Medication use during end-of-life care in a palliative care centre

Abstract

Background In end-of-life care, symptoms of discomfort are mainly managed by drug therapy, the guidelines for which are mainly based on expert opinions. A few papers have inventoried drug prescriptions in palliative care settings, but none has reported the frequency of use in combination with doses and route of administration. Objective To describe doses and routes of administration of the most frequently used drugs at admission and at day of death. Setting Palliative care centre in the Netherlands. Method In this retrospective cohort study, prescription data of deceased patients were extracted from the electronic medical records. Main outcome measure Doses, frequency and route of administration of prescribed drugs Results All regular medication prescriptions of 208 patients, 89 % of whom had advanced cancer, were reviewed. The three most prescribed drugs were morphine, midazolam and haloperidol, to 21, 11 and 23 % of patients at admission, respectively. At the day of death these percentages had increased to 87, 58 and 50 %, respectively. Doses of these three drugs at the day of death were statistically significantly higher than at admission. The oral route of administration was used in 89 % of patients at admission versus subcutaneous in 94 % at the day of death. Conclusions Nearing the end of life, patients in this palliative care centre receive discomfort-relieving drugs mainly via the subcutaneous route. However, most of these drugs are unlicensed for this specific application and guidelines are based on low level of evidence. Thus, there is every reason for more clinical research on drug use in palliative care.Electronic supplementary materialThe online version of this article (doi:10.1007/s11096-015-0094-3) contains supplementary material, which is available to authorized users.

Hypoalbuminaemia and decreased midazolam clearance in terminally ill adult patients, an inflammatory effect?

“…Midazolam is often used in terminally ill patients and is the drug of choice for palliative sedation [3][4][5][6]. It is metabolized in a two-phase process.…”

A retrospective medical records review of risk factors for the development of respiratory tract secretions (death rattle) in the dying patient

“…This is a clinically relevant finding given 60 mg was the median dose of midazolam in Masman et al. 's study ().…”

“…McNamara, Minton, and Twycross (1991) found that although the median dose was 30-35 mg/24 hrs of midazolam for all indications, the range for muscle relaxation was 10-60 mg/24 hrs, for terminal agitated delirium 10-240 mg/24 hrs and for multifocal myoclonus or as prophylaxis against seizures 15-80 mg/24 hrs. More recently, Masman, van Dijk, Tibboel, Baar, and Mathôt (2015) showed that the median dose had increased to 60 mg/24 hrs since their previous assessment.…”

Pharmacists in Home/Hospice/Palliative Care Settings

“…Elective organization courses for palliative care are crucial to giving viable patient care. Numerous regularly endorsed medications (eg, promethazine, morphine sulfate) might be utilized in nontraditional courses [30]. Topical gels containing metoclopramide, diphenhydramine or lorazepam may found worthful for patients with unmanageable sickness and spewing [31,32].…”