The use of midazolam and haloperidol in cancer patients at the end of life.This is part II of a two-par article on the management of common symptoms in terminally ill patients. In addition to pain, patients who are approaching the end can tbol shut you down life commonly have other symptoms. Unless contraindicated, prophylaxis with a gastrointestinal motility stimulant laxative and a stool softener is haloperidol uses in cancer patients in terminally ill patients who are being given opioids. Patients with low performance status are not candidates for surgical treatment of bowel obstruction. Cramping abdominal pain associated with mechanical bowel obstruction often can be managed with morphine titrating the dosage for pain and octreotide.
When is Haldol the Right Choice?
This is part II of a two-par article on the management of common symptoms in terminally ill patients. In addition to pain, patients who are approaching the end of life commonly have other symptoms. Unless contraindicated, prophylaxis with a gastrointestinal motility stimulant laxative and a stool softener is appropriate in terminally ill patients who are being given opioids.
Patients with low performance status are not candidates for surgical treatment of bowel obstruction. Cramping abdominal pain associated with mechanical bowel obstruction often can be managed with morphine titrating the dosage for pain and octreotide.
Delirium is common at the end of life and is frequently caused by a combination of medications, dehydration, infections or hypoxia. Haloperidol is the pharmaceutical agent of choice for the management of delirium. Dyspnea, the subjective sensation of uncomfortable breathing, is often treated by titration of an opioid to relieve the symptom; a benzodiazepine is used when anxiety is a component of the breathlessness.
Physical symptoms other than pain often contribute to suffering at the end of life. Part I of this two-part article reviewed the management of fatigue, anorexia, cachexia, nausea and vomiting in patients with cancer, acquired immunodeficiency syndrome AIDS and other terminal illnesses.
Part II discusses measures to alleviate constipation, delirium and dyspnea. With appropriate diagnosis and management, many of these symptoms can be alleviated in patents who are approaching the end of life. Constipation is a frequent cause of nausea and vomiting in terminally ill patients.
Management depends on assessment and manipulation of the four major components required for normal bowel movements: Constipation resulting from opioids is dose-related, and patients do not develop tolerance to this side effect. Prophylaxis is crucial because opioid-induced constipation is much easier to prevent than to treat. All patients for whom opioids are prescribed should be given a prophylactic gastrointestinal motility stimulant laxative and a stool softener, unless use of these agents is contraindicated.
A stool softener alone is usually not sufficient to alleviate opioid-induced constipation. Mechanical bowel obstruction occurs in approximately 3 percent of patients with cancer who are receiving hospice care. In terminally ill patients with low performance status, surgical treatment of bowel obstruction is not appropriate because of high mortality and recurrence rates. Cramping abdominal pain associated with mechanical bowel obstruction primarily results from the accumulation of secreted bowel fluid.
This problem can often be managed with titration of the morphine dosage to manage pain, along with the administration of octreotide Sandostatin , a synthetic somatostatin that inhibits the intraluminal secretion of intestinal fluid. Treatment with medications commonly used to manage nausea and vomiting e.
Use of these drugs is discussed in part I of this two-part article. The exception is the prokinetic agent metoclopramide Reglan , which may worsen symptoms of mechanical obstruction. Stool softeners and osmotic agents may be useful in patients with partial mechanical obstruction.
Delirium is a disturbance of consciousness and cognition with a sudden onset that may be accompanied by increased psychomotor activity. Delirium often heralds the end of life and may require active sedation in up to 25 percent of patients. Caution is advised in patients with low fluid intake, as psyllium may cause impaction.
Sorbitol 30 mL every 2 to 4 hours until stool. Bed-ridden patients; neurodegenerative disorders; drugs, including morphine, tricyclic antidepressants, scopolamine Transderm Scop , diphenhydramine Benadryl , vincristine Oncovin , verapamil Calan and other calcium channel blockers, iron, aluminum and calcium salts.
Adapted with permission from Hallenbeck J, Weissman D. Fast fact and concepts Constipation—what makes us go. Retrieved April 23, , from: Common causes of delirium near death include hypoxia, infections e. As the time of death approaches, hepatic and renal function deteriorates, and patients become more vulnerable to delirium, particularly delirium caused by medications.
Discontinuing unnecessary drugs or prolonging the dosing interval for necessary drugs may help to clear the sensorium. A recent study 5 found that despite a high incidence 88 percent , delirium was reversible in approximately 50 percent of dying patients.
In this study, opioids, other psychoactive medications and dehydration were the most frequent causes of reversible delirium. Dehydration is usually asymptomatic in terminally ill patients; however, when dehydration results in delirium, gentle rehydration may be beneficial if there is a need for the patient to be more alert.
Another study 6 identified factors associated with an increased risk of delirium in patients older than 80 years. In addition to reducing risk factors for delirium, the physician may be able to prevent its onset in an elderly patient by avoiding five precipitating conditions: Altered mental status may be precipitated by a combination of therapies.
Anesthetics, analgesics, antibiotics, anticholinergics, antihypertensives, antiarrhythmics, anticonvulsants, histamine H 1 and H 2 antagonists, and other drugs have been associated with the onset of delirium in patients treated in intensive care units ICUs. The two goals of symptomatic care in the dying patient are to determine the cause of the mental status symptoms and to institute measures to control these symptoms as they affect the quality of life for the patient and family.
Alternatively, the patient may require sedation for the comfort of all involved in care. Terminal sedation is a treatment of last resort and is beyond the scope of this article. Full discussions of this subject are available in the literature. Hospice workers have noted that a changed mental status is more pronounced in patients who have been undergoing a significant psychosocial or spiritual struggle. They would argue that sedation is not appropriate in this setting.
The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication. Haloperidol is the agent of choice for the management of delirium associated with hyperactivity at the end of life. A well-designed, double-blind study 8 comparing haloperidol a high-potency neuroleptic , chlorpromazine a low-potency neuroleptic and lorazepam a benzodiazepine in the treatment of delirium in hospitalized patients with AIDS found haloperidol to be the preferred drug.
Greater improvement of mental status symptoms occurred within 24 hours after the initiation of haloperidol in a low dosage 2. Studies have not been completed in other patient populations; thus, it is not clear whether these findings are true for all terminally ill patients.
Medications commonly used to manage delirium are listed in Table 2. Nonpharmacologic interventions for delirium can also be of benefit. For example, a family member or other person e. Use of physical restraints should be avoided unless absolutely necessary; if required, restraints should be used in conjunction with sedation.
Although labeled by some as hallucinations, these encounters usually appear to be comforting to dying patients and consequently may not require medical treatment.
Dyspnea, which is a subjective experience of difficult or distressed breathing, has been described in patients with cancer 70 percent , AIDS 11 to 62 percent and other terminal illnesses. Objective findings may not adequately reflect the distress experienced by patients with dyspnea. The original hospice studies 20 conducted during the late s found that 75 percent of patients with cancer and lung involvement had dyspnea; however, of those with dyspnea who were entered in hospice programs, only 39 percent had primary lung problems.
In the same studies, fully 24 percent of patients with dyspnea had no obvious etiology for the symptom. Hence, not all patients with dyspnea have severe pulmonary pathology or tachypnea, and vice versa. This distinction is important because symptomatic treatments are directed toward the end point of relieving the symptom dyspnea , not the sign tachypnea. The pathophysiology of dyspnea can reflect the regulation of breathing central, psychiatric , the act of breathing weakened intercostal muscles or the need to alter breathing patterns because of increased activity or hypoxia.
The treatment of dyspnea is best directed at the underlying cause if known. Some causes and appropriate interventions are listed in Table 3. When dyspnea is not reversible by specific cause-directed treatment, symptomatic treatment is given Table 4. Opiates, titrated to achieve the desired effect with acceptable toxicity, are considered the mainstay of the symptomatic treatment of dyspnea. In some studies, 28 , 29 opiates have been reported to increase exercise tolerance and reduce the perception of breathlessness in patients with chronic obstructive pulmonary disease.
Other studies 30 — 32 have not been able to substantiate this benefit. More clinical trials are needed. A recent study 33 at St. Christopher's Hospice in London found that titrated oral morphine improved dyspnea in 60 percent of patients with terminal cancer. However, significant short-term adverse effects particularly sedation occurred, causing some patients to drop out of the trial. The authors of the study advised physicians to inform patients with dyspnea about the side effects of opioids and to monitor carefully for such effects.
Although treatment can be beneficial in relieving fatigue and improving quality of life, it is expensive and must be given for 4 to 6 weeks before benefits become apparent.
Giving a dosage of 10, units daily for two weeks may reduce this time. Principles and practice of supportive oncology. Given these caveats, many physicians who provide palliative care manage dyspnea with opioids administered by oral, subcutaneous and inhaled nebulizer routes, with the dosage titrated to a level at which the symptom is relieved. Benzodiazepines, titrated until dyspnea is relieved, are commonly added to the opioid regimen to alleviate the anxiety associated with breathlessness.
Explain to the family that external signs e. Minimize the patient's distress by encouraging the family to avoid having disagreements in front of the patient. Minimize the patient's exertion by providing a bedside commode and transporting the patient by wheelchair; avoid exposure to hot, humid weather and extreme temperatures.
Have the nursing staff or family give the patient massages and provide distraction with music or by reading aloud to the patient. Hydrocodone, 5 mg orally every 4 hours. Morphine, 5 mg orally; titrate dose every 4 hours.
Oxycodone Roxicodone , 5 mg orally; titrate dose every 4 hours. Hydromorphone Dilaudid , 0. Nonpharmacologic measures can also be of great value. Interventions include providing good air movement near the patient, keeping cool room temperatures, and proposing and instituting measures to minimize the patient's exertion or anxiety. Movement of air by a fan may calm the patient. The administration of oxygen or air can significantly reduce dyspnea in patients with advanced cancer.
Measures designed to minimize stress can be useful in treating dyspnea. Exertion on the part of the patient can be limited by providing a bedside commode, using a wheelchair for transport and avoiding exposure to hot, humid weather or extreme temperatures.