The three end-of-life drugs are morphine for pain and breathlessness, lorazepam for anxiety, and haloperidol for agitation and nausea, though no official list exists.
Hospices often send these medications home together in a small package called a comfort kit. At Comfort & Peace Hospice, our Registered Nurse Case Manager manages medications and symptoms, and guides each family on which one fits the symptom in front of them.
Highlights
- Morphine treats pain and breathlessness, lorazepam treats anxiety, and haloperidol treats agitation and nausea.
- In a survey of 135 palliative care clinicians in 9 countries, 80% of final-round participants named morphine, midazolam, and haloperidol as essential for the last 48 hours of life.
- Many comfort kits add a fourth medication that dries the throat secretions behind the death rattle.
- In a survey of 49 caregivers, 76% used only 1 medication from the comfort kit.
- The Hospice Medical Director and the nurse set every dose, and families give a medication on the nurse’s instruction.
| Medication | What it is | What it treats | Other names you may hear |
| Morphine | Opioid | Pain and shortness of breath | Liquid morphine |
| Lorazepam | Benzodiazepine | Anxiety and the restlessness that comes with it | Ativan |
| Haloperidol | Antipsychotic | Agitation, confusion, and nausea | Haldol |
| Drying medication | Anticholinergic | Wet, noisy breathing from throat secretions | Atropine, glycopyrrolate, scopolamine |
What the three end-of-life drugs do
Each of the three end-of-life drugs treats a different symptom: morphine eases pain and breathlessness, lorazepam calms anxiety, and haloperidol settles agitation, confusion, and nausea.
The National Cancer Institute lists delirium, shortness of breath, pain, and a rattle sound with breathing among the common symptoms of the final days. One medication cannot cover all four, which is why a hospice team keeps more than one within reach.
Why does hospice give morphine?
Hospice gives morphine for two symptoms, pain and the feeling of not getting enough air. The National Cancer Institute states that opioids may relieve shortness of breath in people near death and are commonly used for pain. Drowsiness, constipation, and early nausea are the side effects families notice most, and our guide to morphine in hospice covers each.
Why does hospice give Ativan?
Hospice gives Ativan, the brand name for lorazepam, to ease anxiety and the restlessness that can travel with it. Lorazepam is a benzodiazepine, and one hospice study found it among the drugs placed in emergency kits at admission. Benzodiazepines can also worsen confusion in some patients, a caution explained in our guide to lorazepam at the end of life.
What is haloperidol used for in hospice?
Hospice teams use haloperidol, sold as Haldol, for agitation, confusion, and nausea near the end of life. Haloperidol is an antipsychotic. Delirium is common in the final days, according to the National Cancer Institute, and can show up as restlessness or hallucinations. Restlessness of that kind has a name, terminal agitation, and several possible causes.
Why no official list of three exists
The number three comes from research on which medications clinicians rely on most, and it was never issued as an official list.
The clearest source is a 2013 survey published in the Journal of Palliative Medicine. Researchers asked 135 palliative care clinicians in 9 countries which medications should be on hand for the last 48 hours of life. In the final round, 80% of the 90 participants agreed on morphine, midazolam, and haloperidol.
Midazolam, the second name, is a benzodiazepine like lorazepam, and United States hospices lean on lorazepam. In a national sample of 554,022 Medicare hospice patients enrolled from 2014 to 2016, 56.4% received lorazepam, 52.8% received morphine, and 28.6% received haloperidol. American families hear “Ativan” where the survey says midazolam for that reason.
The 2013 survey also looked at cancer care only. A patient with dementia, heart failure, or lung disease may need a different mix, and the hospice team builds the medication list around the person.
What are the 4 end of life drugs?
The four end-of-life drugs are the usual three plus a medication that dries secretions in the throat. Clinicians in the 2013 survey agreed a drying medication was needed and differed on which one. Atropine, glycopyrrolate, and scopolamine are common choices, and each is aimed at the wet breathing sound known as the death rattle.
What a hospice comfort kit holds
A hospice comfort kit holds small amounts of the medications a patient is most likely to need quickly, usually an opioid, a benzodiazepine, an antipsychotic or anti-nausea drug, and a drying medication.
Comfort kits exist for the hours between nurse visits. A symptom that flares at midnight during hospice care at home can be treated without a pharmacy run when the medication is already in the house.
Kit contents change with the hospice and the patient. A person with a history of seizures or severe nausea may have a kit that looks different from a neighbor’s.
A comfort kit works like the fire extinguisher under the kitchen sink. Families keep one hoping never to use it, and having it within reach saves a midnight drive when something flares. In a telephone survey of 49 bereaved caregivers who had been given a kit of rescue medications, 76% used only one medication from it. That survey was small, so the figure describes a pattern more than a rule.
What is an end of life comfort pack?
An end of life comfort pack is another name for a hospice comfort kit: a small, prescribed supply of medications kept in the home for symptoms that come on fast. A hospice doctor orders the contents, a pharmacy fills them, and the family uses them on the nurse’s direction. Emergency kit and e-kit mean the same thing.
Whether end-of-life drugs speed up death
Studies have not linked morphine to dying sooner, and the evidence on lorazepam and haloperidol is thinner and more mixed.
The National Cancer Institute addresses the opioid worry directly, noting that studies have not found a link between opioid use and dying sooner.
Lorazepam and haloperidol have a shorter research record, and one large study raises a caution for a specific group. Researchers writing in JAMA Network Open followed 139,103 nursing home residents with dementia who were newly enrolled in hospice. Starting a benzodiazepine was associated with a 41% higher risk of death within 180 days, and starting an antipsychotic with a 16% higher risk, compared with matched patients who did not start one.
The dementia study drew on Medicare records and reports an association. A study of that design cannot show the medication caused the deaths, and its findings apply to nursing home residents with dementia.
A fair question for any family is which symptom a medication is treating and what else has been tried. Our nurses expect that question.
Families link the medication to the death because of timing. Comfort medications tend to arrive in the home during the same weeks the illness is advancing fastest. Deep sleep, pauses in breathing, and cool hands are among the expected changes in the last 24 hours of life, and the National Cancer Institute lists them as part of dying itself.
How long is someone on end of life medication?
Time on end of life medication ranges from a few days to many months, because the prescription follows the symptom and the illness sets the timeline. Some hospice patients take morphine for months and stay alert. Others open a comfort kit only in the final days, and some never need one.
How the hospice team chooses a comfort medication
The hospice team chooses a comfort medication by matching it to the symptom the nurse finds on assessment, under the direction of the Hospice Medical Director.
A patient pulling at the sheets could be in pain, frightened, short of breath, or confused, and each of those points to a different medication. Sorting out which one is the nurse’s job.
At Comfort & Peace Hospice, our Registered Nurse Case Manager performs a full assessment of how a patient is feeling, manages medications and symptoms, and reports to the Hospice Medical Director, who specializes in pain control and symptom management. Our hospice team discusses patients at interdisciplinary meetings, so a medication change reflects more than one person’s read of one visit.
A family in Chula Vista or Escondido who calls at night reaches our on-call team, and we visit when a phone call is not enough.
When pain, anxiety, or respiratory distress gets out of control, Continuous Care puts our team at the bedside for several hours a day, up to 24 hours a day, until the crisis is resolved.
Hospice has four levels of care, and Continuous Care is the one built for symptoms that are out of control.
See the four levels of hospice care
Continuous Care happens at home, without a move to a facility.
What families do when a comfort medication is needed
Families call the hospice nurse first, describe what they see, and give a comfort medication only when the nurse directs it.
Consider a composite example, drawn from common patterns and no single patient. A daughter caring for her father in La Jolla wakes at 2 a.m. to find him restless and tugging at his blanket. She calls her hospice’s nurse line and describes what she sees. The nurse asks a few questions, tells her which medication to open and how much to give, and stays reachable while it takes effect.
Our nurses answer around the clock and come to the home when a call does not settle things.
Red flags: signs to report to the hospice nurse
- Grimacing, a furrowed brow, or moaning
- Breathing that looks like hard work
- Restlessness that does not settle
- New confusion, or seeing things that are not there
- A symptom that returns after a medication was given
Any of these is a reason to call now and skip waiting for the next scheduled visit.
Recommended: five questions to ask the hospice nurse when medications arrive
- Which medications will be kept in the home, and what is each one for?
- Which symptoms mean I should call you?
- Who tells me when to give something, and how do I reach them at night?
- Where should the medications be stored?
- What happens to medications that are never used?
Dose, timing, and combinations belong to the Hospice Medical Director and the nurse. Giving more than directed, giving two medications together without instruction, or using a medication prescribed for one symptom on another carries real risk, including heavy sedation and slowed breathing. Comfort medications also need a spot out of reach of children and visitors.
Underneath the medication question, families often carry a larger worry about whether pain at the end of life can be controlled. The National Cancer Institute’s answer is that pain in the final hours can usually be controlled.
Key Takeaways
- The three end-of-life drugs are morphine, lorazepam, and haloperidol, and each treats a different symptom.
- The number three traces to clinician surveys and was never an official list.
- Many kits add a fourth medication for throat secretions, and contents differ by hospice and by patient.
- Studies have not linked opioids to dying sooner, and one large dementia study linked benzodiazepines and antipsychotics to higher mortality.
- The Hospice Medical Director and the nurse set every dose, and families give medication on the nurse’s direction.
A hospice nurse can explain what each comfort medication is for and when it gets used.
Ask a hospice nurse about comfort medications
Comfort & Peace Hospice answers around the clock at (858) 304-2555.
Frequently Asked Questions About End-of-Life Drugs
1. Does every hospice patient get a comfort kit?
Many home hospice agencies provide a comfort kit, and the contents and timing differ from one hospice to the next. Some deliver a kit at admission, and others order medications as symptoms appear. The reliable way to find out is to ask the hospice nurse at admission which medications will be kept in the home.
2. Can family members give comfort kit medications?
Family caregivers commonly give comfort kit medications at home, following the hospice nurse’s instructions. The nurse explains which medication matches which symptom and what amount to give, and families call for direction when something changes. Caregivers who feel unsure can ask the nurse to go through each step again or to visit.
3. How often can you give lorazepam on hospice?
The interval for lorazepam is set by the Hospice Medical Director for each patient and written on the prescription label. A safe answer depends on the patient’s size, other medications, and response to earlier doses, so a general number from the internet does not apply. Call the hospice nurse with any question about timing.
4. Do end-of-life drugs make a person sleep all the time?
Drowsiness is a known effect of morphine and lorazepam, and the illness itself also brings more sleep. The National Cancer Institute notes that people near death withdraw and spend more time sleeping. A family that sees a sudden change in alertness after a medication should tell the hospice nurse, who can review the plan.
5. Who pays for comfort kit medications?
Medications related to the terminal diagnosis are covered under hospice care, and Comfort & Peace Hospice accepts Medicare, Medi-Cal, and most private insurance. Coverage details differ by plan, so our team can look up a specific policy. Situations where extra charges can apply are listed in our guide to hospice costs.
