palliative meds

[Kissy1818]

Just a little query so do we tend to only use midazolam in the last few days of life for palliative patients? Why is this and also why do we tend to uusethe sc route rather than iv? Thanks in advance

[lifelearningrn, BSN, RN]

I have never used this with my patients. The benzo of choice for us is Ativan, though I do have a patient taking scheduled Klon and had another one on Xanax (she had occasional anxiety attacks).

[toomuchbaloney]

I've never worked with a hospice agency which had midazolam on the formulary for end of life care as the preferred or "go to" benzo.

We use subcutaneous meds rather than IV because IVs are painful to start and more difficult to safely maintain in the home with the family providing the majority of the care.

[pfeliks]

Our "benzo" of choice for end of life palliation is Ativan Intensol (2mg/ml). No needles necessary. Optimal comfort.

[rpsychnurse]

I've only seen midazolam ordered once for a palliative patient, and he suffered from anxiety previously. Ativan/clonazepam had had minimal effect on him.

Normally we use Ativan if anything.

I agree with an earlier poster- SC sites are less painful and easier to maintain in palliative patients than IV sites.

[Red Kryptonite]

I know one reason my hospice agency uses subQ before IV, aside from it being less painful and invasive, is because LPNs can administer subQ but not IV. We employ a lot of LPNs so inpatient staffing is less complicated the fewer patients there are on IV meds.

[Pondmud]

Same here - lorazepam or diazepam are choice #1 and #2. We may use the IV route if it's a picc line, but in the absence of that, and if the patient cannot take PO even as a slurry, we will go with the subcutaneous injection. Maintaining IV access pretty much doesn't happen at all on my unit.

[Gooselady, BSN, RN]

I wonder if it is SQ because of the slower absorption rate than IV. Versed is hard core, we used it once in a while as part of a 'terminal' drip, but mostly we used Ativan 1mg/1ml. When the Versed was ordered, it was only in IV infusion form, as in a bag on it's own pump that was Y'd into the primary IV. We didn't usually get parameters to titrate Versed, but did for Ativan and the variety of narcotic infusions.

Has anyone here heard of using low dose Ketamine IV infusion in a 'terminal' drip situation? I was in charge and a brand spankin' new RN came to me, appropriately, having just received that order from the doc. I double checked with the doc, who explained her stage 4 lung cancer was causing spasmodic coughing (that was an understatement, I still remember that poor lady). All fired up to FINALLY help this lady get relief, the new RN and I hung and double checked the Ketamine and viola', it really helped.

Months later I was chatting with the RN House supervisor and mentioned this. Her eyes got buggy and she said our floor (medical oncology) didn't have a policy/procedure in place to make it 'legal' for us to give, and the pharmacy should have stopped the order. We went ahead and developed a p&p for it, due to how much it helped this patient.

[ktwlpn, LPN]

We use lorazepam -S/L . In the past year we have been able to obtain good symptom control through end of life for all of our residents without having to go to more invasive routes of admin.

[KelRN215, BSN, RN]

When we used versed for end of life patients when I worked in the hospital, it was via continuous IV infusion. But, I work pediatrics and most of the dying children we saw had cancer so already had some sort of central IV access.

[Pondmud]

We've used versed and ketamine NCA for terminal stages, but only rarely. I don't know if it's written up as such in the P&P's, or if this is how our medical team views these meds, but we treat it as palliative sedation and there are a *lot* of paperwork consent/ethics things involved when these are ordered.

I don't know what the differences are in absorption for sq vs IV, except to say that I bet there's some wide variance in absorption rates given factors like cachexia and third-spacing. I suspect that at my facility as well, it's to allow LVN's to administer meds that we might favor SQ even when there is IV access.

[toomuchbaloney]

There is a big difference between a terminal sedation and controlling anxiety with a benzo.

When patients have elected to be sedated for the duration of their life we use midazolam and the patient is hospitalized at GIP level of care.