Particularly as someone approaches their last year of life, and has decided they only want to be “kept comfortable”, it can be confusing trying to decide what might help reach that comfort goal and what will not likely be helpful. The following describes some choices which might help them live more comfortably.
First and most important, our experience – supported by the published research – confirms that the fewer drugs a senior takes, the more comfortable they are and the longer they live! For more information, ask the nurse for the handout Polypharmacy [or read it on the website comfortcarechoices.com].
Method of delivery (route of administration): Unless specified otherwise, most of the drugs listed below can be given by swallowing, subcutaneous (injected under the skin – we avoid starting intravenous), suppository, or by applying a topical cream. Where a drug has an additional benefit or route of delivery, it will be pointed out.
Response Variations: Individuals may react differently to the same drug; some are very sensitive whereas others require extremely high doses for the same effect. This means we need the observations of family to help adjust the dosages to achieve our goal of comfort.
Morphine (for pain and shortness of breath)
Morphine is an opioid (naturally occurring narcotic). It is considered the ‘gold standard’ drug for controlling pain and can be very helpful for relieving shortness of breath. Two great advantages are there is no limit to the amount that can be given and it can be taken by any route.
For those people with chronic or constant pain, it is important for them to take their pain reliever regularly – not just “when needed”. Because long-term pain affects the body different than short-term or acute pain, it requires that the medicine be given on schedule – as in every four to six hours – to keep ahead of the pain. And, when pain occurs between scheduled doses, additional drug should be taken for this “breakthrough” pain. Residents will not become “addicted” to the narcotic.
Residents with Alzheimer’s (or another) dementia often cannot tell us when they have pain – all we see is their agitated behavior. Using a pain scale to monitor their response, we have found that morphine works better than the major tranquilizers [atypical anti-psychotics such as Seroquel] to control the agitation, helping them to live more comfortably, longer.
All narcotics have side-effects. Constipation requires stimulant laxatives (e.g. senokot, Miralax). Nausea and sedation are common initially, but these tend to improve after a few days. For people who have been in pain a long time, as their pain is relieved with the morphine it is normal to be sleepy for a few days initially; if this doesn’t improve, there are different medications which can help. Muscle twitching can occasionally occur but if this not bothersome, there is no need for treating it. Confusion is sometimes seen in the beginning (this is not an allergy) but can be treated with a drug such as Haldol (below).
If a person is truly allergic to morphine (a rare event), other narcotics such as Dilaudid [hydromorphone] or Percocet [oxycodone] or methadone can be used instead.
Compazine [prochlorperazine] (for nausea & vomiting)
This is an excellent drug for controlling nausea/vomiting. It is more effective and has less sedation and risk of confusion than does Phenergan [promethazine].
Reglan [metoclopramide] (for nausea & vomiting, or reflux)
Reglan has many useful purposes: nausea/vomiting, reflux (heartburn), constipation (promotes small bowel movement). It can rarely cause someone to become rigid in their muscles; reducing the dose is usually all that needs to be done.
Haldol [haloperidol] (for confusion, or for nausea)
Haldol is the drug of choice for treating acute delirium (confusion caused by a drug or infection or associated with dementia). It does not affect the blood pressure and helps to stop hallucinations and agitation. (Occasionally it causes a worsening of the confusion!) It is very helpful also for nausea. In someone with seizures, it’s possible (but rare) to trigger a seizure.
Ativan [lorazepam] (for muscle spasms, or for anxiety)
This is the standard medicine for anxiety, helping to calm a person; it can be helpful for sleeping. It is a good muscle relaxant for spasms, twitching and tremors. Taken without an antidepressant, it can aggravate depression in someone; and can make delirium (confusion) worse in many seniors.
Decadron [dexamethasone] (for bone-related pain, or appetite, or nausea)
Decadron is a steroid (“cortisone”) which means it is anti-inflammatory, reducing swelling/irritation from tumors (especially brain tumors); it is excellent for reducing the pain associated with cancer in bones. A beneficial side-effect is that it increases appetite. It often helps reduce nausea. All steroids have side-effects over the long term (months) but for patients receiving palliative/comfort care, usually the benefits outweigh any side-effects.
For Pneumonia, Do Antibiotics Help Control Symptoms?
Before antibiotics, pneumonia was called the “old person’s friend”: it was the most common cause of death and offered a failing elder an escape from their suffering. But now, antibiotics may interfere artificially in the natural end-of-life process.
Generally, antibiotics do not help control pain or shortness of breath; their purpose is to kill bacteria and cure an infection. They do not help directly or immediately with pain relief; to that end, morphine, breathing treatments, and other drugs, are more effective.
If the goal is comfort only, and to not prolong suffering or the dying process, there is the option of not taking an antibiotic. Your doctor will discuss this with you.