Final days:AGITATION

[JamiRN]

Can anyone give me any suggestions for dealing with agitation with dying patients.

I have had three such patients where nothing seemed to help.

One gentleman had not experienced any pain throughout his dying process, no pain meds were used. He was not on any medications his last few days. He began hallucinating. His family was at his bedside 24/7, "fixing the plow...getting the parts...etc" His family did not want any narcotics. We used Benadryl the last day to help him rest for brief moments.

A middle aged woman with ovarian cancer. She had pain control with DCN until the final week in which her pain became more intense, tried oxycodone, Morphine (threw up) and Fentanyl (rash). She could only sleep for a few hours at a time, then was just wild. Hallucinations, anger, bound and determined to get up and get somewhere yet too weak to lift her head from the pillow. We tried Lorazepam, Haldol, scents of lavender, pastor care...

What have you used to help? Thanks:)

[txspadequeenRN, BSN, RN]

DCN.... absolutly worthless, Darvocet N-100. There are so many things that can be done for comfort and pain. It is good we can network like this and get ideas....:)

excuse my ignorance by what is dcn?

i agree w/txspadequeen that out of all remedies out there, i use mso4 and ativan most liberally, along w/haldol if the ativan doesn't work. whenever i see terminal restlessness, i need to first rule out pain; second is constipation.

anyway, i would appreciate knowing what dcn stands for.

thanks,

leslie

[doodlemom]

Are we talking about a patient that is imminent? (I cant spell). Someone who is dying can suffer from terminal restlessness, fear and he could be in pain (without telling anyone). I personally think that anyone dying has no buisness using DCN. Why did the families not want narcotics? This is where education comes into play. Families at my facility are so uneducated on meds. Even if you try to educate them they pull some old wives tale out and forbid the morphine (uggg if you want to run the show and you know more than me take the patient home)........ How much ativan did you use and how often? I have very good results with ABHR gel ,compounded combination of Ativan, benadryl, haldol and reglan. Dosages vary of course according to patient and condition. Did you try roxanol, this is made to be given sublin or ativan intensol. I have given ungodly amount of morphine and ativan together.. :uhoh21:

We've used ABHR for nausea and sometimes add decadron if there is swelling from tumor creating an obstruction. What would the reglan do for restlessness? We just use plain ABH for agitation.

[doodlemom]

Did you try roxanol, this is made to be given sublin or ativan intensol. :uhoh21:

BTW, We haven't had access to Ativan Intensol sincle early last winter. All of the pharmacies keep telling us that the company is going to start making it again but that it's not available yet? Anybody else having this problem?

[txspadequeenRN, BSN, RN]

The reglan is used for N&V it works well in combo with the haldol.

We've used ABHR for nausea and sometimes add decadron if there is swelling from tumor creating an obstruction. What would the reglan do for restlessness? We just use plain ABH for agitation.

[txspadequeenRN, BSN, RN]

Now that I think of it , there was a time not to long ago they were sending us ativan pills to dissolve in tiny amounts of water for subling use.... I argued moaned and cussed I thought they were just being cheap.

BTW, We haven't had access to Ativan Intensol sincle early last winter. All of the pharmacies keep telling us that the company is going to start making it again but that it's not available yet? Anybody else having this problem?

[leslie :-D]

Now that I think of it , there was a time not to long ago they were sending us ativan pills to dissolve in tiny amounts of water for subling use.... I argued moaned and cussed I thought they were just being cheap.

as a sidenote, reglan's frequent se's are drowsiness and diarrhea, which i find convenient as an antidote to restlessness and opioid-induced constipation.

as for the intensol, our medical director never allowed it because he said it was something we could do at the facility and it was just throwing away money. i'm wondering if insurance has stopped reimbursing for it? actually there was alot our med'l dir had us do, bowing to our creative resources rather than using a hospice pharmacy. we made alot of different cocktails either for po, sl or via mask. talk about being frugal.

[JamiRN]

DCN.... absolutly worthless, Darvocet N-100. There are so many things that can be done for comfort and pain. It is good we can network like this and get ideas....:)

I agree 100%. Darvocet is worthless. Sometimes, with hospice patients, there is not enough time to 'change' the deep set beliefs they (families/pts) have. Thanks:)

[jerseyRN]

what's DCN?

[aimeee, BSN, RN]

Darvocet N-100. I hadn't seen it referred to by those letters before either. At least that one makes sense. I still haven't figured out where they get APAP out of acetaminophin.

[Ashera, LPN]

Can anyone give me any suggestions for dealing with agitation with dying patients.

We use a lot of SL/PO Roxinal 20-40mg (1-2ml)q1-2h with 1-2mg Ativan q4h If the Roxinol has not been already 'flavored' the ativan dissolves instantly in it. Even if your pt is LOC3-4 - this small amount is absorbed quickly inside the cheek.

Methadone tabs dissolve quickly in unflavored roxinal as well and if you are using those bid/tid - on a pt that isn't able to swallow - being able to dissolve them sure seems better than putting them through a PR route. Methadone of course does come in liquid - but if you have Roxinal ordered PRN - it's easy to dissolve if your pt is having a lot of breakthrough pain.

Some pts do very well on Ativan, others a paradoxical effect and Haldol works. For some of my pts - I love the ABH gel - 1-2 syringes of 1mg/25/1mg q6

and then...there good ol' phenobarb - when the agitation is so severe - they are climbing over the rails and screaming.

But as others have posted down the line here - always check the much overlooked full bladder/bowel -

Each pt is so different - wish it was one-stop-shopping. Different ca's have such different pains associated with them.

So many reasons for the agitation - so many different things to try. It's not always a physical pain either, we have to realize. So many parts to this dying process - body, mind, soul - It's a different puzzle piece every time - and as frustrating as it can be - when something 'works' and we can ease this passage - the rewards are so wonderful that we simply forget the hard times.