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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.
Mary Mihalyo B.S., PharmD, CGP, BCPS

Hospice Nurse Fellow Spotlight: Deanne Sayles, R.N., MN, CHPN, FPCN

mary deanne drewRecently, I enjoyed reconnecting with colleague Deanne Sayles, R.N., and learning of her receipt of the honor of Hospice Nurse Fellow from the Hospice and Palliative Nurses Association. Deanne and I created a presentation called “Interdisciplinary Medication Management for Hospice” for the 2013 NHPCO Clinical Team Conference and a webinar for our Brainy Brunch series in 2012 on Pediatric Hospice and Palliative Care. She’s an exceptional collaborative partner, with particular insights about the provision of hospice pharmaceutical care from the nursing perspective. This article features highlights drawn from a recent conversation about the importance of collaboration between pharmacists and nurses when caring for patients.

Deanne, why would you say this designation is important to the hospice nurse profession?

The recognition is important within a team or in a company, as it means they are selective and that there’s someone on their team who has achieved the highest honor in hospice and palliative nursing. You see the importance of that kind of thinking every day, Mary, in Delta Care Rx’s commitment to have excellent, high quality nurses working alongside excellent, high quality pharmacists.

So you see pharmacists and nurses as care team partners?

Yes. The knowledge a hospice and palliative care nurse offers to the team includes caring for patients across care settings, whether at home or in inpatient settings such as nursing homes. That insight helps the Delta Care Rx pharmacist understand what it’s like to be at the bedside when someone on the team reaches out for assistance.

Delta Care Rx offers continuing education training to hospice and palliative care nurses. Why should nurses consider pharmaceutical care related topics for furthering their knowledge?

You’ll find that the bulk of education and product training aimed at nurses focuses on delivering care and administering medications to the patient. When patients are cared for at home, those medication teachings sometimes need to be supplemented by the expertise of the Delta Care Rx pharmacist during a consultation or webinar education.

What are some of the greatest challenges hospice and palliative care nurses face while working in the field?

When patients live a great distance from town, and pharmacies can’t deliver… Delta Care Rx, for example, overcomes this barrier to care by shipping medications quickly and without non-transparent added costs. But in severe pain cases, or during severe weather such as a blizzard in mountainous regions, the nurse may need to ensure the medication gets there by other creative means. That’s a situation that occurs rarely, but nurses are committed to finding solutions for their patients. Another great challenge is the rigorous, frequently changing regulatory scrutiny hospices experience. The documentation requirements put a lot of pressure on nurses to deliver care quickly and efficiently. Additionally, compassion fatigue and lack of self-care drain the nurses’ empathy banks. We need to address the continual “giving” burden that nurses experience by identifying and using ways to re-charge.

You are a nurse, but also a consultant. How did you find your niche?

Quality client services require a certain level of expertise in hospice and palliative learning. When I help other nurses acquire those skills, they can offer the best support to patients and families. That’s my focus: helping nurses give the best quality care to their patients. I also focus on helping hospice agencies train and educate their staff on best clinical practices in hospice and palliative care.

What about nurses who are new to hospice care?

Nurses need to carefully prepare for each visit, which includes a thorough review of the medications listed on the patient profile. I strongly recommend they have a mentor with whom they debrief, at least monthly. This work is very intense. Most of us need to bounce patient cases off someone else to help deal with our own feelings. We are unable to help people manage grief, unless we’ve dealt with our own.

From this perspective, how should hospice nurses best work with pharmacists in patient care?

It’s incumbent upon the nurse to study medications, know what medications are and what they do, to discuss and observe side effects with patients and families. The nurse manages medications, notes side effects, and requires ready access to a medication management expert. The pharmacist is that expert. Having a hospice PBM on board with consulting availability is ideal; the nurse can be at the bedside of a patient and consult a pharmacist while observing symptoms.

How would you explain this relationship to a pharmacist or nurse new to the field?

It works like this: Nurses pick up the phone and reach out to pharmacists as needed. With a new patient, the medications get organized; with an existing patient, the nurse knows when medications change. It’s his or her job to monitor patients for therapeutic responses to medications and adverse experiences. In turn, the pharmacist provides recommendations and expertise in medication management so that care can be delivered safely and effectively.

The nurse brings those recommendations to the hospice physician and interdisciplinary team. Ultimately, it is the responsibility of the hospice physician to use the information provided to make a decision in prescribing. This is how pain and symptom management issues get resolved.

How do you feel about receiving the hospice nurse fellow recognition?

It was absolutely mind-blowing to be in the room. The board of directors held a reception for the 11 new fellows. One of the nurses was someone I had worked with in AIDS care back in the 1980s. There was a wide range of expertise. We’re functioning as a mini-team now, setting up phone conferences and brainstorming about how we wish to contribute to the Hospice and Palliative Nurses Association and the future of the profession.

Mary Mihalyo, PharmD, is the CEO of Delta Care Rx.

About Deanne Sayles, R.N.

Deanne Sayles, R.N., received Hospice Nurse Fellow recognition in January 2017. She has cared for the terminally ill since 1979, experiencing life-limiting disease across care settings, and managed protocols for both curative and palliative pharmaceuticals at a large pharmaceutical company for 7 years. In 2010, she founded the first local chapter of the Hospice and Palliative Nursing Association. Since 2003, her consultancy focuses on elevating patient and family experiences through quality hospice and palliative care nursing.

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Drew Mihalyo, PharmD

Notes from the @AAHPM #Twitter Board: A Pharmacist’s Reflections on #hpm17

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Self-reflection is a powerful tool for integrating the experiences and messages of the spring conference of the American Academy of Hospice and Palliative Care. As President & COO of Delta Care Rx, I met a lot of people, many of whom I hope to speak with again at the National Hospice and Palliative Care Organization’s 32nd Annual Management & Leadership Conference in April.

Here is my “Top 5” idea list, supported by the wise words of a range of colleagues who said it best on the event’s public Twitter Board using #hhpm17. I look forward to learning more in the days ahead.

#1 – We’re educating “Policymakers” every day

The clinicians attending – doctors, nurses, pharmacists, and advanced students – offer vital contributions to a nation with a rapidly aging population. Hospice care made its debut almost half a century ago, but we may at times find we’re still educating policymakers about palliative care, hospice, and professional practice.

End of life care issues have gained new traction due to recent political rhetoric. I recently cut through the noise of the Aid In Dying debate to suggest proactive approaches for pharmacists. Here, Andi Chatburn shares a statement by Mark Ganz, responding to public remarks made by Senator Paul Cruz:

Thoxbee Me replaces it with a simple message and clear defining characteristic, which supersedes politics.

The practitioner versus clinician debate is tied directly to the way professionals are perceived by the public and lawmakers. Thomas W. LeBlanc and Drew Rosielle hone in on a possible strategy for the way professionals might choose to refer to themselves and their roles.

#2 – Effective, affordable pain management is integral to palliative care and patient quality of life.

A lot of the conversation coming out of the conference focused on the use of opioids and dose tapering. As a pharmacist, this was a topic that I certainly found interesting. At Delta Care Rx, colleagues and I are part of this discussion with Physicians and Nurses who utilize our On Demand Pharmacist Services (ODPS). These services supplement an interdisciplinary approach regarding Conditions of Participation, or complaint medication management.

Colleague Sarah Scott Dietz kindly provided a photo of the summary on opioids presented at the conference, and it provides context for the discussion around these specific class of medications, as listed below.

Admittedly, I’m relatively new to Twitter as a live platform for sharing information across the discipline. I’ll share a few of those posts that had relevance for me here. The first set of responses focused on pain management options in a positive vein.

Methadone: “I love methadone” most common phrase heard at our exhibit. (Virtual Hospice)

Midazolam: “Intranasal and buccal midazolam – safe, effective and inexpensive in treating seizures! Better than lorazepam/diazepam,” (Armida Parala Metz)

Levorphanol: “treatment for phantom pain” (Marvin Delgado-Guay); “can you even get levorphanol? I tried 1 or 2 years ago. Got blanked,” from Dr. The Frog, aka Skip Bidder. Akhila Reddy MD notes “Levorphanol available now but have to pre-order it, expect pharmacy to take 2 to 3 days to get it.” Levorphanol is a “forgotten opioid” (Marvin Delgado-Guay) and “more education and research needed.”

Cannibis: "I do know that no one dies of a marijuana overdose because there are no cannabanoid receptors in the brainstem." (Courtney Simmons)

Naloxene kit: “If your patient is on opioid & benzo consider ordering a naloxone kit-will need PA may have to pay out of pocket, talk with their pharm.” (Kimberly Curseen)

Other pain management options were treated with more skepticism, with posts of the Pharm Ladies seminar by attendee Courtney Simmons.

Codeine: “We should just vote codeine off the island.”

Sufentanil: “…not impressed with sufentanil, think best use may be on the battlefield or other places we can’t give parenteral.”

Amtiza: “Post marketing warning for syncope and hypotension. …warning of high cost & not much better efficacy.”

Kratom: “Can produce opioid effect with abuse, being rescheduled as C-1. Currently an herbal.” (a relative of the coffee plant)

Documentation processes were found to be critical for success. Being able to collect prescribing data is a must when defining a path forward. While many organizations have access to reports that help with this documentation or tracking of patterns, often the actual prescribing information is lacking granularity that can be instead accessed on the front end (of the ordering process) when e-Prescribing technology is utilized to the fullest extent. Shireen Heidari expressed the need for thorough documentation at a GIP level, saying:

#3:Starting with the telephone call, possible transition to tele-health technology or telemedicine options are the way of the future in some care scenarios.

 

LeBlanc offered a caution that the way ahead for #palliativecare is patient needs, not prognosis. Shirley Otis-Green and Kyle Edmonds suggest the need for data-driven decision making within the field.

#4. Inter-professional education for pharmacists, nurses, and care teams will develop communicative leaders offering patients a range of skill sets and abilities.

Socialization, mentoring, internships, curriculum design, and human sources of inspiration will fuel professional commitment within the growing field.

 

I read with particular interest the discussion of curriculum for interns, fellows, and other clinicians entering the field. Delta Care Rx offers a comprehensive internship program for pharmacists in our Pittsburgh, PA area offices via our Delta Campus educational program. We have also support the next generation of both nurses and pharmacists via collaborative efforts with clients of ours in their local communities.

The curriculum in each case offers exposure to the very important  interdisciplinary care team and student-mentor approach. We see a continuous call to action for these types of learning initiatives from AAHPM members. Last year, we partnered with Four Seasons Compassion for Life in North Carolina to develop a similar curriculum for nurses entering hospice and palliative care professions. You can learn more online about that in our news release and a magazine feature.

Once operating in our profession, the next generation is inspired by leaders in the field and their interests are encouraged in special interests groups.

#5. Palliative Care professionals require self-nurturance for long term success.

The best “medicine” for caregivers does not come in a bottle, but instead: time in nature, inner work, the desire to transform, self-awareness, cultural reflection, and self-care.

 

Finally, we welcome the feeling of satisfaction that comes from learning/growing personally and professionally (while celebrating the lives we touch).


Drew Mihalyo, PharmD is Founder, President, and COO at Delta Care.

About Delta Care:
Delta Care – http://www.deltacarerx.com/, transforms and improves the hospice pharmacy industry through business transparency, innovation, extreme customer service, and the maintenance of vital community-pharmacy relationships. As a pharmacist owned, privately held provider, Delta Care sets the industry benchmark for pharmacy benefit management, on-demand pharmacist services, and hospice tailored electronic prescribing. Additionally, Delta Care offers tools and technologies to simplify essential workflow and ordering processes within hospice settings.

DCRx Logo Partnership 300dpi JPG

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Drew Mihalyo, PharmD

What Do You Need to Know About State Opt-out Provisions, Access and Costs?

mortar 321795 1920A January 2017 article in the New York Times suggests concerns for pharmacists in the hospice care sector concerned with “aid in dying” impacts on practice and care

Last month, the New York Times ran an article, “Physician Aid in Dying Gains Acceptance in the U.S.” It outlines the current “Aid in Dying” debate among hospice and palliative care physicians and providers. Questions raised through this debate create ethical, legal, and professional issues for pharmacists and pharmaceutical companies.

The goal here is not to discuss the moral or ethical dilemmas each of us necessarily considers deeply and personally. For those who would like to do so, a 2011 article in “American Journal of Health System Pharmacy” may prove useful. Also, “Aid-In-Dying Practice in the United States Legal and Ethical Perspectives for Pharmacy,” was published in Research in Social and Administration Pharmacy (Summer 2016). The JAMA Journal from January 2016 focused on diverse issues clinicians face in death, dying, and end of life.

Additionally, clinicians may also wish to refer to position statements on the issues issued by American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA).

Here, we’ll focus on implications of mainstream coverage in the January 2017 New York Times article. Specifically, this piece will address two issues with relevance to pharmaceuticals: state opt-out provisions, access and costs.

Issue 1: State Opt-Out Provisions
The New York Times article states that in the U.S. states that have opt out provisions for hospice physicians: “State opt-out provisions allow any individual or institution to decline to provide prescriptions.” It follows logically that pharmaceutical industry professionals would have a similar ability to decline to provide prescriptions.
Opt out provisions are determined at the state level. State laws impact pharmaceutical professionals, informing practices and procedures. State legislatures determine laws regarding professional pharmaceutical practice and govern access to particular types of medical procedures. Statutes differ from state to state, and may or may not resemble industry policy. We have a responsibility to remain current in our area of expertise.

Issue 2: Access and Costs
The article also delineates cost and access concerns of patients who would choose to end their pain and suffering by ending their lives. Less than one percent of hospice and palliative care patients in the four U.S. states with “Aid in Dying” provisions ever choose to exercise those rights. Those few hospice patients require access to a pharmacist willing to fill their prescriptions. Then, cost becomes a factor.

The New York Times notes the increase in cost for barbiturates from a couple of hundred dollars in years past, to $3-4,000 after insurance. The article reveals that Valeant Pharmaceuticals acquired Seconal, a commonly prescribed barbiturate, in advance of California’s 2015 legislation. Then, the company deliberately “spiked the price.”

Apart from ethics concerns, we are left with more questions than answers.
• Should pharmaceutical companies inflate costs for formerly affordable prescription drugs?
• How should price be determined?
• What mark-up can consumers realistically expect to pay for a prescription?

These types of questions have both broad and situational implications within pharmaceutical professions. We might also ask if intended usage of the drug should determine market price, or if substitutions are appropriate in terminal cases.

Without doubt, informed hospice pharmacists remain critical to pain and symptom management teams for those with serious illness or at end of life.


Drew Mihalyo is founder and president of Delta Care Rx.

About Delta Care Rx:
Delta Care Rx – http://www.deltacarerx.com/ – transforms and improves the hospice pharmacy industry through business transparency, innovation, extreme customer service, and the maintenance of vital community-pharmacy relationships. As a pharmacist owned, privately held provider, Delta Care Rx sets the industry benchmark for pharmacy benefit management, on-demand pharmacist services, and hospice tailored electronic prescribing.

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Holly Lassila, DrPH, MSEd, MPH, RPh

Acute Myocardial Infarction in Women

2016 12 28 10 12 46The American Heart Association recently released a scientific statement concerning Acute Myocardial Infarction in Women.1 Cardiovascular disease is still the leading cause of death in women in the United States and globally and of the 2.7 million women with a history of an (myocardial infarction) MI, more than 53,000 have died of an MI, and an estimated 262,000 were hospitalized for AMI and unstable angina. The differences in the clinical presentation between men and women have consequences for timely identification of symptoms, appropriate triage, diagnostic testing and treatment. Compared with men women are more likely to have pain in the upper back, arm, neck, and jaw as well as unusual fatigue, flu-like symptoms, dyspnea, indigestion, nausea/vomiting, palpitations, weakness, and a sense of dread and anxiety feeling.

Mehta LS, et al reported the top ten things to know about acute myocardial infarction in women:

1. Although there has been a reduction in cardiovascular mortality death in women in the US, there has not been a substantial decline in acute MI event rates or MI deaths in young women. 

2. Compared with older women, younger women are trending with worse risk factor profiles and higher mortality.

3. Plaque characteristics differ for women, and recent data have suggested a greater role of microvascular disease in the pathophysiology of coronary events among women even though epicardial coronary artery atherosclerotic disease remains the basic cause of acute MI in both men and women.

4. Date from autopsy studies have shown that women have an increased prevalence of plaque erosion compared to men, and that MI without obstruction coronary artery disease (CAD) is more common at younger ages and among women.

5. Any young woman who presents with an acute coronary syndrome without typical atherosclerotic risk factors should be suspected of having spontaneous coronary artery dissection (SCAD). This is a very rare condition and occurs more frequently in women. The clinical presentation of SCAD can be unstable angina, MI, ventricular arrhythmias, and sudden cardiac death.

6. Recent evidence suggests that depression in women is a powerful predictor of early-onset MI, showing a strong association with MI and cardiac death in young and middle-aged women than in men of similar ages. In the general population, depression is 2 times more prevalent in women than in men.

7. Women with risk factors such as high blood pressure and diabetes have an increased risk of heart attack compared to men.

8. As mentioned above, women are more likely to present with pain in the upper back, arm, neck, and jaw, as well as unusual fatigue, dyspnea, indigestion, nausea/ vomiting, palpitations, weakness, and a sense of dread, compared with men who present with central chest pain.

9. Research suggests that women are delayed in seeking treatment for acute MI compared to men. Reasons for the delay include living alone, interpreting symptoms as non urgent and temporary, consulting with a physician or family member and fear and embarrassment.

10. Women, compared to men, tend to be undertreated and are less likely to participate in cardiac rehabilitation after a heart attack.


 Submitted by: Holly Lassila, DrPH, MSEd, MPH, RPh; Hospice Clinical Pharmacist at Delta Care Rx


 References:
1. Mehta LS, et al; on behalf of the American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. Acute myocardial infarction in women: a scientific statement from the American Heart Association [published online ahead of print January 25, 2016]. Circulation. doi: 10.1161/CIR.0000000000000351.

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Sydney Janusey, PharmD

HAART and Palliative Care: A Combined Approach

2016 12 28 9 53 55

Drug therapies continue to evolve so often that the goals of their intended care for certain disease states also change. A classic example of this shift would be the medications used to treat HIV and AIDS. Less than a few decades ago the medications for HIV/AIDS were purely thought as palliative and were used to keep patients from suffering near the end of life. Now with highly active antiretroviral therapy (HAART) as a first line treatment option, patients are living without an imminent threat to their health status. However, there are a few points to consider when looking at HAART and patients at the end of their life in need of symptom management and palliation. The drugs used to treat HIV/AIDS come with a lot of side-effects and drug interactions, particularly interactions with medications used in palliative care. Palliative care in HIV/AIDS does not always have to be an alternative treatment, but one that can be combined with disease-state focused therapy1.

Important goals of palliative care include treating pain, fatigue, weight loss, nausea, vomiting, and depression. Here are some examples of medications appropriate for treating these signs.
1. For the symptom of fatigue, consider managing with prednisone, dexamethasone, or methylphenidate.2

2. For the symptom of weight loss, consider managing with prednisone, dexamethasone, or megestrol acetate (non-preferred).2
3. For the symptom of nausea and vomiting, consider managing with metoclopramide, haloperidol, prochlorperazine, promethazine, lorazepam, or corticosteroids.2
4. For the symptom of depression, consider managing with methylphenidate, prednisone, or dexamethasone.2

As medications are added to a patient’s care plan it is very important to consider a few crucial interactions between HAART and commonly used palliative care medications.2 The protease inhibitors ritonavir, indinavir, nelfinavir, saquinavir and amprenavir as well as non-nucleoside reverse transcriptase inhibitor (NNRTI) delavirdine interact with commonly used antidepressants including fluoxetine, paroxetine and sertraline. The NNRTIs efavirenz and nevirapine interact with anticonvulsants carbamazepine, phenytoin, and phenobarbital. In addition to these interactions on the basis of the cytochrome P450 enzyme the following medications should also be used with caution: meperidine, methadone, codeine, morphine, fentanyl, dronabinol, benzodiazepines and zolpidem.2

Inevitably there will come a time when discontinuation of HAART is warranted.2 With this discussion comes the question of benefit versus. risk of therapy.2 The benefit is based on the patient’s prognosis and treatment goals for their end of life care. The benefits of continuing therapy include protection against encephalopathy or dementia, relief of constitutional symptoms and a psychological benefit from comfort that treatment is being maintained.2 The risk includes the continued build up of adverse effects from medications no longer truly working, patient comfort, and complication of end of life care and advance planning.2

As palliative care services continue to grow and play a greater role the trend is shifting towards palliation of symptoms.2 These medications should be given much earlier in care allowing patients to be comfortable for a longer period of time than just at the end of life.2 Eventually, however, removing HAART with a heavy side-effect profile and focusing on symptom palliation will lead to the most comfort for the patient and ideal treatment for their last days.1


 Submitted by: Sydney Janusey, PharmD; Hospice Clinical Pharmacist at Delta Care Rx


References:
1. O’Neill, Joseph F et al. A Clinical Guide to Supportive and Palliative Care for HIV/AIDS. US Department of Health and Human Services. Health Resources and Services Administration. HIV/AIDS Bureau. 2003. Accessed February 28, 2016.

2. Selwyn, Peter A; Forstein, Marshall. Overcoming the False Dichotomy of Curative vs Palliative Care for Late-Stage HIV/AIDS. JAMA, Vol 290, No 6. August 13, 2003.Accessed February 16, 2016.

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