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5 Articles in this Series
Introduction
Florida #1 in Opioid Prescribing
Love and Pain
Myofascial Pain Syndromes
Naloxone Under Prescribed by Pain Physicians
Preventing 'Pharmacomistakes' at End of LIfe

Preventing 'Pharmacomistakes' at End of LIfe

5 Common Conditions and Caveats

Delirium

Delirium is extremely common among palliative care patients, occurring in 28% to 83% of patients during the last week of life—a frightening psychological event that carries a DSM IV diagnosis. Fifty-four percent of patients will recall the experience after recovery, and of those, 80% recall the experience as “severely distressing.”

Prescribing lorazepan, a common practice, makes the experience of delirium worse. Compared to other agents, two separate studies found that lorazepan was less effective than dexmedetomidine (Precedex), haloperidol (Haldol), or chlorpromazine (Thorazine) in the treatment of delirium, and caused more side effects.

For people at risk for delirium, avoid new prescription of benzodiazepines or consider reducing or stopping when possible. Use opioids with caution (but recognize that untreated pain can trigger delirium).

Dementia

Dementia or dementia-related psychosis—agitation, hallucinations, wandering—are common problems affecting palliative care patients and have a real impact on the patient’s quality of life, as well as on the quality of life of caregivers. Antipsychotic use should be limited in this patient group, according to Dr. McPherson, due to an increased risk of adverse events, such as falls, strokes, and sudden cardiac death. This warning applies to both conventional antipsychotics, such as chlorpromazine and haloperidol, and atypical antipsychotics, such as aripiprazole (Abilify), olanzapine (Zyprexa) quetiapine (Seroquel), and risperidone (Risperdal).

For patients with dementia, Dr. McPherson encourages clinicians to start low and go slow when symptoms are severe enough to warrant treatment. A response to antipsychotic therapy should be seen within 1 to 2 weeks of starting therapy, at which point clinicians should re-evaluate continued therapy. When these treatment are successful, they “soothe the inner turmoil that makes life intolerable for these patients,” improving their quality of life dramatically.

Nausea

Nausea can be as complicated to treat as pain. Nausea and vomiting is extremely common, especially in patients with end-stage cancer (40% to 70%). It is also more common in women and patients <65 years of age. Nausea and vomiting affects 4 levels of quality of life: physical well-being, psychological well-being, social well-being, and spiritual well-being. When selecting an antiemetic, the clinician must identify: 1) the likely cause, 2) the pathway by which each cause triggers the vomiting reflex, 3) the neurotransmitter receptor involved, 4) the most potent antagonist to the receptor identified, 5) a route of administration, and 6) dosage. Easy, right?

Haloperidol is the most potent agent at DA2, and scopolamine is the most muscarinic. The 5HT3 receptor antagonists are not effective in treating opioid-induced nausea and vomiting, and are untested in patients with cancer-related nausea and vomiting.

Glycemic Control

There have been numerous publications and guidelines promoting tight glycemic control for patients with diabetes. But when that patient is at the end of life, a lot of these guidelines no longer apply, according to Dr. McPherson. This may be difficult for a lot of patients (and families) to accept, so patient/caregiver education becomes essential. For patients with advanced illness, hemoglobin A1c levels are likely meaningless. Therefore, checking blood sugar levels and injecting insulin may cause more distress than it helps.

Dr. McPherson proposed the following goals: prevent symptoms of either hyper- or hypoglycemia. Target the blood glucose levels between 140 and 250 mg/dL during the last weeks of life (unless the patient is symptomatic); modify monitoring plan; and make sure to communicate your goals with the family.

Corticosteroid

“No one should die without a steroid on board!” noted Dr. McPherson. Corticosteroids meet multiple needs at end of life. Choosing which type of steroid—either glucocorticoid or mineralocorticoid—is dependent on patient-related variables.

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