Eli's Hospice Insider

Published on Thu Nov 27, 2008 PDF

These mishaps can happen more often than you'd think

Haphazard medication management creates a number of risks for hospice patients and opens the door to provider liability. That's why the team needs a standardized approach to get everyone, including the patient and family, on the same page in addressing this vital aspect of care.

Start by making accurate medication reconciliation a priority. If you don't, a patient could suffer an unexpected drug-drug interaction that could be difficult to figure out in some cases. For example, "if someone is taking a certain medication, it can affect absorption of another medication," cautions Tim Simpson, RN, CHPN, VP of Clinical Services & Palliative Care at Seasons Hospice in Des Plaines, Ill.

A patient could also be taking outdated medications or ones prescribed by a physician that the hospice team doesn't know she's seeing. And medications such as blood thinners in combination with anti-hypertensives or psychoactive medications can, for example, increase a patient's risk for falls and serious injuries.

The reality: Medication reconciliation errors can easily occur. For example, the patient, family, or caregivers may forget to tell the nurse about a medication, says Mary Lynn McPherson, PharmD, BCPS, professor and vice chair in the Department of Pharmacy Practice and Science at the University of Maryland in Baltimore. In reviewing 58 hospice patients, a resident who works for McPherson found that every single one of them had a medication reconciliation error. "Each patient took 19 medications, on average, and the average number of reconciliation errors was 8.7," she reports. 

Strategy #1: Tap the pharmacist to ensure the hospice has the most accurate list of the patient's medications -- and that they match what the staff thinks the patient is taking, McPherson says. Hospice staff should do medication reconciliation at admission and at each recertification. It's also "a good practice to have the nurse case manager verify the medication history behind the admitting nurse," McPherson adds.

Good idea: When providing hospice care in the home, some nurses ask the patient or his family to collect his prescription and OTC medicines, vitamins, and any herbal remedies in a bag or basket to review together. This approach also gives the nurse an opportunity to review the patient's history with the patient or his family.

Strategy No. #2: Create a systematic approach. There's no way a nurse can remember 40 different meds, Simpson says, noting he's seen hospice patients on that many at a time. Thus, to help the nurse identify potential problems, the hospice either needs a pharmacist on staff or a software program built into an electronic patient record system, he suggests. In fact, Seasons Hospice uses both.

Strategy # 3: Tailor meds to care goals. The team should evaluate the appropriateness and goal of each medication, including a risk/benefit assessment. For example, a person with end-stage AIDS may be taking HIV anti-virals that aren't helping him anymore, but they are causing the person to be nauseated and worsening his neuropathic pain, McPherson cautions.

If a medication, such as a statin, requires two to three years to produce a benefit, then it's not worth the patient taking it, McPherson adds. The medication often has side effects, and it's just "another pill to swallow," she says, not to mention expensive. 

"Don't come in on the first visit or two and upset the apple cart," by talking about starting or stopping medications, McPherson cautions. "You have to develop a working relationship with the patient and family first. Some people are afraid of stopping the medications, and others are afraid of starting certain ones, like opioids."

Patient choice should also factor into the decision-making process. For example, Simpson has seen patients with end-stage AIDS want to continue their antiviral medications even though their T cell counts remain very low. And that's their choice, he says. If family members want their Mom to have IV fluids to "prevent the perceived discomfort of dehydration, we may review what we think the impact of the treatment will be, including swelling or kidney overload, and choose to continue the treatment."

Another challenge: When caring for hospice patients in the nursing home, you may have to educate staff that has qualms about giving medications known to raise concerns with state surveyors. For example, nursing homes may get concerned when hospice wants to use medications on the BEERS list, notes Cherry Meier, RN, MSN, with VITAS Innovative Care in Flat Rock, N.C. However, some of the medications on that list work well for people at end of life. For example, Haldol really eases terminal restlessness, she adds.

Don't miss: Prevention has its place. "There is absolutely a role for flu immunization and even pneumococcal vaccinations in hospice," McPherson says. She also looks to see whether a patient has received the Zostavax vaccine to prevent shingles. "We wouldn't necessarily recommend giving the immunization ... although hospice patients are certainly at risk to develop shingles. But we do not infrequently give the flu and pneumococcal vaccination."

The hospice also has to reach closure with patients about which medications it will provide as part of the hospice benefit, as opposed to the ones the patient will be responsible for obtaining, McPherson says.