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General Operational Topics

In Reply To: Use of VAlium for end of life restlessness
Next Reply: Re:Re:Use of VAlium for end of life restlessness
Previous Message: Re:Use of VAlium for end of life restlessness

Post Re:Use of VAlium for end of life restlessness
Author: rnielsen
Date: Jun 19, 2009 4:00 pm
How well is the valium working for you?

We use Ativan, which I have found very dissappointing. Half the time it makes the patient worse, and if it works, you have to sedate the patient into unconsciousness before they stop shouting or crawling out of bed.

Terminal delirium may be different than sepsis/hospital related delirium, but in sepsis induced delirium, brain dopamine levels are high and acetylcholine levels are low, and I have been having a better response from Haldol 1-3 mg now and tid (routine), and donepizel/Aricept 5 mg now and q pm. than I ever got with prn dosing of haldol or with haldol alone.

Terminal delirium may be different in that reticular activating system failure is at least part of what is going on. In one case I had excellent results adding Ritilan 5 mg po @ 8:00, 10:00, 12:00, 2:00. The patient woke up and remained responsive to the family until just a few hours before death.

It can be hard to convince a nurse to give Ritalin to an agitated patient, but it is kind of like ADD. Improved RAS function is calming.
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Re:Re:Use of VAlium for end of life restlessness (by Weissman on 06/19/2009)
The standard of care for managing terminal restlessness/delirium is a major tranquilizer (e.g. haldol, thorazine). As noted by the previous post, benzodiazepines (Ativan, Valium) can lead to worsening agitation and should be reserved for special circumstances. Dosing major tranqs is like opioids; if you assume the symptom is continuous, you need a continuous order and a prn order, such as Haldol 2 mg q8 and 2 mg q1h prn. I am well aware many physicians, especially in nursing homes, avoid or even refuse to prescribe major tranqs, this is contrary to best medical evidence and should be corrected through policies and standard order sets. Of note: many cases of terminal delirium are due to palliative care meds, the biggest offenders being anticholinergics (e.g. scopolamine patches) and/or opioids (often in association with myoclonus). Consultation with a palliative care physician or APNP is warranted.
See Palliative Care Fast Facts #1 and #60 for more details and references; www.eperc.mcw.edu

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