anxiety vs. agitation; Ativan vs. Haldol

Posted
by aging1 Member

does your hospice use benzos for agitation? (i.e. aggressiveness, paranoia, delusions)

  1. 1. does your hospice use benzos for agitation? (i.e. aggressiveness, paranoia, delusions)

    • yes, and it works
    • yes, but they shouldn't - it's disinhibiting and makes behavior worse
    • no - we know better
    • no - we use antipsychotics for. . . psychotic thinking or behavior

49 members have participated

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?

icuRNmaggie, BSN, RN

Specializes in MICU, SICU, CICU. Has 24 years experience. 1,970 Posts

Some home hospice programs provide the family with a med kit with roxanol and lorazepam SL, and bowel care meds.

I thought it was pretty standard but maybe it's not.

I agree that lorazepam can make some people more confused disinhibited and agitated. A little haldol or seroquel can help.

Hospice is not my forte and hats off to you for taking on this really challenging work.

elkpark

14,633 Posts

All the benzos (not just Ativan) do make delirium worse -- they are one of the main groups of deliriogenic drugs (opioids, BZDs, anticholinergics, antihistamines). What makes things tricky is that, if the agitation is actually severe anxiety, Ativan might be a good choice. If they're agitated for any other reason, including delirium, Ativan is not a good choice.

Our hospice comfort kit has both as well as senna s and dulcolax suppositories. I agree with haldol for delusions although some HCWs are more reluctant to give it than others.

lifelearningrn, BSN, RN

Specializes in School Nursing. Has 8 years experience. 2,517 Posts

Both ativan and haldol are in our comfort kit, along with senna, doculax suppositories, APAP suppositories, and morphine. Ativan is for anxiety, haldol for agitation. We used to include Thorazine for severe agitation, but the price has tripled so we no longer include it as a regular medication.

toomuchbaloney

Has 44 years experience. 7,921 Posts

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?

What does the Medical Director or the PharmD provide you in terms of guidance on this topic?

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience. 6,089 Posts

On our hospice residents in my SNF we usually use a combination of Ativan, Benadryl, Haldol, and Reglan for end stage agitation. It comes in suppository form and gel form. It has worked really well for us, although I did have to convince a few people that we are allowed to use Haldol in long term care.

aging1

2 Articles; 25 Posts

Not much. I think I need to raise the question in an organization-wide way. Just sent out an email about this - thanks.

NanaPoo

Specializes in School Nursing, Hospice,Med-Surg. Has 18 years experience. 762 Posts

Years ago in our inpatient hospice we had a topical gel in a syringe called BARPH (Benadryl, Ativan, Reglan, Phenergan, Haldol). IIRC, we used it for agitation. Does anyone still use that?

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience. 6,089 Posts

Eastside....we use Benadryl, Haldol, Ativan, and Reglan gel and suppositories for end stage agitation.

Nash3222

45 Posts

Hell0, I have been doing Hospice for 8 years.

Personally Haldol does not seem to work very well. Several years ago for severe agitation, restlessness we use to use Liquid Thorazine and it worked 95% of the time very well ( 25 mg). Then we switched for some unknown reason to using haldol instead. Know what? It works about 5% of the time after you have given it 3-4-5-6 times ( Q 3O min, until s/s reside) and multiple calls to the Doc. Meanwhile you have a agitated/restless PT on your hands, a upset family if they are around to see this, or a angry next shift if this is going on late in your shift. Benzo's worked well, Thorazine almost always worked.

How much haldol were you giving each time?