Medication use during end-of-life care in a palliative care centreSend the page " " to a friend, relative, colleague or yourself. We do not record any personal information entered above. Use haloperidol with caution in the geriatric patient. The elderly are more prone to orthostatic hypotension and have greater sensitivity to anticholinergic effects. In addition, the elderly, particularly elderly females, may be more likely to develop extrapyramidal side effects, including tardive haldol dosage hospice. Elderly patients may require intratympanic steroids for sudden sensorineural hearing loss initial doses of haloperidol, followed by careful titration. Antipsychotics such as haloperidol are not FDA approved for the treatment of dementia-related psychosis in geriatric patients and there is a boxed warning to haldol dosage hospice effect haldol dosage hospice the drug labels.
Haldol (haloperidol) dose, indications, adverse effects, interactions from ghid-supraveghere.info
Background In end-of-life care, symptoms of discomfort are mainly managed by drug therapy, the guidelines for which are mainly based on expert opinions. A few papers have inventoried drug prescriptions in palliative care settings, but none has reported the frequency of use in combination with doses and route of administration. Objective To describe doses and routes of administration of the most frequently used drugs at admission and at day of death.
Setting Palliative care centre in the Netherlands. Method In this retrospective cohort study, prescription data of deceased patients were extracted from the electronic medical records. Doses of these three drugs at the day of death were statistically significantly higher than at admission. Conclusions Nearing the end of life, patients in this palliative care centre receive discomfort-relieving drugs mainly via the subcutaneous route.
However, most of these drugs are unlicensed for this specific application and guidelines are based on low level of evidence. Thus, there is every reason for more clinical research on drug use in palliative care. The online version of this article doi: In approximately , persons died in the Netherlands, almost one-third of them from the consequences of cancer [ 1 ].
A systematic review on symptom prevalence in patients with incurable cancer found that the most reported symptoms were: The goal of palliative care is symptom control by a combination of non-pharmacological measures and drugs.
Palliative experts have reached consensus on the essential drugs to treat specific symptoms. These have been compiled in two different but largely overlapping lists: Regrettably, both lack recommendations on optimal dose or route of administration. Existing recommendations [ 5 , 6 ] on dose and route of administration are mainly based on level 3 and 4 evidence from case studies or from expert panels.
Level 1 evidence from a systematic review or randomized controlled trials is available only for NSAIDs administered to relieve nociceptive pain [ 7 ] and morphine to alleviate dyspnea [ 8 ]. Level 3 evidence is available for the treatment of cancer pain with oral morphine [ 9 ]. Haloperidol treatment of a delirium in hospitalised patients is based on level 2 evidence from well designed, non-randomized trials [ 10 ]. Recent updates of systematic reviews for morphine and haloperidol found no new significant information [ 11 , 12 ].
The choice of drug and dose tailored to the individual patient is thus hardly supported by evidence from prospective clinical trials. Likewise, there is little evidence for the optimal route of administration, although the subcutaneous route is often preferred in palliative care. Dose adjustment may be needed because liver and kidney function undergo changes at the end of life [ 13 , 14 ].
It follows that a number of drugs used in palliative care are unlicensed or off-label [ 15 , 16 ]. Only a few studies in palliative care units [ 17 — 19 ] and services for mainly outpatients groups [ 20 — 23 ] have described medication use in palliative care. To our knowledge, there are no published studies describing the most used drugs with their doses and administration routes, on admission and at the day of death in a large group of patients receiving palliative care.
The aim of this study was to evaluate what drugs were administered, and at what dose and route of administration, from admission to day of death in patients admitted to a single palliative care centre. Ethical approval from a review board was not required, since this is a descriptive retrospective study.
For retrospective analysis of patient files ethical approval is waived according to Dutch law. All patient data were handled and processed in accordance with the recommendations of Good Clinical Practice.
This retrospective cohort study was performed in Laurens Cadenza in Rotterdam, the Netherlands. This is the largest palliative care centre in the Netherlands, with 20 beds for terminal care and symptom management; from to patients are admitted annually.
Age, gender, primary diagnosis, comorbidities, and duration of admission were extracted from the electronic medical records. Medication data of all deceased patients in were extracted: Only the regular prescriptions for maintenance therapy were included, because the electronic prescription system does not detail how much as needed medication was given. Drugs were prescribed according to the symptom-specific Dutch national palliative guidelines [ 5 ]. The presence of symptoms was daily checked by the nurses and reported to the physicians, but validated assessment instruments were not standard of care.
One covering the day of admission Ta , the other the day of death Td. Medication was categorized by the anatomical therapeutic chemical ATC classification system [ 24 ]. The ATC system groups the drugs into 5 different levels according to the organ or system on which they act and according to their chemical, pharmacological and therapeutic properties.
For this study we used the main therapeutic-group level. Furthermore, the WHO classification of analgesic drugs was applied: Equivalent subcutaneous doses of oral drugs were calculated by dividing oral morphine doses by 3 and oral haloperidol doses by 2 [ 5 , 25 , 26 ]. The daily dose was calculated as the dose of the prescribed patch divided by the number of days the patch was in place. Insomnia was mainly treated by a single subcutaneous bolus of midazolam or by intermittent boluses.
Data were analysed using descriptive statistics. McNemar test served to detect differences in numbers of patients receiving the 3 most frequently used drugs both at Ta and Td. We limited ourselves to these three drugs to prevent repeated testing with too small samples. Differences in the daily doses of these drugs for patients receiving these both at Ta and Td were evaluated with the Wilcoxon signed rank test. In the study year , patients had been admitted.
Ten had been discharged in the course of and 16 were still alive at 1st January All other patients died in the palliative care centre and were included for analysis. Advanced malignancy, mainly of the digestive or respiratory organs, was the main reason for admission A median of two comorbidities IQR 1—4 had been documented.
Drug prescriptions had not been issued for two patients; one died quickly after admission and stayed for a few hours only, all medications for the other patient had already been discontinued shortly before admission. A total of prescriptions for patients has been extracted, of which were regular prescriptions Morphine, midazolam, haloperidol, butyl scopolamine and fentanyl were prescribed more frequently at Td than at Ta.
This increase was most notable during the last week before Td as shown in Fig. Top individual regular drugs in bold at the day of admission Ta and the day of death Td ; given in descending order for the day of death.
Differences in top individual drugs at admission dark grey bars and at day of death white bars ; shown in descending order for the day of death. Three classes were prescribed more frequently at Td than at Ta: While the top at Ta included beta blocking agents, psycho-analeptics and anti-thrombotic agents, those drug classes were not included in the top at Td.
Table S1, see supplement. Percentages of patients with a prescription of the top drug classes at Ta and Td are shown in supplementary Figure S1. Numbers of patients with analgesics classified by the different grouping systems are given in supplementary Table S2.
The two most frequently prescribed opioids, i. The median daily doses of the top-3 drugs at Td were: The three most common routes of administration were: Percentages of patients with prescriptions of solid oral drugs declined from Use of the subcutaneous route increased from Ta Prescriptions of a transdermal drug almost doubled from Ta to Td, from Prescriptions via the various routes of administration at the day of admission Ta and the day of death Td ; given in descending order for the day of death.
Morphine, midazolam and haloperidol were almost exclusively given via the subcutaneous route. At Ta morphine was given subcutaneously to At Td these percentages had even increased to This study found that morphine, midazolam and haloperidol were the most frequently prescribed drugs at the day of death for patients in the largest palliative care centre in the Netherlands.
Doses of these drugs were statistically significantly higher than those at the day of admission. Other studies, too, found that morphine, midazolam and haloperidol were the most prescribed drugs in the palliative setting [ 30 — 33 ].
These drugs are given to relieve symptoms such as pain, restlessness and agitation, which are frequently seen in advanced cancer [ 2 ]. The latter difference is probably explained by the fact that Nauck and co-workers also included patients who were discharged from the centre, whereas we solely considered patients who died in the palliative centre.
An explanation for this wide range could be the studied time frame. Midazolam is often stopped in the last days before death, to avoid that patients become comatose.
Many more patients in the present study were prescribed haloperidol than in the study by Nauck et al. Our higher figures may be explained by the difference in the studied patient population; we only included patients who died in the palliative centre. Haloperidol is the drug of first choice to treat delirium. We suspect, however, that haloperidol is also prescribed in agitated or restless patients who have not been clearly diagnosed with a delirium.
Therefore, assessing delirium with a validated scale, such as the Confusion Assessment Method, should become standard of care. In the present study the median number of drugs decreased from 6 to 4 as death approached, probably because in our centre oral drugs are stopped when a patient enters a recognizable dying phase [ 38 ].
Other studies, however, have reported increasing numbers of drugs towards death [ 20 , 22 , 23 ], possibly to control a new or advancing symptom. The doses of the top drugs compared well to the titration schemes given in the national symptom specific guidelines [ 5 ]. However, midazolam dose titration should be guided by regular assessment of level of sedation.
Other studies found median haloperidol doses of 2. In practice the recommended starting dose of 0. Moreover, in elderly patients a low starting dose is recommended to prevent neurological and cardiovascular effects [ 25 ]. Over the admission period a shift occurred from the oral route to mainly the subcutaneous route, in line with recommendations from both the guidelines [ 5 , 6 ] and the Liverpool Care Pathway for the dying [ 38 ].
The subcutaneous route is preferred in palliative care because most patients are unable to take oral medication at the end of life and the intravenous route is often complicated by infection or discomfort.
Absorption via the subcutaneous route may be suboptimal, however, especially in cachectic cancer patients with very little or no subcutaneous fat. Although the subcutaneous route is preferred in palliative care, this route has not been fully studied.