Palliative Medicine and End of life care

What medications are associated with preventable hospital admissions?

• Warfarin

• Insulin

• NSAIDs

• Digoxin

• Antihypertensives

• Benzodiazepines

• Oral hypoglycaemics

• Methotrexate

• Opiated

• Drugs with a narrow therapeutic window e.g. lithium, digoxin, carbamazepine →narrow but not as narrow as others

• injectable or enternal medicines

Conditions associated with preventable admissions include

• COPD/Asthma

• Parkinson’s disease

• Diabetes

Pharmacists should look out for adherence issues, a new request for compliance support or if there are social, physical or cognitive impairments

What is a clinical risk?

A clinical risk includes the disease type e.g. COPD/ heart failure/ asthma

What is a medicine related risk?

E.g. inadequate monitoring, drug adverse reactions which are associated with increased risk of admission

What is a social risk?

Social risk comes from patients who are not independent, immobile, reliant on care of others for daily activities. Many individuals require support at home and not all carers can provide support with medicines

What is the COM-B model?

This explains patient behaviour and is applied to medicine adherence, smoking cessation etc to better understand why patient does (or does not do) a particular behaviour

Capability - e.g. is the patient able to take the medication? Physical ability to open tablets? Swallow tablets? Use inhalers? Psychological ability to understand how to take medicines?

Opportunity - Quality of healthcare communication e.g. poor consults mean the patient may lack the opportunity to follow instructions. Religious or cultural beliefs that affect whether or not to take the medication.

Motivation - whether the patient wants to take their medications, driven by reflective motivation and how the patient thinks about their treatment e.g. patients will have an opinion on statins before they take it

Behaviour - this all affects behaviour

Name different aids to help medicine taking.

• pill crusher

• Multi-compartment aids MCAs

• tablet crusher

• blister popper

• pill timers and alarms

• devices to help administer eye drops

Why is polypharmacy a concern?

• Good medicine reviews can prevent hospital admission. The more medicine a patient takes, the more potential for adverse effects which increases the risk for hospital admission. Polypharmacy increases the risk of drug interactions.

• The more medicines a patient takes, the more likely they will become non-adherent

• Cost burden

• Increased risk of falls in elderly

• Elderly patients / frail patients are at risk due to physiological variations such as weight, body mass, renal function, cancer etc - can all effect drug metabolism, drug distribution, excretion etc.

What is meant by deprescribing?

This is the planned and supervised process of dose reduction or the stopping of a medication that might be causing harm or is no longer needed/ of any benefit. Deprescribing is part of good prescribing - backing off when doses are too high or stopping medications that are no longer needed.

Active participation from the patient is required

What are the most common medications associated with adverse drug effects?

• opioid analgesics

• NSAIDs

• Anticholinergics

• Benzodiazepines

• Cardiovascular agents, CNS agents and musculoskeletal agents

What are the principles of prescribing in the elderly?

• Avoid prescribing prior to diagnosis

• Start with a low dose and titrate slowly

• Avoid starting 2 agents at the same time

• Reach therapeutic dose before switching or adding agents

• Consider non-pharmacological agents

What is social care?

This is the personal care that people need, which is provided in the community home, allowing people to live in their preferred place. Help with getting dressed, cleaned etc. It the person does not recieve the appropriate social care then they will end up being admitted to the hospital.

Is medicine administration in the community a health or social care task?

Everyone has a role in this, pharmacists, the providers of the services, commissioners who assess properly etc. We would administer medication e.g. oral but if it is PEG, S/C or rectal route, then healthcare concern to help with administration.

What happens when organisations only allow carers to give medicines from MDS?

• Some oral medicines cannot go into MDS e.g. due to stability issues

• PRN medicines in MDS may be given when they are not needed at that time. e.g. patient has UTI and prescribed antibiotics, community pharmacy delivers medication in original packaging and because they are not in trays the carer cannot give it to them.

• This means in this case the carer has to support/ encourage the patient to take the medicine themselves and the carer not to document this as its technically not allowed

• This will be problematic if the patient lacks the ability to take thier medication

What is needed to overcome the issue with organisation requiring MDS?

• Training to administer all medicines safely

• Clear understanding of benefits and risks of using an MDS system

• Agencies requiring the use of MDS should establish formal contracts with community pharmacies to provide medicine support.

What are environmental causes of falls?

• rugs

• doormats

• slippery stairs

• wet floors

• slipper baths

• lives alone

• alcohol

What are muscular causes of falls?

• muscle weakness

• arthritis

• spinal disease

• pain

• use of walking aids

What are the neurological causes of falls?

• medication

• stroke

• epilepsy

• parkinsons disease

• dementia

• neuropathy

• depression, anxiety

Name medications which increase risk of falls

• BZDs

• Zopiclone

• Sedating antihistamine

• Dopamine agonists

• Alpha blockers

• Anti-anginals

All work on the circulation to increase risk of falls - can lead to sedation, hypotension, postural hypotension, bradycardia, tachycardia, ortostatic hypotension

What are the current roles of pharmacists in care homes?

• supply

• medication handling

• wastage reduction

• storage

• training

• information and advice

• medicine reviews

• prescribing

• parent/ family discussions

Pharmacists have key role in communication when transferring between care providers, community pharmacy can provide information to secondary care and vice versa

What is the discharge medicine review service?

This allows community pharmacists to review discharge medicines to help patients understand discharge processes.

In palliative care, what medications would we consider deprescribing?

• Aspirin - for primary prevention - no longer needed now as we are preventing something that is a long-term issue. Only placing the burden of medicine

• lipid-lowering medication - deprescribe

• Blood pressure - no longer worried about this in palliative care

• Anti-ulcer medication

• Oral hypoglycaemics / anti-diabetic medications - risk of fall decreases

• Osteoporosis - risk of falls is low when palliative

• Vitamins/ minerals - can do without, not really required

Medicines can always be restarted if required

What do we mean by palliative care?

This is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessments and treatment of pain and other problems, physical, psychological or spiritual

What are conditions that would be considered life-threatening?

• cancer

• motor neuron disease

• dementia

• parkinsons

• multiple sclerosis

• stroke

• frailty

• heart failure

• COPD

• Pulmonary fibrosis

• renal failure

• liver failure

For each of the following, explain the decline in patients before death occurs

• Organ failure

• Cancer

• Dementia & Frailty

• Organ failure - steady decline over time, patients become more frail and have an acute crisis period where they are hospitalised

• Cancer - patients remain function for sometime and then rapid decline before death

• Dementia, frailty - function is low before decline and death

How do we know if a patient needs palliative care? What conversations do we need to have?

Would we be surprised if this patient dies in the next 6 months?

• Assess the patient, family, and dependents including children for supportive and palliative care needs

• review treatment and medication priorities

• consider patient for general practice palliative care register

• consider advance care plan discussion with patient and family - e.g. organising where the patient will be when they die.

What are clinical indicators that someone is dying?

• Performance status is poor - limited self care - in bed / chair 50% of the day or deteriorating

• Progressive weight loss over the past 6 months

• two or more unplanned admissions in the past 6 months

• a new diagnosis of progressive, life limiting illness

• two or more advanced or complex conditions

• Patient is in a nursing care home or NHS continuing care unit or needs more care at home

How would you describe someone’s breathing, blood pressure, pulse rate, and renal function

Breathing - breathlessness or chest pain at rest

Blood pressure - systolic reading less than 100mmHg

Pulse rate - over 100

Renal impairement - less than 30 ml/min

Heart failure also - severe valve or corary artery disease

What symptoms do patients get when they die and what medicines do we use?

• Pain - opioids - morphine/ oxycodone

• Breathlessness - opioids or midazolam

• Agitation / restlessness - Midazolam / levomepromazine

• Nausea and vomiting - cyclizine, metoclopramide, haloperidol

• Respiratory secretions - Hyoscine hydrobromide, glycopyrronium

• Dry/sore mouth - biotene toothpast

• pressure areas - pressure relieving mattresses

What formulation do medications need to be for palliative care?

Medications need to be injectables suitable for subcutaneous route

How are palliative care medications administered?

Given via syringe driver

What is anticipatory prescribing?

• typically seen in community pharmacy

• typically on friday afternoon so patient have medications at home if they die over the weekend

Medication will be ampoules e.g.

• morphine sulphate 10mg/ml - 5mg to be used subcutaneously as directed - supply 10 ampoules

• Midazolam injection 10mg/2ml - 5mg to be used subcutaneously as directed - supply 10 ampoules

• Hyoscine hydrobromide injection 400mcg - as directed - supply 3 ampules

• Levomepromazine injection 25mg/ml - as directed - supply 5 ampoules

• haloperidol injection 5mg/ml - as directed - supply 5 ampoules

• water for injection as directed - supply 5 ampoules