Crisis Management in Hospice Patients

Objectives Crisis Management in Hospice Patients Identify common symptoms & crises seen in hospice and palliative care patients and how to treat them both non-pharmacologically and with drug therapy Ellen Fulp, PharmD, CGP VAHPC Annual Conference Richmond, VA May 15, 2015 Review patient cases Questions & Answers Symptoms and Crisis Situations Pain Dyspnea Terminal Secretions Intractable Nausea Agitation Anxiety Hallucinations Restlessness Seizures Bleeding 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 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 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 1

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 (PO) Begin with: 5mg of morphine PO No improvement after 1 hour: give a second 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 (Subcutaneous) Begin with: 2mg of morphine subcutaneously No improvement after 30 minutes: give a second dose Repeat doses every 30 minutes until pain has resolved Maximum dose of 15mg SQ If pain persists, contact prescriber Pain: Opioid Naïve (IV) Begin with: 2mg of morphine IV No improvement after 15 minutes: give a second dose Repeat doses every 15 minutes until pain has resolved Maximum of dose of 15mg IV If pain persists, contact prescriber Pain: Opioid Tolerant Administer current short-acting opioid at DOUBLE the current oral dose OR administer the opioid via subcutaneous injection or IV route 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 Pain Management 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 Dose may be swallowed passively 2

Dyspnea Sensation of difficulty breathing Subjective Dyspnea Crisis: a sudden worsening of dyspnea with an uncomfortable awareness of breathing during which the patient cannot manage to catch their breath Symptoms: chest tightness, breathlessness, wheezing, and pain upon inhalation 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 Calm the patient and adjust to a semi-reclined or seated position Apply a cool compress to the cheek and encourage breathing with a pursed-lip technique Ensure air supply: open window, fan, oxygen Initiate opioid therapy Morphine, Oxycodone If necessary, add benzodiazepine therapy 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 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. Dyspnea Management Dyspnea can cause anxiety which may increase shortness of breath Benzodiazepine Adjunct Therapy 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 Terminal Secretions Patients may lose the ability to swallow saliva, causing it to pool in the throat Breathing may become noisy and sound rattled 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 3

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 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 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 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 TID- QID 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 4

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 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 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 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 Combination of agitation, anxiety, and hallucinations Often observed in patients during their last days of life 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 Identify the patient s primary symptom and treat it with the therapies previously described 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 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! 5

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 Palliative sedation may be necessary if your patient s symptoms are not responsive to low doses of benzodiazepines and antipsychotics. If the potential for seizure is suspected, consider keeping an emergency seizure kit on hand This kit should include a benzodiazepine in a non-oral formulation 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 In the event of a seizure: 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 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 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 6

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 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 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 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 #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? 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? 7

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 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 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 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 #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 #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? 8

Crisis Case #4 Crisis Management 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 Agitation Dyspnea Bleeding Seizures Intractable Nausea Anxiety/Restlessness Pain Crisis Management Haloperidol, Lorazepam Morphine, Lorazepam Epinephrine/Afrin Diazepam, Midazolam Haloperidol, Prochlorperazine, Ondansetron Lorazepam, Chlorpromazine Morphine, Oxycodone References Büttner, Michael, et al. "Is low-dose haloperidol a useful antiemetic?:a meta-analysisof published and unpublished randomized trials." Anesthesiology 101.6 (2004):1454-1463. Connelly J, Weissman DE. Seizure Management in the Dying Patient. Fast Facts and Concepts. April 2010; 229. Available at: http://www.eperc.mcw.edu/fastfact/ff_229.htm. D Arcy,Yvonne. ManagingEnd-of-LifeSymptoms. AmericanNurseToday. Vol. 7 No. 7. July2012. End of Life Curriculum Projects, US Veterans Administration. http://endoflife.stanford.edu/m16_pall_sed/meds.html End of Life Symptom Guidelines: Dyspnea.Vancouver Island Health Authority. 2008 Gallagher R. Dyspnea.In: Downing GM, Wainwright W, editors. Medical Care of the Dying. Victoria,B.C.Canada: Victoria Hospice Society Learning Centre for Palliative Care; 2006. p. 365-75. Haloperidol (Haldol ). Clinical Pharmacology. Revised 4/23/13. Kintzel P, et al. Anticholinergic medications for managing noisy respirations in adult hospice patients.am J Health Syst Pharm 2009. Last Days of Life. National Cancer Institute. http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/patient/page2#keypoint24 Lorazepam (Ativan ). Clinical Pharmacology. Revised 4/28/2013. Managing an Acute Pain Crisis: Care at End of Life Education Guidelines. JAMA evidence.mcgraw-hill Global Education Holdings, LLC. 2011 McPherson, Mary Lynn. Demystifying Opioid Conversion Calculations:A Guide for Effective Dosing. American Society of Health-System Pharmacists,Inc. 2010. PalliativeCare for the Patient with Incurable Cancer or Advnaced Disease:Dyspnea. Guidelines & Protocols Advisory Committee of BC Cancer Agency: Family Practice Oncology Network 2011. Terminal Secretions/Congestion. Hospice Palliative Care Program: Symptom Guidelines. FraserHealth. Approved by the Hospice Palliative Care, Clinical Practice Committee, November 2006. Astolfi J. Chapter 12. Palliative Care. In: Wells BG, ed. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aid=7967629. Accessed November 26, 2013. Hallenbeck, James L. Palliative Care Perspectives. Oxford University Press.2003. 9