Hospice, Palliative Care, and End of Life

-community resources

-home care

-formal and informal care

-assisted living

-nursing facilities

-sub-acute care facilities

-hospice and palliative care

-hospital

What is the care continuum?

community resources

-independent living

-MS department of human services

-division of aging on adult services (DAAS)

-pharmacy services

Division of Aging on Adult Services (DAAS)

-congregated meals program

-home delivered meals program

-adult day care centers

-legal assistance and advocacy

-companion program

-transportation systems

-respite care

pharmacy services

-pill boxes

-med sync

-pill packs

-home delivery

home health care

-Wide range of services provided in the home, opposed to a medical facility, for the treatment of an illness or injury

-pharmacy services

-Activities of daily living (dressing, cooking, chores)

-Skilled nursing care (wound care, IV medicine, nutritional therapy)

-Therapy (speech, occupational, physical

What are some of the services offered in a wide range of services provided in the home?

-Pharmacist home visits

-Drug Regimen Review (required, but not required to be performed by a pharmacist)

What are the pharmacy services offered in home health care?

informal care

unpaid to provide care (fam caregivers)

formal care

paid to provide care (have training and education to provide care)

assisted living

-Provides care and services as an alternative to residents who are no longer able to live independently, but do not need 24-hour medical care provided by a Nursing Facility.

-Require assistance with some activities of daily living (ADLs)

-Including medication management

-State regulated (NO federal regulations)

-Emphasizes hospitality

skilled nursing facilities (SNF)

-aka nursing facility or nursing homes, provide post-acute care treatment, skilled nursing care, appropriate medical monitoring, and assistance with ADLs, that many seniors require as they age, experience acute care hospitalizations, and multiple health issues

-Residents require assistance in most all of their ADLs

-Federally regulated

-Consultant Pharmacist (required to review every pt chart every 30 days)

hospital

-Provide acute care services for older adults. Common reasons for hospitalization include: congestive heart failure, COPD, coronary atherosclerosis, diabetes, infection, fall-related injuries, medication mistakes/SEs, injuries from a car accident, pneumonia, and stroke.

-Geriatric services

-Senior friendly ER

-Geriatric psychiatry

-Early mobilization programs

-Palliative/Comfort Care

hospice/palliative care

-Specialized medical care for people living with life-limiting illnesses. Hospice and palliative care services can be provided in hospitals, nursing homes, outpatient palliative care clinics, or at home.

-Interdisciplinary team

-Focuses on quality of life and symptom management

-Federally regulated

require hospices to consult with on "individual with education and training in drug management"

What is the federal requirement in hospice/palliative care?

age-friendly health system aims

-Follow an essential set of evidence-based practices;

-Cause no harm; and

-Align with What Matters to the older adult and their family

-What Matters

-Medication

-Mentation

-Mobility

What are the 4Ms framework of the age-friendly health system?

Goal is to improve quality of life for both the patient and family at any stage of a serious/chronic life-limiting illness

What is the goal in palliative care?

Goal is to relieve suffering, improve quality of life, and assist with decision making for patients with terminal illnesses

What is the goal in hospice care?

Goal is to provide immediate relief of symptoms in a patient who is very close to death

What is the goal in comfort care?

palliative care

-No prognosis requirement for eligibility

-Can be along with curative treatment

-Care is focused on providing relief from symptoms and stress of the illness

-Provided by an interdisciplinary specially-trained team of doctors, nurses, pharmacists and other specialist to provide comprehensive support

-No requirement for a terminal diagnosis or condition

-Must have a serious and/or chronic illness that is life limiting

-Any age

-Any stage in illness (it can be curable)

-No physician certification of illness is necessary

-Physician must make an order/referral to palliative

What is the eligibility for palliative care?

palliative services

-Pain and symptom management

-Can continue with aggressive and/or life saving treatments

-Can be provided in any setting

-Help patients identify how they define "quality of life"

hospice care

-Integrated model of palliative care at the end of life

-Eligibility requires expected prognosis of 6 months or less

-Focuses on comfort, dignity, quality of life/relationship closure

-Affirms life - neither hastens nor postpones death

-Diagnosis of life-limiting condition

-Prognosis of 6 months or less if the disease runs its normal course

-Certification of terminal illness by physician

-Must indicate reduced life expectancy

-For Medicaid hospice: Must agree to discontinue curative treatment (unless < 21 years old)

-Frequent hospitalizations in the past 6 months

-Progressive weight loss

-Increased weakness, fatigue, and somnolence

-Change in cognitive and functional abilities

-Compromised activities of daily living (ADLs)

-Disease specific eligibility criteria (cancer, AIDS, COPD, dementia, stroke, CHF, liver or renal disease)

What is the hospice care eligibility?

false

T/F: If you chose hospice care you wont get other medical care.

hospice care services

-Emotional and care goals

-Holistic care provided by interdisciplinary team

-Respite and/or caregiver training

-Medications for symptom relief

-Medical equipment and supplies (Hospital bed for home)

-Bereavement for family for one year following patient death

short term inpatient care

If the patient's symptoms temporarily require the resources of an inpatient facility, the Medicare hospice benefit will cover this until the symptoms are controlled and the patient returns to their primary residence.

official caregiver

Family members can be trained to be an _________ and then be compensated for that time as well

Home

Hospice facility/residence

Hospital

Nursing facility

Correctional facility

Homeless shelter

**Wherever the patient is located**

Where is hospice care provided?

benefits of hospice

-On average live 29 days longer

-Pain brought to comfortable level within 48 hours

-Higher quality of life than not on hospice

hospice care insurance coverage

-Services typically 100% covered with no out-of-pocket cost for patients or families

-Bills and reimbursement are handled between the hospice care organization and Medicaid/Medicare

-Insurance, HMOs, and private pay also have plans

-Combination of any of the above

-Treatments meant to cure illness or prolong life rather than symptom control (except VA or peds)

-Long-term room and board (must come off of hospice services)

-Care in an emergency room, inpatient facility care, skilled nursing care, or ambulance transport (unless arranged by hospice team)

-Outpatient visits for management of hospice diagnoses

What is NOT covered by Medicare while a pt is in hospice care?

-Compassionate care to patients with life limiting illnesses

-Symptom management - ensuring patient comfort is a top priority while maintaining dignity

-Psychosocial management (emotional support)

What are the similarities in hospice and palliative care?

-Reserved for eligible terminally ill patient when treatment is no longer curative during the last 6 months of life

-Does NOT do anything to include prolonging life

How does hospice care differ from palliative?

-Not subject to a prognosis

-No eligibility requirements

-Patient can continue to receive life extended treatment through different phases of life limiting condition

-Can work alongside a long term treatment plan that aims at recovery

How does palliative care differ from hospice?

Comfort Care

-Provided in patients whose death is imminent

-Goal is to enhance quality of life through alleviation of distressing symptoms that are common during the last few days or weeks of life

-Basic palliative care interventions

-Immediate relief of symptoms

-Used to achieve comfort for the patient rapidly

-All diagnostic or therapeutic measures are normally discontinued at this point

-Psychosocial and spiritual care often provided as well

Physician Assisted Death

-Occurs when a physician facilitates a patient's death by providing the necessary means and/or information to enable the patient to perform the life-ending act

-Highly controversial

-"Death with Dignity" laws (WA, OR, CA, CO, NM, NJ, HI, DC, VT, ME)

statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs, ect

What meds have questionable benefits during the last 3 months of life?

Deprescribing Considerations

-Limited life expectance are at risk for adverse drug events

-Use of preventative medications may cause more harm than benefit

-Time to benefit may be several years

-avoid discontinuing meds that could lead harm if the med is discontinued

Statins

Antiplatelets

ACE inhibitors

ARBs

Anti-osteoporosis medications

Calcium channel blockers

What are the common prevention meds that have deprescribing considerations?

Advanced Directives

Written, legal instructions regarding your preferences for medical care if you are unable to make decisions for yourself

Living Will

Spells out medical treatments you would and would not want to be used to keep you alive, as well as your preferences for other medical decisions

Medical Power of Attorney

-AKA "Durable Power of Attorney" or "Healthcare Proxy"

-Type of advance directive in which you name a person to make decisions for your when you are unable to do so

Do Not Resuscitate/Do Not Intubate

orders can be included or separate from other advanced directives

Goals of care

Ask patient/family members about their understanding of their current health

Ask about how much information they would like to know

Ask what medications they would like to receive or not

Who they would like to be present/not present

Who is providing care

What should you communicate when addressing cultural differences in the approach to death, pain and palliative care?

physical elder abuse/neglect

inflicting pain or injury

psychological/emotional elder abuse/neglect

intimidation, humiliation, isolation, or verbal assult

financial elder abuse/neglect

misusing or stealing an older adult's money or property

sexual elder abuse/neglect

any non-consensual sexual contact

self neglect

when an older person fails to meet their own basic needs, often due to cognitive or physical decline

mandated

We are __________ reporters of elder abuse to Adult Protective Services.

-Underuse of medication: Suggest neglect, withholding meds, or financial exploitation.

-Overuse or inappropriate refills: Could indicate chemical restraint or caregiver misuse.

-Forged prescriptions or discrepancies: May signal financial or medication diversion.

-Multiple prescribers or pharmacies: Potential caregiver exploitation or fragmented care.

-Nonadherence without clear reason: Could point to fear, confusion, or lack of support

What are the med related indicators of elder abuse/med misuse?

-pain

-dyspnea

-N/V

-constipation

-D

-anorexia/cachexia

-insomnia

-depression

-respiratory congestion

-anxiety

-delirium

-dry mouth, hiccups

What are the common symptoms of end of life?

Routes of Administration

-Subcutaneous (intermittent or continuous infusion)

-Gastrostomy tube

-Intravenous

-Nasal and oral transmucosal

-Injectables can be absorbed by buccal, sublingual, and nasal routes

-Rectal catheter

-Transdermal

no

Is dying always painful?

alleviate as much pain as possible while maintaining QoL

What is the goal of pain in end of life?

heating/cooling pads, relaxation

What are the non-pharm txs for pain in end of life?

opioids are the cornerstone of therapy

Morphine every 2 hrs

What is the pharm tx for pain in end of life?

dyspnea

difficulty breathing

Dyspnea

-Only reliable measure is patient self-reported

-Respiratory rate, pulse oximetry, blood gas, ect do not correlate to the feeling of breathlessness

-May provide treatment if using accessory muscles or RR >35 breaths/minute

-Treat underling issue

Common causes of dyspnea in end of life

Anxiety

Airway obstruction

Bronchospasm

Hypoxemia

Pleural effusion

Pneumonia

Pulmonary edema

Pulmonary embolism

Thick secretions

Anemia

Metabolic

Family/financial/legal/spiritual/practical issues

Elevation of the head of the bed

Cool room temperature

Open a window

Use a fan

Relaxation

Fluid restriction and/or sodium restriction (if related to pulmonary edema)

Humidified air

Non-invasive positive pressure mask

Relaxation training

Consider supplemental oxygen (2-6 LPM nasal cannula)

What are the non pharm txs for dyspnea in end of life?

low dose opioids (titrate to effect)

What is the mainstay of tx for dyspnea in end of life?

Benzos

Lorazepam 0.5-2 mg every hour prn; adjust based on response; schedule 2-4 times/day after pt is calm

What is 1st line in dyspnea end of life if caused by anxiety?

loop diuretics

Avoid at night for "off periods" if from a cardiac cause

What is first line for dyspnea tx end of life if cause by pulmonary edema or HF?

nitrates: nitroglycerin slow infusion (0.2-0.4 mg/hr) or 2% nitroglycerin ointment 1-2 inches topically every 6 hours

Avoid at night for "off periods" if from a cardiac cause

What is another tx option for dyspnea end of life caused by pulmonary edema or HF?

-DOC: Albuterol inhaler 1-2 inhalations every 4-6 hours PRN; consider spacer

-Addition of ipratropium 1-2 inhalations 3-4 times per day

-Nebulizer treatments are exhausting

-Consider oral corticosteroids

-Consider appropriate antibiotics is bacteria cause is suspected

What is the tx for dyspnea end of life with bronchospasm?

-Atropine (eye drops) given sublingually

-Transdermal scopolamine: 1.5 mg disc every 3 days

-Glycopyrrolate: 1-2 mg twice-three times daily or 0.1 mg IV/IM three-four times daily

-Hyoscyamine: ER 0.375-0.75 PO q12h

What is the tx for secretion control dyspnea end of life?

-Iron, vitamins as needed

-Transfusion

-Erythropoietin (50-100 units/kg IV or SC three times weekly

What is the tx for dyspnea end of life related to anemia?

•Benzodiazepines (lorazepam used most commonly)

•Haloperidol

•SSRIs: sertraline, paroxetine, citalopram

What is the tx for anxiety end of life?

depression end of life

-Many causes may be related to coming to terms with death

-Early intervention is best

-Increases risk of advancing disease

-Can worsen symptoms of dying

-Amphetamines can provide rapid resolution of depression symptoms, though may decrease appetite, exacerbate anxiety, or cause insomnia (may also improve these symptoms if related to depression)

-Methylphenidate

-Dextroamphetamine

-SSRIs: sertraline, citalopram, escitalopram

-Bupropion

-SNRIs: venlafaxine, duloxetine (takes ~6 weeks for full effect)

-Mirtazapine (helpful with concomitant anorexia)

-TCAs: amitriptyline (may help with concomitant neuropathic pain, though AEs may be limiting)

What are the txs for depression end of life?

insomnia end of life

-"Sundowning": day/night reversal

-Evaluate med regimen for causes (glucocorticoids, some SSRIs)

-Treat pain, depression, delirium, anxiety, spiritual distress (chaplain or minister)

-open the blinds during the day and make sure it is dark at night

-Schedule TCAs and sedating meds at bedtime

-Trazodone

-Lorazepam

-Temazepam

-Haloperidol (if related to delirium)

-Melatonin

-Ramelteon

What is the tx for insomnia end of life?

delirium end of life

-Acute, altered level of consciousness associated with reduced attention, memory, delusions/hallucinations, incoherent speech, altered sleep/wake cycles

-Common end of life problem with many causes

-Unrelieved pain or other symptoms, fever, infection, advanced disease, stroke/CNS event, drug withdrawal, medication side effects (steroids, benzodiazepines, medications with sedative or anticholinergic effects)

-Requires thorough assessment

-Correct cause before medicating

Identify reversible cause

Quiet, well-lit room

Family members/familiar surroundings

Avoid physical restraints

What are the non-pharm txs for delirium end of life?

-Haloperidol 1-2 mg PO/SC/IV every 2 hours until settled then PRN (preferred)***

-Quetiapine (preferred)

-Risperidone

-Olanzapine

-Lorazepam (can have paradoxical agitation)

What are the pharm txs for delirium end of life?

Nausea/Vomiting end of life

-79% of patients may experience moderate to severe nausea in the final week of life

-Treatment is based on etiology

-Increased risk factors: female, younger age, anxiety, medications, gyn/stomach/esophageal cancers, electrolyte imbalances

common causes of N/V end of life

-Psychological (anxiety, pain, anticipatory)

-Metabolic (liver/renal failure)

-CNS (elevated intracranial pressure, tumors, meningitis)

-Drugs (opioids, antibiotics, chemotherapy)

-GI (obstruction, gastritis/GERD, constipation)

relaxation techniques, acupuncture, eliminate odors/offending foods, stop offending medicines

What are the non-pharm txs for N/V end of life?

Ondansetron

What is the general first line (esp if oncology related) N/V end of life tx?

Metoclopramide

SE: D, EPS

What is the first line agent for N/V end of life if associated with delayed gastric emptying?

hydroxyzine

What is the agent for N/V end of life if associated with anticipatory N/V or med induced?

prochlorperazine, haloperidol

What is the agent for N/V end of life if associated with delirium?

Scopolamine (takes a few days to work - transdermal every 3 days; SE: dry mouth, confusion, tachycardia

What is the agent for N/V end of life if assocaited with secretions?

Promethazine (SE: sedation), prochlorperazine (SE: hypotension, EPS, sedation), NK1 antagonists (aprepitant, fosapipratant, netupitant, rolapirant)

What are the agents for N/V end of life if associated with infection or inflammation?

Prochlorperazine, haloperidol (SE: hypotension, EPS, sedation, QTc prolongation with higher IV push doses), ondansetron (fewer SE than prochlorperazine)

What are the agents for N/V end of life if associated with toxins stimulating the chemoreceptor trigger-zone in the brain (opioids)?

olanzapine

What is used to treat refractory N/V end of life?

lorazepam

What is used to treat N/V end of life associated with anxiety?

constipation end of life

-Multiple causes - decreased appetite/intake, decreased motility, chronic opioids, anticholinergic medications, diseases (cancer, diabetic gastroparesis, neurological diseases - ALS, Parkinson's, ect)

-Individualized therapy

-Take into consideration if they are taking medications by mouth or not

increase fluid intake

What is the non pharm tx of constipation in end of life?

Stool softeners generally inadequate alone

Stimulants laxatives: Senna 2 tablets BID; Bisacodyl 5-15 mg daily

Sorbitol or lactulose 30-45 mL daily

Enemas or suppositories (use if NPO

What are the tx options for constipation end of life?

-Methylnaltrexone (SE: abdominal pain, flatulence, nausea, dizziness, diarrhea) - takes 4 hours to work

-Lubiprostone (SE: nausea, diarrhea)

-Naloxegol (SE: N/V/D, gas, HA, stomach pain)

What are the tx options for opioid induced constipation end of life?

diarrhea end of life

Causes vary (consider C diff, partial obstruction/constipation, GI infections, laxative dose, dietary issues, ect)

Loperamide

Diphenoxylate w/ atropine

Octreotide (severe or refractory)

Antibiotic-associated colitis:

Metronidazole

Oral vancomycin

Fidaxomicin (refractory)

What are the txs for diarrhea end of life?

anorexia

loss of appetite

cachexia

inability to maintain weight often implies protein/calorie malnutrition (often assocaited with cancer)

anorexia and cachexia end of life

-May loose desire to eat due to nausea, illness, ect.

-Do NOT force food/drink - loss of appetite is common and a normal part of dying

-Force feeding can cause pain/discomfort

favorite foods, food that tastes good (taste alterations), ice chips, smaller portions

What are the non pharm tx options for anorexia and cachexia end of life?

-Glucocorticoids

-Megestrol suspension (VTE risk)

-Dronabinol (used in AIDS patients)

-Mirtazapine

-Cyproheptadine

-Metoclopramide (if due to gastric emptying)

Titrate off or stop treatment if no improvement within 1 month, appetite declines on medication, or life expectancy is days to weeks

What is the pharm tx for anorexia and cachexia end of life?