Deprescribing Interventions by Palliative Care Clinical Pharmacists Surrounding Goals of Care Discussions.

Background: Palliative care (PC) pharmacists can play an important role in optimizing medications for patients with serious illnesses by aligning patients' goals with their treatment regimens. Objectives: The objectives of this study were to (1) quantify successful pharmacist deprescribing interventions incorporated in the hospital discharge plan and (2) describe deprescribing interventions by medication class, reason for discontinuation, and perception of patient/caregiver understanding and acceptance. Methods: This pilot study included 45 inpatient PC consultations and collected data on deprescribing interventions performed by PC clinical pharmacists in Maryland and Washington, D.C., U.S. Descriptive statistics were used to analyze outcomes. Results: Eighty-two percent of recommendations were successfully implemented during hospitalization and included in the discharge plan. Medication classes recommended for discontinuation included vitamins/supplements (20%), antidiabetics (13%), antiplatelets (10%), anticoagulants (10%), statins (10%), antihypertensives (7%), proton pump inhibitors/H2 blockers (7%), antibiotics (5%), dementia medications (1%), and antidepressants (1%). Top reasons for discontinuation included pill burden, unacceptable treatment burden, and potential harm outweighs potential benefit. Conclusions: Results of this study demonstrate PC pharmacists' deprescribing recommendations have a high rate of successful implementation by the primary inpatient care team.

Getting to the Heart of the Matter: A Regional Survey of Current Hospice Practices Caring for Patients With Heart Failure Receiving Advanced Therapies.

BACKGROUND:: No guidelines exist regarding care for patients with advanced heart failure (HF) receiving hospice care while continuing advanced HF therapies such as left ventricular assist devices (LVADs) or continuous inotropes. OBJECTIVE:: We surveyed hospice providers in our tristate region to determine hospice demographics, current practices for care of patients with advanced HF, and perceived challenges of providing advanced HF therapies. DESIGN:: Cross-sectional survey of hospice clinical and administrative leaders. RESULTS:: Forty-six respondents representing 23 hospices completed the survey. Over half (27/46) held leadership administrative roles, and most (37/46) had more than 5 years of hospice experience. Although lack of experience and cost were cited as primary barriers to providing inotrope therapy in home hospice, about half of respondents (24/46) said they would manage inotropes. All participants said their respective hospices accept patients with implantable cardioverter-defibrillators; over half (28/46) said they accept patients with LVADs into hospice care. Lack of experience with LVADs was the most frequently cited barrier. Most participants were interested in training and support by an advanced HF program to facilitate hospice care of patients receiving these advanced therapies. General access to hospice services for patients with HF at their organization was considered adequate by 30 of 46 participants. Most (32/46) reported that referrals are made too late. CONCLUSIONS:: Hospice specialists reported widely varied practice experiences caring for patients with HF receiving advanced therapies, noted specific challenges for care of these patients, and expressed a desire for targeted HF education.

Safe and Appropriate Use of Methadone in Hospice and Palliative Care: Expert Consensus White Paper.

Methadone has several unique characteristics that make it an attractive option for pain relief in serious illness, but the safety of methadone has been called into question after reports of a disproportionate increase in opioid-induced deaths in recent years. The American Pain Society, College on Problems of Drug Dependence, and the Heart Rhythm Society collaborated to issue guidelines on best practices to maximize methadone safety and efficacy, but guidelines for the end-of-life scenario have not yet been developed. A panel of 15 interprofessional hospice and palliative care experts from the U.S. and Canada convened in February 2015 to evaluate the American Pain Society methadone recommendations for applicability in the hospice and palliative care setting. The goal was to develop guidelines for safe and effective management of methadone therapy in hospice and palliative care. This article represents the consensus opinion of the hospice and palliative care experts for methadone use at end of life, including guidance on appropriate candidates for methadone, detail in dosing, titration, and monitoring of patients' response to methadone therapy.

Effectiveness of integration of palliative medicine specialist services into the intensive care unit of a community teaching hospital.

BACKGROUND: Collaboration between palliative medicine and the intensive care unit (ICU) represents best practice and offers important benefits. However, achieving effective collaboration between these two specialties can be challenging. OBJECTIVE: Assess effectiveness of integrating palliative medicine specialists in the ICU. DESIGN: Retrospective chart review. RESULTS: Of 201 patients who qualified for palliative consultation using a palliative screening tool, 92 were referred and 109 were not referred for palliative medicine consultation. The number of screening criteria met was similar between the two groups. Palliative medicine consult volume increased significantly compared with preintegration (7.7±3.4 versus 4.4±2.8 consults per month, p=0.04). No significant difference in hospital mortality was found between the referred and unreferred groups (32/92 [35%] versus 26/109 [24%], p=0.09). ICU length of stay was significantly shorter in the referred group (7 versus 11 days, p<0.001). Referred patients were more frequently enrolled in hospice compared with unreferred patients (32/92 [37%] versus 3/109 [3%], p<0.001). ICU physicians referred patients significantly more often for dementia and ventilator withdrawal (13/16, p=0.003; 24/29, p<0.001, respectively) and significantly less often for ICU stay longer than 10 days (21 versus 49, p=0.001). CONCLUSIONS: Integrating palliative medicine specialists into intensive care was associated with a significant increase in use of palliative medicine services and a significant decrease in ICU length of stay for referred patients without a significant increase in mortality. The screening tool effectively identified patients at high risk of death. Given the high mortality rate of the unreferred patients, the criteria could be more widely adopted by ICU physicians to consider expanding palliative medicine referrals.

50 practical medication tips at end of life.

Patients with a life-limiting illness frequently experience pain and other symptoms. It is important to pay close attention when medication therapy is used to manage these symptoms. Occasionally, practitioners need to be creative in selecting, dosing, administering, and discontinuing medications at the end of life because of the patient's changing health care needs. This article offers practical end-of-life medication tips including, but not limited to, medication administration; guidance on how to increase and decrease doses; medication selection for difficult-to-treat patients; alternative dosage formulations; routes of medication administration; debridement medication regimens; and appropriate drug therapy selection.

Impact of standardized palliative care order set on end-of-life care in a community teaching hospital.

BACKGROUND: We evaluated use of medications and interventions in patients receiving a new standardized palliative care order set (PCOS) compared with patients receiving no palliative care orders and those with an order for comfort measures only (CMO), the largely ineffective method used at our institution before implementation of the order set. METHODS AND RESULTS: We conducted a retrospective chart review of all patients who died at our community teaching hospital between November 2006, 8 months after PCOS implementation, and May 2007. Of 106 patients in the study group, 31 (29%) were treated using the PCOS, 6 (6%) received the CMO order, and 69 (65%) did not receive either. Patients in the PCOS group had significantly more orders for every palliative medication (p ≤ 0.05). Opioids and anxiolytics were made available to every patient in the PCOS group. Most PCOS patients received orders for antiemetic, antipsychotic, antisecretion, and laxative medication during the end-of-life period. No CMO patients and few patients in the no palliative care orders group received orders for these medications. The PCOS and CMO group similarly limited nonpalliative interventions, whereas the nonpalliative group had relatively high use of these interventions until death. CONCLUSION: The palliative care order set implemented at our community teaching hospital significantly improved adherence to accepted palliative care treatment principles for patients at the end of life.

Fifty reasons to love your palliative care pharmacist.

Pharmacists have much to offer in caring for patients with an advanced illness. To celebrate the role of pharmacists in palliative care, we wanted to share 50 excellent reasons to love your pharmacist. This list was compiled by 3 pharmacists specializing in end-of-life care spanning from inpatient palliative care to home-based hospice. Our goal is to increase awareness among other hospice and palliative care practitioners by recognizing the skills pharmacists contribute in caring for patients at the end of life. We divided the list into categories: provision of pharmaceuticals, optimizing medication regimens, education and drug information, patient safety, and administration/formulary management.

Impact of writing "comfort measures only" orders in a community teaching hospital.

OBJECTIVES: We compared end-of-life care for patients with and without orders for "comfort measures only" (CMO) and evaluated whether standards for palliative medicine were met. DESIGN: We retrospectively reviewed the charts of 40 patients, 20 with and 20 without a CMO order, who died in our community teaching hospital from October 2003 through September 2004. Appropriate use of medications and interventions and documentation of symptoms and family consultation were examined. RESULTS: There were no significant demographic differences between the groups. Family meeting (18/20 versus 7/20, p < 0.001) and do-not-resuscitate/do-not-intubate (DNR/DNI) code status (20/20 versus 8/20; p < 0.001) occurred significantly more frequently in the CMO group. There were no other significant differences in prescribing medications or treatments. Notation of symptoms common at the end of life did not differ between the groups except for nausea/vomiting, which was more common in the non-CMO group. In the CMO group, opioids were significantly more available and antibiotics and routine laboratory work were significantly less common after the CMO order, but no other differences were observed. CONCLUSION: CMO orders alone were insufficient for redirecting changes in care at the end-of-life.