Resources for Physicians: Hospice Pearls for Treating Symptoms
There are many methods of treating pain, here are just a few:
- Short-acting morphine works best for people with cancer in the soft tissues of their body. Starting dose is 5-10mg oral q4hr or 1-3mg IV q3hr prn pain.
- People with a history of opiate abuse will often need large amounts of opiates to control pain.
- There is no maximum dose of opiates as long as increases are given gradually.
- Increasing opiates by 25-50% when needed will help pain without causing respiratory depression.
- If a person is still complaining of pain, they are not at risk of respiratory depression with an additional dose of opiates.
- Long acting opiates such as MS-Contin, Oxy-Contin or fentanyl patches should be ordered if patients take short acting medications frequently.
- Do not start fentanyl patches without any other pain medications. The patch does not reach peak levels until 12-24 hours after it is first started. Your patient will be in pain until then.
- Patients with tumors in their bones will have more pain relief from steroids and NSAIDS than from opiates alone.
- Patients with neuropathic pain will respond better to certain
anti-seizure meds than Opiates or NSAIDS alone.
- Avoid opiate/acetaminophen combination pills for hospice patients; the acetaminophen limits the amount of opiate the patient can use.
- The DEA will not investigate you for using opiates properly.
- Opiates and benzodiazepines are very effective for treating SOB. They reduce the sense of panic from the patient. They may be used separately or together. If you only use one – opiates are superior.
- Any breathing implement short of a ventilator is appropriate for hospice. Do not be afraid to order liquid O2, C-pap, or Bi-PAP as needed.
Steroids, benzodiazepines, and older antipsychotics (Haloperidol) often help with nausea, as well as traditional anti-emetics.
- Anti-histamines only treat itching from red and inflamed skin. Use other treatments for other causes.
- Colesevelam 625mg 3 tabs BID is helpful for itching due to elevated bilirubin in liver failure – even if jaundice is not yet visible.
- Morphine in high doses can cause itching without a rash.
Unresolved hiccoughs can be very distressing. Using oxygen, Baclofen, or even Chlorpromazine can help relieve them.
Terminal Congestion (Death Rattle)
- The death rattle is usually not distressing to the patient – it may be distressing to those around the patient.
- Repositioning the patient may decrease the sound of congestion.
- Injectable anticholinergic drugs such as Atropine or Scopolamine may decrease secretions and decrease congestion.
Hospice patients frequently do not have enough time to benefit from SSRIs or other antidepressants if started near the end of life. Using amphetamines can cause a quick reversal in mood for a patient who has a shorter time to live.