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Blog articles are provided as informational purposes only and are not intended to constitute medical advice. Medication protocols are subject to patient’s medical provider’s authorization.

 

 

Medications used to treat psychiatric conditions and symptoms are commonly used in the hospice setting. It has been reported that antipsychotics are in the top 20 most frequently prescribed pharmacological class of medications in hospice patients. Adverse effects of these medications can easily be overlooked but can have significant effects on the patient. This article will examine adverse events associated with common psychiatric medications, including serotonin syndrome, neuroleptic malignant syndrome, extrapyramidal symptoms, and tardive dyskinesia.

 

Benzodiazepines are used for a variety of indications in the hospice setting, including insomnia, breathlessness, agitation, seizures, nausea/vomiting, myoclonus, and palliative sedation (see details outlined below).

Although they share many class effects, unique properties of individual benzodiazepines have clinical implications. For example, benzodiazepines can be classified based on their half-life (short, intermediate, and long). The benzodiazepine with the shortest half-life is triazolam. The longest is diazepam. The terminal half-life may be affected by liver or kidney dysfunction, age, drug-drug interactions, gender, race, or even route of administration. For example, the half-life of diazepam may be up to 174 hours when administered intramuscularly.

 

Pain is one of the most common symptoms we encounter as hospice clinicians, but it is also the most difficult to treat, particularly with opioid allergies, complex opioid conversions, and declining ability to swallow.

Opioid Allergies

 

History: 

The patient was on a high dose morphine, patient-controlled analgesia (PCA) pump and had severe cancer pain. He reported to have "pain all over" even when not being touched. He developed a myoclonic twitch several days prior. He wanted to die early and was suicidal due to the pain and discomfort. Goals of care were to manage his pain with oral medications so he could be more mobile and spend time with family. But since his pain could not be controlled with IV morphine via PCA pump, the team was hesitant to remove or reduce the pump for fear of increasing his pain. They were stuck, and so was the patient.

As a result, ProCare PharmacyCare clinical pharmacy was consulted.

 

Hospice goals of care focus on optimizing comfort and quality of life, rather than treatment and prevention. Anticoagulation therapy and monitoring are not aligned with comfort and quality of life, and can cause harm from bleeding. Anticoagulation does not provide comfort or control symptoms. For these reasons, anticoagulation is frequently discontinued.

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