Danielle Pierotti RN, PhD, AOCN, CHPN Chief Nurse/Director of Clinical Practice HCI Hospice. with you at every step

Transcription

1 Danielle Pierotti RN, PhD, AOCN, CHPN Chief Nurse/Director of Clinical Practice HCI Hospice

2 Objectives Review current policy and environmental issues influencing medication choices at end of life Discuss evidence supporting improved quality of life with reduced medication use at the end of life Identify key strategies to change course

3 Pharmaceutical Policy in Hospice Hospice COPs and Part D Changing interpretation of related-unrelated All medications vs. related to terminal illness Back billing Medication reconciliation with prior provider Readmission issues Coverage for copays Differences between payers

4 Pharmaceutical Costs Inconsistent decision making Lack of decision support tools Outdated formularies NPI numbers Limited pharmacy shelf space Limited pharmacy willingness to stock General rising costs Newest drugs used after failure of others

5 Improved Quality of Life Adults>65 years are about 13% of the population using 33% of all prescriptions For every $1 spent on medications- $1.33 was spent to treat a med related problem Readmission- 30% of admissions (>75yrs) 40% of hospital patients take between 5-9 different prescriptions

6 Improved Quality of Life Polypharmacy= the use many drugs and /or the use of more medications than are clinical indicated Wastes resources- medications, time, money and energy Potentially harmful- drug interactions, compounded side effects, confusion about use

7 Improved Quality of Life The Prescribing Cascade Research with prescribing patterns demonstrates that side effects of one drug are treated with new drugs EX. Donepezil for early Alzheimer's leads to urinary incontinence now treated with oxybutynin EX. metoprolol and lisinopril and furosimde; now patient reports feeling dizzy and weak and is scared to engage in normal behaviors just getting old?

8 Improved Quality of Life Drug cessation is not well discussed Pharmaceutical research is exclusive to when to USE medications not when to stop them Little research has been done about: Long term use of most meds Actual patterns of interaction the physiology of polypharmacy When to stop common, preventative or stabilizing agents (i.e. aspirin, antihypertensives, PPIs)

9 Improved Quality of Life Drug discontinuation is emotional Experienced as a loss of something tangible Maybe evoke a sense of giving up May involve fear if I stop I will have a heart attack Of being bad but my doctor told me I could never stop this

10 Improved Quality of Life Drug cessation may include risks of perpetuating hospice myths Hospice actively helps people to die Hospice takes everything away Hospice is only for the last few hours or days Hospice doesn t want to pay for anything

11 Improved Quality of Life As swallowing becomes difficult, medications become a source of pain, suffering and risk As activity decreases, normal digestion slows, food intake is less fullness is reached sooner- are the pills the first choice? With renal and hepatic impairment how predictable is the medication? Are the conditions being treated changing?

12 Improved Quality of Life Natural vs. side effect Patient reports of feeling off nausea, muscle aches, falls, dizziness, cognitive changes feeling fuzzy Statins cause muscle aches Antihypertensive meds can cause dizziness PPIs cause numerous GI issues- Nausea, constipation or diarrhea Oral hypoglycemic agents

13 Improved Quality of Life Lack of evidence everywhere Structure of research (controlling for as many variables as possible) keep people with multiple co-morbidities and multiple drugs out of studies Evidence has demonstrated gender differences in medications related to BMI and metabolism Numerous studies have demonstrated harm to older patients when pressure, glucose and cholesterol is controlled to standards

14 Improved Quality of Life There is little high grade evidence about discontinuation of medications at EOL. How do you feel? What could be causing unpleasant symptoms? What can be done to relieve your suffering?

15 Example: diagnosis COPD Calmoseptine Amlodipine Aspirin Senna Gas relief tablet Metoprolol Isosorbide Prednisone Fentanyl Albuterol inhaler Pantoprazole Fordadil inhaler Acetaminophen Lactulose Augmentin Creon Sucralfate Oxycodone Tamsulosin Trazodone Albuterol nebulization Levaquin Sertraline Lorazapam Asmanex inhaler

16 Example: diagnosis COPD Calmoseptine Amlodipine Aspirin Senna Gas relief tablet Metoprolol Isosorbide Prednisone Fentanyl Albuterol inhaler Pantoprazole Fordadil inhaler Acetaminophen Lactulose Augmentin Creon Sucralfate Oxycodone Tamsulosin Trazodone Albuterol nebulization Levaquin Sertraline Lorazapam Asmanex inhaler

17 Example: diagnosis COPD Calmoseptine Amlodipine Aspirin Senna Gas relief tablet Metoprolol Isosorbide Prednisone Fentanyl Albuterol inhaler Pantoprazole Fordadil inhaler Acetaminophen Lactulose Augmentin Creon Sucralfate Oxycodone Tamsulosin Trazodone Albuterol nebulization Levaquin Sertraline Lorazapam Asmanex inhaler

18 Professional Standards and Ethics Beneficence- to do good Hospice is about reducing suffering and supporting quality of life To do good we must seek opportunities to heal Non-Maleficence-Do no harm Do not inflect harm Side effects ignored is harm Need to balance risks and benefits

19 Professional Standards and Ethics Double effect- Use of morphine to relieve acute pain has a risk of shortened life Eliminating other medications to relieve side effects may have a risk of shortened life Why is one acceptable and the other not?

20 Professional Standards and Ethics Autonomy and Human Rights Patient autonomy is based on informed consent. Informed consent is only met when all information is shared. Evidence repeatedly demonstrates when people are informed of risks and benefits of treatment options they regularly decide for less intervention.

21 Medication Reconciliation Adopt reconciliation practices to verify What are you actually taking? Why are you taking it? How long have you been taking it? Have you had any problems with it? How does it make you feel? What happens if you forget to take it? When does it need to be re-filled?

22 Key drug groups Use of preventative medications at end of life Statins: Large side effect profile Acute renal failure Myopathy and myalgia's Liver impairment Numerous drug interactions Vitamins Eye drops Questionable time frame for protection

23 Key drug groups Anti-hypertensives Protective element is to reduce the effects of decades of hypertension Anorexia, activity, general debility are naturally lowering pressure Continued use could cause harm is the pressure artificially low?

24 Key drug groups Antihyperglycemics What is the greater risk high or low glucose? Malnutrition and metabolic issues reduce the need to control blood glucose What feels bad?

25 Next steps Separate cost from care Move to practical policy to embody all medications are related Shift costs currently paid by Part D to hospice Improve data management of actual symptom management Start talking about drug cessation at the time of prescribing

26 References American Nurses Association, Ed. Fowler, M. (2008) Guide to the Code of Ethics for Nurses: Interpretation and Application. Retrieved on Spetember 18, 2014 from urses/code-of-ethics.pdf. Collier, K., Kimbrel, J., & Protus, B. (2013). Medication Appropriateness at end of life. Home Healthcare Nurse; 31(9) Protus, B. (2014). Clinical case study; Determining relatedness, medication appropriateness and therapeutic interchange options. Hospiscript Newletter. 10(2), 2-3. Marks, S. (2014). Does Mom still need to take all these pills? Hospiscript Newletter. 10(2), 4. Riker, G., & Setter, S. (2012) Polypharmacy in older adults at home. Home Healthcare Nurse. 30(8) Riker, G., & Setter, S. (2012) Polypharmacy in older adults at home; Part 2. Home Healthcare Nurse. 31(2) Tjia, J., Velten, S., Parsons, C., Valluri, S., & Briesacher. B. (2013). Studies to reduce unnecessary medication use in frail older adults: A systematic review. Drugs & Aging; 30; Van der Cammen, T., Rajkumar, C., Onder, G., Sterke, C., & Petrovic, M. ( 2014) Drug cessation in complex older adults: time for action. Age and Aging; 43,