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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2593_Библиотеки_им_академика_М_И_Перельмана
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pulmonary disease, renal disease, stroke, and coma. Patients with
cancer are eligible if they present with metastatic disease or
progression from an earlier stage to metastatic disease with either a
continued decline in spite of therapy or if they decline further
disease-directed therapy.
The determination of whether M.P. meets eligibility requirements
for Medicare Hospice Benefits must be based on the established
LCDs for dementia as a result of Alzheimer disease. These criteria
include the following, from the Functional Assessment Staging Tool
(FAST) Scale
56–58
:
Stage 7 or beyond, according to the FAST Scale
Stage 7A: Can speak six or fewer intelligible words in a day or
during an interview
Stage 7B: Speech ability limited to the use of a single intelligible
word in a day or during an interview
Stage 7C: Cannot ambulate without assistance
Stage 7D: Cannot sit up without assistance
Stage 7E: Loss of ability to smile
Stage 7F: Loss of ability to hold head up independently
Unable to ambulate without assistance
Unable to dress without assistance
Unable to bathe without assistance
Urinary and fecal incontinence, intermittent or constant
No consistently meaningful verbal communication; stereotypical
phrases only or the ability to speak is limited to six or fewer
intelligible words
One of the following within the past 12 months: aspiration
pneumonia, pyelonephritis, septicemia, decubitus ulcers (multiple,
stages 3 and 4), fever (recurrent after antibiotic treatment)
Inability to maintain sufficient fluid and caloric intake with 10%
weight loss during the previous 6 months or serum albumin <2.5
g/dL
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The Palliative Performance Score Version 2 (PPS) (Table 6-1)
gradates the extent of disability and can be used to assist in the
determination of hospice eligibility.59 M.P. meets the previous criteria
and is eligible for hospice because of her Alzheimer disease. She
clearly is debilitated. She is unable to speak intelligently, cannot feed
herself, is not oriented to time or place, is incontinent of urine and
stool, has lost about 20% of her weight during the past year, has a
serum albumin of 2.2 g/dL, and has a PPS rating of 30% (ie, totally
bedbound, unable to do any activity, confused). In addition, she has
a number of comorbidities, experienced a recent episode of
aspiration pneumonia, and finished a course of antibiotic therapy.
Table 6-1
Palliative Performance Score (PPS) Version 2
Instructions: PPS level is determined by reading left to right to find a “best
horizontal fit.” Begin at left column reading downward until current ambulation is
determined; then, read across to next and downward until each column is
determined. Thus, “leftward” columns take precedence over “rightward” columns.
Source: Reprinted with permission from Victoria Hospice Society. Palliative
Performance Scale (PPSv2), Version 2. Medical Care of the Dying. 4th ed.
Victoria, British Columbia, Canada: Victoria Hospice Society; 2006:120.
http://www.victoriahospice.org/health-professionals/clinical-tools. Accessed April
13, 2016. Copyright © 2001 Victoria Hospice Society. The Palliative Performance
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Scale version 2 (PPSv2) tool is copyright to Victoria Hospice Society and replaces
the first PPS published in 1996 [J Palliat Care. 9(4):26–32]. Victoria Hospice
Society, 1952 Bay Street, Victoria, BC, V8R 1J8, Canada,
www.victoriahospice.org.
MEDICATION MANAGEMENT
CASE 6-1, QUESTION 2: M.P. has no known allergies. Her current medications
are memantine 10 mg twice daily, aspirin 81 mg once daily, alendronate 70 mg
weekly, esomeprazole 20 mg daily, lovastatin 20 mg with dinner, megestrol 40
mg/mL 5 mL (200 mg) twice daily, levothyroxine 0.1 mg daily, multivitamin daily,
beclomethasone metered-dose inhaler one puff daily, albuterol 2.5
mg/ipratropium 0.5 mg via nebulizer every 4 hours as needed for wheezing or
shortness of breath, acetaminophen 325 to 650 mg every 6 hours as needed for
mild pain or fever, olanzapine 5 mg at bedtime as needed for restlessness and
aggressive behavior, milk of magnesia 30 mL daily for constipation, and a
bisacodyl suppository 10 mg every 3 days as needed if there is no bowel
movement. The hospice medical director has determined that the aspiration
pneumonia, UTI, and COPD are related to M.P.’s terminal prognosis. What is
your assessment of M.P.’s medication regimen? Which medications is the
hospice required to provide, and which might be discontinued?
Hospices are required to provide (pay for) all medications related
to the terminal diagnosis and secondary diagnoses that contribute to
the terminal prognosis within the hospice POC. The POC is the
individualized plan of treatment developed for each patient
formulated at the start of care and updated regularly by the
interdisciplinary group or team (IDG/IDT). The Conditions of
Participation mandate that the IDG be composed of a physician,
registered nurse, social worker, and a pastoral or other counselor.
18
A registered nurse coordinates the implementation of the POC.
Some hospice program IDGs have incorporated a pharmacist into
the group to review medication issues.
The large array of medications being taken by M.P. is similar to the
medication lists of many hospice patients. These patients are often
elderly and have a long history of several chronic medical conditions
for which they have been taking multiple medications. In most cases,
the medication lists of patients who are admitted into a hospice
program have seldom been reviewed, updated, or modified in light of
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the present medical situation. Admission to a hospice program
represents a change in the level of care and is the most appropriate
time for a review and reconciliation of all medications to ascertain the
necessity of each, with the goal of optimizing efficacy and minimizing
the potential for adverse effects, medication errors, and
inappropriate costs.
In reviewing medications for the elderly, The Beers Criteria for
Potentially Inappropriate Medication Use in Older Adults is frequently
used to identify medications that may cause adverse events and
subsequent harm. In the 2019 version, under “Intent of Criteria,” it
states that the criteria are not intended for use in the hospice and
palliative care setting.60 While alerting clinicians to the potential for
problems with included medications, this does acknowledge that in
end-of-life care, medications are often used specifically for their
adverse effects, such as anticholinergics to reduce sialorrhea
(drooling) in patients with ALS, doxepin for sedation or itching, and
mirtazapine for sedation or appetite stimulation and should not
necessarily be avoided in these patients.
Because M.P. is to be enrolled into a hospice program, her care
should not be focused on curative treatments, but rather on the
management of discomforting symptoms and on improving her
quality of life in the time remaining. M.P.’s medications should be
analyzed with the goal of simplification. Unnecessary medications
should be discontinued and alternatives added to manage two or
more symptoms concurrently. The hospice medical director has
determined that CAD, COPD, UTI, aspiration pneumonia, and
multiple wounds are related to M.P.’s terminal prognosis and thus are
identified as secondary diagnoses for hospice care. The following
changes should be considered:
Acetaminophen. This analgesic is often helpful in relieving mild
pain, particularly in immobile elderly patients.61 A trial of around-
the-clock acetaminophen could be helpful, and the hospice would
pay for it.
Albuterol/ipratropium combination. The hospice program is
required to pay for medications related to M.P.’s aspiration
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pneumonia and COPD. This combination inhalation formulation (or
the components as separate products) should be continued if she
is able to participate in her nebulizer treatments and it improves
her breathing (see Chapter 19, Chronic Obstructive Pulmonary
Disease and Chapter 107, Geriatric Drug Use).
Alendronate. This bisphosphonate drug can be discontinued
because the treatment of osteoporosis is not an important
consideration at this terminal stage of her life nor is it related to her
terminal prognosis. Thus, the hospice would not cover it.
Furthermore, M.P. is bedbound; alendronate should be ingested in
the upright position, and patients should remain upright after
taking the medication to decrease the risk of alendronate-induced
esophageal irritation (see Chapter 110, Osteoporosis). Pain that
she may experience from osteoporosis can be treated with
analgesics.
Aspirin. The low-dose aspirin is intended to decrease the risk of
cardiovascular clotting. The aspirin will not increase M.P.’s comfort
or quality of life. It would be covered by her Medicare Hospice
Benefit, and can be continued unless her primary care provider
prefers its discontinuation or she experiences adverse effects.
Beclomethasone. This patient is not functioning well cognitively (ie,
not oriented to time, person, or place) and would be unable to
effectively time the inhalation of a breath to the actuation of her
metered-dose inhaler and it should be discontinued. If needed, a
systemic corticosteroid (eg, prednisone) might improve her COPD
symptoms and also improve her appetite and sense of well-being.
The potential for adverse effects is modest with short-term
corticosteroid use.
Bisacodyl, milk of magnesia. Constipation in patients with terminal
illnesses is common, occurring in as many as 87% to 90%
because of decreased gastrointestinal (GI) motility with advanced
age, metabolic disturbances, decreased physical activity, lack of
adequate fiber and fluid intake, and use of constipating
medications (eg, opioids, anticholinergics, psychotropic agents).
62–
65
The milk of magnesia, with an occasional bisacodyl suppository,
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has been an adequate laxative regimen for this patient; however,
the milk of magnesia should be discontinued if her renal function
deteriorates. If an opioid is later prescribed for M.P., a mild
stimulant laxative (eg, senna) can be added, from two tablets at
bedtime up to eight tablets daily.66 Osmotic agents such as
polyethylene glycol (PEG), oral sorbitol, or lactulose can be
prescribed if needed. Mineral oil 30 mL daily is an option if the
stool is hard; however, mineral oil should not be considered for
M.P. because of her risk of aspiration. Bulk-forming laxatives
should also be avoided in this population because they may not
ingest adequate water to prevent a fecal impaction. In cases of
refractory constipation, the use of methylnaltrexone bromide, an
opioid antagonist available as a subcutaneous injection and an
oral tablet, can reverse opioid-induced constipation by
antagonizing opioid effects within the GI tract without affecting
systemic analgesia.
67–70
This quaternary derivative of naltrexone
does not cross the blood–brain barrier. Dosing is weight based
and should be adjusted if a patient’s creatinine clearance (CrCl) is
<60 mL/min and the patient is in severe hepatic impairment. The
most common adverse events in adults with advanced illness are
abdominal pain, flatulence, nausea, dizziness, and diarrhea.
67
Other FDA-approved alternatives for opioid-induced constipation
are naloxegol, naldemedine, and lubiprostone (see Chapter 24,
Lower Gastrointestinal Disorders).
Esomeprazole. This proton-pump inhibitor may be unnecessary
because alendronate-induced esophageal or GI irritation would not
be an issue subsequent to its discontinuation. However, if a
proton-pump inhibitor is needed, nonprescription generic
omeprazole or lansoprazole is preferred because they are more
cost-effective.71 If a patient such as M.P. cannot swallow intact
tablets, a capsule formulation can be opened with the contents
mixed with soft food and swallowed intact.
Levothyroxine. This thyroid medication should be continued until
M.P. is no longer able to swallow. This medication, however, would
not be covered under her Medicare Hospice Benefit, which is
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based on her Alzheimer disease, and was deemed not related to
the terminal prognosis.
Lovastatin. Cholesterol-lowering agents are not necessary during
the last 6 months of life and can be discontinued without resulting
in harm to M.P.72 Lovastatin would not improve the quality of her
life at this stage of her terminal illness and would not be covered
by her Medicare Hospice Benefit.
Megestrol. The progesterone derivative, megestrol, in doses of 400
to 800 mg daily, can substantially stimulate appetite and induce
weight gain.
73,74
If an undernourished hospice patient desires to
eat more, the patient or their family may desire an appetite
stimulant. It is unclear whether stimulation of appetite in a
cognitively impaired patient will result in weight gain or improved
nutritional status. Because the benefits in this situation are
unclear, the potential of adverse effects (eg, venous thrombosis) of
megestrol needs to be considered, especially in M.P., who is not
ambulatory and had been taking low-dose aspirin for prevention of
cardiovascular clotting.75 If M.P. is given an oral corticosteroid, as
discussed previously, she may experience improved appetite as
an added benefit, thus negating the need to utilize megestrol
acetate.
Memantine. Because the N-methyl-D-aspartate (NMDA) antagonist,
memantine, has been modestly effective in improving performance
in patients with moderate-to-severe Alzheimer disease, but with
decreasing effectiveness over time, it is probably of limited utility
for M.P.76 (see Chapter 108, Geriatric Neurocognitive Disorders). It
would be reasonable to taper and discontinue M.P.’s memantine
subsequent to discussion with appropriate hospice team members
and M.P.’s family.
77,78
It can be restarted if her behavior
deteriorates. If she continues with it, the hospice would provide it.
Multivitamins. Multivitamins and other nutritional supplements are
unlikely to improve M.P.’s comfort or quality of life. The
discontinuation of these drugs would simplify medication
administration, decrease the potential for medication errors, and
decrease costs.
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Olanzapine. An antipsychotic (eg, olanzapine, haloperidol,
quetiapine) is often prescribed off-label to manage the agitation
and confusion encountered by patients with dementia. Behavioral
modifications can be tried (see Chapter 108, Geriatric
Neurocognitive Disorders), but paranoid or delusional behavior
may require drug therapy. Small doses of antipsychotics, such as
haloperidol or olanzapine, may offer a dual effect and be very
useful in treating opioid-induced nausea and vomiting, although
randomized clinical trials demonstrating efficacy are lacking.
79,80
They would be covered by M.P.’s Medicare Hospice Benefit.
Quetiapine is the agent of choice when more sedation is required
and has replaced the use of chlorpromazine because of cost
considerations.
71
SYMPTOM MANAGEMENT
The National Consensus Project for Quality Palliative Care has
developed Clinical Practice Guidelines for Quality Palliative Care.
5
The purpose of this document “is to promote access to quality
palliative care, foster consistent standards and criteria, and
encourage continuity of palliative care across settings.” In Domain 2:
Physical Aspects of Care, guidelines and criteria are provided for
interdisciplinary collaboration using available scales and other tools,
for the assessment, documentation, and treatment of pain and other
symptoms that are acceptable to both the patients and their families
as a preferred practice.5 The Center to Advance Palliative Care
(CAPC) provides tools, education, communication, and training for
practitioners to provide optimal palliative care.
81
CASE 6-1, QUESTION 3: As soon as the hospice admission and assessment is
completed, the nurse, in consultation with the IDG, develops a plan for symptom
management and orders a comfort kit for M.P. What are the components of this
kit, and why is it useful?
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Some hospices use an order set or a general comfort kit to provide
medications to treat anticipated symptoms for a specific patient.
82,83
These medications are placed in the home or facility where the
patient resides. This facilitates the availability of medications to
patients who encounter anticipated symptoms and is convenient
when caregivers are instructed by the patient’s primary care provider
or the hospice physician to provide the medication to the patient.
Patients at end of life experience a large number of symptoms
including pain, anorexia, cachexia, weakness and fatigue, dyspnea,
cough, nausea and vomiting, dysphagia, constipation, diarrhea, dry
mouth, oral sores, wounds and pressure sores, edema, ascites,
incontinence, confusion, delirium, anxiety, and depression.
84
In general, the prevalence of each symptom is difficult to measure
or predict and demonstrates a high degree of variability. The
occurrence of symptoms, however, can vary significantly, even within
the last week of life, and the need for frequent assessment of
patients cannot be overemphasized. Some combination of morphine,
lorazepam, haloperidol (or olanzapine), ondansetron, and an
anticholinergic agent generally provided as a concentrated oral
liquid, an orally disintegrating tablet (ODT), or a rectal suppository
are commonly ordered for hospice patients. Drugs that can palliate
more than one symptom, such as morphine for pain or dyspnea, or
haloperidol or olanzapine for agitation or nausea, are particularly
suited to inclusion in a comfort kit.
Morphine. Every hospice patient should have a short-acting
opioid available for the palliation of unrelieved dyspnea and pain.
Although morphine can cause respiratory depression, small doses
are very effective in controlling dyspnea by multiple mechanisms:
vasodilation, reduced peripheral vascular resistance, inhibition of
baroreceptor responses, reduction of brainstem responsiveness to
carbon dioxide (the primary mechanism of opioid-induced respiratory
depression), and lessened reflex vasoconstriction caused by
increased blood PCO2 levels. Opioids can reduce the anxiety
associated with dyspnea and might also act directly on opioid
receptors present in the airways.
85–90
They can be given in low doses
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orally, sublingually, parenterally, or via inhalation for this purpose
without causing respiratory depression. A Cochrane Review,
however, showed that due to the small number of randomized,
blinded, controlled studies, the evidence for the use of opioids to
palliate dyspnea was of low quality.91 In addition, no evidence to
support the use of nebulized opioids was found, although this route
may be useful if patients are experiencing intolerable side effects
from systemic agents.92 Table 6-2 provides an overview of both the
nonpharmacologic and pharmacologic treatment of dyspnea.
Table 6-2
Treatment of Dyspnea at End of Life
Nonpharmacologic Methods
Pursed-lip breathing
Upright position
Relaxation
Meditation
Use of a fan or open window to circulate air over the face
Pharmacologic Therapy
Systemic opioids (short-acting agents) in small doses given orally,
sublingually, or via injection can be given every 1–2 hours as needed.
Long-acting agents can be added to supplement the routine use of short-acting
opioids.
Inhaled opioids deliver medication via nebulization directly into the airway,
avoiding first-pass metabolism, allowing use of smaller doses, theoretically
minimizing side effects such as drowsiness. May cause local histamine
release, leading to bronchospasm. Use nonpreserved sterile injectable
products. More cumbersome and expensive owing to use of nebulizer and
nonpreserved parenteral products; evidence does not show that nebulized
opioids provide greater benefit than does nebulized saline.
Agents: morphine 2.5–10 mg in 2 mL of 0.9% saline; hydromorphone 0.25–1 mg
in 2 mL of 0.9% saline; fentanyl 25 μg in 2 mL of 0.9% saline
Generally given every 2–4 hours as needed for breathlessness
Benzodiazepines are useful for the anxiety associated with breathlessness.
Sources: Gutstein HB, Akil H. Opioid analgesics. In: Brunton LL, Lazo JS, Parker
KL, et al, eds. Goodman & Gilman’s: The Pharmacological Basis of Therapeutics.
11th ed. McGraw-Hill; 2006:547; Parshall MB, Schwartzstein RM, Adams L, et al.
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