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at 7 of 10 (on a scale of 0–10), the use of multiple opioids, and the
use of excessive PCA boluses. Once an infusion with PCA dosing is
started, there is no need to continue other long-acting opioids (ie,
transdermal fentanyl) or oral agents for breakthrough pain. The PCA
doses serve as the rescue doses for breakthrough pain, and pain
relief should be titrated using this method alone. Once pain is well
controlled, an oral long-acting agent can be considered if the patient
is able to swallow. To do otherwise creates a chaotic approach.
Patients reporting allergic reactions to opioids should be carefully
asked to describe the precise nature of the purported allergic
reaction. True allergies to opioids are rare; patients often refer to an
adverse reaction as an allergy or have experienced an effect from
the histamine release that is associated with opioids.
Hydromorphone, especially injectable hydromorphone, is much more
expensive and no more effective than is morphine and is best
reserved for use in patients who cannot tolerate morphine because
of adverse effects. Patients who are truly allergic to morphine should
be treated with fentanyl or methadone because of the low incidence
of cross-reactivity with these agents.
Although D.V. had been prescribed ketamine every 3 hours in the
hospital, it is unrealistic to expect that this can be continued in the
home setting. D.V. and his wife would probably be glad to
discontinue it and replace it with an alternative because of his need
to be dosed so often. Discontinuation may result in an exacerbation
of pain, and he should be monitored.
D.V.’s constipation is currently treated with multiple medications
within the same therapeutic class. It would be more prudent to
maximize the use of a single agent within a category, rather than
using two products at less than the maximally recommended doses.
D.V. can use a higher dose of senna (up to four tablets twice daily),
and then, if necessary, continue to use the PEG 3350.
62–65
D.V. also takes multiple medications for his nausea and vomiting.
The serotonin antagonist ondansetron provided as an ODT can be a
good option, as an alternative to IV ondansetron. Another good
alternative is olanzapine ODT because it provides anticholinergic,
anti-dopamine and anti-serotonin activity.80 He had also been
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directed to take lorazepam for his nausea and vomiting; however,
benzodiazepines are not effective antiemetics. They are given to
manage the anxiety associated with nausea and vomiting and are
particularly useful in managing the anticipatory nausea and vomiting
that is commonly encountered during chemotherapy administration.
Metoclopramide can be useful for D.V.’s nausea and vomiting if his
physical examination reveals hypoactive bowel sounds. It is also
useful for treating hiccups, and the need for baclofen can be
reassessed.
CASE 6-3, QUESTION 2: A few days after arriving home, D.V. asks his hospice
nurse, “Can’t you just give me something to end it all?” He has not been
sleeping well, is tired of taking so many medications, and wants to alleviate the
burden he feels he is imposing on his wife. How should the hospice nurse
respond?
In patients who are terminally ill, suffering may continue despite
maximal palliative efforts. As a result, practitioners continually
encounter patients’ requests for the ending of their lives because of
overwhelming suffering. Medical aid-in-dying is legally available in
several states, and although substantial numbers of clinicians can
imagine situations in which aid-in-dying would be requested,
willingness to actively participate in the ending of a patient’s life is
low.
134–150
A recent literature review did not find any studies
examining pharmacists’ direct experiences with aid-in-dying.
151
Nonetheless, pharmacists should be aware of and understand
issues around the practice. The NHPCO has developed
comprehensive resources, the LAD (Legally Accelerated Death)
Series, for clinicians.
152
The State Information document contains
links to state statutes and statistics, organizational policy statements
(including ASHP’s), and provides a bibliography.
153
In a small
number of patients, it may be desirable to reduce suffering by the
thoughtful use of medications to induce light to moderate
sedation.
154–157
Unlike aid-in-dying, the intent of palliative sedation is
to relieve suffering, not to hasten death. Death may, however, result
as an unintended consequence of escalated drug dosing, as a
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double effect. Data is lacking on the effect of palliative sedation on
quality of life and survival following this intervention, and patients
may continue to experience pain, dysphoria, or other adverse
events.
158,159
Palliative sedation should only be initiated as a last
resort in severe cases not responsive to other palliative measures,
and only after thorough discussion of the important clinical and
ethical issues with the patient, family, and other clinical team
members.
160–162
Medications used successfully to induce sedation for these
patients include benzodiazepines, barbiturates, and propofol,
generally given in combination.
163
The goal is to attain light to
moderate sedation to preserve the airway. Opioids are continued to
manage pain and prevent withdrawal. A best practice is to develop
organizational policies, standardized orders, and quality assurance
monitoring.
164
A trial of palliative sedation with IV midazolam could
be initiated and managed by the hospice nurse at a rate of 1
mg/hour and gradually increased if needed to the desired effect.
163
For use in the home, crushed phenobarbital tablets administered via
a rectal catheter could be added if the desired effect is not attained
with midazolam alone.
165
Use of other agents such as propofol and
dexmedetomidine are best reserved for use in inpatient settings.
Before considering palliative sedation, patients should be
thoroughly assessed for insomnia, depression, pain, and other
symptoms. Underlying reasons for insomnia should be explored and
treated. Poor pain management is often the cause for considering
palliative sedation. As many as 10% to 20% of patients with cancer
may have pain that does not respond to standard systemic
analgesics.
166
Interventional techniques, including the administration
of spinal opioids and/or local anesthetics may be useful, but may not
be practical to initiate for the actively dying patient at home.
167–169
CASE 6-3, QUESTION 3: Repeated increases in the hydromorphone infusion
basal rate (he is now at 25 mg/hour) had little effect on managing D.V.’s pain,
and his consistent use of up to 120 PCA attempts in 24 hours reflects his
continued pain. He describes the intensity of his pain as 8 of 10. Before
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considering palliative sedation, what other therapeutic interventions can be
implemented for D.V.?
In D.V., lidocaine 0.5 to 1 mg/kg/hour administered IV or
subcutaneously might be useful to assist in the management of his
severe neuropathic pain.
170–173
Lidocaine purportedly interrupts pain
transmission by blocking sodium channels (see Chapter 55, Pain
and Its Management). D.V. was started on lidocaine 1 mg/kg/hour IV.
A bolus dose was not given because of the short half-life of
lidocaine. Overnight, his use of hydromorphone boluses dropped to
one. He now reports his pain as 1 of 10 and that he slept through the
night for the first time in months. During the next 2 days, the
hydromorphone basal rate was tapered to 5 mg/hour. He did not
experience any lidocaine toxicity, such as perioral numbness,
metallic taste, or somnolence. D.V. continued on lidocaine, using no
hydromorphone boluses for the next 2 weeks, until he died at home
surrounded by his family.
KEY REFERENCES AND WEBSITES
A full list of references for this chapter can be found at
http://thepoint.lww.com/AT12e. Below are the key references and
websites for this chapter, with the corresponding reference number
in this chapter found in parentheses after the reference.
Key References
Electronic Code of Federal Regulations. Title 42, Chapter IV, Subchapter B, Part
418. Hospice care. Updated February 8, 2021. Accessed February 9, 2021.
https://www.ecfr.gov/current/title-42/part-418 (18)
Herndon CM, Nee D, Atayee RS, et al. ASHP guidelines on the pharmacist’s role
in palliative and hospice care. Am J Health Syst Pharm. 2016;73: 1351–1361.
(53)
Hughes MT. The pharmacist and medical aid in dying. Am J Health Syst Pharm.
2017;74(16):1253–1260. (149)
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Institute of Medicine. Dying in America: Improving Quality and Honoring Individual
Preferences Near the End of Life. The National Academies Press; 2015. (84)
McPherson ML, Walker KA, Davis MP, et al. Safe and appropriate use of
methadone in hospice and palliative care: expert consensus white paper. J
Pain Symptom Manage. 2019;57(3):635–645. (127)
National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines
for Quality Palliative Care. 4th ed. National Coalition for Hospice and Palliative
Care; 2018. Accessed September 28, 2020.
https://www.nationalcoalitionhpc.org/ncp (5)
The American Society of Health-System Pharmacy. Policy position on medical aid-
in-dying. Accessed January 9, 2021.
https://www.ashp.org/-/media/assets/policy-guidelines/docs/policypositions/policy-positions-ethics.ashx (150)
Key Websites
American Academy of Hospice and Palliative Medicine (AAHPM).
http://www.aahpm.org/
Center to Advance Palliative Care (CAPC). http://www.capc.org/
Centers for Medicare & Medicaid Services (CMS).
https://www.cms.gov/Center/Provider-Type/Hospice-Center.html
End of Life Online Curriculum.
http://endoflife.stanford.edu/M00overview/introlrnoverv.html
Hospice Foundation of America (HFA). http://www.hospicefoundation.org/
International Association for Hospice & Palliative Care (IAHPC).
http://www.hospicecare.com/
MedlinePlus. Hospice care. http://www.nlm.nih.gov/medlineplus/hospicecare.html
National Hospice and Palliative Care Organization (NHPCO).
http://www.nhpco.org/
National Hospice and Palliative Care Organization (NHPCO). Pediatric palliative
care and hospice. http://www.nhpco.org/pediatric
Palliative Care Network of Wisconsin Fast Facts and Concepts.
https://www.mypcnow.org/fast-facts/
Pallimed: A Palliative Medicine Blog. http://www.pallimed.org/
Society of Palliative Care Pharmacists. http://www.palliativepharmacist.org
The National Consensus Project for Quality Palliative Care.
http://www.nationalconsensusproject.org
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