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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.
Delta Campus Pharmacy Student

Tube Feeding Considerations in End of Life Care

Enteral feeding tubes may be helpful for nutrition support in patients that cannot eat but have a working gastrointestinal tract. Administering medication in these tubes is useful for patients that cannot take it another route, but issues can arise. This article discusses some factors that can affect medications given this route and ways to avoid common issues related to administration down a feeding tube.

The placement site of the tube can alter the medication efficacy. Most oral medications are absorbed in the small intestine. Some medications, for example antacids, sucralfate, and bismuth, act locally in the stomach and would provide minimal benefit if administered in a tube that bypasses the stomach. In addition, if medications that rely on extensive first-pass metabolism, such as opioids, beta-blockers, or tricyclic antidepressants, are administered in a tube that ends in the jejunum, they will have increased absorption and greater efficacy possibly leading to more adverse effects. First-pass metabolism is a result of the drug entering the liver after absorption in the gut resulting in much of the drug being metabolized before reaching the systemic circulation. This is taken into consideration when dosing this type of medication and if it is bypassed, by administering into the jejunum, it leads to a higher concentration of drug than intended

The tube size also plays an important part in deciding medication administration. Small bore tubes are more comfortable for the patient but are more likely to clog, especially with medication administration. Only liquid medications should be used in a Dobhoff tube to prevent clogging. Large bore tubes are less likely to clog, but it is important to know that if the tube is being used for suctioning, medications should not be given down that tube because they might be removed before absorption.

Medications should not be administered or mixed with tube feedings because they can interact and lead to negative effects. Phenytoin is the most well-known medication in this situation, decreasing blood levels of the drug up to 75% when administered with tube feeds. It is recommended to hold feedings 2 hours before and after each dose if possible. Warfarin efficacy is reduced when administered through a feeding tube and INR should be monitored more closely. Other medications can form precipitates with tube feedings, such as iron supplements and sucralfate. Liquid medications prepared as syrups can be acidic and denature proteins in the feeding, causing clumps and leading to clogs.

Liquid dosage forms are the preferred form for enteral administration of medications. Suspensions and elixirs are preferred over syrups because they are less likely to clog. Many liquid preparations contain large amounts of sorbitol which can cause GI upset or diarrhea. There are also liquid medications with high osmolality, above 1000 mOsm/kg, which will draw water into the GI tract and lead to cramping, diarrhea, or vomiting. A few examples of medications with high osmolality include acetaminophen elixir, cimetidine solution, metoclopramide hydrochloride syrup, and lithium citrate syrup.

Medications that should not be crushed include tablets that are controlled-release, enteric-coated, teratogenic, or irritants. Disrupting the controlled-release mechanism can cause toxic blood levels of the drug and enteric-coated drugs do not crush well and when mixed with water will bond together creating a clog. If the medication is teratogenic it should not be crushed for the safety of the staff. Capsules with microencapsulated pellets, such as Depakote Sprinkle and Effexor XR, can be opened and the pellets can be administered in large bore feeding tubes.

The tube should be flushed with a small amount of water both before and after medication administration. Flushing helps prevent clogs and interactions between different medications or tube feeds. Also, if medications are scheduled to be administered at the same time, they should not be given down the tube at the same time but rather administered separately while flushing the tube in between each medication. This is important because medications can precipitate or interact if given together increasing the risk of clogs or decreasing efficacy. Also, it is recommended to hold feeding for 30 minutes before and after the medication is administered if it requires administering on an empty stomach and the tube ends in the stomach. No holding is required if the tube ends in the intestine rather than the stomach.

If clogging does occur it is recommended to intervene as soon as possible by flushing with warm water. It is not recommended to try flushing with acidic liquids, such as soda or cranberry juice, because it has not shown to be more effective than water and might compound the issue by precipitating proteins from the feedings. Instead, an alkalized enzyme solution should be used. It is prepared by crushing one sodium bicarbonate 324mg tablet and one pancrelipase tablet mixed together with 5mL of water.

Overall, medication use in feeding tubes can be complicated with many different factors involved. Problems such as clogged feeding tubes and disruption of medication efficacy negatively affect both the patient and the staff. It is important to recognize why these problems can occur and to follow proper administration guidelines to prevent them in the future.


Submitted by: Alexander Fringes, PharmD Candidate 2016


References:
1. PL Detail-Document. A Stepwise Approach: Selecting Meds for Feeding Tube Administration. Pharmacist’s Letter/Prescriber’s Letter. June 2014. 
2. Williams NT. Medication administration through enteral feeding tubes. Am J Health-Syst Pharm. 2008; 65(24): 2347-57. doi: 10.2146/ajhp080155.
3. Beckwith CM, Feddema SS, Barton RG, Graves C. A Guide to Drug Therapy in Patients with Enteral Feeding Tubes: Dosage Form Selection and Administration Methods. Hosp Pharm. 2004; 39(3): 225-37.
4. Emami S, Hamishehkar H, Mahmoodpoor A, Mashayekhi S, Asgharian P. Errors of oral medication administration in a patient with enteral feeding tube. J Res Pharm Pract. 2012; 1(1):37-40. doi:10.4103/2279-042X.99677.

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Irene Petrides, PharmD

Oral Hygiene in End of Life Care

Oral mouth discomfort is often seen in advanced illness and this can strongly affect quality of life. It is therefore important to keep a close watch on a patient’s oral hygiene and make it a priority in the plan of care. Oral health issues can include but are not limited to dysphagia, nutrition and taste problems, thick mucus, difficulty speaking, denture related issues, nausea and vomiting, stomatitis, hypersalivation, mucositis, thrush, and xerostoma.1

Assessment of the patient’s self-care ability is the first step. This will help determine the level of support a patient a will require. Not all patients need full care, a simple reminder or assistance by a caretaker may provide a basic approach in order to stay on the right path of the daily oral regimen. Once a care plan is established, there are measures that can be taken in order to avoid complications which include using a soft toothbrush, avoid mouthwashes that contain alcohol, rinse with saline or soda water, or use moist gauze to wipe cheeks after each meal.2,7 In addition, it is imperative to review medications in order to rule out any undesired oral mucosa effects associated with medication therapy.1 The goal is to maintain optimal oral hygiene with minimal discomfort. Most of the time a proactive approach is desired however in hospice we are often using a palliative oral care approach in symptoms that already exist. Once preventative and standard oral hygiene procedures have been properly assessed and addressed, it may become necessary to treat common complications.

Mucositis is a painful condition that often presents as red or white lesions in the mucosal lining of mouth, pharynx and digestive tract. In the late stages it is associated with fibrosis of connective tissue and hypovascularity. It is most often seen in patients who have received toxic chemotherapy and radiotherapy in head and neck cancer.1,6 Palliative treatment includes viscous lidocaine 2%, combination oral rinse (lidocaine, diphenhydramine, sorbitol and Mylanta), and chlorhexidine gluconate.1

Oropharyngeal Candidiasis (oral thrush) is a condition where white patches can be located in the mouth, inner cheeks, throat, palate and tongue and also is associated with pain. The tissue under the white patches is often raw and sore. The patient may have bad breath, unpleasant taste in the mouth, or dry mouth. Medications that can cause thrush include corticosteroids, antibiotics, and chemotherapy. Patients who have a higher prevalence of candidiasis are those who have cancer, HIV, uncontrolled diabetes, and smokers.3,7 Treatment includes antifungal mouthwash (nsystatin) or lozenges (clotrimazole). Administration of systemic fluconazole or itraconazole may be necessary in the management of more severe cases.1 It is important to remember that if a patient wears dentures they must also be treated separately with antifungal mouth rinse.5

Xerostoma is a symptom referring to dry mouth. Nearly 75% of hospice patients are affected by xerostoma, which is the most common cause of malnutrition in palliative patients. It is often associated with difficulty chewing, altered taste burning sensation, and thick saliva.1,3 Causes of xerostoma may include dehydration, vomiting or diarrhea, medications with anticholinergic activity, benzodiazepines and opioids, radiation, HIV/ AIDS, diabetes, renal failure, and Sjogrens syndrome.1,3 Treatment includes oral hydration such as humidifiers, stimulating salivary reflexes with medications like xylitol, administration of the cholinergic agonist pilocarpine, or using saliva substitutes such Biotene®.

Hypersalivation also known as sialorrhea is an increase in salivary flow. Patients who have neurological conditions such as Parkinson’s disease or amyotrophic lateral sclerosis may find it difficult to manage hypersalivation. Often medications are contraindicated in the treatment due to the side effects associated with anticholinergic drugs. If the patient’s quality of life is affected, anticholinergic medications such as atropine, glycopyrrolate, or scopolamine can be used.1

Dysphagia, or difficulty swallowing effectively, is a common symptom seen in hospice care. Food debris and saliva accumulate in the oral cavity which can increase bacterial growth. Inadequate oral hygiene at this point in care may increase the patient’s risk of developing aspiration.4 Therefore dysphagia may not only have a negative impact on oral health but also on the systemic health of a hospice patient. Despite minimizing debris in the oral cavity with adequate oral hygiene other preventative measures are necessary in order to avoid undesired complications. The most common non-invasive approaches include pleasure feeding, pureed diet, and crushing medications.1,4

Awareness of oral hygiene in the hospice patient should be an extension of the palliative care plan. Identifying oral health barriers, preventing major complications and treating oral conditions is the mainstay of managing oral hygiene. In conclusion comfort care and palliative treatment are established in oral care if a patient can eat and drink adequately with minimal pain or discomfort.


References:

1. Mulk BS, Chintamaneni RL, Mpv P, Gummadapu S, Salvadhi SS. Palliative Dental Care- A Boon for Debilitating. Journal of Clinical and Diagnostic Research : JCDR. 2014;8(6):ZE01-ZE06. doi:10.7860/JCDR/2014/8898.4427.

2. Chen X, Chen H, Douglas C, Preisser JS, Shuman SK. Dental treatment intensity in frail older adults in the last year of life. Journal of the American Dental Association (1939). 2013;144(11):1234-1242.

3. Alt-Epping B, Nejad RK, Jung K, Groß U, Nauck F. Symptoms of the oral cavity and their association with local microbiological and clinical findings—a prospective survey in palliative care. Supportive Care in Cancer. 2012;20(3):531-537. doi:10.1007/s00520-011-1114-z.

4. Gallagher R. Swallowing difficulties: A prognostic signpost. Canadian Family Physician. 2011;57(12):1407-1409.

5. Saini R, Marawar P, Shete S, Saini S, Mani A. Dental Expression and Role in Palliative Treatment. Indian Journal of Palliative Care. 2009;15(1):26-29. doi:10.4103/0973-1075.53508.

6. Davies, Andrew, and Ilora G. Finlay, eds. Oral care in advanced disease. Oxford University Press, 2005.

7. O’Reilly M. Oral care of the critically ill: a review of the literature and guidelines for practice. Australian Critical Care. 2003;16(3):101-110. doi:10.1016/s1036-7314(03)80007-3.

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Lori Osso-Connor, PharmD, CGP

Role of Warfarin in Hospice and Palliative Care

Patients who make the hospice choice have opted for comfort measures and are no longer seeking life sustaining treatment. However, as hospice professionals encounter daily, many patients are admitted on medications that are considered treatment and are used for curative measures and not palliative measures.

The risk for thromboembolism in hospice and palliative care patients increases due to advanced age and diagnoses such as cancer or cardiomyopathy. Warfarin (Coumadin®) is indicated as treatment to prevent clotting in atrial fibrillation, thromboembolic disease, and artificial heart valves. It is a medication that poses a clinical challenge on whether to continue or discontinue when the patient becomes hospice appropriate. Warfarin’s mechanism of action is to inhibit Vitamin K epoxide reductase which decreases the Vitamin K in the body and decreases clotting. While warfarin is typically indicated as treatment, it could be argued that it is used in hospice and palliative care to provide comfort by reducing the risk of pain and swelling in the extremities due to DVT, unilateral weakness, or paralysis related to stroke.

However, there are several arguments that can be made to support the discontinuation of warfarin in hospice and palliative care. Some issues to consider include:

• The use of warfarin requires PT/INR lab work to ensure therapeutic efficacy. Studies have shown that hospice and palliative care patients require more frequent INR monitoring. These blood draws may be undesirable to the patient and or caregivers at this point in care. Additionally, poor venous access may make obtaining the blood difficult.

• Warfarin is a medication that has many drug-drug interactions including many antibiotics and drug-dietary interactions which could pose unnecessary complications to the patient. Some examples of drug–drug interactions with warfarin in which the anticoagulant effect is increased include levofloxacin (Levaquin ®), sulfamethoxazole/ trimethoprim (Bactrim ®), prednisone, and NSAIDS. In addition, Vitamin K rich foods may decrease the effects of warfarin. Therefore, it is most important to keep a consistent type diet.

• As intake declines or is erratic, the dietary vitamin K may fluctuate which could increase the risk of a bleed or clot.

• Nausea and vomiting could impact the medication adherence which may alter INR due to drug interactions.

• When a dose is changed, it takes 5-6 days to take full effect. If the PT/INR is not carefully managed, it leads to additional increases or decreases in the dose and a myriad of additional blood draws.

• The risk of an intracranial hemorrhage in a debilitated ambulatory patient who may fall is greater than the benefit in preventing a stroke.3

• The risk of a GI hemorrhage is about 8%.1

• The 1-year risk of stroke in atrial fibrillation is 2% in patients treated with warfarin and 4% in those untreated.1

Do the benefits of continuing outweigh the risks? Some factors to consider when facing this decision include: indication, prognosis, bleeding risk, thrombosis risk, nutritional status, appropriate monitoring, medication adherence, medication changes, and patient/family preferences. It is also important to consider whether a new clot will impair the patient’s function or quality of life. As one can see, the choice to discontinue warfarin is a difficult one and is not always clear cut. The risks verse the benefits in each patient must be assessed in accordance with the family and patient’s goals. This individualized approach will help the hospice care professional determine whether the benefits outweigh the risks to the patient and make an appropriate choice.


References:

1. Allen, Richard. “10 Drugs to Reconsider When a Patient Enrolls in Hospice.” NHPCO Newsline(2014): 5.

2. Hill, Robin, Kerri Martinez, Thomas Delate, and Daniel Witt. “A Descriptive Evaluation of Warfarin Use in Patients Receiving Hospice or Palliative Care Services.” Journal of Thrombosis and Thrombolysis 27.3 (2008): 334-39.

3. Von Gunten, Charles, David Weissman, and Janet Abraham. “Fast Fact #278 Warfarin and Palliative Care.” #278 Warfarin And Palliative Care. Web. 26 Feb. 2015

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Char Cole, PharmD, CGP

Impact of Bariatric Surgery on End of Life Care Symptom Management

Obesity is a growing concern in the United States. There are three major types of bariatric surgery done in the United States to combat the obesity problem.

1. Vertical Banded (Stapled) Gastroplasty

2. Adjustable Gastric Banding

3. Roux-en-Y Gastric Bypass

Weight loss occurs by causing malabsorption or by restricting gastric volume or a combination of both. Banding procedures limit the amount of intake, whereas the Roux-en-Y procedure not only reduces the stomach size, it also changes the site of attachment of the small intestine. The Roux-en-Y procedure bypasses the lower portion of the stomach and a much smaller stomach pouch (15-30 mL capacity) is created, then the small intestine (the entire duodenum and part of the proximal jejunum) is removed from the lower stomach and attached to the newly formed stomach pouch. This procedure reduces the surface area that is available for absorption of nutrients and medications.

Different medications have different requirements for absorption and ultimately effectiveness. Medications in aqueous solution are more rapidly absorbed then those in oily solutions. Medications are soluble at different pH levels. Different medications that are more soluble at acidic pH are absorbed in the stomach, whereas medications that are more soluble at alkaline pH are absorbed in the small intestine. Intestinal enzymes are also necessary for the absorption of some medications. The Roux-en-Y Gastric Bypass can alter medication absorption.

Reducing the amount of time needed for absorption of the medication is essential for safe and effective use of medications. The formulation of the medication can be sufficient to reduce the amount of time needed in the stomach/small intestine for absorption. When possible the use of pills that can be crushed should be considered, as well as liquids, subcutaneous, intravenous, rectal, vaginal, intranasal and transdermal formulation and/or routes of administration should be considered. Avoid or use with caution any medication that has a long stomach absorptive phase.

Oral non-steroidal anti-inflammatory drugs (NSAIDs), salicylates and bisphosphonates should be avoided. These medications can cause or increase the potential of the patient to develop ulcers in the new much smaller stomach and/or reduced small intestines in all types of bariatric surgery. If the use of these medications are essential, then consider alternative routes of administration such as topical or injectable. Delayed release preparations of all medications such as CR, SR, XR, LA, EC, etc. should be avoided in Roux-en-Y Gastric Bypass.

Pain management in end of life care is essential. The use of MS Contin or morphine ER should be avoided in patients that have had a Roux-en-Y Gastric Bypass. Due to the reduced surface area of the gastrointestinal tract, the use of immediate release formulations would be a better alternative to extended release preparations. The use of immediate release formulations or non-extended release formulations may require a more frequent dosing schedule; however the Roux-en-Y bypass patient will be more apt to achieve more consistent pain management.

It is important to inform all healthcare providers of a patient’s bariatric surgical history if it exists as this will alter the medication therapy chosen for the patient. The length of time the patient is status post bariatric surgery has no impact to the medication therapy consideration. Once a patient has had bariatric surgery, medications will always need to be adjusted to take into account the changes made to the gastrointestinal tract through the bariatric surgery and how this will alter the absorption of medications. All medication therapies chosen for a bariatric surgery patient should be evaluated for effectiveness and for the increased potential for side effects if the proper monitoring is not done.


References:

1. Vanhoose K. Medication Absorption after Gastric Bypass. Advance Healthcare Network for NPs and PAs. www.ADVANCEforNPs\&Pas\_PrinterFriendly.htm

2. Rogula T, Schauer P. Medications after Bariatric Surgery. www.Medicationsafterbariatricsurgery.htm

3. Miller AD, Smith KM. Medication and Nutrient Administration Considerations after Bariatric Surgery. AM J Health Syst Pharm.2006;63(19):1852-1857.

4. Lawrecki T. How is drug absorption altered by bariatric surgery? University of Illinois Chicago College of Pharmacy

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Michelle Mikus, PharmD

Death with Dignity: An Overview & Legislative Update

Death with Dignity has become a household phrase since People magazine published young Brittany Maynard’s story concerning the issue. As a result of her emotional experience and story, Death with Dignity and “right to die” proponents all over the country have been refueled to get bills passed and laws put in place giving certain terminally ill patients the choice to end their own lives. Working in their favor are five states that already allow patients the right to die: Oregon (law passed in 1994), Washington (2008), Montana (2009), Vermont (2013), and New Mexico (2014). It should be noted that in both Montana and New Mexico a court case must be involved before being deemed lawful. Because of this, there is not much utilization.

In the three states that have laws allowing physician assisted suicide, certain criteria must be met in order to receive a prescription for the necessary medications:

1. Patient must be a resident of Oregon, Washington, or Vermont.

2. Patient must be 18 or more years old.

3. Patient must be capable of making health care decisions for themselves.

4. Patient must be diagnosed with a terminal illness that will result in death within six months.

5. Two physicians must evaluate that all above criteria is met.

In addition to all criteria being met, there are waiting periods before some of the steps can be accomplished. This includes the longest waiting period of 15 days between the first and second oral requests to the physician. In addition, there is a 48-hour waiting period before the prescribed medications can be picked up at a pharmacy.

In December of 2014, Medscape published an ethics report focused on “Life, Death, and Pain” that was given to 21,531 physicians in both the US and Europe. The very first question was “Should physician-assisted suicide be allowed?” The results in favor of allowing this were 54%, which is an 8% increase since the 2010 survey asking the same question (statistics from the US physicians only). Not far off from these physician results are results from a recent Gallup poll, in which 58% of Americans answered in favor of physician assisted suicide and 7 out of 10 were in favor of euthanasia for terminally ill patients.

Many states have legislation in the works to allow Death with Dignity acts similar to Oregon’s. States include: Connecticut, Hawaii, Kansas, New Jersey, and Pennsylvania. In 2012 Massachusetts voters blocked a right to die act with 51% against the act and 49% in favor. In early 2014, the New Hampshire House of Representatives rejected a bill that would allow such a law. Legislators in Colorado plan to introduce a bill in the 2015 session that would make physician assisted suicide legal.

There are many arguments both for and against laws allowing physician assisted suicide. However, regardless of opinions, it cannot be ignored that it is a hot topic and there will continue to be legislation throughout this coming year regarding the subject. Join us for a Brainy Brunch in December of 2015 to take a closer look at physician assisted suicide and the most recent news surrounding the topic.


REFERENCES:

1. Death with Dignity Across the U.S. Updated November 13, 2014. http://www.deathwithdignity.org/advocates/national. Accessed December 20, 2014.

2. Eckholm E. New Mexico Judge Affirms Right to ‘Aid in Dying.’ The New York Times. January 13, 2014. http://www.nytimes.com/2014/01/14/us/newmexico-judge-afirms-- right-to-aid-in-dying.html?module=Search&mabReward=relbias%3Ar&_r=0. Accessed December 20, 2014.

3. Kane, L. Medscape Ethics Report 2014, Part 1: Life, Death, and Pain. December 16, 2014. http://www.medscape.com/features/slideshow/public/ethics2014-part1. Accessed December 20, 2014. 

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