anxiety vs. agitation; Ativan vs. Haldol

[aging1]

I've been a nurse since before you were born, and a hospice nurse for 7 years. My concern/peeve is this:

Ativan is sometimes ordered and given for agitation, with no Haldol or other antipsychotic available. This drives me to. . . psychosis.

In my book, benzos are for insomnia and/or anxiety, in pts who still have their marbles.

In pts who have delirium and delusions, especially paranoid delusions, I think benzos frequently make them worse. AND make them fall - the confusion and restlessness are no better, and they're more unsteady.

I often use the two in concert, but I NEVER choose to use a benzodiazepine as first line in someone who is striking out, confused, and especially paranoid.

When I rule the world, I'll be sure that every admission has a kit containing a little Haldol, Ativan, OMS, and atropine drops. Oh, and a stunning array of bowel meds.

Thoughts?

[chopwood carrywater]

We have one doc who prefers to start very low and very slow

And another who if the circumstances warrant it has given the order for prn haldol 3 mg q 5 minutes until symptoms are managed. Then we calculate a maintenance dose if needed.l

[toomuchbaloney]

Good palliation of these noxious symptoms is important in hospice care.

As well, we must be mindful of the regulations for LTC and ALFs which monitor and prohibit chemical restraint of patients for the convenience of staff who are stretched too thinly to safely supervise these patients.

While that is generally not the intent of the medications it is important that the true intent is clearly identified in a well written POC agreed upon by the family of the suffering patient, the MD, the pharmacist, the RN CM, and the facility. Goals and objectives for that med POC will help the facility to stay out of hot water should they be audited.

This is why I previously inquired as to the direction provided by the MD and PharmD...this must represented as a well thought out plan with achievable goals consistent with hospice goals and the regulations of the facility industry.

Good luck.

[Nash3222]

There is no cookie cutter answer. Benzo's may work for hallucinations for some, not for others. Haldol may work for some , not for others. Thorazine may work for some not others. I am not trying to make you angry or psychotic. It has been my experience MORE than NOT that a PT that is bouncing off the walls, ( hallucinating, T.R. or what ever) I have thrown tons of Haldol at them with poor results. In the old days we used to use 25 mg of liquid thorazine and it worked. I have seen 0.5mg of ativan or 5 mg of Valium work in a situations like this. There is no ONE Answer. Know your Patient and you WILL know what works for them.

Yes in home care we use emergency packs: Morphine, A Benzo, and and an anti-cholinergic ( atropine, levsin, etc).

[Nash3222]

usually 05.mg Q 15 or 30 min. "until s/s stop" , the thing is, more than not: You have given your 4th or 5th dose of Haldol and it has not begun to touch the s/s. Some like Haldol, if it works, go for it. But as a nurse it can be aggravating when the Doc want's you to continue with Haldol and its not working and your PT is climbing the walls and you know what will work ( 25 mg thorazine) but you can't get an order for it. Then after your 3rd page to the doc they finally agree to the Thorazine. Its like gee why didn't we do this an hour ago? Benzo's, Haldol, Neuroleptics, They all work, its just figuring out what works best for that particular patient. What works for one may not work for another.

[Nash3222]

There is no cookie cutter answer. Benzo's may work for hallucinations or delirium for some, not for others. Haldol may work for some , not for others. Thorazine may work for some not others. I am not trying to make you psychotic. It has been my experience MORE than NOT that a PT that is bouncing off the walls, ( hallucinating,delirium, T.R. or what ever) I have thrown tons of Haldol at them with poor results. In the old days we used to use 25 mg of liquid thorazine and it worked. I have seen 0.5mg of ativan or 5 mg of Valium work in a situations like this. There is no ONE Answer. Know your Patient and you WILL know what works for them.

Yes in home care we use emergency packs: Morphine, A Benzo, and and an anti-cholinergic

(atropine, levsin, etc).

[Gooselady, BSN, RN]

That same dilemma was a constant go-round on the med oncology unit I worked at. Just enough patients responded best to either one or the other that the proponents of "Haldol only" never got off the ground. It seems to be an issue more common to the elderly with Ativan, and so we used Haldol first, as a rule, with delirium or the elderly. Then again, I remember several elderly with dementia who wigged out on Haldol, but Ativan worked. We never did come to a conclusion, in spite of the evidence.

[Anxiousshell]

Hi everyone I have a serious question and would appreciate any or all input. So I have Extreme anxiety issues with a co PTSD diagnosis...I have been on almost EVERY SSRI they make (the latest on viibryd). And the only thing that moderately controlled my panic attacks was clonazepam a benzo! ( when I get my panic attacks my heart rate has been as high as 163 b/m for hours the highest heart rate was 210 b/m.) At one time I was prescribed clonazepam 1 mg 3x's daily and it kinda worked. The problem now is because of a horrible accident causing unbearable pain I got addicted to herion (that's a long story I didn't start with "H" but i couldn't get enough pain relief with RX pain meds then try and find a doctor that would listen to me about my pain is a whole other storu). So now I sought treatment for my herion addiction and currently on Suboxone. I have stayed clean for 5 years now. OK so now my psychologist will not prescribe benzo's because of the subs...I have panic Attacks 5-7 x's a week...I just came back from the ER. Today from one of these attacks. My psychologist has tried putting me on Viibryd, Savella not working in the least. I was wondering about Haldol has anyone heard of Haldol prescribed for panic attacks? Would Haldol potentate my suboxone? Long story thank you for reading and your responses I am going out of my MIND!!!!!!!!

[CapeCodMermaid, RN]

We're not allowed to give ANY medical advice here.

[ktwlpn, LPN]

Sorry for everything you are going through.Per our ToS we are prohibited from giving any medical advice.This is a hospice forum.Sounds like you need a lot of support,hopefully you are in contact with the right people who can provide it.

[PghRN15]

Our kits contain the same: Morphine, Ativan, Haldol, Dulcolax, APAP, and Atropine. We use Ativan for anxiety and Haldol for delirium / agitation.

[midazoslam]

I'm just a mere learner of hospice and pall care, however from what I understand in my local Pall Care team, haloperidol and midaz are used together most frequently for agitation, and distressing psychotic features. If no psychotic features, then no halo.

Most benzos can wreak havoc, and lead to a delirium which is a really crappy and distressing complication for everyone involved.

[rnin0513]

We don't have comfort kits unfortunately (don't get me started) but I have great success in lorazepam for terminal RESTLESSNESS at very end of life (the picking, reaching, life review stuff). For agitation/combativeness we use Haldol but I have way more success with ketamine nasal spray. Which also works really well for bone pain too. Sometimes our hands are tied in facilities. Some DONs are way behind the 8 ball in allowing antipsychotics in "their building" even though it's being used off label. Sx management has its frustrations for sure!