As an experienced hospice nurse, I understand the challenges that terminally ill patients and their families face. One of the biggest challenges is managing symptoms such as pain, , and nausea. Hospice comfort medications can help provide relief and improve the quality of life for patients in their final days. In this article, we will discuss some of the most used hospice comfort medications and when they might be used for comfort.

Before we start, please understand that none of the medications used by hospice are euthanizing medications. One of the primary goals of hospice is comfort at end-of-life, and NOT making your loved one die faster.

Morphine

Morphine comes in pills or liquid form and is commonly used to treat pain, shortness of breath by easing the sensation of breathlessness, and . It has mild fever reducing properties as well as being a mild cough suppressant.

Common side effects of morphine include constipation, and sedation/. Uncommon side effects include itching, nausea with or without vomiting (this typically goes away in a few days and can be managed by anti-nausea medication), and hallucinations. It is important to note that these side effects can be managed with proper dosing and monitoring by hospice professionals.

If your loved one is experiencing significant pain or difficulty breathing, morphine may be recommended as a hospice comfort medication. It is typically administered as a liquid or tablet, and the dosage is carefully monitored to ensure the patient receives the appropriate amount of pain relief. The maximum daily dose of morphine is 1,600 mg which is exceedingly difficult to reach considering a full 1 mL syringe of morphine is 20 mg and a single 30 mL bottle of morphine contains 600 mg of morphine. Common starting dosing of morphine ranges from 0.25 mL (5 mg) to 0.5 mL (10 mg) every two hours as needed for pain; but it is not uncommon to have patients be given 1.0 mL (20 mg) every hour as needed.

Lorazepam

Lorazepam comes in pill or liquid form and is used to treat , shortness of breath and . It can also be used to treat insomnia and attempt to prevent or minimize seizures.

Common side effects of Lorazepam include constipation, sedation, and .

If your loved one is experiencing anxiety, restlessness, or , lorazepam may be recommended as a hospice comfort medication. It is typically administered as a liquid or tablet, and the dosage is carefully monitored to ensure the patient receives the appropriate amount of anxiety relief. The maximum daily dose of lorazepam is 10 mg. Common dosing ranges from 0.25 mL (0.5 mg) to 0.50 mL (1.0 mg) every four to six hours as needed.

Other Common Hospice Comfort Medications

In addition to morphine and lorazepam, there are several other hospice comfort medications that may be used to manage symptoms such as pain, nausea, and . Some of these medications include:

  • Acetaminophen (Tylenol): This medication can help reduce pain and fever in hospice patients. The maximum daily dose is 3,000 mg with the most common dose of 500 mg tablets, take two tablets every 8 hours as needed for mild pain or fever greater than one hundred degrees Fahrenheit.
  • Atropine: This medication can be used to help dry up secretions in the mouth and throat, which can be common in patients who are nearing the end of their lives. As this medication is typically used in the last 24-to-72 hours of life, there's typically no concern for a maximum dose; the common use is one to two drops under the tongue every hour as needed for the gargling/gurgling/rattling that can occur at end-of-life.
  • Haloperidol (Haldol): This medication can help manage , , psychosis, and hallucinations at end of life. The maximum daily dose is 30 mg. The most common dose is 0.5 ml (1 mg) every 6 hours as needed.
  • Hyoscyamine (Levsin). Like Atropine, this medication can be used to help dry up secretions in the mouth and throat, which can be common in patients who are nearing the end of their lives. As this medication is typically used in the last 24-to-72 hours of life, there's typically no concern for a maximum dose; the common dose is one tablet under the tongue every two to four hours as needed.
  • Ondansetron (Zofran): This medication can help manage nausea and vomiting. The maximum daily dose is 24 mg per day. The most common dose is 4 mg every 4 hours as needed.
  • Prochlorperazine (Compazine): This medication can help manage nausea and vomiting that can occur during the end-of-life journey. The maximum daily dose is 40 mg. The most common dose is 10 mg every 6 hours as needed.

It is important to note that each patient is unique, and their symptoms may require different medications or dosages. Also as important is that hospice agencies are unique and what one uses for “comfort medications” may vary from hospice to hospice.

Hospice professionals will carefully assess the patient's symptoms and recommend the appropriate hospice comfort medications based on the individual needs of your loved one.

Using Comfort Medications Safely

While hospice comfort medications can be highly effective in managing symptoms and providing comfort to patients, it is important to use them safely. Here are some tips for using comfort medications:

  • Work closely with a hospice team: Hospice care is a team effort, and it is important to work closely with a hospice team to manage medications and ensure that patients are receiving the right dose of medication for their needs.
  • Journal what comfort medications you give and approximately when they were given.
  • Monitor for side effects: Comfort medications can cause side effects, so it is important to monitor patients closely for any signs of drowsiness, confusion, or other side effects. If you or your loved one is noticing side effects, 1) call your provider immediately if the side effects are distressing or otherwise scary, and 2) please journal the experience.
  • Store medications safely: Comfort medications should be stored in a safe and secure location, out of reach of children, pets, and visitors.
  • Dispose of medications properly: When comfort medications are no longer needed, they should be disposed of properly. Talk to your hospice team about how to dispose of medications safely.

Benefits of Hospice Comfort Medications

Hospice comfort medications can provide a range of benefits to patients and families, including:

  • Relieving pain and other symptoms: Medications such as morphine can help manage pain, while medications such as lorazepam can help manage anxiety and agitation.
  • Improving quality of life: By managing symptoms, hospice comfort medications can help improve a patient's overall quality of life, allowing them to enjoy time with loved ones and engage in meaningful activities.
  • Increased sense of control: By managing symptoms effectively, patients may feel more in control of their situation and more able to focus on what matters most to them.
  • Reducing stress for families: Hospice comfort medications can help ease the burden on families who may be struggling to manage their loved one's symptoms on their own.
  • Better sleep: By managing symptoms such as pain, anxiety, and nausea, patients may be able to sleep better, which can have a positive impact on overall well-being.

What Families and Loved Ones Should Know

It is understandable for families and loved ones to feel hesitant or uncomfortable with the idea of hospice comfort medications. However, it is important to understand that these medications are designed to provide relief and improve the quality of life for patients in their final days.

Here are some important things to keep in mind:

  • Hospice comfort medications are carefully monitored and administered by hospice professionals. A doctor with prescribing privileges is always involved. Most hospice agencies have a hospice pharmacy that reviews your loved one's allergies and the interactions of each medication your loved one is taking or might take based on what's available in the home within the knowledge of the .
  • None of the comfort medications are euthanizing agents. Hospice professionals are present to provide comfort, encouragement, and support, not speed up the dying process.
  • Side effects are carefully managed to ensure the patient is as comfortable as possible. You help in this matter by bringing any side effects noticed to your hospice team.
  • The goal of hospice care is to provide comfort and improve the quality of life for the patient and their loved ones.

It is also important to talk to your loved one's hospice team about any concerns or questions you may have. They can provide guidance and support as you navigate this challenging time.

Conclusion

In conclusion, hospice comfort medications can provide significant relief for terminally ill patients. Morphine and lorazepam are two of the most commonly used hospice comfort medications, but there are several others that may be recommended based on the patient's individual needs. If you have any questions or concerns about hospice comfort medications, it is important to speak with your hospice care team for guidance and support.

Resources

Hospice Does Not Euthanize

Pain Assessment in Hospitalized Older Adults With Dementia and Delirium

Pain Assessment in Dementia – International Association for the Study of Pain (IASP)

Pain Assessment in People with Dementia: AJN The American Journal of Nursing

PAINAD Scale Offers Alternative to Assessing Pain in the Dementia Patient – JEMS: EMS, Emergency Medical Services – Training, Paramedic, EMT News

Pain Assessment in Advanced Dementia Scale (PAINAD) – MDCalc

Uncontrolled Pain and Risk for Depression and Behavioral Symptoms in Residents With Dementia

Chronic Pain & Symptom Tracker: A 90-Day Guided Journal: Detailed Daily Pain Assessment Diary, Mood Tracker & Medication Log for Chronic Illness Management

Pain And Symptom Tracker: Daily Pain Tracking Journal Detailed Pain Assessment Diary, Medication, Supplements Food & Activities Log for Chronic Illness Management

Pain Assessment and Pharmacologic Management

Adult Nonverbal Pain Scale (NVPS) Tool for pain assessment

Assessing pain in patients with cognitive impairment in acute care

FLACC Pain Scale

Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment in Non-Communicative Adult Palliative Care Patients

Pain Assessment in People with Dementia

Tools for Assessment of Pain in Nonverbal Older Adults with Dementia: A State-of-the-Science Review

Understanding the physiological effects of unrelieved pain

Untreated Pain, Narcotics Regulation, and Global Health Ideologies

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side , A Guide for Caring for the Dying at Home

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