financial burden, fear of abandonment)
• Spiritual pain
• Preexisting risk factors (prior psychiatric
  disease, substance abuse)

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Risk Factors

• Medications
• Benzodiazepines (lorazepam, etc.)
• Chemotherapy
• Steroids
• Beta blockers
• Calcium channel blockers
• Analgesics

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Suicide

• Incidence in the elderly is double that in other
  populations
• Discussion of thoughts of suicide may reduce the
  risk
• High risk if recurrent thoughts/plans

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Suicide Risk Factors

• Depression
• Substance abuse
• Psychiatric admission within the year
• Psychotic disorders
• Widowed or divorced
• Poor social network
• Family discord

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Management of Depression

• Identify risk factors
• Early intervention (improves symptoms, restores
  function)
• Psychotherapeutic interventions (cognitive and
  behavioral)
• Medications

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Psychotherapeutic Interventions

• Improve patient understanding
• Explore religious and spiritual concerns
• Create a different perspective
• Identify strengths
• Re-establish self-worth
• Develop new coping strategies
• Educate about modifiable factors
• Possible use of electroconvulsant therapy.
• Review level of care

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Pharmacologic Management

• Psychostimulants
• SSRIs
• Tricyclics
• Atypical antidepressants

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Psychostimulants

• Rapid effect (2-3 days)
• Diminishes opioid sedation
• Not usually an appetite suppressant
• May exacerbate
• Tremulousness
• Anxiety
• Anorexia
• Insomnia

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Psychostimulates

• Methylphenidate (Ritalin)
• Modafinil (Provigil)
• Dextroamphetamine
• Pemoline (Cylert) (no longer available)

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SSRIs (Serotonin Specific Reuptake Inhibitors)

• Latency of 2-4 weeks
• Highly effective (70)
• Well tolerated
• Once daily dosing
• Low doses may be effective in advanced illness

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SSRIs

• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Sertraline (Zoloft)

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SSRIs

• Side effects (dose related)
• Increased intestinal motility-loose stools,
  nausea vomiting
• Asthenia
• Sleep disturbance
• Headaches
• Sexual dysfunction
• Hyponatremia

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Tricyclic Antidepressants

• Amitriptyline (Elavil)
• Desipramine (Norpramin)
• Doxepin (Sinequan)
• Imipramine (Tofranil)
• Nortriptyline (Pamelor)

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Tricyclic Antidepressants

• Not recommended as first-line therapy
• Latency 3-6 weeks
• Adverse effects are common (contraindicated in
  cardiovascular disease)
• May be appropriate with
• Chronic/neuropathic pain
• Weight loss/insomnia
• Urinary urgency

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Tricyclic Antidepressants

• Side effects
• Constipation
• Dry mouth
• Orthostatic hypotension (increased risk of falls)

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Atypical Antidepressants

• Mirtazapine (Remeron)
• Venlafaxine (Effexor)
• Duloxetine (Cymbalta)
• Bupropion (Wellbutrin)
• Trazodone

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Mirtazapine (Remeron)

• Attractive choice in the elderly
• Increased appetite and weight gain
• Increased somnolence at lower doses
• Lack of cardiotoxicity
• Low risk for drug to drug interactions

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Mirtazapine (Remeron)

• Adverse effects
• Dry mouth
• Constipation
• Dizziness
• Abnormal dreams
• headache

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Norepinephrine and Dopamine Reuptake Blockers

• Bupropion (Wellbutrin)
• Advantages in elderly patients due to lack of
  sedative effects, cardiotoxicity, and sexual
  dysfunction
• Side effects
• Agitation, headache, dizziness, tremor, insomnia,
  anorexia, nausea
• Seizures have been reported with doses greater
  than 400 mg/day

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Serotonin 2 Antagonists/Serotonin Reuptake
Inhibitors

• Trazodone
• Very sedating at low doses (lt100mg)
• Increased orthostatic hypotension
• Adjunct to analgesics

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Summary

• Depression is.
• Challengingdifficult to treat
• Overwhelming to patients, families, and
  caregivers
• A reason for placement in LTCF
• Easily misdiagnosed
• An opportunity to improve the quality of life for
  the patient and/or caregiver

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Anxiety
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Objectives

• Understand how to diagnose anxiety
• Review risk factors for anxiety
• Understand management of anxiety

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Diagnosis of Anxiety

• Psychological reactions
• Insomnia
• Irritability
• Inability to concentrate
• Poor coping skills
• Symptoms and physical features
• Anorexia
• Nausea
• Hyperventilation
• Palpitations
• Sweating.

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Risk Factors

• Changes in life situations
• Direct or indirect effects of terminal illness
• Exacerbation of preexisting conditions.

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Pharmacologic Treatment of Anxiety

• Benzodiazepines
• Lorazepam (Ativan)
• Temazepam (Restoril)
• Oxazepam (Serax)
• Diazepam (Valium)
• Barbiturates
• Pentobarbital
• Thioridazine (Mellaril)
• Haloperidol (Haldol).

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Delirium Terminal agitation
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Objectives

• Define Delirium and Terminal Agitation
• Describe the Causes for Delirium and Terminal
  Agitation
• Identify the key factors for assessment of
  Delirium and Terminal Agitation
• Explain the goals and interventions for treatment
  of Delirium and Terminal Agitation
• Discuss patient and family education regarding
  Delirium and Terminal Agitation

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Delirium Terminal Agitation

• Must be differentiated from anxiety and dementia
• Impacts cognitive skills
• Acute process
• Waxes and wanes, usually worse at night
• Must assess over 24 hour related to erratic
  symptoms seen over day
• Occasional incoherent word usage, but not verbal
  loss
• Hallucinations
• Hyperawareness, and possible emotional liability
• May show apathy, fear, or rage
• Treatment must include psychosocial support and
  calm environment

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Common Causes of Delirium Terminal Agitation

• D rugs, especially psychotropics
• E lectrolyte or glucose abnormality
• L iver failure
• I schemia or hypoxia
• R enal failure
• I mpaction of stool
• U rinary tract or other infection
• M estastases to the brain

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Step 1 Assessment

• Maintain a high index of suspicion for delirium.
  It may be life threatening proper assessment is
  essential.
• Use a screening tool to assess cognition even in
  patients who do not appear confused. Do not rely
  solely on orientation questions.

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Step 1 Assessment (cont.)

• Ask specifically about hallucinations (usually
  visual and tactile) and paranoid ideation.
• Examine and look for signs of infection, opioid
  toxicity (myoclonus, hyperalgesia), dehydration,
  uremia, hepatic encephalopathy, etc.
• Order investigation when appropriate, e.g., CBC,
  electrolytes, ionized calcium, urea, and
  creatinine, urinalysis, CXR, O2 sats, etc.

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Step 2 Treating the Underlying Cause if
Appropriate

• Opioid toxicity Change to another opioid.
• Sepsis Start antibiotics if appropriate,
  considering the goals of care.
• Drugs Stop, wean, or decrease possible offending
  drugs, e.g., tricyclic antidepressants,
  benzodiazepines

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Step 2 Treating the Underlying Cause if
Appropriate (cont.)

• Dehydration Consider Hypodermocyclis with normal
  saline (if the site leaks or swelling is
  uncomfortable, give 150 u hyaluronidase into the
  SC site before infusion usually unnecessary)
  reassess daily. If IV line is already
  established, hydration can be given IV.

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Step 2 (cont.)

• Hypercalcemia Treat for dehydration. Consider
  Calcitonin, saline furosemide, IV
  Biphosphonates (Alendronate, Pamidronate)
• Hypoxia Treat underlying cause and administer
  O2.
• Urosepsis If possible remove indwelling urinary
  catheter and treat infection with appropriate
  antibiotics

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Medications Used to Manage Delirium Terminal
Agitation in Patient with Advanced Disease

• Generic Name Approximate Daily Dose
  Route
• Neuroleptics
• Haloperidol 0.5-5 mg every 2-12 h
  po, IV, SC, IM
• Thioridazine 10-75 mg every 4-8 h
  po
• Chlorpromazine 12.5-50 mg every 4-12 h
  po, IV, IM
• Methotrimeprazine 12.5-50 mg every 4-8 h
  IV, SC, po
• Molindone 10-50 mg every 8-12 h
  po
• Drioerudol 0.625-2.5 mg every
  4-8 h IV, IM
• Atypical Neuroleptics
• Olanzapine 2.5-20 mg every 12-24
  h po
• Risperidone 1-3 mg every 12-24 h
  po
• Quetiapine 25-200 mg every 12-24
  h po

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Medications for Delirium Terminal Agitation
(cont.)

• Generic Name Approximate Daily Dose
  Route
• Benzodiazephines
• Lorazepam 0.5-2.20 mg
  every 1-4 h po, IV, IM
• Midazolam 30-100 mg
  every 24 h IV, SC
• Anesthetics
• Propofol 10-70 mg
  every h IV
• 
  Up to 200-400 mg/h

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Step 3Treatment for Moderate to Severe Agitated
Delirium

• For Moderate Delirium
• Haloperidol (Haldol) 1 to 2 mg PO or SC
  hourly as needed to
• calm a
  crisis then q 6 to 12 h PO or by infusion
• If more sedation is needed consider
• Thioridazine (Mellaril), or 25-50 mg PO hr until
  calm, then q 6 to 12 h
• Chlorpromazine (Thorazine) 25-50 mg PO, PR, or IV
  hr until calm then q 6 to 12 h or by infusion
• For Severe Agitated Delirium Reassess for
  reversible causes and if necessary, consider the
  addition of benzodiazepines or a high dose of a
  sedating phenothiazine, even though they may
  cause more clouding of the sensorium.

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Step 3 (cont.)

• Lorazepam (Ativan) 1-2 mg hourly, PO, SL,
  or IV
• Midazolam (Versed) 0.4 to 4 mg/h
  continuous, SC a mean dose of 2.9 mg/h (70 mg/d)
  was effective in 22 of 23 patients in one series
• Chlorpromazine (Thorazine) 100 mg every hour IV,
  PO, PR
• Some patients are held by a combination of
• Haloperidol (Haldol) 5 to 20 mg/d and midazolam
  (Versed) 10 to 100 mg/d via continuous
  subcutaneous infusion
• In rare cases, when none of the above methods
  work during the final hours of life, consider
  therapeutic sedation with
• Phenobarbital 130 mg SC hourly until calm and
  then subcutaneous infusion (600 to 1200 mg/d)
• When all else fails, consider
• Thiopental (20 to 200 mg/h) or methohexiatal
  sodium (Brevital Sodium) continuous IV infusion
  titrated to unconsciousness

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Step 4 Psychological Supports for the Restless
Patient

• Provide information in accord with individual
  wishes.
• Permit expression of emotion.
• Clarify concerns and problems.
• Involve patient in decision making.
• Provide continuity of care from named staff.
• Provide group discussion for information and
  support.
• Provide music therapy.
• Provide art therapy.
• Teach relaxation techniques.
• Provide aromatherapy.
• Arrange for a change of scenery.

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Step 5 Family and Staff Education

• Confusion and agitation are often expression of
  brain dysfunction. Misinterpretation of symptoms
  as pain can result in excessive use of opioids,
  resulting in aggravation of the agitation.
• Most patients have limited or no recollection of
  their symptoms after the episode subsides.

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Step 5 (cont.)

• The treatment goal is comfort, not prolongation
  of life.
• Delirium may be superimposed on preexisting
  dementia unrecognized by family or healthcare
  professionals.
• Urinary retention and constipation in cognitively
  impaired patients can be misdiagnosed as agitated
  delirium or crescendo pain.

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Summary

• Delirium Terminal agitation is multifactorial.
• Must be recognized early and differentiated from
  anxiety or dementia
• Reversible causes, if any, should be corrected
• Rapid efficient therapy should be initiated as
  soon as possible

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Questions Discussion
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GU Symptoms
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Objectives

• Define the various GU symptoms experienced at the
  end of life
• Discuss the causes of the various symptoms
• Discuss the various treatment alternatives

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GU Symptoms Experienced at the End of Life

• Urinary incontinence
• Urinary retention
• Bladder spasms
• Hematuria
• Infections
• Fistulas

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Urinary incontinence - causes

• Infections
• BPH
• Overflow
• Spastic bladder
• Medications
• Trauma
• Dementia
• Disease states (diabetes, etc.)
• Cord compression
• Direct tumor invasion of bladder
• Others

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Urinary incontinence - treatments

• Depends on underlying or suspected causes as well
  as functional status of patient prognosis
• If infection suspected prognosis warrants, U/A,
  CS, and appropriate antibiotic Rx otherwise
  acetaminophen frequent changes/ diapers, etc.
• If BPH or urinary obstruction suspected in
  female, consider tamsulosin (Flomax), terazosin
  (Hytrin), catheter, etc.
• Overflow incontinence due to neurogenic bladder
  treated with catheter.
• Spastic bladder treated with anticholinergics
  (oxybutinin (Ditropan)).

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Urinary incontinence - treatments

• If caused by medications (diuretics, others)
  consider change in Rx, or symptomatic Rx.
• If due to trauma to GU tract, treat
  symptomatically.
• If due to dementia, attempt frequent toileting,
  consider diapers, educate family staff, rarely
  use catheter.
• If secondary to other disease (diabetes) control
  primary disease state.
• If due to cord compression, may require MRI and
  emergency radiation Rx /- steroids.
• If due to direct tumor invasion, consider
  frequent linen changes, diapers, minimize fluid
  intake, or catheter.

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Urinary retention - causes

• Constipation/ fecal impaction
• Medications (opioids, antiemetics,
  antihistamines, antidepressants, anti
  cholinergics
• Obstruction
• BPH
• Tumors
• Strictures
• Neurogenic bladder
• Cord compression
• Tumor invading neural plexus(s)
• Chemotherapy-induced neuropathies
• Diabetic neuropathy
• CVA
• Degenenerative neurological disorders

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Urinary retention - treatments

• Also depends on functional status of patient and
  prognosis.
• If due to constipation/impaction, proper
  treatment of GI disorder will result in rapid
  correction of problem.
• If due to medications, consider change in
  therapy.
• If due to obstruction, trial of tamsulosin
  (Flomax), terazosin (Hytrin) if this fails,
  catheterization (intermittent or indwelling).
• Neurogenic bladder always need catheter or
  suprapubic (unless cord compression Rx with
  radiation/steroids)

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Bladder spasms - causes

• Infection
• Radiation
• Blood or clots or stones causing irritation
• Catheters
• Tumors invading spinal cord or direct bladder
  invasion

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Bladder spasms - treatments

• Treat the underlying pathology if possible.
• If due to infection, U/A, CS, antibiotics
• If due to blood, clots or stones
  cathterization/irrigation may help.
• If due to catheter remove, reinsert smaller
  caliber or smaller balloon.
• Non-specific treatments include
• Anticholinergic medications (oxybutanin)(Ditropan)
  
• NSAIDs to relieve irritation (may induce
  hematuria)
• BO suppositories (Belladonna Opium)
• Bladder irrigation with 0.25 acetic acid
  solution or 0.25 bupivacaine (20 cc q 8-12 h)

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Hematuria - causes

• Infections
• Tumors
• Radiation or chemotherapy cystitis
• Kidney stones
• Bleeding diatheses

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Hematuria - treatments

• Frequently, the hematuria is a MINOR problem
  however it upsets the patient and/or family.
• All treatment decisions depend on severity of
  problem, patients condition and prognosis.
• If due to infection treat with antibiotic
• If due to tumor consider radiotherapy,
  cauterization, laser, or simply reassurance
  comfort measures.
• If due to stones, treat with hydration opioids
  to assist passage.
• If due to bleeding diatheses, consider bladder
  irrigation with cold saline, epsilon-aminocaproic
  acid (Amicar) or 1 alum in sterile water.

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Infections

• CAUSES
• Poor perineal hygiene
• Bed-bound state
• Inadequate fluid intake
• Generalized debility and loss of defense
  mechanisms
• TREATMENTS
• Depend on condition of patient prognosis
• Antibiotics, fluids v.s. comfort measures only

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Fistulas

• 2 incidence due to tumors
• Most frequently caused post-op hysterectomy,
  prostatectomy, rectal resections, other pelvic
  surgeries or radiation
• May be uretorovaginal, ureterocutaneous,
  rectovaginal, enterovescical, vesicovaginal,
  rectoureteral
• Treatments depend on condition of and prognosis
  of patient.
• Insertion of catheter with spontaneous closure
• Surgery
• Symptomatic/comfort treatments

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Questions Discussion
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Anorexia Fatigue
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Objectives

• Define anorexia fatigue
• Discuss the various causes
• Describe how to perform an adequate assessment
• Describe various pharmacological
  non-pharmacological treatment modalities

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Anorexia - definitions

• Loss of appetite
• May be due to malignancy
• Known as cancer anorexia-cachexia syndrome
• May also be seen in elderly debilitated patients

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Anorexia - causes

• Cancer Anorexia-Cachexia Syndrome
• Metabolic abnormalities
• Abnormal glucose uptake by normal cells due to
  direct effect of tumor
• Increased insulin resistance
• Glucose intolerance
• Increased gluconeogenesis by breakdown of muscle
  proteins and fat stores resulting in loss of lean
  body mass weight loss
• Release of cytokines by tumor or host
• Tumor necrosis factor (TNF) (cachectin)
• Interleukin-1, Interleukin 6
• Gamma interferon

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Anorexia additional causes

• Cancer Anorexia-Cachexia Syndrome
• Direct effect of malignant tumors causing loss of
  appetite
• Abdominal fullness early satiety
• Taste changes
• Nausea vomiting
• Dry mouth
• Uncontrolled pain
• Constipation
• Changes in smell
• Mucositis due to opportunistic infections
• Mechanical obstruction
• Side effects of chemo radiation treatment

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Anorexia additional causes

• Anorexia in elderly debilitated patients
• Loss of ability to eat independently due to
  decreased mobility
• Impaired cognition
• Dislike of modified consistency diets
• Upper extremity dysfunction due to strokes or
  other CNS disorders
• Dysphagia due to multiple causes (stroke, ALS,
  Parkinsons, esophageal motility disorders, etc.)
• Impaired dentition/ poor fitting dentures
• End stages of CHF, COPD
• Depression

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Anorexia performing an adequate assessment

• Perform a complete HP including medication
  review
• Special attention to oral cavity
• Special attention to abdominal exam
• Review all prescription and non-prescription
  medications
• Determine food preferences dislikes
• Perform psychosocial evaluation to include
  presence of depression, fear, anxiety
• Determine if patient is bothered by the symptom
  OR is it the family that is upset?
• Determine if etiology is reversible or
  non-reversible due to disease state.

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Anorexia non- pharmacological treatments

• Remove dietary restrictions
• Allow intake of favorite foods snacks
• Modify texture, temperature, spiciness of foods
• Remove noxious smells from environment
• Discontinue or lower doses of offending
  medication(s)
• Smaller portions
• Offer alcoholic beverages if patient desires
• Explain that loss of appetite is expected with
  the illness
• Instruct family NOT to force feed or ridicule
  patient
• Improve oral hygiene
• Enlist assistance of dietician if needed

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Anorexia pharmacological treatments

• Prednisone (5-10 mg TID) or Dexamethasone (4 mg
  daily)
• Metoclopramide (Reglan) (10 mg before meals)
• Dronabinol (Marinol) (2.5 mg BID)
• Megestrol acetate (Megace) (400 mg BID)
• Cyproheptadine (Periactin) (4 mg TID)
• TPN (rarely, if ever has actually been shown to
  shorten survival due to complications)
• PEG or NG tubes (rarely if ever due to
  complications)
• Increased risk of aspiration
• Shortens survival due to complications
• Has NOT been shown to heal decubitus ulcers

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Fatigue - definitions

• Also described as weakness (asthenia)
• Lack of sufficient energy to perform usual
  activities
• Described as
• Feeling tired
• Feeling sleepy

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Fatigue - causes

• Frequently seen with all chronic illnesses or
  end-stage illnesses
• Malignancies
• End-stage CHF
• End-stage COPD
• End-stage neurological disorders
• End-stage AIDS
• End-stage renal disease
• End-stage liver disease
• Generalized debility
• Depression

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Fatigue performing an adequate assessment

• Perform a complete HP including medication
  review
• Review all prescription and non-prescription
  medications
• Assess nutritional status
• Perform psychosocial evaluation to include
  presence of depression, fear, anxiety
• Determine if patient is bothered by the symptom
  OR is it the family that is upset?
• Determine if etiology is reversible or
  non-reversible due to disease state.

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Fatigue- non-pharmacological therapy

• Plan of care to include adequate rest periods to
  reduce fatigue
• Protect from injury due to possible falls
• Try to instill a positive attitude
• Provide psychosocial support including
  counseling, relaxation, guided imagery
• Passive ROM
• Gentle exercise or short course of P.T.

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Fatigue- pharmacological therapy

• No specific medication exists
• Discontinue hypotensive medications, diuretics,
  hypoglycemic medications, sedatives
  tranquilizers
• Corticosteroids (Prednisone 5-10 mg daily)
  (Decadron 4 mg daily) will induce a felling of
  well-being
• Methylphenidate (Ritalin) will increase level of
  arousal decrease sensation of fatigue
• May also use dextroamphetamine, modafinil
  (Provigil)

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Questions Discussion
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The Last Days of Life
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Objectives

• Define the phases of the last days of life
• Describe the signs symptoms
• Discuss the components of an assessment
• Discuss the treatment alternatives
• Discuss the psychosocial bereavement issues

84
Last days of life definitions of phases

• PRE-ACTIVE
• last 2 weeks
• ACTIVE (IMMINENT)
• last 72 hours

85
Pre-active phase- signs symptoms

• Diminished appetite thirst
• Decreased urinary output
• Progressive lethargy weakness
• Limited attention span
• Increased sleep
• Increased dependence on caregivers
• Bedbound state in formerly active patient
• New onset of bowel or bladder incontinence
• Withdrawal from surroundings others
• Verbalization to an external source increasing
  disorientation
• Picking at bed clothes or in the air
• Terminal restlessness

86
Active phase signs symptoms

• Clouding of consciousness
• Decreased responsiveness to external stimuli
• Eyes glassy, pupils unfocused
• Refusal of food or fluid
• Tachypnea with periods of apnea (Cheyne-Stokes)
• Increased use of accessory muscles for
  respiration
• Tachycardia gt 125 beats/minute
• Hypotension
• Difficulty or inability in obtaining BP or P
• Cold hands feet with mottling
• Terminal congestion (death rattle) or pulmonary
  edema
• Patient may have an unexpected surge of energy or
  alertness during the last 24-48 hours

87
Last days of life performing an assessment

• Perform physical mental status exam with
  special emphasis on vital signs, patterns of
  respiration, temperature appearance of skin
• Determine phase
• Discontinue all but comfort medications
• Determine what psychosocial needs are needed

88
Last days of life - treatments

• Treatments for family
• Treatments for patient

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Last days of life treatments for family

• Try to soothe them answer questions
• Prepare them for the final days
• Be vague about How long?
• Reassure them that the patient is not in pain,
  hungry or thirsty
• Allow sufficient time for them to express their
  feelings
• Request chaplain and/or social worker as needed
• Acknowledge the stress the family is under
• Reinforce the good care the family has been
  providing
• Suggest the family speak to the patient hold
  their hand since the patient will find comfort in
  this
• Allow the family to have private time with the
  patient
• Suggest that friends, relatives, children,
  grand-children visit

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Last days of life treatments for patient

• Tell patient Its alright to let go
• Place blankets on patient if cold mottled
• Offer ice chips if patient will accept
• Increase mouth care to address increased
  secretions
• Elevate head of bed or turn head to side to
  assist breathing
• Continue aggressive pain symptom management
• Adequate opioids
• Continue liquid oral meds, or rectal, or
  transdermal or clysis (rarely I.V.)
• Lorazepam (Ativan) or equivalent anxiolytics
• Acetaminophen for fevers
• Atropine or hyoscyamine (Levsin) or others for
  excessive secretions death rattle
• Aggressive treatment for terminal agitation or
  delirium

91
Opioids for pain management and/or dyspnea

• Morphine
• 5-10 mg liquid po/sl q 1-2 h prn pain/SOB
• 1-3 mg IV q 1-2 h prn pain/SOB (in-patient
  status)
• 1-3 mg/hr continuous IV (in-patient status)
• 5-20 mg nebulized q 4 h prn SOB
• 5-10 mg in suppository q 1-2 h prn pain/SOB
  (least preferred)
• May be given subcut. (clysis) if not cachectic or
  overly edematous (for this route, hydromorphone
  (Dilaudid) is preferred.)
• BE SURE TO ADMINISTER AT LEAST 25 of PATIENTS
  ORIGINAL DOSE EVEN IF ALL MEDS HAVE BEEN D/Cd
  DUE TO IMMINENT STATE TO AVOID OPIOID WITHDRAWAL

92
Management of dyspnea

• Opioids
• Anxiolytics
• Lorazepam (Ativan) 0.5-2 mg p.o. or I.V. q4h prn
  SOB
• Diazepam (Valium) 2-20 mg p.o. or I.V. q4h prn
  SOB
• Alprazolam (Xanax) 0.25-2 mg p.o. q4h prn SOB
  (least preferred)
• Oxygen

93
Management of excessive secretions Terminal
Congestion (Death rattle)

• Atropine ophthalmic solution 1 1-2 gtts s.l.
  q1-2h atc or prn
• Atropine injection 0.4-0.6 mg iv/sq q4-6h atc or
  prn
• Hyoscyamine (Levsin) 0.125-0.25 mg po/sl q4-6h
  atc or prn
• Glycopyrrolate (Robinul) 1-2 mg po/sl tid atc or
  prn
• Transderm scopolamine patches not indicated in
  actively dying patients

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Management of terminal agitation delirium

• Previously discussed earlier today

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After the death of the patient

• Anticipate extreme grief reactions from the
  family
• Comfort the family
• Have chaplain visit with family ASAP
• Chaplain will attend to immediate needs
• Chaplain will discuss funeral, memorial plans
• Chaplain will arrange for bereavement follow-up
  services
• Have nurse or social worker notify funeral home
• Appropriately discard medications

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