The primary focus of hospice care is the palliation of symptoms. These guidelines review the basics of pain and symptom management. The initial plan, ongoing revisions in the plan, and evaluations of its effectiveness must be the joint effort of the hospice nurse, attending physician, hospice medical director, patient/family, other members of the hospice team, and pharmacist. The dosages listed in these guidelines are the usual adult dosages, but smaller doses are recommended for older patients, or those with renal or hepatic impairment. All unusual or unexpected reactions to a medication must be reported promptly to the attending physician and/or the medical director. Questions or concerns may be directed to one of the following at 847-685-9900: Patient Care Manager, Chief Nursing Officer or Medical Director.

I. CONSTIPATION:

Because of immobility, decreased oral intake, and regular use of opioids, constipation is a common problem for the hospice patient. An ounce of prevention really is worth a pound of cure! The following interventions are commonly recommended:

To prevent constipation:

1. Increase fluid intake to 4 eight oz. servings whenever possible.
2. Increase dietary intake of fiber (prunes, bran, fruit) to enhance bowel motility.
3. Use bulk agents, e.g. Metamucil, on a regular basis, but only if the patient is ambulatory and well-hydrated.
4. Use stool softeners with peristalsis stimulant (Senekot-S) on a daily basis when using opioids. A rough guide: use 1 Senekot-S for every 15 mg morphine or equivalent; use 4 Senekot-S for every 25 mcg of Duragesic patch.
5. Sorbitol or lactulose (1-8 Tbsp/d) may be a useful adjunct if the patient is taking fluids.

To treat constipation (which is no BM for 2 days):

1. Always check for fecal impaction; if present, use manual disimpaction and/or oil retention enema.
2. Begin Dulcolax suppositories, Fleet’s enema, or tap water enemas. Use a "push/pull" approach using oral and rectal measures to get and keep the bowels moving.

II. AGITATION AND ANXIETY:

For unexplained agitation, first make sure that the patient’s basic needs are met, i.e., the patient is not in pain, hungry, hypoxic, impacted, or in urinary retention. Remember the importance of nonpharmacologic measures--quiet, calm environment, preserved sleep-wake cycle, etc.

For anxiety, use lorazepam (Ativan) 0.5-5 mg PO q4h prn. Anecdotal evidence suggests that alprazolam (Xanax) may be more helpful in COPD and other pulmonary patients. Avoid Valium and older benzodiazepines in older patients because they build up in the system.

For insomnia with depression, try trazodone (Desyrel) 50-200 mg PO qhs.

For sleep, try lorazepam (Ativan) 0.5-2 mg, temazepam (Restoril) 7.5-30 mg, haloperidol (Haldol) 0.5-2 mg, zolpidem (Ambien) 5-10 mg.

For agitation or psychosis, use haloperidol (Haldol) 0.5-2 mg q6h (up to 10 mg/d) or thioridazine (Mellaril) (more sedating) 10-50 mg q6h prn (up to 800 mg/d).

III. DIARRHEA:

Always check for fecal impaction!!
Discontinue offending medications, especially magnesium-containing antacids (Mylanta), laxatives, Reglan. Consider C. difficile colitis if history of recent antibiotic use. Treat with Flagyl 500 mg PO QID for 10 days.

1. Place the patient on clear liquids (water, clear soups, juice, Gatorade, flat soda pop, tea) until the diarrhea stops.
2. Consider the use of Lomotil or Imodium (available OTC) 2-4 tabs initially, then 1-3 tabs q4h prn.
3. Introduce solids in a prudent and stepwise fashion. Begin with full liquids, then advance to the BRAT (bananas, rice, apples, toast) diet, then to a regular diet as tolerated. Avoid dairy products for 48 hours after cessation of diarrhea.
4. If the patient is on tube feedings, decrease the rate by 50% or dilute feedings 50/50 with water.
5. If the diet is well tolerated for 24 hours, then resume the laxatives at decreased doses.

IV. DYSPNEA:

There are multiple etiologies to dyspnea, and the assessment based on the patient’s diagnoses, past history, and physical exam will assist in treating the symptoms. For example:

1. If history of emphysema or asthma, use albuterol nebulizer treatments q4h prn.
2. If CHF, or possibility of fluid overload, use diuretics.
3. If URI or pneumonia, consider trial of oral antibiotics in certain cases.
4. Thoracentesis or pleurodesis are rarely used in hospice, but can be considered in select cases for pleural effusions.

The following strategies are used in most cases of dyspnea, which is a common and usually nonspecific symptom:

1. Oxygen through nasal cannula or face mask.
2. Morphine (via the routes of PO, sublingual, buccal, or rectal; use the doses described above for pain). Morphine decreases the respiratory drive and air hunger, as well as the CNS response to hypoxia and hypercarbia and may actually improve ventilation.
3. There is some initial experience with nebulized morphine treatments which can help ease intractable breathlessness in patients with COPD and lung mets. Starting dose is 2.5 - 5 mg of injectable morphine diluted in 5cc sterile water, and used as a regular nebulizer treatment. Bronchospasm is an unusual complication.
4. For treatment of the "death rattle", use scopolamine gel, available topically 0.25mg/0.1ml gel q12h; or hyoscyamine 0.125 mg SL q4-6h or 0.375 capsules PO q8-12h.

V. COUGH:

Again, establishing an etiology of the cough helps with management. Consider URI, CHF, GERD, or cough related to ACE inhibitor therapy (Captopril, Vasotec, etc.). Consider the following for palliation of cough:

1. OTC remedies such as Robitussin
2. Tessalon perles
3. Cough syrup with codeine, ex Robitussin AC
4. Morphine, esp if other modalities are ineffective or patient is having pain as well
5. Trial of steroids if pulmonary tumor (dexamethasone 2-4 mg q6h or prednisone 20-60mg/d)
6. Consider short course radiation therapy

VI. HICCUPS:

Hiccups normally occur as a result of irritation of the diaphragm by surrounding structures or by irritation of the phrenic nerve in the neck or mediastinum. Rarely, hiccups are due to a CNS cause or uremia.

If the old tried and true remedy of 1 tablespoon of sugar doesn’t work, chlorpromazine (Thorazine) 10-50 mg PO QID, metaclopramide (Reglan) 10-20 mg PO QID, or baclofen 5-10 mg QID are often effective.

VII. ITCHING:

Patients can occasionally develop itching from opioid-induced histamine release. Premedication with diphenhydramine (Benadryl), hydroxyzine (Atarax), or cimetidine (Tagamet) decreases histamine release. Occasionally opioids need to be changed to agents that do not release histamine, such as oxycodone, oxymorphone, and fentanyl.

VIII. MOUTH DISCOMFORT:

1. Dryness - evaluate the necessity for medications with anticholinergic side effects such as Elavil, Reglan, Benadryl, scopolamine. Do frequent oral care with saline or hydrogen peroxide: water in 1:4 dilution. Sour candy such as lemon drops are often helpful. Saline substitutes are also available. Pilocarpine 1-2% 1-5 drops prn may be useful.
2. Thrush - use Diflucan 100 to 200 mg daily for five to seven days, nystatin 5 ml swish and swallow QID for 7 days, or Mycelex troches.
3. Pain - try "stomatitis cocktail": equal parts of diphenhydramine, Maalox, and lidocaine.

IX. SEDATION:

This is usually secondary to opioid medications. Tolerance to the sedation develops after 24-72 hours. The patient may also seem more sleepy if they have not slept well recently because of pain. If sedation persists, it is recommended to give a lower dose of the drug more often or change to another opioid. Rarely CNS stimulants such as caffeine or methylphenidate are used.

X. NAUSEA AND VOMITING (N&V):

Persistent nausea and vomiting is always concerning for a bowel obstruction. Results of the rectal exam (to rule out an impaction), auscultation of the abdomen for bowel sounds, and palpation of the abdomen should be reported to the attending.

Always assess the patient and try to treat the specific cause of the nausea.

1. Evaluate medications (NSAIDs, theophylline, digoxin, certain antibiotics); discontinue if possible, or at least reduce the dose.
2. If pain occurs between meals, or at night, be suspicious for peptic ulcer disease; try H2blocker (ranitidine (Pepcid) preferred because of lower cost).
3. Rule out impaction; see treatments for constipation.
4. Try lorazepam for component of anxiety or situational nausea.
5. Begin or adjust dexamethasone (or other steroids) if increased intracranial pressure is a concern.
6. If slow gastric emptying (emesis of undigested food hours after eating, or a sense or persistent fullness), try metoclopramide (Reglan) 10-20 mg q4h or cisapride (Propulsid)10-20 mg q6h.

Usually the cause of N&V is due to multiple factors that cannot be changed (i.e. tumor, opioids, chemical abnormalities in the body that stimulate the chemoreceptor trigger zone (CTZ) in the brain.) A stepwise approach to N&V is begun:

1. Begin diet as tolerated; sips of clear liquids.
2. Promethazine (Phenergan) 25 mg or prochlorperazine (Compazine) 10-25 mg PO q6h prn.
3. Compazine suppositories 25 mg PR q12h or scopolamine gel 0.25 mg/0.1ml topically q12h if the patient is unable to take oral medications.
4. More severe symptoms warrant haloperidol (Haldol) 1-5 mg PO q6h prn.
5. For severe N&V, increase dose of Haldol to 10-15 mg in divided doses. Consider adding Reglan or steroids. Haldol, Reglan, or scopolamine may be given SQ by continuous infusion. Newer but extremely expensive agents such as ondansetron (Zofran) are rarely needed if the above measures are followed. Consideration of their use must be approved by the hospice medical director.

XI. SKIN CARE:

Prevention is easier than the cure! Keep the patient clean and dry, and turned frequently. Use careful techniques for lifting and turning. Use egg crate, water, or specialized mattresses if needed to prevent further breakdown. Skin protection barriers, such as A&D ointment should be used with incontinent patients. Stage 2-4 decubitus ulcers can be managed with saline dressings, Duoderm, and Carrington products, among others. Malodorous ulcers improve with topical Metrogel or metronidazole (Flagyl) tablets, crushed and sprinkled over wound, along with nystatin powder.