I am a new hospice physician. Their approach to non-malignant pain and agitation in end stage dementia patients appears to occ. favor opioids and benzos for patient “ comfort” over risk of falls. Besides the usual ” behavioral first approach,” I would greatly appreciate seasoned advice as to which specific scenarios should prevail pos or neg 4 adding meds. One example would be patient having increasing falls. Another one is that a CNA has already gotten hurt. What other criteria come 2 mind?

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Hospice director for several years. I hope I understand your question/concern:
-Obviously the literature says "behavioral interventions first" How realistic is this in a unit (assuming you're in a unit) with 10 other patients with acute symptoms is up for debate.
-Though Anti-psychotics in dementia do increase mortality and morbidity in conventional settings, it is acceptable to use them after a thorough goals of care discussion with POA/family.
-The Pain assessment scales in dementia DO work if applied correctly, and untreated pain is a significant cause of delirium. Utilizing opioids at their lowest effective dose is completely acceptable. Usually "cleaner" opioids with less metabolites like fentanyl or dilaudid.
-Benzos should only be reserved specifically for things like terminal delirium, not used routinely for "behavioral control". that would be considered a chemical restraint and it is unethical.
-Always procure and DOCUMENT adequate fall precautions.

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Hopefully, you've figured things out. It's common for hospice nurses to ask for everything at the same time. Do not sedate a pt with opioids; they're not supposed to be used for this. Eval for pain, constipation, etc. Try behavioral things. If staff are at risk, I will sedate for baths, etc and not all day. They need to be awake enough to eat safely. Any med mentioned will increase fall risk and should not be used. I will use the 2nd generation anti-psychotics if needed. -- Pall Care MD with 25+ years experience.

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