Administration and Prescription Patterns of Lorazepam at End of Life in a Residential Home for the Dying

Background: Many patients approaching the end of life experience symptoms that are managed through the use of medications. Lorazepam (Ativan) is a benzodiazepine that is often used to treat anxiety and other symptoms common at end of life, such as seizures and nausea. When patients are on hospice at home, familial caregivers are responsible for administering lorazepam to treat these symptoms. Hospice can prescribe lorazepam for a scheduled regimen, or "as needed" PRN regimen to allow caregivers the freedom to administer additional medication if necessary. Since there is no requirement to document medication, little is known about the use of lorazepam at home and how often caregivers are burdened with making decisions about its use. The goal of this study was to examine lorazepam prescribing practices in a community-run residential home for the dying, where hospice records all medication prescriptions. Caregivers also document how often medications are administered. The extent to which lorazepam regimens were on a scheduled vs. PRN basis was studied as a way of determining how often caregivers had to gauge when to administer lorazepam. The frequency with which changes in patient medications were made and total lorazepam consumption were also examined to assess caregiver burden.
Methods: Data on the dose of lorazepam prescribed vs. administered was recorded from the files of 216 hospice patients who were cared for at the Joan Nicole Prince Home in Scotia, New York between February 2007 and July 2019. Scheduled and PRN lorazepam doses were calculated for the first 24 hours of care and on the day of death.
Results: A majority (81.8%) of patients were prescribed lorazepam at the home and most of these patients (94.4%) had PRN prescriptions. There was a significant increase in the total amount of lorazepam consumed from the day entering the home (17%) to the last 24 hours of care (27%).
Discussion: Lorazepam was prescribed to hospice patients very frequently and caregivers were often tasked with making decisions about whether to administer as needed doses to patients. While the administration of lorazepam increased as patients progressed toward death, consumption was low compared to doses allowed, which may have been the result of several issues, including caregivers' hesitation to administer full doses allowed by hospice. These results suggest that greater support of caregivers may be needed when caring for terminally ill patients experiencing anxiety at the end of life.