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The contents of this blog contain topics relevant to end of life care written by our own hospice clinical pharmacists. Continue to check this site regularly for the newest post or subscribe to the RSS feed below.

Dr. Jessica Horsley earned her Doctor of Pharmacy degree from University of Charleston in Charleston, WV. She joined Delta Care Rx as a Hospice Clinical Pharmacist in 2014 and brings experience from hospital, home infusion, and mental health specialty pharmacy practice settings. Dr. Horsley is an active member of the American Society for Health-System Pharmacists and associated state organizations and has presented research regarding medication reconciliation at the national meeting, as well as provided student programming support for state meetings. Her background as a musician gives her knowledge and perspective on successful non-pharmacological interventions in the treatment of the hospice patient. Dr. Horsley plans to achieve board certification in 2017.

Jessica Horsley, PharmD

Medication Reconciliation and Transitions of Care at End of Life

According to The Joint Commission, medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care. Accurate and complete medication reconciliation can prevent numerous prescribing and administration errors. Medication errors related to medication reconciliation typically occur at the "interfaces of care"—when a patient is admitted to, transferred within, or discharged from a health care facility. Common causes of medication reconciliation errors include inaccuracies or omission during transcription, poor documentation, communication breakdown, and workflow disruption.

Additionally, in hospice and palliative care, some patients may be too ill, injured, young, or disabled to actively participation the medication reconciliation process. Patients may need the assistance of another person (e.g., family member, significant other, surrogate decision maker) if they are overwhelmed in managing their condition, are not proficient in speaking or reading English, or face health literacy challenges that might prevent them from understanding medication use directions. When the patient is unable to actively or fully participate in the medication reconciliation process and has requested assistance from another person, involve the authorized person(s) in the medication reconciliation process. This involvement should occur at all interfaces of care . 

Medication Reconciliation Best Practices:

1. The hospice has a standardized medication reconciliation process in place that is completed and reviewed by the IDT within 5 days of the initiation of care.

a.Medication reconciliation needs to be performed at every nursing visit comparing most current medication sheet from EMR to med sheet that is in patient's home.
b.Medication reconciliation occurs at every IDT meeting where patient cases are reviewed.

2. Any discrepancies that are identified are clarified with the physician and/or pharmacy consultant within 24 hours.

3. There is a process in place to review current medications to determine which ones are related to the primary and secondary diagnosis and therefore the financial responsibility of the hospice.

a. First Verify – collect an accurate list of ALL medications the patient is taking. This becomes the “ONE TRUE SOURCE”
b. Second, Clarify – any questions about which drugs, which dose and which frequency.
c. Third, Reconcile by reviewing this list with the hospice physician and/or pharmacy consultant along with any questions or concerns in order to obtain clarification or revised orders.


4. Provide medication and medication reconciliation education to staff and consider as yearly competency.

a. Assure Staff Training includes at least the following:
        i. Ask the patient/caregiver before the first visit to collect all of the patient’s medications. 
        ii. Note any discrepancy between the prescription on the bottle and what the patient states he/she is taking. 
        iii. Ask about the use of non-prescription medications. 
      iv. Identify any combination of medications that may be contraindicated or medications that seem to be inappropriate such as those on the Beers Criteria.

5. Assure staff has access to AND a process in place to use up to date medication information and software programs to analyze medication interactions, duplication, adverse effects etc.

6. Assessment of the patient and caregiver's ability to administer medication should be done at every nursing visit so that teaching can be customized to their needs and to enhance the safety of medication administration.  Hospice staff can consult with the Delta Care pharmacist during the visit to ensure that questions are answered.

Many of these “best practices” are already in place for your hospice by using Delta Care Rx on-demand pharmacist services. Utilizing a staff properly trained for appropriate medication reconciliation with the patient or caregiver paired with the consultation and information provided by Delta Care pharmacists is an important partnership to prevent dangerous medications errors and curb symptom management issues that may be due to inappropriate medication use and interactions. Although data specifically related to medication errors in hospice and palliative care are sparse, one study found that all hospice patients had at least one medication discrepancy, with an average of eight per patient. Most commonly these discrepancies were omission of medications. Most drug interactions identified were moderately severe. Owing to the fact that polypharmacy often increases as a patient ages and/or becomes more ill, it is prudent to always perform accurate medication reconciliation at each transition of care and provide timely updates to medication profile to ensure that an accurate medication list is always at the ready.


References:
1. The Joint Commission. Using medication reconciliation to prevent errors. Sentinel Event Alert. January 2006; 35. Available from:http://www.jointcommission.org/assets/1/18/SEA_35.PDF
2. Visiting Nurses Association of America. Patient Safety: Medication reconciliation and management. VNAA Blueprint for excellence. Available from: http://0101.nccdn.net/1_5/3d0/168/33c/A-Guide-to-Medication-Reconciliation-and-Management.pdf
3. Kemp L, Narula P, McPherson M, Zuckerman I. Medication reconciliation in hospice: a pilot study. Am J Hosp Palliat Care [serial online]. June 2009;26(3):193-199. Available from: MEDLINE Complete, Ipswich, MA. 

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Jessica Horsley, PharmD

Intranasal Medication Administration: Suitable Drugs and Devices

Compared to intravenous (IV) and other invasive routes of administration, intranasal (IN) administration of medications provides several benefits with regard to safety and efficacy. This route of administration is needleless, requires no sterile technique and is pain-free and well tolerated by patients. The transmucosal drug absorption offered by this route offers a rapid onset of action, with dosing and bioavailability similar to IV dosing.

Variability in intranasal drug absorption can be attributed to both drug and patient-related factors. Drug formulations should be concentrated and potent and of a volume of less than 1mL (preferably less than 0.2mL if possible). Physicochemical drug properties are of importance, as optimal absorption is dependent on the molecular weight and hydro- or lipophilicity of the drug. Lipophilic medications with a molecular weight of less than 300 Da are most suitable for IN administration. The patient’s transepithelial passage proves to be another variable affecting drug absorption. Abnormal nasal blood flow, rhinosinusitis, radiation to the head/neck, diseases affecting mucociliary clearance like cystic fibrosis, and cigarette smoking may all affect mucosal health, and therefore IN drug absorption. Drug interactions for IN administration are considered relative and include phenylephrine and oxymetazoline.

With regard to IN administration, most nursing professionals and even patients are familiar with nose drops or aerosol sprays like sodium chloride nasal spray or fluticasone. For those medications without a commercial nasal dosage form available, options for administration in the past have included compounding into drops/spray, or using a syringe and cotton ball. These methods may prove problematic due to immediate swallowing, rapid clearance, and posterior delivery of medication. A new option, drug atomization, now exists to address these failures in IN drug delivery. An atomized spray delivers small particles to the nasal mucosa rapidly and without regard to patient positioning. Three commercial devices exist for IN drug atomization: Mucosal Atomization Device, Accuspray Nasal Spray and Kurve Controlled Particle Dispersion. Although considered off-label use, the therapeutic uses of IN-administered drugs include seizures, hypoglycemia, opioid overdose, epistaxis and anesthesia. Suitable medications for IN administration applicable to the hospice population include fentanyl, benzodiazepines, ketamine, naloxone and lidocaine.1

2016 06 29 12 57 45

For information regarding nasal atomization products:

LMA MAD Nasal
http://www.lmana.com/pwpcontrol.php?pwpID=6359

BD Accuspray SCF
http://www.bd.com/pharmaceuticals/products/nasal-spray.asp

Kurve CPD
http://www.kurvetech.com/nasaltechnology.asp 

 


References:

1 Jen, C. No IV access, get MAD! Powerpoint presentation at: the American Society for Health-System Pharmacists Midyear Clinical Meeting; Dec 7-11 2014; Anaheim, CA.

2 Wolfe TR, Braude DA. Intranasal medication delivery for children: a brief review and update. Pediatrics. 2010;126(3):532-7.

3 Gallagher EJ. Nasogastric tubes: hard to swallow. Ann Emerg Med. 2004;44:138-41.

4 Pandey RK, Bahetwar SK, Saksena AK, Chandra G. A comparative evaluation of drops versus atomized administration of intranasal ketamine for the procedural sedation of young uncooperative pediatric dental patients: A prospective crossover trial. J Clin Pediatr Dent. 2011;36:79–84.

5 Tsze DS, Steele DW, Machan JT, Akhlaghi F, and Linakis JG. Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. Pediatr Emerg Care. 2012 Aug;28(8):767-770.

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Jessica Horsley, PharmD

Music Therapy in Hospice and Palliative Care

Music Therapy (MT) is an established health profession in which music is used within a therapeutic relationship to address physical, emotional, cognitive, and social needs of individuals. It is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program. Although note-worthy and possibly soothing in nature, activities like bedside and lobby performances, background music and providing media players/headphones are NOT considered clinical music therapy.

Board Certified Music Therapists (MT-BC) work in a variety of settings including schools, nursing facilities, hospitals, and hospices. After assessing the strengths and needs of each client, the qualified music therapist provides the indicated treatment including creating, singing, moving to, and/or listening to music. Through musical involvement in the therapeutic context, clients' abilities are strengthened and transferred to other areas of their lives. Music therapy also provides avenues for communication that can be helpful to those who find it difficult to express themselves in words.1

MT has shown benefit for many conditions relevant to the care of a hospice patient. In dementia, including Alzheimer’s, MT can reduce behaviors like agitation,2 improve speech and attention,3 even make shower/bath times easier for patients and caregivers.4 Incorporating MT into Parkinson’s therapy improves gait,5, 6 speech and mood.7 Of particular interest to the hospice population, MT can treat anxiety,8 dyspnea9 and pain.10 MT is not only appropriate for adult hospice patients; it also proven exceptionally useful in the pediatric population,11 including those with Autism spectrum disorders.12

Benefits of MT extend beyond relieving patient symptoms. It can oftentimes be associated with a reduction in stress, as reported amongst both family13 and professional caregivers. Beyond the physical/emotional benefits of MT to patients, families and caregivers, it may even offer benefit to hospices seeking cost-saving strategies. A growing body of evidence supports that MT can decrease medication and care costs (by decreasing nursing visits) for patients, offsetting the cost of MT.14

 

Aside from cost-savings, MT offers another benefit over medications – it has only one true contraindication: patient preference. A recent survey of U.S. hospices estimated that MT is provided as a discretionary service by over half of the hospices nationwide. Further, hospices that offer MT report that it is more often preferred by patients than any other complementary treatment method.9 If MT is not currently offered by your hospice, patients can be referred to an independent MT-BC by a prescriber. According to the American Music Therapy Association, about 20% of MT-BC receive third party reimbursement. These payers include Medicare and private insurance. Additional funding sources may include state departments of mental health and/or developmental disabilities, private auto insurance, worker’s compensation, foundations and grants.15

Although many MT-BCs work in institutional settings, home-based music therapy (HBMT) is a growing field relevant to home hospice providers. These programs can include home visits by a MT-BC and/or instruction of spouses, family members and other caregivers in selected MT techniques, which can offer lasting effectiveness and cost-savings.16 Like many growing fields, more research into the provision and implementation, as well as efficacy and cost-benefits of this innovative service are needed, but the current body of literature suggests MT is a strong addition to a hospice and/or palliative care service’s complementary and alternative treatment offering.

How to find a Board Certified Music Therapist:
Certification Board for Music Therapists
http://www.cbmt.org/certificant_search
This email address is being protected from spambots. You need JavaScript enabled to view it.

American Music Therapy Association  
http://www.musictherapy.org/about/find/
This email address is being protected from spambots. You need JavaScript enabled to view it. 


REFERENCES:

1 Definition and Quotes about Music Therapy. American Music Therapy Association web site. http://www.musictherapy.org/about/quotes/. Accessed June 20, 2015.
2 McDermott O, Crellin N, Ridder HM, Orrell M. Music therapy in dementia: a narrative synthesis systematic review. Int J Geriatr Psychiatry. 2013;28:781–794
3 Ceccato E, Vigato G, Bonetto C, et al. STAM protocol in dementia: a multicenter, single-blind, randomized, and controlled trial. Am J Alzheimers Dis Other Demen. 2012;27:301-310.
4 Ray KD, Fitzsimmons S. Music-assisted bathing: making shower time easier for people with dementia. J Geront Nurs. 2014;40:9-13.
5 Bella SD, Benoit CE, Farrugia N, Schwartze M, Kotz SA. Effects of musically cued gait training in Parkinson’s disease. Ann N Y Acad Sci. 2015;1336:77-85
6 de Dreu MJ, van der Wilk AS, Poppe E, Kwakkel G. Rehabilitation, exercise therapy and music in patients with Parkinson’s disease: a meta-analysis of the effects of muscle-based movement therapy on walking ability, balance and quality of life. Parkinsonism Relat Disord. 2012;18:S114-119.
7 Haneishi E. Effects of a music therapy voice protocol on speech intelligibility, vocal acoustic measures, and mood in Parkinson’s disease. J Music Ther. 2001;38:273-290.
8 Horne-Thompson A, Grocke D. The effect of music therapy on anxiety in patients who are terminally ill. J Pall Med. 2008;11:582-590.
9 Burns DS, Perkins SM, Tong Y, Hilliard RE, Cripe LD. Music therapy is associated with family perception of more spiritual support and decreased breathing problems in cancer patients receiving hospice care. J Pain Symptom Manage. 2015. In press.
10 Krout RE. The effects of single-session music therapy interventions on the observed and self-reported levels of pain control, physical comfort, and relaxation of hospice patients. Am J Hosp Palliat Care. 2001;18:383-390.
11 Lindenfelser KJ, Hense C, McFerran K. Music therapy in pediatric palliative care: family-centered care to enhance quality of life. Am J Hosp Palliat Care. 2012;29:219-226.
12 Simpson K, Keen D. Music interventions for children with autism: a narrative review of the literature. J Autism Dev Disord. 2011;41:1507-1514.
13 Choi YK. The effect of music and progressive muscle relaxation on anxiety, fatigue, and quality of life in family caregivers of hospice patients. J Music Ther. 2010;47:53-69.
14 Romo R, Gifford L. A cost-benefit analysis of music therapy in a home hospice. Nurs Econ. 2007;25:353-358.
15 How to find a music therapist. American Music Therapy Association web site. http://www.musictherapy.org/about/find/. Accessed June 20, 2015. 16 Schmid W, Ostermann. Home-based music therapy – a systematic overview of settings and conditions for an innovative service in healthcare. BMC Health Serv Res. 2010;10:291.

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