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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.

 

 

Exceptional pain and symptom management is an essential component of hospice care. Hospice clinicians must consider cost-management in addition to therapeutic appropriateness when choosing medications for their patients at the end-of-life. This article will focus on common end-of-life symptoms seen in the hospice setting, including pain, anxiety and agitation, nausea and vomiting, constipation, dyspnea, and terminal secretions and how to cost-effectively manage these symptoms.

Pain Management

When assessing the patient’s pain, there are certain patient factors that should be evaluated. The patient’s diagnosis, allergies, renal and hepatic function, and swallowing status can all affect which medication to choose. The type of pain that the patient is experiencing will also impact choice of medication. Common types of pain seen in the hospice setting are nociceptive pain and neuropathic pain. For mild to moderate nociceptive pain, acetaminophen and NSAIDs are usually first-line. Opioids are typically utilized for moderate to severe pain, with morphine being generally regarded as the most cost-effective short-acting opioid. Other short-acting opioids often used in the hospice setting include oxycodone and hydromorphone. For a patient who requires long-acting pain control, an extended-release opioid can be effective. Morphine ER and methadone are typically the most cost-effective long-acting opioids available. Notably, methadone is effective for neuropathic pain and can be administered via many routes to a patient who cannot swallow. However, because of its unique pharmacokinetic profile, methadone must always be dosed by an experienced clinician and under close supervision. Other adjuvants for pain management in the hospice patient include oral corticosteroids, gabapentin, and tricyclic antidepressants.

Anxiety, Agitation, Terminal Restlessness

When assessing an anxious or agitated patient, it is important to first determine if there are any underlying issues that may be causing the patient’s change in behaviors. Is the patient in uncontrolled pain? Is there an underlying infection that is causing the patient to be restless or confused? Are the patient’s bowels moving? Benzodiazepines are typically used as first-line to treat anxiety or agitation, with lorazepam being the most cost-effective option. Antipsychotics can be used if benzodiazepines are ineffective. Haloperidol is typically the most cost-effective medication in this class, and quetiapine is the most preferred cost-effective option in patients with Parkinson’s disease. For severe anxiety or agitation, medications like divalproex or phenobarbital can be effective.

Nausea & Vomiting

For patients complaining of nausea/vomiting, it is important to try to identify the most likely trigger for the nausea. Several different neurotransmitters and receptors are involved in the emetic pathway, and targeting these receptors can help select which antiemetic agent to utilize.  The table below summarizes which treatments are available:

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 Bowel Management

Constipation is the most common adverse effect occurring with chronic opioid use. Since many hospice patients are utilizing opioids, whether scheduled or on an as needed basis, prophylactic treatment for constipation using a stimulant laxative should be part of the patient’s regimen. First-line stimulant laxative treatment is typically senna, or senna with docusate. An osmotic laxative can be added as a second-line agent, with sorbitol being a more cost-effective option than lactulose. Polyethylene glycol is also a cost-effective osmotic laxative, and is often recommended in cancer guidelines, but the fluid volume may be difficult to swallow for patients with dysphagia.

Dyspnea, Shortness of Breath

Difficulty breathing often occurs at the end-of-life, especially in patients with end-stage lung disease. Patients may complain of feeling short of breath, and their respiratory rates often reflect the feeling of breathlessness. Opioids are typically a mainstay of treatment of dyspnea at end of life, with morphine being the most cost-effective choice. Many patients may request to continue to use their inhaler devices, such as metered-dose inhalers or dry powder inhalers. These devices require manual dexterity, coordination, and deep inhalation. Most hospice patients are too weak or lack coordination to perform the necessary functions to use these devices appropriately. Additionally, the costs of these inhaler devices can be hundreds of dollars per device. For these reasons, it is preferred to use alternatives such as albuterol or ipratropium via a nebulizer. Oral corticosteroids can also be beneficial for dyspnea when inhaled therapies alone are not fully effective.

Terminal Secretions

Also known as “death rattle” or “terminal congestion”, terminal secretions often occur within the last few hours of life. Although these secretions are not disturbing to the patient, caregivers and family members hearing this noise often perceive the patient to be in distress and request treatment. Hyoscyamine and atropine drops are often chosen as first-line agents due to their cost and quick onset of action. It is important to remember that data to support the use of any antisecretory agent is limited, so supportive care and family education is essential.

Your ProCare clinical pharmacists are experts in pain and symptom management strategies that are cost-effective and patient-specific. We are available 24/7/365. Please contact us if you would like recommendations for your patient care needs!

 

Written by: Kiran Hamid, R.Ph.

 

References

  1. Lexicomp  Drug Database. Available by subscription only from: online.lexi.com.
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  3. Watson, J. (2018, October). Nociceptive Pain. Retrieved from https://www.merckmanuals.com/home/brain,-spinal-cord,-and-nerve-disorders/pain/nociceptive-pain
  4. World Health Organization Pain Ladder for Adults. http://www.who.int/cancer/palliative/painladder/en/
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  6. Palliative Pharmacy Care. JM Strickland. Agitation and Delirium. Pgs. 77-89. American Society of Health-System Pharmacists. Bethesda, MD. 2009.
  7. Marschke, M.  Dementia, Delirium, Depression and Anxiety at End of Life.  Available at: www.amsa.org/dd/Depression.ppt.  Accessed Jan 17, 2011.
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  9. McPherson ML. (2018, February). Management of Opioid-Induced Constipation in Hospice Patients. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28423917
  10. Ross, D. et al. (2001, September). Management of Common Symptoms in Terminally Ill Patients:   Part II. Constipation, Delirium and Dyspnea. Retrieved from https://www.aafp.org/afp/2001/0915/p1019.html#afp20010915p1019-t4https://www.ncbi.nlm.nih.gov/pmc/articles/PMC155633/
  11. Clark, L. (2011, January). Risky Business: Anticoagulation Therapy in the Setting of Hospice and Palliative Care. Retrieved from https://www.jpsmjournal.com/article/S0885-3924(10)00861-4/fulltext
  12. Fahrni J, Husmann M, Gretener SB, Keo HH. Assessing the risk of recurrent venous thromboembolism--a practical approach. Vasc Health Risk Manag. 2015;11:451–459. Published 2015               Aug 17. doi:10.2147/VHRM.S83718
  13. Madison, M. (2015). Managing Complex Symptoms in End of Life Care[PowerPoint slides].
  14. Davis, Caralyn. (2020, March). COVID-19 Not in Your Building? 10 Keys to Limiting Spread and Impact. Retrieved from https://www.aadns-ltc.org/Resources/details/post/covid-19-not-in-your-building-10-keys-to-limiting-spread-and-impact/2020-03-25.
  15. Amirav, I. (2020, March). Transmission of Corona Virus by Nebulizer- a serious, underappreciated risk! Retrieved from https://www.cmaj.ca/content/re-transmission-corona-virus-nebulizer-serious-underappreciated-risk.

 

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