Palliative care has different goals than curative care, particularly for hospice patients nearing the end of life. It can be difficult to find pharmacological guidance for the conditions and comorbidities encountered in hospice. Enclara Pharmacia’s Palliative Pearls series helps fill the gap. Inspired by real life clinical consultations between hospice clinicians and Enclara pharmacists, these clinical case studies and reviews are provided as a service to the entire hospice community.
1. Opioid-Induced Hyperalgesia: Overview and Management Approach
What happens when the drugs meant to treat pain cause it instead? KD’s pain was worsening to the point that even her sheets hurt. Her clinicians suspected that her high dose of continuous morphine and frequent bolus doses could be causing neurotoxic side effects. Opioid-induced hyperalgesia (OIH) is just one of a handful of neurotoxic effects that also include myoclonus (muscle twitching or jerking), delirium, and hallucinations. Relatively rare and not well understood, it presents a major challenge to symptom palliation. Find out what can work for these patients.
2. Depression at End of Life
It’s no surprise that many patients facing a life-limiting diagnosis experience new or worsening depression. Additionally, many common co-morbidities and pharmacological treatments can cause symptoms of depression. That makes diagnosis and treatment a special challenge in hospice care, further exacerbated by the fact it can take months for patients to realize the full benefits of many antidepressants – time hospice patients may not have. Read about the options and best practices for treating depression in this population.
3. Drug Interactions in Hospice: Important Considerations
Hospice admission often includes changes to a patient’s medication regimen and patients are likely to have multiple attributes that put them at higher risk of drug interactions. These include advanced age, regular use of greater than 7 medications and multiple comorbidities. Drug interactions can occur between two or more drugs (drug-drug), between a drug and a disease state (drug-disease) or between a drug and food/drink (drug-food). It’s important to also be wary of therapeutic duplications (prescribing 2 or more medications unnecessarily for the same indication), especially during transitions of care and managing formulary-related substitutions. Learn more about how to keep your patients safe.
4. Pain Management Considerations in ESRD
Patients with end stage renal disease (ESRD) present special challenges. Up to 50 percent of patients with ESRD experience some type of pain and just over 40 percent report experiencing significant pain on their last day of life. Recognizing the prevalence of pain in this population, being armed with pain assessment skills and awareness of appropriate therapies are important skills for hospice clinicians. This case study explores the relationship between renal function and opioids and what treatments may be appropriate. Find out how to best serve patients with ESRD and pain.
5. Anticonvulsants and Rectal Use: Best Practices
Seizures are a rare but serious complication at end of life. The incidence of seizure occurrence in hospice patients is not known. Anticonvulsant therapy should continue, if possible, for patients with a history of seizures, brain tumors with experience of seizures, or a history of status epilepticus. In addition, many patients on maintenance therapy may lose the ability to swallow reliably. The ability to administer medication via alternate routes is important to avoid hospital or hospice IPU admission for seizure management. Learn how rectal administration can help.