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6 - Palliative and Hospice Care |
147
C 2: H C
Setting:
Recently discharged from hospital admission to home hospice care.
Subjective:
AK is a 76-year-old man who presents to home hospice with worsening pain in his bones due
to metastatic prostate cancer. He was recently discharged from the hospital. On this admis
-
sion his pain regimen was increased. He reports taking his morphine immediate-release
tablets every 4 hours around the clock, but they do not control his pain. He also reports fatigue
throughout the day that is bothersome because he wants to spend as much time as he can
with his family, although he reports it is difficult to sleep at night. AK also reports a decrease
in appetite over the last month. Since deciding to transition to hospice, he has noticed more
anxiety and depressed days.
Past Medical History:
Metastatic prostate cancer (initially diagnosed 8 years ago; metastatic disease to the bone,
liver, and lung), hypercholesterolemia, neuropathic pain, depression.
Medications:
Oxycodone immediate release 10 mg every 4 hours as needed for pain, oxycodone extended
release 30 mg every 12 hours, simvastatin 20 mg daily, gabapentin 600 mg twice daily, dulox-
etine 20 mg once daily.
Allergies:
None.
Social Histor
y:
Retired professor from community college; lives with wife; has children who are all very close
to their parents; attended a Methodist church until recently, when his pain worsened.
Family History:
Noncontributory.
Objective:
Ht 70˝, Wt 159 lb, BP 135/83 mmHg, P 83 BPM, RR 17/min.
Physical Examination:
Recent CT scan showing worsening disease in L4 and L5 regions of the spine, new lesions
present in liver, increase in size of lesions in lung compared to previous scan, increased pain in
spine.
Labs:
CBC within normal limits except hemoglobin 10.2 g/dL, hematocrit 32.6%, electrolytes within
normal limits, BUN 17 mg/dL, serum creatinine 1.1 mg/dL.
Assessment:
AK is a 76-year-old man with worsening metastatic prostate cancer recently enrolled in home
hospice for management of symptoms and comfort care. It is estimated that AK has a prog
-
nosis of <6 months to live, and likely <2 months.
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| Fundamentals of Geriatric Pharmacotherapy
Plan:
1.
Increase oxycodone extended release to achieve better pain control. Counsel patient that
he can take oxycodone immediate release every 1–2 hours as needed instead of every 4
hours. Add meloxicam 7.5 mg for treatment of bone pain.
2.
Add methylphenidate 2.5 mg in the morning to decrease disease-associated fatigue as
this is distressing to the patient.
3. Add mirtazapine 7.5 mg at bedtime to help with sleep and appetite.
4.
Consider increasing duloxetine dose; however, based on patient’s limited life expectancy
of <2 months, this may not be beneficial.
5. Discontinue simvastatin because it is not improving AK’s quality of life and only adding to
his pill burden.
6.
Offer to invite a chaplain or his home pastor to visit with him and his family.
Rationale:
1.
Currently, AK is taking his immediate-release breakthrough medication every 4 hours
around the clock with no relief. In this case, his extended-release pain medication should
be increased. It is also advisable to instruct the patient to take his immediate-release
oxycodone every 1–2 hours as needed instead of every 4 hours. This allows the patient
to take the medication based on the peak effect rather than the duration of action (i.e.,
4 hours). It would also be beneficial to the patient to add meloxicam to his medication
list. NSAIDs have been shown to decrease bone pain in patients with bone metastases.
Starting at a lower dose would be appropriate in an elderly patient. Meloxicam is given
once daily and has fewer GI side effects than some of the other NSAIDs, and this is why it
was chosen.
2.
AK complains of fatigue during the day that interferes with time with his family. In this
case, methylphenidate would be an appropriate option to offer this patient. This medica-
tion may help decrease the fatigue. In addition, psychostimulants can provide a rapid
response in mood. In this patient with worsening depression and a life expectancy of <2
months, methylphenidate may help with these symptoms.
3.
Another complaint that is affecting AK’s quality of life is trouble sleeping and decreased
appetite. At this point in AK’s life, the decreased appetite he is experiencing is bother-
some to him. Low doses of mirtazapine can help with trouble sleeping and may also help
increase his appetite. Should AK live longer than 2 months, the mirtazapine may also help
with AK’s worsening depression.
4.
It would not be wrong to recommend increasing AK’s duloxetine dose; however, there is a
chance if AK only lives 2 months or less this would not benefit the patient. Increasing the
dose of duloxetine should be discussed and, if no contraindications, be considered in this
patient.
5. It would be appropriate to recommend discontinuing simvastatin in this patient. Currently,
simvastatin offers no improvement in quality of life in this patient with a life expectancy of
<2 months.
6. Finally, AK mentioned in his social history that he regularly attended church prior to his
illness worsening. You could offer to invite a chaplain or pastor from his home church to
visit with him regarding any spiritual concerns AK may have.
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149
C S
The development of palliative and hospice care
over the past decades has improved the quality
of life for older adults afflicted with complex,
chronic, usually terminal illnesses. As the elderly
patient approaches death, many considerations
must be taken into account. It is important to
review a patient’s medications for appropriate-
ness. As a pharmacist, it is also important to
understand these signs and symptoms as well
as understand management options available
to relieve these symptoms. Many symptoms
that accompany death may also occur months
to years prior to death in the elderly population
(e.g., pain, depression). These symptoms are
often managed similarly; however, depending on
a patient’s life expectancy, appropriate manage-
ment strategies may differ.
It is also important to consider a patient’s
cultural beliefs and spiritual background and
concerns. Although limited evidence is available
about the role of the pharmacist and spiritual
care, research shows that patients do want their
healthcare professional to enquire about their
spiritual needs.
S-A Q
1. What number of medications has been
shown to increase the risk for adverse drug
interactions by >80%?
2. Which is the most useful and flexible class of
medications for treatment of pain in patients
at the end of life? What are available options
for treatment of neuropathic pain in the palli-
ative care setting?
Clinical Pearls
• Teamwork in palliative care is important because it relies heavily on many different dis-
ciplines for knowledge, expertise, understanding, and resourceful thought. An interpro-
fessional team is made up of experts who are team players able to adapt to changing
needs of the patient. These types of teams benefit the patient and the family, as well as
the team members themselves. The overall goal of palliative care is achievement of the
best quality of life for patients with terminal illnesses. Given this goal, many improve-
ments in quality of life and symptom control will come from medication therapy. This
reinforces the vital role pharmacists have in hospice and palliative care and the fact that
they should be integral members of the interprofessional team.
•
A patient may be discharged from hospice if he or she improves and no longer needs
hospice care. These patients are said to “flunk” hospice or to be “hospice graduates.” At
age 80, Art Buchwald, a famous writer/columnist for the Washington Post, decided to
forego hemodialysis and enrolled in hospice, expecting to die in a few weeks. However,
his kidneys continued to function, and he left hospice after 5 months, wrote a book, ap-
peared on several news shows, and described himself as a “poster boy” for the benefits
of hospice.
116
Older adults may improve when enrolled in hospice because aggressive,
toxic treatments are stopped, and supportive care is initiated that may stabilize a patient
who has been losing weight and growing more debilitated. These patients may re-enter
hospice in the future if their chronic illness progresses so they are again determined to
have a prognosis of 6 months or less.
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| Fundamentals of Geriatric Pharmacotherapy
3. Describe the phenomenon of sundowning
in terminally ill patients. What would be an
appropriate medication to recommend for
treatment?
4.
What class of medications is recommended
as first-line treatment of depression in the
elderly whose life expectancy is >2 months?
5. What medication could be recommended
for first-line management of dyspnea in end-
of-life care?
6. Distinguish between proportionate pallia-
tive sedation versus palliative sedation to
unconsciousness versus ordinary sedation.
What is the most common agent used for
proportionate palliative sedation?
7.
What do the letters of the EASE tool, used in
counseling grief, represent?
8.
What are the differences between palliative
care, hospice, and comfort care?
9.
How may understanding cultural differences
help a pharmacist working with patients in
palliative or hospice care?
10. How are medications evaluated differently
for appropriate use in patients in palliative
and hospice care?
R
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Pharmaco-
therapy
Issues of
Aging
PART II
Chapter 7: Cardiovascular Disorders ..........................................................................................................157
Chapter 8: Respiratory Disorders ................................................................................................................199
Chapter 9: Renal and Urologic Disorders .................................................................................................... 221
Chapter 10: Endocrine Disorders ................................................................................................................257
Chapter 11: Gastrointestinal Disorders and Nutrition ..................................................................................293
Chapter 12: Central Nervous System Disorders ..........................................................................................333
Chapter 13: Psychiatric Issues ....................................................................................................................377
Chapter 14: Pain and Sensory Disorders .....................................................................................................417
Chapter 15: Musculoskeletal and Connective Tissue Disorders ................................................................. 439
Chapter 16: Anemia and Preventive Therapy .............................................................................................479
Chapter 17: Infections and Antimicrobial Stewardship ...............................................................................515
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