Medication Management in Advanced Illness

Mary Lynn McPherson, PharmD, BCPS, CPE, FASPEHere are some tips that may be useful. I’m very fond of an Intensol. These are highly concentrated oral solutions of a medication. Morphine and oxycodone 20 mg/ml, methadone 10 mg/ml, haloperidol, Ativan, and dexamethasone all come as this highly concentrated oral solution. Even if someone is obtunded and they can’t swallow easily, you can put up to 1 ml in the buccal cavity, prop up their upper body about 30 degrees and it slowly trickles down the throat. We can manage people without using invasive therapy such as IV medications right up to the last moment of life, which is a tremendous boon.

Haloperidol is a fabulous drug for treating delirium. There is a black box warning about using haloperidol to treat delirium in people who have dementia because it does increase the risk of death from cardiovascular disease. But you have to consider that inner turmoil of someone with delirium who is very close to the end of their life; very scary for patients and for the families as well. Also, it’s a fabulous drug to treat nausea and vomiting, garden-variety nausea and vomiting at the end of life. I think it’s a drug with a lot of utility. One of the practitioner mistakes that I see is prescribing a benzodiazepine like Ativan, because generally the delirium worsens. If someone is awake and alert and they’re anxious then you can use a benzodiazepine, but if somebody has delirium, you want to use an antipsychotic drug, such as haloperidol or perhaps one of the newer drugs like Seroquel.

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