Long-Term Care Survey Alert

Medication regimens at end of life provide a window into your care.

Your terminally ill resident's medication record had better show that the facility is meeting his palliative care needs -- or surveyors will prescribe their own remedy in the form of F tags for unnecessary drugs and poor quality of care.

The major question: How do you manage a person's medication regimen as death approaches? asked Deidra Woods, MD, FACP, CMD, a hospice medical director speaking at the March 2006 American Medical Directors Association annual meeting in Dallas.

There's more to doing so than "just either stopping drugs or continuing drugs in someone who is terminally ill or may look like they are terminally ill because of adverse drug reactions or other medical complications," cautioned Steven Levenson, MD, CMD, in introducing Woods' AMDA session.

Key concept: The drugs that you want to keep or initiate at the end of life are the ones that improve patient comfort, said Woods. The clinician might also continue prescribing medications whose abrupt withdrawal would precipitate symptoms -- for example, calcium channel blockers and beta blockers. But rather than waiting 48 hours before death when a person physically can't swallow anymore, make a plan for tapering and withdrawing drugs, including SSRIs, Woods advised AMDA conferees. That way, you avoid "compounding the dying process" with withdrawal symptoms.

Tip: Supplying a nicotine patch for patients no longer able to smoke can relieve nicotine withdrawal symptoms, Woods added. She suggested facilities also consider stopping meds for secondary or primary prevention or problems that have resolved. Also consider stopping drugs with a "heavy monitoring burden." Warfarin is a prime example, she added.

Also keep in mind that some drugs accumulate as the patient's physiology declines, including warfarin and even SSRIs, she added.

The Beers List May Not Apply

Some of the drugs on the Beers list of potentially inappropriate drugs for geriatric patients are "drugs of choice" at end of life, said Woods.

A key example: Haloperidol (Haldol) is on the Beer's list, but it's an "excellent anti-emetic" and can be given twice a day (BID), Woods said, noting that it has fewer adverse effects than other medications for nausea.

Yet in her work in hospice care, Woods has encountered situations where nursing facility DONs, medical directors and/or consultant pharmacists say, "We don't use that drug in our facility." In addition, some of the antihistamines for patients with chronic itching caused by end-stage renal or liver disease are also on the Beer's list, Woods noted.

Proactive strategies: Document the indication for a drug on the Beer's list, such as Haldol or an antihistamine. Then monitor the patient for adverse drug effects and "make a judgment" and document it about whether those adverse effect are acceptable based on a continued benefit to the patient, advised Woods. Also consider involving hospice in the resident's care, Woods counseled. Hospice can provide an almost "get out of jail free card" because it labels what you do as a comfort measure. As a result, the facility may be less likely to be held up to scrutiny for the medications it uses for symptom management, she said.

Consider These Additional Meds

Analgesics and anxiolytics top the list of comfort meds at the end of life. The precaution about prescribing opioid analgesics is that you have to add laxatives to prevent constipation, said Woods.

Other palliative care medications include the following:

Steroids. These drugs "stimulate appetite," enhance mood and make a person more alert. "We typically use Decadron because of the [longer] duration of action," she said. Decadron does have some adverse effects in the long term "but we aren't worried about the long term" in caring for the dying patients, Woods noted.

Amphetamines. Again, these are considered potentially inappropriate medications but they can be extremely very useful in end-of-life care, said Woods. You can dose the patient taking high-dose opioids with an amphetamine early in the morning to allow him to be alert and interactive for several hours during the day, Woods explained.

The amphetamines are also "excellent antidepressants" with rapid onset of action, she said.

Address Nausea, Dyspnea, the 'Death Rattle'

Nausea is a very common problem in end-of-life care that's most often caused by constipation, Woods relayed. The "hospice motto" of "eat what you want and sleep when you feel like it" has been addended by hospice nurses to say "and keep your bowels moving."

As for treating nausea, haloperidol  BID either subcutaneously or in an oral concentrate that delivers a substantial dose in a small amount of liquid can offer relief, Woods said. If nausea has a cerebral source, anxiolytics can help, she added.

Opioids are the drug of choice to treat dyspnea at the end of life. Woods noted there's no literature to support inhaled morphine as being more effective than oral morphine for dyspnea. But some patients want it and "we don't argue with them."

Woods noted that a patient's noisy respiration can be very disturbing to his or her loved ones.

Solution: Once the person starts withdrawing from interactions with others and the environment and stops oral intake, you can administer a scopolamine patch to prevent accumulation of secretions and the "death rattle," Woods relayed.

Clinical gem: To help relieve dyspnea, keep the air in the patient's room cool and "moving." Sitting in front of a fan, for example, creates air movement over the trigeminal nerve, which can help dyspnea, Woods said. "That's probably why oxygen helps [dyspnea] even when it doesn't change [the patient's] oxygen saturation," she said.

Tap This Key Expertise

The pharmacist can often recommend non-traditional treatments or unique dosage formulations that will aid in symptom relief for patients nearing the end of life, comments Carla Saxton McSpadden, a pharmacist with the American Society for Consultant Pharmacists.

"In addition, consultant pharmacists, during their routine medication regimen review process, can help ... identify patients who may benefit from palliative care approaches or treatments," she tells Eli.