Table 3.

Initial pharmacologic management for symptoms in end-of-life emergency department patients

Medication	Detail
Nausea and vomiting
Ondansetron (serotonin-receptor antagonist)	4–8 mg PO/IV every 8 h. Common “first-line” antiemetic that is generally well tolerated. Also preferred in patients with Parkinson’s, Lewy body dementia, or restless leg syndrome as it does not affect dopamine. Constipation is a common side effect.
Metoclopramide and prochlorperazine (dopamine-2-receptor antagonists)	5–10 mg PO/IV every 8 h. Older antiemetics that are still often used for nausea as well as headache. Metoclopramide has a promotility component, so it can be helpful in gastric emptying disorders or constipation, but should be avoided in bowel obstructions. Avoid in patients with Parkinson’s, Lewy body dementia, or restless leg syndrome. Acute motor symptoms like dystonic reactions are possible.
Olanzapine (dopamine-2-receptor antagonist)	2.5–5 mg PO/IV every 6–8 h. A newer dopamine antagonist. Generally, well tolerated. Also useful in treating delirium, anxiety, insomnia, and cachexia.
Steroids, anti-histamines, antihistamines and anticholinergics, cannabinoids, etc.	Generally, avoid in the ED unless recommended by a specialist.
Nonpharmacologic	Ginger and mint products can be helpful, as can sniffing isopropyl alcohol swabs.
Constipation
Sennosides	1–2 tabs (8.6–17.2 mg) once or twice daily. Intestinal stimulant.
Polyethylene glycol	1–2 tablespoons (17–34 g) once or twice daily. Intestinal stimulant.
Docusate	Generally, not helpful as monotherapy. Stool softener. Sometimes used in conjunction with a promotility agent like sennosides.
Bisacodyl enema	Generally dosed once daily. Intestinal stimulant.
Warm tap water and milk of molasses enemas	Can be given up to every 2 h. Work by causing rectal distention and reflex defecation.
Depression and anxiety
SSRIs, SNRIs, TCAs	Traditional mainstay of depression pharmacotherapy. Generally peak effect takes weeks. Not typically started in the ED. However, may be recommended by palliative and/or psychiatry specialists who see your patients.
Mirtazapine	Sometimes used for depression, and also can be helpful for insomnia, nausea, or anorexia. Peak effect shorter than SSRIs, SNRIs, and TCAs, but still not typically started in ED.
Methylphenidate or dextroamphetamine	Stimulants are used to treat depression in patients at the end of life with short (<4 wk) prognosis. Rapid onset. Talk to your palliative and/or psychiatry specialists for guidance.
Olanzapine (dopamine-2-receptor antagonist)	2.5–5 mg PO/IV every 6–8 h. Newer dopamine antagonist. Generally, well tolerated. Also useful in treating delirium, nausea/vomiting, insomnia, and cachexia.
Lorazepam (GABA receptor antagonist)	0.5–1 mg PO/IV every 6–8 h. Rapid onset for relief of anxiety in the ED, but can be deliriogenic. Would generally not prescribe for use at home unless recommended by a palliative care or psychiatry specialist. Higher doses are often needed at end of life.
Delirium Remember that the first step in treating delirium should be identifying and treating reversible causes. The following are medications that can help improve patients’ symptoms and safety.
Haloperidol	0.5–1 mg PO/IV/IM, titrating by 2–5 mg every 1 h until effective dose is found. Recommended daily max 100 mg.
Olanzapine	2.5–5 mg PO/IV every 6–8 h. A newer dopamine antagonist. Generally, well tolerated. Also useful in treating, nausea/vomiting, anxiety, insomnia, and cachexia.
Quetiapine	25–50 mg PO once or twice daily. Agent of choice in delirious patients with Parkinson’s disease or Lewy body dementia who can take PO.
Thorazine	25–50 mg PO/IV, titration by 25–50 mg every 1 h until effective dose is found. Recommended daily max 2000 mg.
Lorazepam	Generally avoided as they can worsen delirium, though in delirious patients with Parkinson’s disease or Lewy body dementia who can’t take PO they’re sometimes used. Patients with “terminal delirium” can consider combining them with another medication like haloperidol. In this case, start with 0.5–1 mg IV/IM, titrating by 1–2 mg every 1 h until effective dose is found.

Abbreviations: ED, emergency department; IV, intravenous; IM, intramuscular; PO, per oral; SNRIs, serotonin and norepinephrine reuptake inhibitors; SQ, subcutaneous; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants.

Data from Jason Bowman, MD.