Be comfortable with comfort Meds
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1 DIAMOND PHARMACY SERVICES Be comfortable with comfort Meds Understanding Hospice medications Presented By: Daniel Barnes, RN Infusion RN Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services You matter because of who you are. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but also to live until you die. ~Dame Cicely Saunders (known as the founder of the modern day hospice) Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Objectives Objectives Discuss the philosophy of Hospice Discuss palliative care versus curative care Explore the symptoms and the medications used for off labeled hospice indications Discuss the fears associated with administering certain hospice medications. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 1
2 In order to understand hospice medications you have to have a basic understanding of hospice and their philosophy. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services The goal of most hospice organizations is to care for the person and not the disease to improve the quality of life by controlling symptoms, provide emotional and spiritual support tailored to the patients needs and wishes. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Support the caregiver by providing training, grief counseling, and support both emotional and physical. Many provide counseling as long as 1 year after the death of the loved one. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 2
3 In most cases the care is provided within the patients home but it can also be provided within skilled nursing facility, residential care centers, in patient hospice facility. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Understanding the philosophy and goals of hospice should make it easier to understand the medications used for care of hospice patients, as most of the medications used are for comfort and not for cure. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Palliative vs. Hospice Care Palliative care Treatment offered to patients with life threatening conditions who are not ready to enter the hospice program because of prognosis or life sustaining therapies. Patients meet with an interdisciplinary team to determine how best to relieve symptoms and provide comfort without attempting a cure Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 3
4 Hospice care Providing patients with less than six months to live with treatments and care to maximize their quality of life, offering the hope of dignity and comfort. Treatments can include symptom controlling interventions as well as comfort measures. Spiritual, psychological, music therapy, and bereavement support are provided to patients and families. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Curative treatments If a hospice patient decides to pursue any type of curative treatment they are no longer eligible for any hospice benefits. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services God who sends the wound sends the medicine ~Miguel de Cervantes Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 4
5 We are going to be discussing the medications that are used in hospice. This is only a partial listing of some of the more commonly used medications any dosages listed are from reference material, most are common dosages and may be changed at the discretion of the physician. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services There is no list that specifies that these are the only medications to use with hospice care, however some payers may limit payment for certain types of medications. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Respiratory Oxygen Dyspnea 1 to 4 L/min prn Cough Robitussin 10ml q 4hrs prn Thick secretions guiafenesin liquid or tabs 10ml q 6hrs prn or 600mg/1 tab PO (by mouth) q 12 hours Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 5
6 Constipation Senna s 2 4 tabs PO HS (Hour of sleep) daily If ineffective add MOM 30ml PO BID(Twice daily) If above ineffective then add Bisacodyl 10mg PR (per rectum) 1 dose or Sorbitol 70% 15ml PO BID Fleets, soap suds or tap water enema PR x 1 Check for impaction and manually disimpact if needed. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Diarrhea Imodium AD 2 mg PO after each loose stool (to max of 16mg per day) Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Dry eyes Artificial tears 2 gtts (drops) each eye PRN (as needed) Dry Mouth Artificial Saliva PO PRN Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 6
7 Skin Protectant To protect skin barrier cream topical PRN Excoriation barrier cream with zinc topical PRN Stage 1&2 decubiti Hydrocolloid topical every 3 days & PRN Skin tear Bacitracin and non adherent dressing topical daily & PRN Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services For the following medications the nurse in consultation with the pharmacist may change the route of administration as needed by the patient as long as there is no dosage conversion required. Route can be changed to sublingual, buccal, liquid, and rectally. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Terminal secretions Atropine ophthalmic drops 1% solution 1 2 gtts (PO SL sublingually) every 2 4 hours PRN Scopolamine patch transdermal (1.5mg) q 3 days Levsin.125mg SL or PO 1 2 tabs every 4 to 6 hours Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 7
8 Agitation, anxiety, restlessness Haloperidol 0.5mg PO every 4 6 hrs PRN (may increase to 1.0mg if ineffective) Lorazepam 0.5 mg PO every 3 4hrs PRN (may repeat in 1 hr if ineffective) Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Edema and Ascites Bumex Dosages for all of the following as Lasix determined by the MD. Dosage may vary based on severity HCTZ Zaroxolyn Aldactone Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Nausea and Vomiting Prochlorperazine 10mg PO or 25mg PR q 6 hours PRN Haloperidol 0.5 or 1.0mg PO every 4 6 hours PRN Reglan Phenergan Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 8
9 Appetite stimulation Dexamethasone (low dose) Megestrol (megace) Remeron (low dose) Prednisone (low dose) Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Insomnia Lorazepam Remeron Restoril Ambien Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Oral thrush Mycostatin oral suspension 5ml swish and swallow 4 x day x 10 days Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 9
10 Seizures Lorazepam 2mg SL or PR q15 minutes max of 6 tablets per occurrence These are meds that may also be used based on patients history Tegretol Klonopin Decadron Valium Depakote Neurontin Phenobarbital Dilantin Depakene Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Analgesics Analgesics Acetaminophen mild pain or fever 650 mg PO or PR Ibuprofen mg PO Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Moderate Pain Acetaminophen with codiene various strengths Acetaminophen with Hydrocodone Acetaminophen with Oxycodone Roxanol (Morphine IR) Oxycodone (OxyIR, Oxyfast) Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 10
11 Severe pain Fentanyl transdermal Hydromorphone (Dilaudid) Methadone Morphine IR, Roxanol Morphine sulfate SR, (MS Contin) Oxycodone IR (Oxyfast and Oxy IR) Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services IV Fluids and TPN IV fluids and TPN On a rare occasion you may receive an order for IV fluids or TPN. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services It is not how much you do but how much love you put in the doing ~Mother Theresa Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 11
12 This is only a partial list patients may be on any medications their doctor wants them to take. Hospice will only pay for approved medications to provide comfort. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Medications that put fear in to the minds of caregivers at the mention of their use Morphine Methadone Are there any others that make you anxious when you hear the name. Fear of addiction There is no basis for any fear about becoming addicted to a narcotic given for pain. Addiction is a problem for those who are not dying. Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services Nurses dispense comfort, compassion and caring without even a prescription ~Val Saintsbury Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 12
13 References Home Nursing Agency Hospice Physician orders Home Nursing Agency Hospice comfort pack order form Hospice Pharmacia medication list by symptom Hospice Patients Alliance Annual Educational Conference Thursday, April 16, Diamond Pharmacy Services 13
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