Palliative care medications, I’m confused! Please help!

offlabel · Sep 30, 2022

He needs more medicine. You don't say what the concentration of ativan is, but it sounds like he needs more. These patients have tolerances to doses that would put a horse to sleep. Give the patient his prescribed meds around the clock until you see his agitation and pain improve. You will not be the reason he dies.

Davey Do · Sep 30, 2022

If the patient's pain & anxiety are no being relieved by the current regimen, then it's not enough to meet a therapeutic goal.

I second offlabel's perspective of a horse., in that tolerance over time increases sometimes dramatically.

Off the top of my head, 4mg/day is a ceiling dose of Ativan. This patient is getting three, therefore, a safe ceiling dose. Clonazepam, being a benzo and chemically very similar to Ativan, a prudent maneuver would be not to give them with each other, but for breakthrough anxiety if there is no relief from anxiety in an hour.

Hydrolozine can be given with a narcotic analgesic to increase the pain-relieving affects. The fentanyl patch serves as a continuous titrated dose for chronic pain.

The therapeutic goals of decreasing pain and anxiety results need to be documented and reported to the PCP for any further intervention. VS, with increased BP, R, & P, along with behavior and the patient's statements, can be overt indicators the therapeutic goals are not being met.

Been there,done that, ASN, RN · Sep 30, 2022

If your patient is always in pain, you are not doing your job. Of course the meds are not too much.. they're not enough. Your patient is dying, whatever causes them to stop breathing , is not up to you, Call a patient care conference stat. There is no ceiling on opiates. Also other options available.

Nurseunite · Sep 30, 2022

1 hour ago, Been there,done that said:

If your patient is always in pain, you are not doing your job. Of course the meds are not too much.. they're not enough. Your patient is dying, whatever causes them to stop breathing , is not up to you, Call a patient care conference stat. There is no ceiling on opiates. Also other options available.

Hi,

I was giving the clonazepam and oxycodone together. Pain would subside and then if anxiety didn’t get better then I’d give the Ativan and then another hour the hydroxyzine. Well another nurse reported me to the family and told the DON I was over medicating so I had to second guess myself.

It has been a whirlwind. Because he was on morphine and oxycode and we were alternating. Then they just put him on the oxy and increase it to 22.5mg.

The oncologist is now in control of pain meds and he wrote for the Ativan. He says the patient is also over medicated because once when he visited he was too sleepy and drowsy. I tried to explain because he doesn’t sleep at night. I finally got an order for sleep.

I feel as if I’m doing everything myself as I’m first shift and the other nurses doesn’t care.

The oncologist told the family the patient cancer isn’t curable but treatable and that he has a 70% chance with chemo to survive this. ( I swear he said it) so the patient and family is in denial about his diagnosis. I stay in my place. He’s also still a full code and doesn’t want to go to DNR.

Nurseunite · Sep 30, 2022

5 hours ago, Davey Do said:

If the patient's pain & anxiety are no being relieved by the current regimen, then it's not enough to meet a therapeutic goal.

I second offlabel's perspective of a horse., in that tolerance over time increases sometimes dramatically.

Off the top of my head, 4mg/day is a ceiling dose of Ativan. This patient is getting three, therefore, a safe ceiling dose. Clonazepam, being a benzo and chemically very similar to Ativan, a prudent maneuver would be not to give them with each other, but for breakthrough anxiety if there is no relief from anxiety in an hour.

Hydrolozine can be given with a narcotic analgesic to increase the pain-relieving affects. The fentanyl patch serves as a continuous titrated dose for chronic pain.

The therapeutic goals of decreasing pain and anxiety results need to be documented and reported to the PCP for any further intervention. VS, with increased BP, R, & P, along with behavior and the patient's statements, can be overt indicators the therapeutic goals are not being met.

Thanks so much for the reply.
Also for the tip about the hydroxyzine. I didn’t know it could also be good for pain relief.

It’s a struggle because the oncologist doesn’t want this patient to get too much of these meds so trying to keep him stabilized is an issue. But why would there be orders if we can’t use them to benefit the patient.

7 hours ago, offlabel said:

He needs more medicine. You don't say what the concentration of ativan is, but it sounds like he needs more. These patients have tolerances to doses that would put a horse to sleep. Give the patient his prescribed meds around the clock until you see his agitation and pain improve. You will not be the reason he dies.

For the Ativan it’s is 2mg/ml.

Home Health Columnist / Guide · Oct 1, 2022

Some resources for you:

NIH: National Institute of Aging: Providing Care and Comfort at the End of Life

Pain Medications for Palliative Care

Common Hospice Medications

Davey Do · Oct 1, 2022

17 hours ago, Nurseunite said:

Also for the tip about the hydroxyzine. I didn’t know it could also be good for pain relief.

Hydroxyzine has a synergistic effect which potentiates pain relief when administered with a narcotic analgesic.

Many a time years ago, a standard PRN IM pain order for Demerol included Vistaril, e.g. Demerol 50mg/Vistaril 25mg.

DavidFR, BSN, MSN, RN · Oct 13, 2022

Can you not install a PCA pump of either Oxycodone, Morphine or Fentanyl?

I'm not in the US so things may be different there, but a PCA would be standard practice for the pain here, both in hospital and homecare settings, and hypnovel (midazolam) for the anxiety.