End of Life Care

Potpourri

100

Antibiotics may be considered in imminently dying patients for symptom relief but there is growing concern that the risk of resistance outweighs the benefit.

Name one infection in which the patient is likely to quickly receive symptomatic relief (benefit >>risk)?

UTI

Skin & soft tissue infections

Eye infections

200

2-5% of all cancer patients will continue to receive chemotherapy within 14 days of death. What is one risk associated with chemotherapy use at the end of life?

1) Significant adverse effects

2) Prolonged hospitalization

3) Increased risk of dying in an ICU

300

What is one early sign of death according to the "Investigating the Process of Dying" study?

(Early sign = high frequency, occurred more than 1 week before death, and had a moderate predictive value that a patient would die in 3 days)

1) Decreased level of consciousness (RASS score of -2 or lower)

2) Decreased performance status

3) Dysphagia of liquids

400

What are two late signs of death according to the Investigating the Process of Dying study?

Late signs = occur mostly in the last 3 days of life & were highly specific for impending death in 3 days

1) Pulselessness on the radial artery

2) Respiration with mandibular movement

3) Decreased urine output

4) Cheyne-Stokes breathing

5) Death rattle

6) Apnea periods

7) Peripheral cyanosis

500

The palliative attending is considering starting megestrol acetate for appetite stimulation in a patient in whom eating is an important quality of life factor. The attending is wondering how common thromboembolic events with megestrol are.

How many patients who take megestrol for appetite stimulation will experience a thromboembolic event?

1 in 6 patients develop a thrombus

1 in 23 will die due to drug

Delirium

100

What percent of hospice patients experience terminal delirium?

50-90%

Most patients have hypoactive delirium (decreased level of consciousness)

200

Name 2 classes of medications with a known risk of causing delirium

1) corticosteroids 2) chemotherapeutic agents 3) opioids, 4) antidepressants, 5) benzodiazepines, and 6) anticholinergic agents

300

Name one medication (including route and dose) NCCN recommends to treat delirium in the actively dying patient.

1) Haloperidol 0.5-2 mg PO, IV or PR Q 1-4 hr PRN

2) Risperidone 0.5-1 mg PO BID

3) Olanzapine 2.5-7.5 mg PO/SL q 2-4 hr PRN (max dose = 30 mg)

4) Quetiapine 25-200 mg PO/SL BID

5) Chlorpromazine 25-100 mg PO/PR QHS with or without lorazepam 0.5-2 mg SC/IV q 4 hr

*If refractory; consider upward titrations of IV lorazepam

400

Why must IV chlorpromazine only be used in bed-bound patients?

High risk of hypotension

500

TY is a 82 year old male with a history of metastatic renal cell carcinoma admitted to inpatient hospice for comfort measures. He has mixed type delirium (decreased level of consciousness with frequent bursts of agitation and aggression toward staff and family members). The doses of his anti-psychotic medications have been maxed out and not appearing to help. The palliative team approaches you for a full medication review.

Labs:

AST 412; ALT 272; Tbili 5.7; SCr 0.9 (CrCl 42 mL/min)

Meds: 2 mg IV Haldol Q 1 hr PRN (first line- agitation); lorazepam 1-2 mg IV Q 1 hr PRN (second line-agitation) Olanzapine 20 mg QHS (delirium); 0.4-0.8 mg hydromorphone IV Q 1 hr PRN (pain - 0 doses used); Famotidine 20 mg IV BID (GERD);  Artificial tears Q 3 hrs PRN (dry eyes - 1 dose used); Oxybutynin 5 mg TID PRN (bladder spasms - 3 doses used)); Prochlorperazine 5 mg IV Q 4 hr PRN (nausea - 5 doses used)

Name 2 suggestions you can make to the NON-antipsychotic medications.

1) Switch famotidine to PPI if really indicated (anticholinergic & renally eliminated)

2) Switch prochlorperazine to ondansetron (anticholinergic)

3) Switch oxybutynin to trospium (less CNS penetration)

Dyspnea & Cough

100

TS is a 67 year old female with a history of CHF admitted to inpatient hospice. She continues to have dyspnea and remains fluid overloaded? Which medication would NCCN recommend to treat TS's dyspnea?

Furosemide

200

Name 2 of the 3 medications NCCN recommends to treat excessive secretions (dosing not needed)

1) Scopolamine (patches NOT a great option for imminently dying patient as onset of action = 12 hours)

2) Atropine SL; 1-2 drops Q 4 hr PRN

3) Glycopyrrolate 0.2-0.4 mg IV or SC q4 hr PRN

300

Which medication could be added to treat dyspnea if anxiety is a contributing factor?

Lorazepam (0.25-1 mg PO q 4 hr PRN if benzodiazepine niave)

400

Which medication used for secretions is LEAST likely to cross the blood brain barrier (and therefore has the lowest risk of delirium)?

Glycopyrrolate

500

Which medication (AND dose) is recommended as first line treatment of dyspnea in the actively dying patient?

Morphine 2.5-10 mg PO q 2 hr PRN (opioid naïve)

Morphine 1-3 mg IV q 2 hr PRN (opioid naïve)

Increase dose by 25% for non-naïve patients

Palliative Sedation

100

What is palliative sedation?

The use of medications to induce unconsciousness to relieve otherwise intractable suffering at the end of life.

200

Who is a candidate for palliative sedation?

Imminently dying patients (life expectancy of hours to days) with refractory symptoms that persist despite comprehensive, interdisciplinary palliative care.

Prognosis should be confirmed by 2 physicians.

Informed consent must be obtained from the patient and/or a family member

300

What are the 2 recommended options for palliative sedation in the imminently dying patient?

1) Midazolam (continuous infusion)

2) Propofol (continuous infusion)

400

Does palliative sedation expedite the process of dying due to respiratory depression? If so- by how many hours or days on average?

No.

Prospective evaluation of 1827 terminal cancer patients. No statistically significant differences in median survival in those who received continuous deep sedation. (27 days CDS group vs 26 days no CDS group; 95% CI -5-4)

500

Through which Doctrine does palliative sedation have its ethical justification?

The Doctrine of Double Effect - provides guidance in situations where an attmempt to do good also produces harm (providing medication for the relief of suffering that also causes respiratory depression)

Death with Dignity

100

What was the first state to enact Death with Dignity legislation?

Oregon (passed in 1994; became law in 1997)

200

Name 3 of the most common reasons patients choose Death with Dignity?

1) Loss of autonomy (91.6%)

2) Unable to enjoy ADLs (89.7%)

3) Loss of dignity (78.7%)

4) Inadequate pain control (25.2%)

300

What are 3 requirements in Oregon for Death with Dignity?

1) Oregon resident

2) Certified by 2 physicians that patient has <6 months to live

3) Drugs prescribed by state licensed physician

4) Patient able to self-administer medications

5) Patient must make 2 oral and 1 written request over a minimum of 15 days

400

What stance do APhA and ASHP take on Death with Dignity?

Remain neutral

-Support professional judgement

-Individual pharmacists may participate or not based on their discretion

-Be a patient advocate

500

What are 2 of the 4 medications included in the DDMP2 regimen for death with dignity? (preferred in Washington state due to decreased time to death)

-Diazepam 1000 mg

-Digoxin 50 mg

-Morphine 15 gm

-Propranolol 2 gm

*Mixed in compounding pharmacy