Here’s a question that comes up in hospice more than you’d think: Why would a hospice patient be on two antipsychotics at the same time? To the average clinician, this raises immediate concerns—duplication, unnecessary side effects, and polypharmacy in a population where comfort is king. I don’t love it when I see it, but here are two possible reasons for duplicate antipsychotics in hospice.
Transitioning – Cross-Taper
Say a patient’s on a relatively high dose of quetiapine for agitation, but it’s just not cutting it. Haloperidol is being added with the intention of eventually discontinuing the quetiapine. During that transition window, both meds are active and having two on board for a period of time makes sense, especially if the dose of the current antipsychotic is fairly high. Does this count as duplicate therapy? Technically yes—but clinically, this might be the most rational and cautious approach to minimize destabilizing symptoms.
Indication
In hospice, you’re not always treating schizophrenia or bipolar disorder. Sometimes antipsychotics are used off-label—think delirium, terminal agitation, or nausea (yes, haloperidol can help with that). When there are two different PRN antipsychotics for the same indication, I’m usually quick to write a recommendation to get rid of one of them to avoid patient/caregiver confusion and avoid giving both at the same time. This is especially true in long-term care and assisted living when staff have to decide which of the two medications they are going to use for the condition. Surveyors will certainly look at and scrutinize this situation. If you are looking for more on long term care consulting, be sure to check out the Insider’s Guide To Long-Term Care Consulting.
On the flipside, if the indication is clear and different, i.e., the patient is receiving PRN olanzapine for nausea and PRN quetiapine for hallucinations, this may be a reasonable situation to consider two antipsychotics if it is what has been effective for the patient.
What other situations have you seen duplicate antipsychotics in hospice?
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