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?

[tokidokifantasy]

Our comfort kits have morphine, ativan, atropine, and suppository. I don't really know how much it all help with my dying patients, because I still see on the pulse ox HR 156, consistently after giving those meds.

[ktwlpn, LPN]

Our comfort kits have morphine, ativan, atropine, and suppository. I don't really know how much it all help with my dying patients, because I still see on the pulse ox HR 156, consistently after giving those meds.

I believe that is just part of the natural dying process and teach staff to ignore the numbers and treat the patient by administering those meds around the clock in end of life care.Does the client appear comfortable and peaceful?Then you attained your goal.

This is a great place to vent and learn....You seem to have some doubts regarding end of life care.........

[CRazyhappyb]

I prefer haldol for terminal restlessness or if it's not enough Nozinan, usually subcutaneous, but this is in a hospital setting. However there are times when haldol alone is not enough which is when I use midazolam, more for the sedating effect than anything else. But I agree I am a little weary about using versed instead of haldol when it's more of a delirum or agitavion vs anxiety.

[GreatDaneAPRN]

CapeCod,

Thanks for writing about the Haldol in LTC facilities. I have realized that some ALF and LTC facilities will NOT allow Haldol. They will allow Morphine and Ativan. Can you shed some light on this issue?

[CapeCodMermaid, RN]

I think much of what we think is right or regulation is based on old ideas. Sure, Haldol is an antipsychotic but it has far fewer side effects for short term use than Seroquel or Risperdal. We only use it for end stage agitation and only in combination with Ativan,Reglan,and Benadryl. I've seen ABHR work wonders on someone who is dying and extremely agitated. As long as it's documented properly with a risk/benefit analysis done, I'm pretty sure you won't get tagged. It's all about what's best for the resident.

[sclpn]

Most of the time if the haldol didn't work it's because the patient needed a bigger dose

[lantanaRN]

1) we provide a comfort kit with Ativan tablet form, Haldol concentrate..for severe agitation and nausea/vomiting, oral MSIR solution, robinul (secretions) Tylenol suppositories. That being said first line of defense for agitation (terminal or otherwise) Ativan, followed by Haldol and for severe terminal agitation unrelivied by the former, phenobarbital subq. I will more likely see a need for the phenol in younger patients who are usually no where near emotionally ready to die. If the reactive to Ativan is increased psychosis obviously we move on to the Haldol

[jdub6]

Jdb_1979 asked about the regs restricting haldol administration in ltc/alf. Recently there has been HUGE media backlash against "drugging elders" with psych meds, and at least in my state they are very stringent when inspecting facilities re: antipsychotics in general but especially haldol. If a pt has a long-standing psych dx (not dementia, but say schizophrenia) and psychiatrists have tried multiple meds and haldol is all that works, it's ok. For any other reason? Nope. Whether they would be this strict for hospice pts I'm not sure but facilities in my area generally won't allow it.

In regards to the OP, I've actually found benzos to be useful for mild agitation and terminal agitation/restlessness. Generally we only use haldol if the pt is combative or a danger to themself or others (constantly oob unsafely, etc) or benzos not effective. Reasoning usually is that haldol has more risk of unpleasant side effects (eps for starters) some of which are permanent. If the person is actively dying it's less of a concern but benzos generally are our first line. (Benzos do cause increased agitation in some older people but in my experience this is rare...almost all reports of "oh that made him worse" actually mean "we have him a tiny dose and he got worse cause it just wasn't enough for him.")

I have also found that many families have bad impressions of haldol, whether from family experience or Dr Google. Usually more accepting of benzos (often even "oh yeah that works great for me, my husband, his parents and my dog.")

We actually use haldol just as much if not more for intractable n/v. Often works when nothing else would.

I am fascinated at the differences in comfort kits. Ours have apap (pr I believe), ativan and haldol tabs (0.5 mg each I believe), levsin tabs, bisacodyl PR, and optional morphine. There is a cardiac one with lasix (po and sq I think) and if ordered sq morphine, and a seizure one which I haven't seen enough to know what it contains (I think ativan suppositories?)

[CapeCodMermaid, RN]

High doses of benzos aren't good either. They can prevent REM sleep which can cause more confusion and anxiety.

[jdub6]

@CapeCodMermaid, good point and thank you-so often I am frustrated as an inpatient nurse when we get a home pt because "we have him his 0.25 of ativan q6and he is still restless!" The pt arrives, clearly terminally restless, (not a touch of insomnia but screaming incoherently, shaking bedrails, pulling out their foley, smearing stool all over their family members, totally unable to stop moving, multiple falls). These pts no longer have normal sleep cycles, they are not capable of calm wakefulness in many cases, and often require massive doses of meds. This is the type of restlessness I mean when I talk about high dose benzos.

On another note, someone mentioned nasal ketamine....so jealous! Particularly given the recent increase in research on ketamine efficacy for many sx. It would never be funded in my company though.

On re-reading this thread, I have to say my state must either have more hospice pts in facilities than most, or the facilities must be more tightly regulated in my state because although we can use haldol in hospice units and hospitals, almost no hospice pts in facilities can be on it even if they have an established dx of an axis 1 psychotic disorder because the state considers it a chemical restraint and it is simply too much trouble for the facility than it is worth. As such, almost all facility pts are on benzos or something like trazodone (facility docs love it, I hate it) for anxiety and agitation. This tends to have a domino effect with the home hospice nurses, especially as pts move in and out of facilities, and as a result they just get in the habit of using ativan or other benzos for agitation. We do usually see success eventually, though not always.

One more thing: someone way back mentioned doubting efficacy due to tachycardia prior to death: I find a lot of my actively dying pts are elderly with histories of afib who are now off their cardiac meds, in multi system failure and back in tachyyrthmia, often afib with rvr. People in afib who receive morphine for sib and pain can be comfortable despite still having high hr. You will never normalize vitals on a dying person but that doesn't mean they are suffering!