The most commonly prescribed drugs include acetaminophen, haloperidol, lorazepam, morphine, and prochlorperazine, and atropine typically found in an emergency kit when a patient is admitted into a hospice facility.
Medicine for pain in palliative care – an appropriate opioid, for example, morphine, diamorphine, oxycodone or alfentanil. Medicine for breathlessness – midazolam or an opioid. Medicine for anxiety – midazolam. Medicine for delirium or agitation – haloperidol, levomepromazine, midazolam or phenobarbital.
The patient will commonly be started on a small dose of sedative (such as a benzodiazepine like midazolam or lorazepam). They may also be given an anti-psychotic (such as haloperidol). Medicines are usually given as injections or through a syringe pump (also known as a syringe driver).
Discussion. We found a high level of consensus among the international clinical PC experts that morphine, midazolam, haloperidol, and an antimuscarinic drug should be available in all settings in which patients are cared for in the last days of life.
Muscle spasm. Parenteral benzodiazepines, such as midazolam, can be used to relieve muscle spasm and spasticity in the last days of life (Table 3).
In palliative care, atropine eye drops are sometimes prescribed to be taken by mouth to treat excessive saliva (spit) production (sometimes called 'drooling').
A bystander hands a medicine bottle to the attending paramedic frantically saying, “They drank this! They drank this!” The bottle contains digoxin 100 mg, diazepam 1,000 mg, morphine 15,000 mg, amitriptyline 8,000 mg and phenobarbital 5,000 mg.
Haloperidol is a butyrophenone derivative and dopamine antagonist. It is commonly prescribed for nausea, vomiting, and delirium in hospice/palliative care. Its use in delirium occurs despite little placebo controlled evidence that antipsychotic medication changes the natural history of delirium.
Midazolam injection is used before medical procedures and surgery to cause drowsiness, relieve anxiety, and prevent any memory of the event. It is also sometimes given as part of the anesthesia during surgery to produce a loss of consciousness.
Opioids are essential for managing pain. Opioids can also alleviate other common distressing physical symptoms including breathlessness. Controlling such symptoms at an early stage is an ethical duty to relieve suffering and to respect a person's dignity.
Atropine, Hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care.
Treatment with opioids Opioids are the drugs of choice for dyspnea at the end-of-life as well as dyspnea refractory to the treatment of the underlying cause.
Metoclopramide is the only prokinetic agent that is currently widely available. It works on the stomach and proximal small bowel, but has little effect on colonic motility. In addition to its prokinetic effects, metoclopramide also antagonizes D2+ receptors in the chemoreceptor trigger zone.
— Giving food and fluids by artificial means (e.g., intravenously) does not usually prolong life or improve its quality. — Providing food and fluids by artificial means may, in fact, increase distressing symptoms such as shortness of breath, respiratory congestion, restlessness, nausea and vomiting.
Conventional lethal injection protocol. Typically, three drugs are used in lethal injection. Pancuronium bromide (Pavulon) is used to cause muscle paralysis and respiratory arrest, potassium chloride to stop the heart, and midazolam for sedation.
If a person is able to safely swallow, they will always be offered fluid to drink. Eventually, the person will stop eating and drinking, and will not be able to swallow tablets. This may be hard to accept, but it is a normal part of the dying process.
Purge fluid is foul smelling, red-brown fluid that may exude from the oral and nasal passages as decomposition progresses, as depicted in the image below.
Atropine counteracted the respiratory depression of morphine, reinforced the feebler drying effect of hyoscine and lessened the inhibitory action of the vagus.
Terminal respiratory secretions, commonly known as a “death rattle,” occur when mucous and saliva build up in the patient's throat. As the patient becomes weaker and/or loses consciousness, they can lose the ability to clear their throat or swallow.
(higher doses of morphine may be appropriate if the patient is already receiving regular strong opioids for pain). Combining opioids and midazolam to manage breathlessness and anxiety in the last days of life is common practice in palliative care.
To reduce the impact of excessive oropharyngeal and / or pulmonary secretions in the dying patient.
Terminal agitation is typically seen during the hours or days before death and can be distressing and overwhelming for caregivers.
Commitment, Conviction, Compassion.
That is what Crossroads Hospice is all about—and whenever faced with adversity or a challenging situation, we consult the three Cs.