When is Haldol the Right Choice?

Posted on Wednesday September 7, 2016 in Hospice Education

haldol

Haldol has received the label of a “bad” drug, but the World Health Organization has deemed it one of 20 essential medications in end-of-life care. It is the drug of choice in hospice for the treatment of terminal agitation and delirium.

Haldol (also known as haloperidol) is an antipsychotic medication. In hospice, it is used to treat terminal delirium, severe agitation in end-stage dementia. Sometimes it’s also used in the treatment of nausea and vomiting and can even be used to treat intractable hiccups. It is a very effective medication in managing all these symptoms.

The hospice nurse always works with the hospice medical director to ensure there is an appropriate indication (reason) for the use of Haldol and will ensure there is a specific goal of therapy.

What is an Appropriate Reason and What is the Goal of Therapy with Haldol?

Haldol may be appropriate in management of terminal delirium in the hospice patient. Terminal delirium is frequently seen as rapid onset of confusion, restlessness, changes in perception and it can — but doesn’t always — include agitation.

Agitated terminal delirium may be an indication death is near and can be quite distressing to the patient and their families. Haldol is the drug of choice to treat terminal delirium, and the specific goal in its use is to minimize agitation and keep the patient as comfortable as possible.

There are reversible causes of delirium. Reversible causes of delirium include:

Pain
Urinary retention
Severe constipation

If the patient is not in the final hours of life and is experiencing delirium, the hospice nurse will assess to ensure any reversible causes for agitation and confusion are identified and addressed.

Haldol can also be effective in the management of severe agitation in end-stage dementia patients as well. Even so, if agitation and confusion have a sudden onset, the hospice nurse will assess the patient to rule out reversible causes.

So is Haldol a Bad Medication?

Haldol may have gotten a “bad” rap because it, along with many medications (and many other antipsychotic medications), has appeared on the “Beers Criteria for Potentially Inappropriate Medication Use in Older Adults” in the past. All the medications on the Beers List are potentially inappropriate.

For Haldol, the list recommended: “Avoid use for behavioral problems of dementia unless nonpharmacological options have failed and patient is a danger to self or others.”

The Centers for Medicare and Medicaid Services (CMS) began an initiative in 2006 to decrease the unnecessary use of antipsychotics in nursing homes and surveyors of skilled nursing facilities. Healthcare professionals in these environments have been mandated to ensure:

Antipsychotic medication has a specific reason to be used
If a patient is receiving antipsychotic medications (including Haldol) for behaviors, they have been appropriately evaluated and other reasons for behaviors have been assessed
Appropriate monitoring of patient response to antipsychotic medications
Gradual dose reductions are attempted
If antipsychotic medications cannot be stopped there is adequate documentation reflecting why it can’t be stopped

Some skilled nursing facilities may avoid use of Haldol, even in hospice patients, because they fear surveyors will give a tag or a deficiency for its use. However, if it is clearly documented on the patient’s medical record that Haldol, or any antipsychotic medication, is being used to manage end-of-life symptoms and the patient is on hospice care, a survey deficiency should not be a concern.

Hospice service providers can partner with skilled nursing facilities to ensure appropriate documentation reflecting the need for Haldol is in the patient medical record.

Haldol is not without side effects, some serious, some less serious, and it may not be right for every behavior or for every patient. But Haldol is not a bad medication. Remember: The World Health Organization has identified it as one of 20 essential medications in palliative care.

If you have questions about the use of Haldol or about the care of hospice patients, please visit our hospice care tips and guides section to learn more. You can also give us a call at 888-564-3405.

Sally Drummond
Crossroads Hospice & Palliative Care
Corporate Pharmacy Consultant, RN, CHPN