Supportive and Preventive Medicine
Lorazepam can be considered as an adjunct, especially with anticipatory vomiting.
| d. | Use of more than one agent from different classes may be necessary for symptom relief. |
|---|
Cough
Excessive coughing can lead to exacerbation of dyspnea and spells of nausea and vomiting, in
addition to disturbing sleep and exacerbating pain.
Non-opioid antitussives such as benzonatate and dextromethorphan may be considered.
All opioids have intrinsic antitussive action by inhibiting the brain stem cough center; however, if
the patient is receiving an opioid for other reasons, adding another opioid has not shown additional
benefit.
| d. | For refractory cough, consider nebulized lidocaine. |
|---|
Secretions
Near the end of life, the ability to clear oral and tracheobronchial secretions diminishes.
Secretions are usually too low in the tracheobronchial tree for gentle oral suctioning to help, and
suctioning can be disturbing.
The treatment mainstay includes anticholinergic and antimuscarinic medications.
Glycopyrrolate (0.2 mg intravenously or subcutaneously every 4-8 hours as needed) or atropine
(1% ophthalmic solution 2 drops sublingually every 4 hours as needed) should be used for
acute symptoms.
ii.
Scopolamine and atropine cross the blood-brain barrier and can be more sedating than
glycopyrrolate.
iii.
The scopolamine patch is more gradual in onset (12 hours).
iv.
More than 1 scopolamine patch may be used for unrelieved symptoms.
Patient Case
An 88-year-old woman is admitted to the ICU for decompensated heart failure, and uncontrollable pain
from the rib fractures she had 1 month ago from a fall. This is her fourth admission to the ICU in the past 5
months. Speaking with her, you find that she wishes not to be resuscitated or intubated but only to be com-
fortable. Her blood pressure is currently 119/70 mm Hg, heart rate 120 beats/ minute, and respiratory rate
55 breaths/minute. Her pain is 9/10 using the Behavioral Pain Scale (BPS). In a meeting with the patient’s
family, all members agree that they do not want to see her suffer any longer. It is decided to initiate a mor-
phine drip at 2 mg/hour. Titration parameters include giving a bolus dose equivalent to the current rate and
increasing the infusion by 25% to maintain a score of 3 (no pain) using the BPS. Her laboratory values are
all within normal limits, including BUN 10 mg/dL and SCr 0.6 mg/dL. The nurse taking care of the patient
believes that the titration parameters are too aggressive. Which would be the most appropriate change in
titration parameters?
an increase in blood pressure or heart rate.
azolam infusion at 2 mg/hour.
dose increase.