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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

Use of Nebulized Morphine for the Management of Dyspnea

Dyspnea, or shortness of breath, is a very common complaint in hospice and palliative care. Up to 70% of end stage cancer or COPD patients experience dyspnea.1 Opioids, such as morphine, have been used to relieve the uncomfortable sensation associated with dyspnea. Oral and parenteral morphine are the most well studied routes of administration for this indication. Unfortunately, systemic absorption of opioids can cause adverse events that may be considered unbearable in the hospice population such as nausea, vomiting, drowsiness, constipation, and respiratory depression. Oral administration of morphine takes 15-30 minutes to take effect and lasts about four hours.2,3 While parenteral administration of morphine takes 6-10 minutes to take effect and also last about four hours. Inhaled opioids have a faster onset of action than the oral route and considered less invasive than the parenteral route.2

The use of nebulized opioids can be considered an appealing option compared to the oral and parenteral routes of administration. However, nebulized opioids are not routinely recommended. This is because there is conflicting data as to their benefit. There are no large-scale studies testing the efficacy of nebulized opioids, and smaller studies show conflicting evidence. Some studies show that nebulized opioids are less effective compared to oral or parenteral administration while others show that nebulized morphine is equally efficacious to subcutaneous morphine.1,4 Some patients are noted to prefer nebulized morphine over other routes of administration.4

A systematic review of 18 clinical trials that evaluated all routes of opioids in the management of dyspnea found a statistically significant benefit with the oral and parenteral routes of administration but found the nebulized route of administration to be no more effective than nebulized saline. However, the authors of this review did note that there might have been insufficient data with the nebulized route of administration to make this claim.8 Another review of 9 clinical trials looking at efficacy of nebulized morphine in the management of dyspnea found that 3 of the trials had positive results, but the rest failed to show improvement after treatment. The authors note that the small number of subjects, variety of disease states, and different outcome measures limited the interpretation of the results.9 Based upon these varying results, the use of nebulized opioids for the management of dyspnea are not routinely recommended. If you are going to consider a trial of a nebulized opioid, then it is recommended to use an injectable vial and not the oral morphine concentrate. A review of the literature will find no place where the oral concentrate has been evaluated and one article that directly states that the oral elixir should not be used.10 There is some belief that the sugar-free formulation of the oral morphine solution can be used via nebulizer, however, there is not literature to support this. It is of note that all current oral morphine solutions are sugar free and that the sugar containing oral morphine solutions are no longer on the market.7 There is some concern if the injectable vial needs to be preservative free for use via nebulizer. This concern comes from the fact the preservatives can induce bronchospasm in some patients. This is a rare but sometimes serious side effect. The preservatives of most concern are sulfites and edetate disodium (EDTA), found in both oral and parenteral preparations of morphine.5,6 It is not necessary to use preservative-free morphine, but caution should be used in patients susceptible to bronchospasms. If you are not using a preservative free product, then it is recommended to monitor your patient during the first administration of the nebulized opioid for this side effect. Typical starting dose for nebulized morphine is 2.5-10 mg; this can be titrated up to 30 mg per dose. Alternatives to morphine include hydromorphone 0.25- mg or fentanyl 25 mcg.1 Doses can be repeated every 4 hours as needed.3 Morphine for injection should be diluted to 2 mL volume with normal saline solution, if needed.1


Submitted by: Shawn Millsop, PharmD Candidate 2016 at Duquesne University School of Pharmacy and Lorin Yolch, PharmD, CGP, FASCP, Director of Professional Education at Delta Care Rx


References

1 Ferraresi V. Inhaled opioids for the treatment of dyspnea. Am J Health-Syst Pharm. 2005; 62: 319-320.

2 Bausewein C, Simon ST. Inhaled nebulized and intranasal opioids for the relief of breathlessness. Curr Opin Support Palliat Care. 2014; 8: 208-212.

3 Sarhill N, Walsh D, Khawarm E, Tropiano P, Stahley MK. Nebulized hydromorphone for dyspnea in hospice care of advanced cancer. Am J Hosp Palliat Care. December 2000; 17(6): 389-391.

4 Bruera E, Sala R, Spruyt, et al. Nebulized Versus Subcutaneous Morphine for Patients with Cancer Dyspnea: A Preliminary Study. J Pain Symptom Manage. June 2005: 29(6): 613-618.

5 Excipients in the label and package leaflet of medicinal products for human use. European Commission. http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/WC500003412.pdf Published July 2003. Accessed June 2, 2015.

6 Beasley R, Fishwick D, Miles JF, Hendeles L. Preservatives in nebulizer solutions: risk without benefit. Pharmacotherapy. January-February 1998; 18(1): 130-139.

7 Gold Standard, Inc. Morphine. Clinical Pharmacology [database online]. Available at: http://www.clinicalpharmacology.com. Accessed June 25, 2015.

8 Jennings AL, Davies AN, Higgins JP, Gibbs JSR, Boardley KE. A Sytematic Review of the use of Opioids in the management of dyspnoea. Thorax. 2002;57:939-44.

 9 Brown SJ, Eichner SF, Jones JR. Nebulized Morphine for Relief of Dyspnea Due to Chronic Lung Disease. The Annals of Pharmacotherapy. June 2005;29:1088-92.

10 Ahmedzai S, Davis C. Nebulised drugs in palliative care. Thorax. 1997;52(Suppl 2):S75-77.

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Shane Donnelly, PharmD

Prescription Drug Misuse, Dependence, and Abuse in the Elderly

Older adults are often left out of the discussion when it comes to prescription drug misuse, dependence, and abuse. Prescription drug abuse is an epidemic in this country, and it’s not just confined to the younger patient population. It is estimated that 11% of elderly patients abuse prescription medication.1

The elderly consume roughly one quarter of the prescriptions sold in the United States.1 Elderly patients often have chronic pain, anxiety, or insomnia that requires the use of potentially addictive medication. Additionally, elderly patients may not be adequately treated with their current therapies. These risk factors, along with social isolation, depression, and limited functionality, make the geriatric population particularly at risk for substance misuse and abuse.

Providing safe and effective care for elderly patients requires that signs of prescription misuse, dependence, and abuse are recognized quickly. The medications that are often abused can lead to events such as falls and accidents that require these patients to be admitted to inpatient units or nursing homes. To effectively manage prescription medication misuse and abuse in this population, the definition of substance misuse, dependence, tolerance, and abuse should be addressed.

Misuse- Prescription medication misuse is the improper taking of medication by the patient. It is most commonly by accident, but can also be intentional. Assess your patient’s ability to take medication correctly. It may be necessary to provide pharmaceutical education to your patient.  Examples include.2

• Taking medication differently than directed on the label due to poor eyesight or reading ability

• Doubling up on doses

• Borrowing medication from friends or family members

• Acquiring medication online to treat self-diagnosed conditions

Physical dependence and Tolerance- Physical dependence evolves from the continued regular use of a substance that results in withdrawal symptoms upon discontinuation. Tolerance to medication occurs when patients need higher doses of medication to achieve adequate symptomatic relief. Patients with physical dependence and tolerance may display drug-seeking behavior that can be misconstrued as psychological dependence (addiction).2 Assess the patient’s current condition and medication profile. The patient’s therapy may be inadequate due to tolerance or lack of efficacy. Communicate concerns with the patient’s physician. The patient may then cease to engage in drug-seeking behavior.

Psychological dependence (addiction)- Psychological dependence is a state that demonstrates loss of control and/or compulsive drug-seeking behavior.3 These patients engage in medication use despite the potential for adverse consequences. These patients need professional help to overcome both physical and psychological dependence. At this point, it is important to understand that these patients are potentially putting themselves and others in immediate danger.

In hospice, it is rare for a patient to become psychologically dependent on medication. It is important to be aware of any signs of substance abuse among family members or caregivers. Recognizing signs of caregiver abuse is important to protect patients and provide the best possible care for the end-of-life stage. It’s important to listen your patient’s concerns regarding their medication and to assess the root cause of medication discrepancies.


References:

1 Culbertson JW, Ziska, M. Prescription drug misuse/abuse in the elderly. Geriatrics. 2008; 63(9): 22-31.

2 Agins, A. Prescription drug abuse: from bad to worse. CEdrugstorenews.com March/April 2012. Retrieved July 5, 2012 at: http://www.cedrugstorenews.com/userapp//lessons/lesson_view_ui.cfm?lessonuid=401-000-12-201-H01.

3 American Psychiatric Association. Diagnostic and Statistical Methods of Mental Disorders (Fourth Edition, Text Revision). Washington, DC: American Psychiatric Association. 2000;199-273

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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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Holly Lassila, DrPH, MSEd, MPH, RPh

Domains of Wellness

What is Wellness? Merriam Webster defines wellness as “the quality or state of being healthy”. The definition of “wellness” in Mosby’s Medical Dictionary is “the dynamic state of health in which an individual progresses towards a higher level of functioning, achieving an optimum balance between internal and external environments”. In general, wellness means overall well-being and from a holistic perspective, wellness incorporates the dimensions of mental, emotional, physical, occupational, intellectual, and spiritual aspects of a person’s life. Each of these dimensions acts and interacts in ways that contribute to our quality of life.

Physical Wellness: A healthy body maintained by good nutrition, regular exercise and avoiding harmful habits.

Intellectual Wellness: A state in which our mind is open to new ideas and experiences and is engaged in the interaction with the world around us. This dimension includes the desire to learn new concepts, improve skills and seek challenges in pursuit of lifelong learning.

Emotional Wellness: The ability to understand our own feelings and cope with the challenges which life brings. Emotional wellness implies the ability to express emotions appropriately, adjust to change and cope with stress in a healthy way.

Social Wellness: The ability to relate and connect with others. Social wellness is our ability to establish and maintain positive relationships with family, friends and co-workers. Spiritual Wellness: This dimension is the ability to establish peace and harmony in our lives. It implies that life is meaningful and has a purpose and the ethics, values and morals that guide us given meaning and direction to life.

Occupational Wellness: The ability to get personal fulfillment from our professions or chosen career fields while maintaining balance in our lives. Occupational wellness means having commitment to our occupations that is satisfying and rewarding.

Environmental Wellness: The ability to recognize our own responsibility for the quality of the air, the water and the land that surrounds us.

In our own self-assessment and self-evaluation of the above dimensions we often discover certain dimensions that are balanced and others that we can improve on. Wellness is an active, lifelong process of becoming aware of choices and making decisions towards a more balanced and fulfilling life.

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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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