___________________________________________ Palliative Care and Pain Management at the End of Life
NONPHARMACOLOGIC TREATMENT OPTIONS FOR DELIRIUM Review all medications; discontinue any unnecessary ones and replace those with a high likelihood of delirium as a side effect. Rotate opioids or lower the opioid dose. Provide orienting cues (e.g., calendar, clock, familiar objects) in the patient’s room. Encourage family to sit with the patient. Encourage activities that are cognitively stimulating (e.g., word puzzles). Ensure good sleep hygiene. Minimize noise and interventions at bedtime. Encourage patient to get out of bed as much as possible. Provide visual and hearing aids, if appropriate. Monitor for dehydration. Minimize use of devices/equipment that are immobilizing (e.g., catheter, intravenous lines). Source: [310; 380; 382; 384] Table 20
PHARMACOLOGIC OPTIONS FOR DELIRIUM IN PALLIATIVE CARE
Drug
Dose Range
Routes of Administration
Comments
Haloperidol
0.5–2 mg every 2 to 12 hours 12.5–50 mg every 4 to 6 hours 2.5–5 mg every 12 to 24 hours 0.25–1 mg every 12 to 24 hours 12.5–100 mg every 12 to 24 hours 5–30 mg every 24 hours 0.5–2 mg every 2 to 4 hours
PO, IV, IM, SC Considered to be first-line treatment.
Chlorpromazine
PO, IV, IM, SC, PR Has more sedative effect than haloperidol, thus is preferred for patients with agitation.
Olanzapine
PO
Sedation has been a dose-limiting effect; poorer response has been associated with older age, pre-existing dementia, and hypoactive subtype. Response may be better with hypoactive subtype; orthostatic hypotension is possible adverse effect. Sedation and orthostatic hypotension are possible adverse effects. Response may be better with hypoactive subtype.
Risperidone
PO
Quetiapine
PO
Aripiprazole
PO
Lorazepam
IV, SC
May be added to treatment with haloperidol if agitation is refractory to high doses.
PO = orally, IV = intravenously, IM = intramuscularly, SC = subcutaneously, PR = rectally. Source: [310; 380; 382; 384; 388; 389; 390]
Table 21
disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis” [396]. According to a study of patients in a palliative care program, the answers to the question “What bothers you most?” included [216]: • Emotional, spiritual, existential, or nonspecific distress (16%) • Relationships (15%) • Concerns about the dying process and death (15%) • Loss of function and normalcy (12%)
Patients at increased risk of distress include individuals with a history of psychiatric disorder, substance abuse, or depres- sion/suicide attempt; with cognitive impairment or commu- nication barriers; with severe comorbid conditions; and with spiritual/religious concerns. Other factors that predispose a patient to distress include rapidly progressing disease, unrelieved pain, and uncontrolled symptoms [206]. Those who live alone, younger individuals, and dependent children are also at increased risk [396]. Gender and sexual minority patients with life-limiting diseases often have distinct sources of suffering [67]. These patients may be disenfranchised from
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MDCA1525
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