2021 Management of Common Conditions PDF

Management of Common Conditions Emily K. Flores, PharmD, BCPS [email protected] Objective Recommend and provide education on optimal management of common acute and chronic conditions in geriatric, palliative, and end-of-life care patients utilizing non-pharmacologic as well as over the counter (OT...

Management of Common Conditions Emily K. Flores, PharmD, BCPS [email protected] Objective Recommend and provide education on optimal management of common acute and chronic conditions in geriatric, palliative, and end-of-life care patients utilizing non-pharmacologic as well as over the counter (OTC) or prescription pharmacotherapy “…to care for people in such a way that they can live as fully as possible with whatever time remains to them…” Dr. Saunders, founder of Hospice Common concerns Common concerns in palliative care include Pain optimal pain management and control of Constipation symptoms like breathing, bowels, mood, and Dyspnea nutrition to improve quality of life Fatigue Depression Common concerns in end-of-life care include Delirium those as well as concerns that come with the Loss of appetite/weight dying process Dehydration As you move along the palliative care continuum Nausea/vomiting you shift from comfort + curative to comfort Terminal secretions Dying process Most dying patients go through social withdrawal, decreased senses (hearing is most persistent), increased sleep, restlessness, disorientation (redirect only if stressed), and decreased nutritional requirements. Force-feeding should be discouraged. Incontinence of urine and bowel is often not a problem until death is near and absorbent pads under the patient or catheterization for comfort may be used. Family members should expect to see flushing, bluish hue to the skin, and cold or clammy skin. Hands and feet may become purplish and blotchy as circulation decreases. Blood pressure decreases and pulse may increase or decrease. Temperature may fluctuate and respirations may increase, decrease, or become irregular with periods of apnea. Congestion can present as a rattling sound in the lungs and/or upper throat as the patients becomes too weak to clear secretions.  Once the dying process is recognized, it should be discussed with family and treatment goals should be confirmed. Discussion should include the goal of stopping all treatments that are not contributing to the patient’s comfort (pulse ox, IV hydration, antibiotics, finger sticks, etc.). Families always want reassurance that their loved one is not suffering. Hydration and feeding issues need to be discussed sensitively. Excellent mouth and skin care should be provided.  Bed bound, loss of interest and ability to drink/eat, Dying Process Time cognitive changes Course Either hypoactive or hyperactive delirium or increasing Early Stage sleepiness Less than 24 hours or up to 10-14 days Further decline in mental status – obtunded “Death rattle” – pooled oral secretions that are not cleared due to loss of swallowing reflex Once entered, it is Mid Stage Fever is common difficult to accurately predict the time course, which may Coma, cool extremities cause considerable Altered respiratory pattern – either fast or slow family distress, as Fever is common death seems to "linger" Late Stage Death http://www.eperc.mcw.edu/fastFact/ff_003.htm Case  Arnold Kelley 82yo WM Colon cancer twice, chemo, 4 years clear Good cognition, PMH of T2DM and stroke Loves his family and does not want to be a burden What will he want when his health inevitably declines? Should we start artificial feeding if he is no longer able to chew and swallow? Should we do chest compressions if his heart gives out? What does his family need to know? What type of advanced directive(s) would best suit him?  Arnold Kelley 83 yo WM Diagnosed with a brain tumor after hospital admission for new onset left lower extremity weakness and inability to walk Offered oral chemo and radiation with chance for cure Some improvement seen with concomitant steroids, but condition worsens and he is re-hospitalized He has developed opportunistic pneumonia and is now requiring oxygen Repeat MRI is done and tumor has not decreased but now crosses the midline and is determined to be a glioblastoma  Arnold Kelley 83 yo WM No additional curative options exist, pneumonia is treated and breathing improves marginally but all functionality continues to decline How long should he stay in the hospital? What nutrition should he receive? Where is he in the palliative care continuum? Is hospice appropriate? Family and patient opt for inpatient hospice as his wife is unable to care for him in the home and he does not have strong wishes to die at home He tells his granddaughter that he has lived a good life and that he will see Jesus soon  Arnold Kelley 83 yo WM At hospice he receives soft nutrition as tolerated and daily his ability and desire to eat decline His wife needs comforting as he stops eating as she has always loved through feeding His ability to carry on conversations declines and he sleeps more each day His breathing effort increases, he no longer gets out of bed He receives oral liquid opioids for comfort and breathlessness  Arnold Kelley 83 yo WM The family is called in and goodbyes are repeated while he is loved on by all Physicians and nurses provide comfort and education throughout the last day He passes the next night with his wife, son, and grandson asleep in the room with him, he was comfortable His wife remarks “he is already there”, meaning he is in heaven now Obituary: https://www.mcdougaldfuneralhome.com/obituaries/Arnold- Kelley?obId=3439040#/obituaryInfo  Chlorpromazine 25-50mg PO/IV every 6 hours PRN for hiccups Lorazepam 0.5-2mg po every 4 hours PRN 2mg/mL oral concentrate Dyspnea, delirium, restlessness Roxanol (morphine sulfate) 5-10mg Q4H; titrate 20mg/mL oral concentrate Haloperidol Allows low volume 1.5mg every 12 hours for nausea/vomiting (and titrate) Pain, dyspnea, tachypnea 0.5mg-5mg Q1-4H for delirium agitation (oral or injection) Haloperidol 2mg/mL oral concentrate  Scopolamine 1 to 3 patches behind ear every 3 days, effective in 2-3 hours 1mg/3days transdermal patch Also available SC/IV Terminal secretions, N/V Megestrol Atropine Daily doses of 400-800mg 1% ophthalmic drops Suspensions not equivalent on a mg 1-2 drops SL every 1-4 hours PRN per mg basis Terminal secretions Megace ES 625mg/5mL ~ 800mg other formulation Megace and generic 40mg/mL Hyoscyamine Megestrol 20mg, 40mg tablets 0.125mg Q8H PRN Anorexia/cachexia 0.125mg/mL oral solution, elixir, SL, or disintegrating tablet Terminal secretions Summary [email protected]