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The Pharmacist’s Role in Hospice | Geriatric Pharmacy Focus · Pharmacy Podcast Network

• 0:05
  Speaker 1: You are listening to the global network of podcasters dedicated
• 0:09
  Speaker 1: to the pharmacy profession. Welcome to the Pharmacy Podcast Network.
• 0:27
  Speaker 2: We have an aging population taking more medications than ever before.
• 0:31
  Speaker 2: On this podcast, I will interview experts in geriatric medicine
• 0:35
  Speaker 2: to gain insights so we can provide optimal care to
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  Speaker 2: patients in their golden years. I'm your host, doctor Tammer Ruggles,
• 0:40
  Speaker 2: and this is the Geriatric Pharmacy Focus. Hello and welcome
• 0:47
  Speaker 2: to episode twenty two of the Geriatric Pharmacy Focus. And
• 0:50
  Speaker 2: today is all about pharmacist role in hospice care. And
• 0:54
  Speaker 2: today with me is Carrie Creps. She is the director
• 0:58
  Speaker 2: of Clinical Services at Pharmacy Associates in Alabama. We met
• 1:03
  Speaker 2: at the American Society of consult Pharmacist meeting a couple
• 1:07
  Speaker 2: years ago and not last year, but I believe it
• 1:09
  Speaker 2: was the conference before. We ended up at the same
• 1:11
  Speaker 2: table at a case studies discussion and immediately hit it
• 1:15
  Speaker 2: off and talked about deep perscribing. And Carrie also has
• 1:19
  Speaker 2: a passion for deeperscribing. She loves our older adults. She's
• 1:22
  Speaker 2: a preceptor and just a passion for appropriate medication use
• 1:26
  Speaker 2: in our older adults, and so I'm so thankful to
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  Speaker 2: have her here. So Carrie, welcome, and if you can
• 1:32
  Speaker 2: maybe just tell us a little bit about yourself.
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  Speaker 1: Well, hello, thank you for having me. It's such an
• 1:36
  Speaker 1: honor to be here. When I first met you, I
• 1:39
  Speaker 1: remember telling you I felt like I was getting to
• 1:41
  Speaker 1: meet like a pharmacy rock star, So it was very exciting,
• 1:45
  Speaker 1: and so it's exciting to be here today too. I've
• 1:49
  Speaker 1: been a consultant pharmacist since two thousand and six, so
• 1:53
  Speaker 1: I'm coming up on twenty years in the business and
• 1:56
  Speaker 1: I've been a pharmacist.
• 1:57
  Speaker 3: For Oh, I'm going myself.
• 2:00
  Speaker 1: I have been a pharmacist since two thousand and two,
• 2:03
  Speaker 1: so I did about four years of I did my
• 2:07
  Speaker 1: time in retail and decided that that was not going
• 2:09
  Speaker 1: to be the long term life for me, and so
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  Speaker 1: I came into long term care and absolutely love it.
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  Speaker 3: So this is a wonderful area to practice in. I
• 2:20
  Speaker 3: love it.
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  Speaker 2: Oh, it's so good to hear you're good at it,
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  Speaker 2: and you certainly don't look like you've been practicing that
• 2:25
  Speaker 2: long to you. And as far as hospice goes, the
• 2:29
  Speaker 2: first question I have for you was, what do you
• 2:31
  Speaker 2: see as the pharmacist role in hospice care.
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  Speaker 1: Well, you know, we've got a bunch of different pharmacists
• 2:38
  Speaker 1: down through the chain of everything that gets done in
• 2:41
  Speaker 1: long term care. But obviously we're responsible for dispensing the
• 2:44
  Speaker 1: medications and making those available to the patients in our
• 2:47
  Speaker 1: long term care facilities in a timely manner, and at
• 2:51
  Speaker 1: the same time, we're assessing the drug interactions and allergies
• 2:55
  Speaker 1: when these new medications for hospice care are added on.
• 2:59
  Speaker 1: And then there's also the possibility of deprescribing when of
• 3:05
  Speaker 1: other medications that are currently on board when we start
• 3:10
  Speaker 1: the medications for hospice care. We may not immediately do it,
• 3:13
  Speaker 1: but at least it's on our radar of Hey, we
• 3:15
  Speaker 1: may eventually want to taper off of some of the
• 3:17
  Speaker 1: medications that we're on as we start to use the
• 3:22
  Speaker 1: hospice comfort measure type medications.
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  Speaker 2: Yeah, I think pharmacists plays such a big role, not
• 3:27
  Speaker 2: only in the dispensing and getting medications to the patient
• 3:30
  Speaker 2: in a timely manner, but also assessing those allergies, what
• 3:34
  Speaker 2: pent and pain medications might work the best for a patient,
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  Speaker 2: What do we do if they're agitated or shortness of
• 3:39
  Speaker 2: breath or just all the different things that come with
• 3:42
  Speaker 2: hospice care. And what I did want to know is
• 3:46
  Speaker 2: is there regulations for hospice care, like there is the
• 3:50
  Speaker 2: State Operations Manual for skill nursing facilities.
• 3:54
  Speaker 1: So the State Operations Manual does not carve out a
• 3:58
  Speaker 1: separate set of regulations for hospice patients are for hospice care.
• 4:02
  Speaker 1: But what they do is they basically overlay hospice specific
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  Speaker 1: requirements on top of the standard nursing home regulations.
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  Speaker 3: So the standard nursing home.
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  Speaker 1: Regulations apply in the long term care setting, but then
• 4:17
  Speaker 1: on top of that, if you were going to bring
• 4:19
  Speaker 1: hospice into the mix as well, there are some requirements
• 4:23
  Speaker 1: that have to be included for hospice care, such as
• 4:26
  Speaker 1: the coordination of care between the hospice agency and the
• 4:29
  Speaker 1: facility to make sure all bases are covered. And then
• 4:33
  Speaker 1: the contract is required with a hospice agency, so the
• 4:37
  Speaker 1: facility has to have a written agreement with the hospice
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  Speaker 1: provider outlining the services that the hospice provider provides to
• 4:45
  Speaker 1: the patient, and then they delegate out the responsibilities accordingly.
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  Speaker 1: So I can tell you as a practitioner, I've never
• 4:52
  Speaker 1: actually seen.
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  Speaker 3: Any of these documents. I've never seen the contract.
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  Speaker 1: I know that they exist and they have to get
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  Speaker 1: signed before hospice care can begin on a patient, but
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  Speaker 1: it's not something that's typically in the medical chart.
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  Speaker 3: It's just a document that's kept on file.
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  Speaker 1: But both the hospice and the facility are responsible for
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  Speaker 1: shared care planning, and of course that's such a big
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  Speaker 1: thing with you know, CMS and our survey teams and
• 5:22
  Speaker 1: things like that, so the state operations may know really
• 5:24
  Speaker 1: isn't great about differentiating between a patient with say like
• 5:28
  Speaker 1: a rehab potential, like a knee replacement or a hip
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  Speaker 1: replacement patient that's there to get better and go home,
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  Speaker 1: compared to a hospice or palliative care patient. The same
• 5:37
  Speaker 1: rules apply, but there are some extra responsibilities expected when
• 5:42
  Speaker 1: a patient is placed on hospice.
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  Speaker 2: The only contracts I've seen when a patient is placed
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  Speaker 2: on hospice, or the only documentation I typically see is
• 5:52
  Speaker 2: you know the list of medications what hospice is going
• 5:55
  Speaker 2: to cover, but the patient is responsible for covering and
• 5:58
  Speaker 2: so I think working in the pharmace, that's the documentation
• 6:01
  Speaker 2: we see. Of course, I need to know, like who's
• 6:04
  Speaker 2: paying for this morphine. Who's paying for you know, the
• 6:07
  Speaker 2: loasapam is it hospice, is it the patient? And so
• 6:11
  Speaker 2: that is that's helpful documentation to see. But yeah, that's
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  Speaker 2: all I've ever seen too when it comes to contracts.
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  Speaker 2: And so there is that layer of yes, the hospice patients,
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  Speaker 2: you know, we still have to abide by all the
• 6:23
  Speaker 2: CMS regulations, right, and then on top of it, hospice
• 6:27
  Speaker 2: regulations also need to be followed. And it does seem like,
• 6:31
  Speaker 2: you know, speaking of the role of the pharmacist, I
• 6:34
  Speaker 2: do catch a lot of open ended PRN you know, lorazapam,
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  Speaker 2: halo paratles that need those end dates, and that does
• 6:43
  Speaker 2: seem to be a struggle for me when it comes
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  Speaker 2: to hospice getting those end dates.
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  Speaker 1: And I will say, you know, that's always been a
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  Speaker 1: source of contention for me because we know that the
• 6:53
  Speaker 1: regulations say that if.
• 6:55
  Speaker 3: You're on a PRN.
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  Speaker 1: Psychoactive medication, it needs a fourteen day stop date and
• 6:59
  Speaker 1: you have to right it every fourteen days. And I've
• 7:02
  Speaker 1: always said when I explain this to my students, when
• 7:05
  Speaker 1: I'm explaining to them the regulations, because of course students
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  Speaker 1: have no background in some of these rules.
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  Speaker 3: I explain to them, I will fight to my death.
• 7:15
  Speaker 1: That is a hill I will die on to protect
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  Speaker 1: my facility. If a should a surveyor get upset with
• 7:21
  Speaker 1: us for having a PRN on a hospice resident, so
• 7:27
  Speaker 1: I explain to them kind of why it looks this
• 7:29
  Speaker 1: way and why that rule is there, which I do
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  Speaker 1: understand and respect. But I also I have never had
• 7:35
  Speaker 1: a surveyor question a hospice patient that has an open
• 7:40
  Speaker 1: ended PRN.
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  Speaker 3: I think it's coming down the road.
• 7:43
  Speaker 1: It probably will happen at some point in time, but
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  Speaker 1: so far it has not been an issue. I do
• 7:49
  Speaker 1: wish that our regulations would sort of carve out some
• 7:54
  Speaker 1: exceptions for hospice, but I think it's like an unspoken rule.
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  Speaker 1: But it's okay if it's hospice, but in other circumstances
• 8:03
  Speaker 1: it's not okay. But it is not written down anywhere.
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  Speaker 2: Yeah, I mean, when you look at the State of
• 8:08
  Speaker 2: Operations manual, they leave zero exceptions in there. But I
• 8:11
  Speaker 2: agree it would be so nice if they carved out
• 8:13
  Speaker 2: exceptions for our hospice patients, for sure, I agree. So,
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  Speaker 2: what are some of the more commonly used medications used
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  Speaker 2: in hospice for both those pain and non pain symptoms.
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  Speaker 1: So for the non pain type circumstances like anxiety and
• 8:31
  Speaker 1: shortness of breath, a benzo dasea pain is common, and
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  Speaker 1: the most common one I see in hospice circumstances is
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  Speaker 1: liquid out of Van or out of Van intensil is,
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  Speaker 1: I think it's brand name, and sometimes we call that
• 8:45
  Speaker 1: air hunger where the respirations slow down and they slow
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  Speaker 1: down significantly, and then after an extended amount of time
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  Speaker 1: without breath, the patient takes a big, deep breath that
• 8:55
  Speaker 1: can make it can be kind of loud and make noise,
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  Speaker 1: and it sounds like struggling to get oxygen. So we
• 9:01
  Speaker 1: call that air hunger, and so out of Van even
• 9:04
  Speaker 1: though we know it slows down respirations, it seems counterintuitive
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  Speaker 1: to use that, but it does kind of calm down
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  Speaker 1: the anxiety associated with that.
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  Speaker 3: Air hunger and struggling to breathe.
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  Speaker 1: So that's the most common one that I see use
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  Speaker 1: for anxiety or agitation and shortness of breath, and then
• 9:24
  Speaker 1: for pain, we usually see non tablet forms of medication,
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  Speaker 1: so not solid dosage forms.
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  Speaker 3: Liquid morphine or roxanol is.
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  Speaker 1: Its brand name, is usually the most common one that
• 9:39
  Speaker 1: I see used in my setting because there is some
• 9:43
  Speaker 1: mucosal absorption, just like the liquid out of van it
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  Speaker 1: can be absorbed sublingually and it's a very small volume
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  Speaker 1: of liquid that's actually needed.
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  Speaker 3: I think it's twenty milligrams per mili liter, so you
• 9:54
  Speaker 3: could actually give a quarter of a millileter and that
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  Speaker 3: provides adequate pain control.
• 10:00
  Speaker 1: Often it doesn't last very long, so you have to
• 10:03
  Speaker 1: give it about every hour or two hours.
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  Speaker 3: But that's a great product to use.
• 10:08
  Speaker 1: But sometimes you also see some other options, like especially
• 10:12
  Speaker 1: if giving something through the mouth is not ideal, so
• 10:17
  Speaker 1: sometimes you'll see rectal positories use transdermal patches, especially if
• 10:22
  Speaker 1: they can't, you know, take medications orally. And then thirdly,
• 10:26
  Speaker 1: I would say one of the major problems we see
• 10:30
  Speaker 1: near and I'm talking very near the end of life
• 10:34
  Speaker 1: is oral secretions can be excessive near the end of life,
• 10:38
  Speaker 1: and that causes some choking or aspiration, coughing, and sometimes
• 10:42
  Speaker 1: even drooling if they're breathing through their mouth. And so
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  Speaker 1: a lot of our hospice companies will use the atropine
• 10:50
  Speaker 1: eye drops sublingually to kind of dry up saliva, and
• 10:55
  Speaker 1: then they also typically order pr in suctioning of the
• 11:02
  Speaker 1: mouth to get rid of some of those thick secretions
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  Speaker 1: that can trigger coughing, and just to kind of help
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  Speaker 1: keep the patient cleaned up.
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  Speaker 3: Things like that.
• 11:13
  Speaker 2: I see that a lot as well. I also see
• 11:16
  Speaker 2: I don't even know how to pronounce this. Yes, so
• 11:20
  Speaker 2: you can get a sublingual tablet, And I see that
• 11:24
  Speaker 2: used a lot for secretions as well. But I'm with you.
• 11:26
  Speaker 2: When it comes to my hospice patients, most of them
• 11:29
  Speaker 2: are on liquid morphine, liquid lorazipam, some atropine or something
• 11:34
  Speaker 2: for excess secretions, and then sometimes also liquid HaLow paradal.
• 11:39
  Speaker 2: That's the most common medications I see used in hospice.
• 11:43
  Speaker 2: That seems to be a good mix of medications that
• 11:46
  Speaker 2: provide comfort. But when it comes to those medications, you know,
• 11:50
  Speaker 2: we know in our older adults, using multiple c ands
• 11:53
  Speaker 2: active medications at one time can cause some side effects,
• 11:56
  Speaker 2: especially sedation, respiratory depression. How do you sort of balance
• 12:00
  Speaker 2: out those side effects with the benefit of the medication.
• 12:04
  Speaker 1: Well, I think you really have to streamline therapy and
• 12:08
  Speaker 1: you want to make sure there's not a lot of duplications.
• 12:10
  Speaker 1: So you may have a patient and I'm just going
• 12:14
  Speaker 1: to try to generalize and think of like a typical
• 12:17
  Speaker 1: hospice patient who has been declining and maybe already was
• 12:23
  Speaker 1: suffering from anxiety and agitation. So they have an order
• 12:28
  Speaker 1: on board for let's say, our prosalam four times a day,
• 12:34
  Speaker 1: and then they get put on hospice because they've had
• 12:38
  Speaker 1: a decline and we're going to add to it out
• 12:42
  Speaker 1: a van. So now we've got two bins of days
• 12:45
  Speaker 1: and fans on board. That's where I like to cut
• 12:47
  Speaker 1: out the duplications. If we're going to add the hospice medications,
• 12:50
  Speaker 1: I'm all for it, but I want to cut out
• 12:53
  Speaker 1: and taper off of anything that may be a duplication.
• 12:57
  Speaker 1: And then I also want to look at are there
• 12:59
  Speaker 1: some opportunity used to get rid of some other things?
• 13:01
  Speaker 1: But it's it all has to really be personalized to
• 13:07
  Speaker 1: the resident and kind of the status of the resident.
• 13:10
  Speaker 1: When I was when I first started consulting as a
• 13:13
  Speaker 1: new consultant, when I thought someone was put on hospice,
• 13:17
  Speaker 1: I thought.
• 13:18
  Speaker 3: They were going to pass within the next seventy two hours.
• 13:20
  Speaker 1: I thought that meant they are calling in the priest,
• 13:24
  Speaker 1: we're reading the last rites we.
• 13:25
  Speaker 3: You know, But after twenty years of doing this.
• 13:29
  Speaker 1: I've seen patients come off of hospice because they no
• 13:32
  Speaker 1: longer met the qualifications. They were on hospice for two
• 13:34
  Speaker 1: and a half years, and they actually weren't at the
• 13:37
  Speaker 1: end of life.
• 13:37
  Speaker 3: They were just kind of going through a rough pad.
• 13:40
  Speaker 2: Oh yeah.
• 13:41
  Speaker 1: And then you also see patients who don't make it
• 13:43
  Speaker 1: through the night after the contract assigned.
• 13:45
  Speaker 3: So everything is just so personalized.
• 13:48
  Speaker 1: You really have to take it on a case by
• 13:50
  Speaker 1: case basis to really look at those side effects and
• 13:54
  Speaker 1: balance the risk versus benefit of the medication regiment. On hand,
• 14:00
  Speaker 1: I don't want to go through and just bushwhack everything
• 14:03
  Speaker 1: that they're on just because we put them on hospite.
• 14:06
  Speaker 3: I want to look at it on.
• 14:10
  Speaker 1: A case by case basis and make some recommendations and
• 14:14
  Speaker 1: kind of prioritize what are we trying to treat here.
• 14:17
  Speaker 1: Are we trying to keep them calm because they're agitated.
• 14:19
  Speaker 1: Are we trying to treat pain because they've got metastatic
• 14:22
  Speaker 1: cancer and it's very painful and it's all over their body.
• 14:26
  Speaker 1: Or are they just not responsive anymore and they're in
• 14:28
  Speaker 1: a deep state of sleep.
• 14:30
  Speaker 3: You know what? You know, you just kind of have
• 14:32
  Speaker 3: to prioritize.
• 14:33
  Speaker 2: It's a little bit different for each patient. It does
• 14:36
  Speaker 2: seem like the hospice providers around here do try to
• 14:39
  Speaker 2: start with lower doses of luazopam and morphine see how
• 14:44
  Speaker 2: the patient does if they're still in too much pain
• 14:46
  Speaker 2: or too much shortness of breath will increase it. But
• 14:49
  Speaker 2: I think that's, you know, their method of trying to
• 14:51
  Speaker 2: figure out, okay, what is the lowest dose that's going
• 14:54
  Speaker 2: to control their pain, make them comfortable, but yet keep
• 14:57
  Speaker 2: them alert and have a good quality of life and
• 14:59
  Speaker 2: able to visit with their family if they come, and
• 15:02
  Speaker 2: then reassess. But of course it comes down to what
• 15:04
  Speaker 2: the patient wants, you know. Does the patient want to
• 15:07
  Speaker 2: feel no pain and be you know, and is okay
• 15:10
  Speaker 2: with being a little bit sedated, or would the patient
• 15:13
  Speaker 2: rather feel a little pain but be awake when their
• 15:15
  Speaker 2: loved ones show up. So I think, you know, it's
• 15:17
  Speaker 2: a conversation with the patient, what are your goals, what
• 15:20
  Speaker 2: matters to you, and then go from there.
• 15:23
  Speaker 1: Right and hopefully we have that opportunity to be able
• 15:26
  Speaker 1: to have that conversation with the patient. Sometimes they decline
• 15:29
  Speaker 1: quickly and we're not able to have that conversation and
• 15:32
  Speaker 1: we have to defer to the family or the sponsor,
• 15:35
  Speaker 1: And you know, I really.
• 15:37
  Speaker 3: Try to.
• 15:40
  Speaker 1: I try to be available to make any suggestions that
• 15:43
  Speaker 1: I can to be helpful. But a lot of times,
• 15:45
  Speaker 1: you know, like you said, the hospice companies kind of
• 15:47
  Speaker 1: have their standard order list that they just go down
• 15:49
  Speaker 1: and check the boxes of what they need.
• 15:52
  Speaker 2: You talked about patients being discharged off hospice sometimes. I'm
• 15:56
  Speaker 2: sure you've seen this too. I'll have a patient go
• 15:58
  Speaker 2: on hospice, stop all their meds and they've breaken right up.
• 16:03
  Speaker 2: You know.
• 16:04
  Speaker 3: I've had that.
• 16:05
  Speaker 2: Happen a few times where they were I believe, just
• 16:08
  Speaker 2: suffering from polypharmacy. Yes, when we cut down on the meds,
• 16:13
  Speaker 2: they feel a whole lot better.
• 16:15
  Speaker 1: Yeah, it's a testament to de prescribing, and the de
• 16:18
  Speaker 1: prescribing works. You know, You've got patients that are ninety
• 16:23
  Speaker 1: plus years old in a skilled nursing facility and they,
• 16:26
  Speaker 1: throughout their life have gone to see different specialists in
• 16:29
  Speaker 1: different physicians, dentists, dermatologists, cardiologists, you name it. They have
• 16:35
  Speaker 1: seen all sorts of different people for different ailments, and
• 16:38
  Speaker 1: they feel like the appointment was a failure. If they
• 16:42
  Speaker 1: don't leave without a script in their hand, or if
• 16:44
  Speaker 1: they leave without a script in their hand and they
• 16:45
  Speaker 1: feel like the appointment was a failure.
• 16:47
  Speaker 3: And so over time, all.
• 16:49
  Speaker 1: These medications have been added to their daily regimen, and
• 16:53
  Speaker 1: then they decline so much that they have to go
• 16:55
  Speaker 1: into a skilled nursing facility, and we just continue all
• 16:58
  Speaker 1: those medications without question. So if you back off of
• 17:02
  Speaker 1: some of those medications that might not be benefiting them,
• 17:05
  Speaker 1: then all of a sudden, they park back up and
• 17:08
  Speaker 1: they're not even a hospice patient anymore because it was
• 17:11
  Speaker 1: the medications that were bogging them down. So I'm im
• 17:15
  Speaker 1: a huge fan and I'm always so encouraged when i
• 17:18
  Speaker 1: see patients kind of bounce back just because we got.
• 17:21
  Speaker 3: Rid of some things.
• 17:22
  Speaker 2: Love it. So when it comes to deprescribing, when a
• 17:27
  Speaker 2: patient goes on hospice, looking at the medication list, they
• 17:31
  Speaker 2: might be on all sorts of medications, a fiery medication,
• 17:34
  Speaker 2: blood pressure statins, so many different medications. How do you
• 17:39
  Speaker 2: decide or how do you help with the decision making
• 17:42
  Speaker 2: when it comes to what should we keep on board
• 17:44
  Speaker 2: and what's appropriate to de prescribe at this time.
• 17:47
  Speaker 1: It absolutely has to do with the condition of the patient,
• 17:52
  Speaker 1: and it's really just a balancing act of using some
• 17:56
  Speaker 1: common sense but customizing it to that patient and where
• 18:00
  Speaker 1: they are in their hospice journey. I hate when people
• 18:04
  Speaker 1: use that term their journey, but it is kind of
• 18:06
  Speaker 1: a journey in this situation. So, like I said, sometimes
• 18:10
  Speaker 1: you have patients who last for seventy two hours on hospice.
• 18:14
  Speaker 1: Sometimes you have patients who last for two and a
• 18:16
  Speaker 1: half years and come off of hospice, and then you
• 18:18
  Speaker 1: have some who don't make it through the night, and
• 18:20
  Speaker 1: then everywhere in between. So one of my favorite strategies
• 18:24
  Speaker 1: to teach my students is how different hospice can look, because,
• 18:29
  Speaker 1: like I said, I thought hospice meant we're at the.
• 18:32
  Speaker 3: End of life, call in the family, calling the priest.
• 18:35
  Speaker 1: So one of my responsibilities as a consultant pharmacist in
• 18:41
  Speaker 1: my facilities is to dispose of medications that are no
• 18:45
  Speaker 1: longer in use, so whether the patient has deceased, or
• 18:48
  Speaker 1: the medication's been discontinued, or the medications expired.
• 18:51
  Speaker 3: So we have to dispose of narcotics, and.
• 18:54
  Speaker 1: We also have to make sure that the records are
• 18:56
  Speaker 1: in order and all doses are accounted for. And one
• 18:59
  Speaker 1: of my favoravorite things to show my students is a
• 19:01
  Speaker 1: very typical textbook hospice document, which is the patient who
• 19:07
  Speaker 1: receives two doses of morphine and then passes peacefully. So morphine,
• 19:13
  Speaker 1: as you know, comes in a thirty mL single you know,
• 19:17
  Speaker 1: a single person bottle, and a lot of times you
• 19:22
  Speaker 1: give a dose of point two five milli leaders to
• 19:25
  Speaker 1: a patient and then maybe an hour or two later
• 19:28
  Speaker 1: another dose and then the resident is deceased and it's
• 19:32
  Speaker 1: not that the morphine did that, it was just that
• 19:33
  Speaker 1: that's what helped them peacefully take their last breaths and
• 19:36
  Speaker 1: pass on. And so that's a very typical situation of
• 19:43
  Speaker 1: hospice and giving hospice meds. But then there's also in
• 19:47
  Speaker 1: that same stack of documents that we're going through, we'll
• 19:50
  Speaker 1: see a patient who got thirty seven doses of morphine.
• 19:54
  Speaker 1: So there's everything is just so personalized, as unique as
• 20:00
  Speaker 1: the hospice process of death and dying is deprescribing as
• 20:04
  Speaker 1: equally as unique, and just like you, deprescribing as a
• 20:09
  Speaker 1: passion of mine across all areas of long term care,
• 20:12
  Speaker 1: and there's a huge opportunity at the end of life
• 20:14
  Speaker 1: to de prescribe, and it really just means using common
• 20:17
  Speaker 1: sense tailored to the individual at hand. And I really
• 20:20
  Speaker 1: don't ever want to withhold medication that would be life
• 20:23
  Speaker 1: sustaining or just medication that someone needs to feel that
• 20:27
  Speaker 1: their best. But I don't want to burden them with
• 20:31
  Speaker 1: medications that could be causing problems, or I don't want
• 20:34
  Speaker 1: to be helping a situation that's no longer a priority.
• 20:37
  Speaker 1: I'm not worried about their bone density. I'm not worried
• 20:40
  Speaker 1: about giving them calcium plus vitamin D in their last three.
• 20:43
  Speaker 3: Days of life. I'm not worried about statins.
• 20:47
  Speaker 1: If you've made it to ninety two years old and
• 20:50
  Speaker 1: you're on a statin, I think the medication has done
• 20:52
  Speaker 1: its job at that point.
• 20:53
  Speaker 3: And you knows.
• 20:55
  Speaker 1: As thankful as I am for things like statins. They
• 20:59
  Speaker 1: do tend to make you. They can cause some muscle pain,
• 21:03
  Speaker 1: and I don't want to cause any pain in someone
• 21:04
  Speaker 1: that where pain is a priority.
• 21:09
  Speaker 3: And even you know this can be kind of a
• 21:11
  Speaker 3: slippery slope.
• 21:12
  Speaker 1: But some of those psychoactive meds that our patients are on,
• 21:16
  Speaker 1: if they're on hospice and they are on morphine and
• 21:19
  Speaker 1: audavan and haldal and atropine drops.
• 21:22
  Speaker 3: They may not even be communicating with us.
• 21:24
  Speaker 1: So if they're in a deep state of sleep, I
• 21:27
  Speaker 1: don't think that they need their zyprexa. You know, not
• 21:30
  Speaker 1: to pick on zyprexa. I'm just you know, pointing out that.
• 21:34
  Speaker 1: But also one of the first things I look for
• 21:37
  Speaker 1: considering the setting of a nursing home is are we
• 21:41
  Speaker 1: on dementia medications like aircept and namenda. Those medications are
• 21:47
  Speaker 1: intended to slow down the process of dementia and maybe
• 21:53
  Speaker 1: slow the progress of the disease down. They have already
• 21:56
  Speaker 1: done their job at this point, and so those are
• 21:58
  Speaker 1: two things that I like to take off as quickly
• 22:01
  Speaker 1: as possible, just because it's.
• 22:04
  Speaker 3: No longer serving that patient.
• 22:08
  Speaker 1: Medications like incontinence medications, the patient's probably already incontinent anyway,
• 22:13
  Speaker 1: So those are those and those have a huge burden
• 22:17
  Speaker 1: on that patient. They can cause a lot of problems
• 22:19
  Speaker 1: the anticholinergic properties of them. If we can get rid
• 22:23
  Speaker 1: of those medications, they might be a little bit more
• 22:25
  Speaker 1: alert and awake and able to possibly even eat and
• 22:30
  Speaker 1: be a little more aware of their surroundings by taking
• 22:34
  Speaker 1: those medications out of the.
• 22:38
  Speaker 3: Medication cup for them.
• 22:40
  Speaker 1: So I really just try to reduce that pill burden
• 22:43
  Speaker 1: where I can. And you know, but there's some other things.
• 22:50
  Speaker 1: From a personal standpoint, I went through hospice with my
• 22:52
  Speaker 1: father in law back in twenty nineteen, and one of
• 22:56
  Speaker 1: the things that kept him alive artificially that I did
• 23:01
  Speaker 1: not know was a nasal canula of oxygen. And we
• 23:07
  Speaker 1: could not figure out why he was still hanging on.
• 23:10
  Speaker 1: And of course we didn't want to we didn't want
• 23:13
  Speaker 1: to speed up the process in any way. But a
• 23:15
  Speaker 1: lot of times hospice companies will order a nasal canula
• 23:19
  Speaker 1: of oxygen and you know, just maybe at two liters,
• 23:22
  Speaker 1: not a high rate of oxygen, but it can be
• 23:26
  Speaker 1: very uncomfortable to keep a nasal canula of oxygen on.
• 23:30
  Speaker 1: And he was always pulling at his oxygen. It bothered
• 23:34
  Speaker 1: him and kind of agitated him a little bit. And
• 23:37
  Speaker 1: when we finally gave him a break from that nasal
• 23:39
  Speaker 1: canula of oxygen, he slipped away. And we thought, and
• 23:45
  Speaker 1: here I am, I work in this industry. No one
• 23:48
  Speaker 1: told me that that would keep someone alive artificially.
• 23:54
  Speaker 3: You know, he had not eaten in a couple of weeks.
• 23:56
  Speaker 1: He had a few SIPs of water here and there
• 24:00
  Speaker 1: it was the oxygen that was keeping him hanging on.
• 24:03
  Speaker 1: And we thought, had we have known, we wouldn't have,
• 24:06
  Speaker 1: you know, because we knew it was so uncomfortable for
• 24:08
  Speaker 1: him to keep on his face and he would pull
• 24:10
  Speaker 1: at it and it was and he was trying.
• 24:12
  Speaker 3: To tell us like, let me go.
• 24:14
  Speaker 1: So we gave him a break from the oxygen because
• 24:17
  Speaker 1: the hospice company came in to bathe them and shave
• 24:21
  Speaker 1: them and you know, have him clean and presentable to
• 24:23
  Speaker 1: the family. And when we took the oxygen off, that
• 24:27
  Speaker 1: was when his SATs dropped. And so I always try
• 24:30
  Speaker 1: to tell that story because it's not common sense, but
• 24:35
  Speaker 1: maybe maybe don't keep certain orders going if they're no
• 24:39
  Speaker 1: longer serving that patient very well.
• 24:42
  Speaker 2: So, yeah, you bring up so many good points at
• 24:45
  Speaker 2: the end of life. You know, are they having trouble swallowing.
• 24:48
  Speaker 2: If they're having trouble swallowing, it's a good point to
• 24:51
  Speaker 2: look at that and discontinue all the ones that aren't necessary.
• 24:54
  Speaker 2: Of course, it's a conversation with the family and the
• 24:57
  Speaker 2: caregiver and the patient to say, you know, what do
• 25:01
  Speaker 2: you want to keep on what aligns with your goals
• 25:04
  Speaker 2: right now? For treatment what doesn't align. And then there's
• 25:09
  Speaker 2: a paper that came out called Deprescribing for People with
• 25:12
  Speaker 2: Dementia a Roadmap, and it came out July twenty twenty five.
• 25:15
  Speaker 2: I really like it. It talks about deprescribing for patients with dementia.
• 25:19
  Speaker 2: But in there there's a tool that you can use
• 25:21
  Speaker 2: for all patients and it's from the University of California,
• 25:24
  Speaker 2: San Diego, and they have a couple different calculators. One
• 25:28
  Speaker 2: is a life expectancy calculator, but we know if our
• 25:31
  Speaker 2: patient's on hospice that they're predicted to live six months
• 25:34
  Speaker 2: or less. So the other tool that's on the website
• 25:38
  Speaker 2: is a time to benefit tool with medications, so you know,
• 25:42
  Speaker 2: if a medication is going to take a year, two years,
• 25:45
  Speaker 2: eight years to benefit, what's the sense in putting the
• 25:48
  Speaker 2: patient on it if they're on hospice. But with pain meds,
• 25:51
  Speaker 2: we know that there's very small time to benefit a
• 25:55
  Speaker 2: couple minutes, half hour hour, so those are likely to benefit.
• 25:59
  Speaker 2: But I think those tools are helpful to use for
• 26:02
  Speaker 2: patients with dinanja and use those tools along with the
• 26:05
  Speaker 2: treatment goals for the patients and carry over, and it's
• 26:07
  Speaker 2: pretty easy, you know, after those conversations, using those tools
• 26:11
  Speaker 2: to kind of decide what's going to benefit what's not.
• 26:15
  Speaker 2: I mean, even looking at diabetes treatment, yes we don't
• 26:18
  Speaker 2: want their blood sugar sky high and we don't want
• 26:21
  Speaker 2: them experiencing hypoglycemia. But other than that, we don't need
• 26:25
  Speaker 2: to keep their A one c at a certain goal exactly.
• 26:29
  Speaker 2: So it's just things like that that eliminate a few pokes.
• 26:34
  Speaker 2: Maybe check aus sugar once a day and see what's
• 26:36
  Speaker 2: happening or whatever it might be. But we certainly don't
• 26:39
  Speaker 2: need to burden the patient with that kind of thing.
• 26:41
  Speaker 2: And with my grandma too, when she was on hospice,
• 26:44
  Speaker 2: they kept her on donepezil, and my goodness, did that
• 26:47
  Speaker 2: make medication make her nose run and she would sit
• 26:50
  Speaker 2: there all day with a tissue. And finally I went
• 26:53
  Speaker 2: to visit her and I'm like, what are we doing
• 26:55
  Speaker 2: with the donepazil. She's already end of life, she doesn't
• 26:58
  Speaker 2: recognize any of us. There's no benefit to it, and
• 27:01
  Speaker 2: the poor ladies just sitting here wiping her nose constantly.
• 27:05
  Speaker 3: Let's just stop it, exactly.
• 27:08
  Speaker 2: I think just even making families aware of these are
• 27:11
  Speaker 2: the benefits but these are the risks and like you say,
• 27:15
  Speaker 2: what the incontinence means? Maybe the patient's not even able
• 27:18
  Speaker 2: to get up out of bed anymore, and so what
• 27:20
  Speaker 2: are we doing with an incontinence med? But it does
• 27:23
  Speaker 2: take someone to look through the med list and go
• 27:25
  Speaker 2: through each one to make an important decision of what
• 27:29
  Speaker 2: should stay and what shouldn't. And if you don't have
• 27:30
  Speaker 2: that conversation and just continue all of them, it's right
• 27:34
  Speaker 2: benefiting the patient.
• 27:36
  Speaker 1: And that's really where our fabulous nurses that are taking
• 27:40
  Speaker 1: care of these patients really come in handy. I will
• 27:42
  Speaker 1: have a conversation with the nurses and be like, do
• 27:44
  Speaker 1: you really think that mister Smith still needs this? And
• 27:46
  Speaker 1: they'll say, no, is we have to crush the tablet,
• 27:49
  Speaker 1: we have to put it in some pudding, and we're
• 27:50
  Speaker 1: worried about him token on the pudding and sometimes we
• 27:53
  Speaker 1: go back and there's still a little bit of the
• 27:54
  Speaker 1: residue of the pudding in his mouth and we feel bad,
• 27:57
  Speaker 1: you know. So you know, there's so many opportunities, and
• 28:01
  Speaker 1: our nurses that are taking care of these patients really
• 28:05
  Speaker 1: can help us to personalize those recommendations. It is not
• 28:08
  Speaker 1: uncommon for me to put those type of recommendations in
• 28:11
  Speaker 1: my pharmacy report, because I'm communicating directly with the director
• 28:16
  Speaker 1: of nursing and the medical director who may not know
• 28:18
  Speaker 1: those little nuances about oh, well, we have to crush
• 28:21
  Speaker 1: the tablet up because he can't swallow a pill anymore,
• 28:24
  Speaker 1: and I didn't you know, the doctor doesn't know that
• 28:27
  Speaker 1: that's what's going on. And so I can kind of
• 28:29
  Speaker 1: bring them up to speed and say, are you sure
• 28:30
  Speaker 1: you want to keep this on board, and I'll say, no,
• 28:32
  Speaker 1: absolutely not, let's discontinue that. So it's really just me
• 28:35
  Speaker 1: being the vehicle talking to the experts in the area
• 28:39
  Speaker 1: and communicating it to their higher ups. And so I'm
• 28:42
  Speaker 1: really just the vehicle, but I can initiate those conversations
• 28:46
  Speaker 1: to help get rid of some things that are just
• 28:50
  Speaker 1: a burden to the patient. And I really try to
• 28:52
  Speaker 1: respect when the families are in the room. I try
• 28:56
  Speaker 1: to reduce as many interruptions in the day of providing
• 29:00
  Speaker 1: care as much as possible, so they can visit with
• 29:02
  Speaker 1: everybody they can have that time and it not be
• 29:05
  Speaker 1: so institutional and rigid with well, now we've got to
• 29:09
  Speaker 1: do blood sugars.
• 29:10
  Speaker 3: Now we've got to give them an insulin injection.
• 29:12
  Speaker 1: Now we need to do this wound care treatment, and
• 29:15
  Speaker 1: you have to do all this.
• 29:16
  Speaker 3: Let's just keep the patients comfortable and let them spend
• 29:19
  Speaker 3: time with their family.
• 29:20
  Speaker 2: That's right. I agree with you, and I agree that
• 29:25
  Speaker 2: nursing staff med aids, they have so much insight on
• 29:29
  Speaker 2: patients and what's necessary, what's not. They're with these with
• 29:32
  Speaker 2: these patients every day, might review their chart once a month,
• 29:36
  Speaker 2: so they know more than I do about if a
• 29:38
  Speaker 2: medication should be discontinued or not. So I have those
• 29:42
  Speaker 2: conversations with the people who are with them every day
• 29:44
  Speaker 2: to see how things are going exactly exactly.
• 29:48
  Speaker 3: That's been my experience as well.
• 29:51
  Speaker 2: Well. Thanks so much for this hospice discussion today. It's
• 29:54
  Speaker 2: been wonderful and it's so interesting to me to see
• 29:57
  Speaker 2: how similar things are in Alabama and North Dakot and
• 30:00
  Speaker 2: just all around. But it seems like things are pretty
• 30:04
  Speaker 2: much the same when it comes to hospice care.
• 30:06
  Speaker 3: I thought about that when I was preparing for this.
• 30:08
  Speaker 1: I thought, I wonder if it's just a regional thing
• 30:11
  Speaker 1: that we use atropine eye drops in the mouth, because
• 30:13
  Speaker 1: I remember the first time I read an order, I
• 30:16
  Speaker 1: thought oh, they typed this wrong.
• 30:18
  Speaker 3: They're not supposed to ft id drops in the mouth.
• 30:20
  Speaker 3: And I asked them about.
• 30:20
  Speaker 1: I said, is this an error? Did they mean to
• 30:23
  Speaker 1: type this? And they're like, yeah, that's what we do
• 30:26
  Speaker 1: on hospice pass. I was like, oh, you give them
• 30:28
  Speaker 1: eye drops in their mouth. So yeah, it is interesting
• 30:31
  Speaker 1: to know that they do it in other areas of
• 30:33
  Speaker 1: the country as well.
• 30:34
  Speaker 2: So yeah, well, thanks everyone for listening, and I will
• 30:37
  Speaker 2: put the Deeper Striving for people at dementia a roadmap
• 30:41
  Speaker 2: in the show notes and also a link to carries LinkedIn.
• 30:44
  Speaker 2: But if people want to find you and connect is
• 30:46
  Speaker 2: LinkedIn the best place to go.
• 30:48
  Speaker 3: That's a great place to find me.
• 30:50
  Speaker 2: All right, there you go, go find Carrie and everyone
• 30:53
  Speaker 2: have a great rest of your day.