Dyspnea

• Pharmacologic
  • Opioids are the primary treatment for dyspnea at EOL
  • Opioid dose generally 25% of the amount used for pain
  • Consider lorazepam as an adjunct
• Non-Pharmacologic
  • Oxygen
  • Elevate head of bed
  • Bedside fan
  • Fluid restriction

Secretions

• Pharmacologic
  • Glycopyrrolate
• Non-Pharmacologic
  • Fluid restriction
  • Gentle suction
  • Reposition
  • Educate families that noisy breathing may occur when death is imminent
  • May be distressing to hear but the child likely does not experience discomfort

Agitation/Anxiety

• Pharmacologic
  • Lorazepam
  • Consider midazolam infusion (if lorazepam required more than q 3 hours)
  • Note agitation caused by delirium may be worsened by benzodiazepine
    • Consider use of anti-psychotic
• Non-Pharmacologic
  • Low lighting
  • Soothing music
  • Familiar people/objects
  • Decrease sensory stimuli
  • Provide developmentally appropriate supportive therapy

Nausea/Vomiting

• Pharmacologic
  • 1st line: ondansetron or granisetron
  • 2nd line: lorazepam
  • 3rd line: prochlorperazine, haloperidol, metoclopramide, dexamethasone
• Non-Pharmacologic
  • Avoid irritating foods and smells
  • Consider etiology/source of nausea when selecting agent
  • Be aware of distinction between true reduction in nausea versus sedation

Pain

• Pharmacologic
  • Opioid with appropriate loading dose
  • Reassess patient frequently
  • Consider repeat doses q 20 min x 3 doses
  • After 3 doses consider continuous infusion
  • Once pain is adequately controlled with intermittent dosing
  • Consider switching to continuous infusion
    • Determine 24 hour opioid use (OME)
    • Consider starting with 50% OME, calculate hourly rate
  • For patients already on a continuous infusion with symptom escalation
    • Adjust rate no more often than every 8 hours
    • Add total prn boluses
    • Divide by the number of hours over which those boluses were given
    • Divide again by 2 (50% reduction)
    • Add to current basal rate, adjust prn dosing based on new hourly Rate
  • General Considerations:
    • No ceiling dose for opioids in EOL symptom management
    • Dosing interval for intermittent dosing may need to be shortened to achieve comfort
    • Take into account other possible sedating medications
    • Consider long-acting opioids that may not yet have achieved steady state (e.g. methadone, fentanyl TD)
    • Consider expected course/nature of pain, anticipated procedure etc.
    • Consider adjunctive medications and non-pharmacologic interventions
    • Consider opioid rotation if significant adverse effects
• Non-Pharmacologic
  • See measures for agitation/anxiety
  • Consider other integrative therapies
    • Acupuncture, biofeedback, guided imagery, mindfulness, Meditation, aromatherapy