Transcript Evergreen Hospice Rotation

Evergreen Hospice Rotation
Ted Williams
PharmD Candidate 2009
PHAR 744
About the Tie
Yes, I wear a bow tie to work
Yes, I wore a bow tie to my rotations
No, it is not a clip on, I tie them myself
every time
My sister got this for me for Christmas
Outline
What is Hospice
Pharmacy role in hospice
Case Study
What is Hospice
Palliative care for terminally ill patients
Must have a terminal diagnosis with <6mo
life expectancy
Must demonstrate gradual decline
Evaluation period of 90 days
Economics of Hospice
Medicare Part B
Flat rate for all care services and
medications
Care in Hospice
Counseling Services
Patient
Familiy
Medication Management
More to come
Direct Care Services
Set up and maintenance of durable medical
equipment
Medication administration
Bathing and feeding
General nursing care
Pharmacy in Hospice
Discontinuation of most maintenance meds
Hypertension
Thyroid
Osteoporosis
Life sustaining meds like insulin are continued
Introduce and/or continue pain management
medications
Opioids
Steroidal and non-steroidal anti-inflammatory meds
Special Considerations for
Pharmacy Management
Long term side effects are of little
consequence
Short to mid term side effects are an issue
Nausea/Vomiting
e.g. opioids
Constipation/Diarrhea
e.g. opioids
Desensitization
e.g. Steroids
Case Presentation
Subjective
Patient: OM
Age: early 60s
PMH
Long history of minor CVD
Long history of minor CVA
5 months prior to visit patient had a massive CVA
Massive CVA
3 months a UCSF MC
Several weeks at skilled care facility in
Vancouver, WA
Several weeks at home under Hospice
Care
Patient is semi comatose and generally
unresponsive, but does visually track and
has some limited reactions
Hospice Care
Patient’s previous cardiologist and
neurologist ended care after major CVA
Patient’s only option for care was Hospice
Wife is not willing to accept prognosis and
continues to shop for a physician
Hospice trial period was to end in January
2007
Objective
Feeding Tube
Condom style urinary catheter
Rectal catheter
Patient is bed bound
Has a pronounced 6cm diameter 1-2 cm deep
ulcer over the coccyx
Vital signs stable, but poor (I did not collect
actual numbers)
Objective
Thyroid and Hypertension medications
have been discontinued
Patient’s wife administers natural
supplements with Ensure feeding regime
Assessment
Patient is terminal, but the wife refuses to
accept this diagnosis
Hospice cannot support long term care of
the patient
Without a primary care physician, the
patient will have a very difficult time
receiving any care
Plan
Patient will attempt to locate a PCP,
Neurologist, or Cardiologist
Hospice will attempt to document a steady
decline in patient’s health
Conclusion
Positives
Valuable service for dying patients
Creative pharmacy practice and problem
solving
Drawbacks
Emotionally taxing