Symptom: Nausea & Vomiting

Emetic is the Greek word meaning to cause vomiting. These medications are antiemetic, meaning they help to control nausea and vomiting. Using evidence-based guidelines, we choose the most likely medicine to control what may be causing nausea and vomiting. There are a few medications used in hospice for antiemetic purposes, including:

• Metoclopramide (Reglan) is often the first medication used for cancer-related nausea and vomiting, along with nausea and vomiting related to liver failure. This medication is also a good choice in gastroparesis (slowed emptying of stomach contents into the lower GI tract without a blockage) as it can also play a role in emptying the stomach contents.
• Haloperidol (Haldol) is often used as the initial treatment for nausea and vomiting related to inoperable bowel obstruction and nausea and vomiting in kidney failure.
• Ondansetron (Zofran) is often used if metoclopramide (Reglan) alone cannot control nausea and vomiting in cancer patients or as the initial treatment for chemotherapy-induced or radiation therapy-induced nausea and vomiting. Ondansetron (Zofran) belongs to a category of medications called 5-HT3 receptor antagonists.
• Scopolamine (Transderm-Scop) & Diphenhydramine (Benadryl) may be used for motion sickness prevention. Scopolamine (Transderm-Scop) is a patch that can work for up to 72 hours. Diphenhydramine (Benadryl) is the same antihistamine you may have taken for allergies, which can also assist in alleviating motion sickness. These additional may also be helpful with secretions.   

Depending on the chosen medication, common side effects may include drowsiness, fatigue, abdominal pain, constipation, extrapyramidal symptoms, hypertension, hypotension, headache, malaise, diarrhea, itching, dry mouth, confusion, and blurred vision.

Symptom: Anxiety/Agitation 

Anxiety and agitation can arise and sometimes require medication assistance to ensure comfort. Anxiolytic medications can work to treat anxiety and agitation. Anxiolytics stems from the Greek words “anxio” or anxiety and “lytic” or to loosen. Often, the medications used for anxiety can assist in agitation.

• Benzodiazepines are used as the medication class of choice for acute anxiety. Benzodiazepines vary in the length of time they work—this class of medication works by increasing the neurotransmitter gamma aminobutyric acid (GABA). Increasing GABA helps to slow down the nervous system and, in turn, has the intended effect of decreasing anxiety. Lorazepam (Ativan) can be used more frequently and can be helpful for acute anxiety and panic attacks. Clonazepam (Klonopin) and Diazepam (Valium) last for a more extended period to control longer episodes of anxiety and agitation. 

Common side effects of these medications include drowsiness/sedation, delirium, memory loss, confusion, fever, and shuffling walk.

• Selective Serotonin Reuptake Inhibitors (SSRIs) are often used to treat chronic anxiety and depression. Citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft) are common SSRIs. For chronic anxiety and depression, these are often better tolerated with fewer side effects. They work by increasing serotonin (a neurotransmitter that controls mood, sleep, and emotion) in the brain. They may take a few weeks to start having the full intended treatment effect. Side effects vary based on the medication, but for this group, the most frequent side effects include nausea, dry mouth, headache, insomnia, tremor, sweating, change in weight, and diarrhea.
• Haloperidol (Haldol) is an antipsychotic medication used in terminal delirium or agitation to improve comfort. Haloperidol (Haldol) works by blocking dopamine receptors in the brain which in turn helps relieve hallucinations and delusions. It is not recommended for dementia-related psychosis. This medication is also often used for nausea control, as highlighted above. Side effects include drowsiness, confusion, abdominal pain, restlessness, tremors, dizziness, dry mouth, and constipation.

Symptom: Pain

Our team completes a pain assessment each visit, and we work together with you to develop a pain management plan.

• Acetaminophen (Tylenol) is a common over-the-counter non-opioid medication for pain relief and reducing fever. It can come in multiple forms, including tablets, capsules, liquids, and suppositories. At the end of life, fever can be a common symptom, and acetaminophen works well to help control this symptom by inhibiting the hypothalamus, which regulates body temperature. Additionally, it can help treat mild levels of pain. Acetaminophen (Tylenol) has side effects including nausea, vomiting, clay-colored stools, stomach pain, itching/skin rashes, and yellowing of the eyes or skin called jaundice.
• Morphine belongs to the opioid class of medications. Morphine can come in several forms, including tablets, capsules, and an oral solution (Roxanol). Morphine is one of the most common medications used in hospice care to treat pain and shortness of breath. Morphine binds to the opioid receptors in the nervous system, which helps reduce the pain response. Common side effects of morphine include drowsiness, constipation, nausea, and vomiting. Patients may also experience dizziness, confusion, or difficulty breathing. It is important to report any side effects to the doctor promptly. Read more here. 
  
• Fentanyl is a powerful opioid medication for severe, primarily cancer-related pain. Fentanyl is available in multiple forms, often utilizing a long-acting patch placed on the skin. It also works by binding to pain receptors within the nervous system to reduce pain and increase the pain threshold. Common side effects of fentanyl include drowsiness, constipation, nausea, vomiting, dizziness, confusion, and/or difficulty breathing.

Click here to learn more about managing pain.

Symptom: Shortness of Breath

Dyspnea or difficulty breathing can be common in those with certain advanced-stage life-threatening illnesses. Nonpharmacological interventions include sitting upright in a bed or chair, using a fan blowing on the individual to feel the air moving and relieve anxiety, utilizing pursed lip breathing in which you inhale through the nose slowly and then slowly exhales over three seconds via a pursed lip technique in which lips are positioned as if you are going to whistle.

• Oxygen is also considered a medication that can relieve the feeling of shortness of breath and accompanying anxiety. Oxygen can be delivered in various ways, but a small tube is typically placed in the nasal passages, called a nasal cannula.
• Morphine, as discussed above, may be used for shortness of breath in advanced illness.
• Benzodiazepines, as discussed above, may be utilized for relief of accompanying anxiety.

Symptom: Excessive Secretions

Another common symptom is noisy breathing caused by increased respiratory secretion. This breathing change can occur when mucous or saliva gathers in the mouth and throat, creating a crackling noise during breathing. Non-medication interventions may include:

1. Repositioning to a side-lying position to facilitate the clearance of secretions.
2. Elevating the head of the bed or sitting upright.
3. Stopping non-essential IV fluids or tube feedings.

Medications that work well for increased secretions are called anticholinergics as they block acetylcholine, helping to decrease salivation.

• Atropine eye drops are an anticholinergic medication that can also be used orally under the tongue to reduce secretions and improve comfort.  
• Hyoscyamine (Levsin) also belongs to the anticholinergic class of medications. Hyoscyamine (Levsin) is available in multiple forms, including tablets, oral dissolvable tablets, and an oral solution. 

Side effects of these medications may include dry mouth, dry eyes, blurred vision, constipation, decreased urine output, confusion, memory impairment, and dizziness.

 

It’s important to note that the use of medications at the end of life should be tailored to the individual patient’s needs and goals of care, and decisions regarding medication use should be made in consultation with the patient, their family, and the hospice team.

Hospice Medication Myths

Hospice does not overload an individual with medications unnecessarily. The hospice philosophy focuses on promoting quality of life and allowing individuals to live life to the fullest. This same philosophy generally means using the least amount of medication to treat symptoms and provide comfort. In addition to medications, non-medication treatments are used in coordination with the expert guidance and education provided by the Honor Hospice Physician and Nursing teams. We also support those we serve with additional team members, including spiritual care provided by our chaplains, massage therapy, psychosocial support from our social workers, and more to ensure we treat all aspects of our patients. Learn more about our team.