Scope

Introduction to Palliative Care

Pharmacist Role in Palliative Care

Case Study in Symptom Management

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Disease Progression

JAMA. 1995;274(20):1591-1598., JAGS. 2002;50:1108-1112.

Predictable decline - Cancer

Erratic decline - Chronic Dz.

Gradual decline - Brain, ICU

Palliative care is an approach that improves the QOL of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

4 http://www.who.int/cancer/palliative/definition/en/

WHO Definition of Palliative Care

Hospice Care & Palliative Care

WHO, American Academy of Hospice and Palliative Medicine. Available at: www.aahpm.org/positions/definition.html.

Curative Life-prolonging Palliative care Hospice care Bereavement

Diagnosis Death Diagnosis

Diseases Distress Discomfort Dysfunction

Populations: Advance cancers, Advance diseases with poor prognosis (CHF, COPD, Dementia, ESRD, HIV/AIDS) Families Patients

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Palliative Performance Scale

Palliative Performance Scale (PPSv2) version 2. Medical Care of the Dying, 4th ed.; p.120. ©Victoria Hospice Society, 2006. www.victoriahospice.org

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Palliative Care Model: “4C”

Center

(Patient & Family)

Comprehensive Coordinated Continuous

รศ.นพ.เตมศกด พงรศม: Palliative care การบรบาลบรรเทา คณะแพทยศาสตรมหาวทยาลยสงขลานครนทร 7

Pharmacist’s Role in Palliative Care Symptom management Medication reconciliation, Interactions, ADRs Advice on medications that may no longer be needed Informing the family on the use of medications

F/U patients after D/C to care giver were able to manage medications at home Providing extra information about medications to GPs

American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 2002;59:1770-3. 8

ASHP Guideline; 2016 Update Level of Palliative and Hospice

1) Essential service

2) Desirable service (more advanced)

Role and specialty activity 1) Direct patient care

2) Medication review and reconciliation

3) Education and medication counseling

4) Administrative role

American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 2016;73:1351-67.

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D/C Medication

Patient log book and refer to Palliative care network Follow up: mobile phone / home visit Palliative care network: medication refill service Patient dead: send drug return back to pharmacy

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Home Visit: Drug Verification

Adherences (patient diary)

Current drug use, CAM, herbal use

Quantity (dose, amount), Quality (physical),

Medication use, techniques, route of administration

Remove unnecessary medication out of the treatment plan

SAFETY AND EFFICACY MONITORING 11

A Burden Of Symptoms

Pain 89%

Fatigue 69%

Weakness 66%

Anorexia 66%

Lack of energy 61%

Nausea 60%

Dry mouth 57%

Constipation 52%

Early satiety 51%

Dyspnea 50%

Vomiting 30%

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Shoemaker LK, et al. Cleve Clin J Med 2011;78(1):25-34.

Essential Medicines In Palliative Care 1) Anorexia: DEXAMETHASONE

2) Anxiety: DIAZEPAM and LORAZEPAM

3) Constipation: DUCUSATE and SENNA

4) Delirium: HALOPERIDOL

5) Depression: AMITRIPTYLINE and FLUOXETINE

6) Diarrhea: LOPERAMIDE

7) Dyspnea: MORPHINE

8) Fatigue: DEXAMETHASONE

9) N & V: METOCLOPRAMIDE

10)Pain: IBUPROFEN and MORPHINE

11)Respi tract secretion: HYOSCINE HBr

13 International Association for Hospice and Palliative Care (IAHPC), Jan 2013

Anesthetics And Pain Medication: 2015 Opioids Morphine sulfate : cap, tab, SR cap, SR tab, oral sol, sterile sol

Pethidine hydrochloride : sterile sol

Fentanyl citrate : sterile sol, sterile sol (as citrate), transdermal therapeutic system (as base)

Benzodiazepine Diazepam : cap, tab, sterile sol

Midazolam hydrochloride : sterile sol

Midazolam maleate : tab 14

Case Study 1 Jenny is a 16-year old Thai young woman with Osteosarcoma who has been receiving AI regimen.

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Case Study 1 Complains of worsening pain in her right hip and knee (Pain

score 7/10)

Current pain medication: - MST (10 mg) 1 tab oral q 12 hr

- Morphine syrup (2 mg/ml) 5 ml oral q 2 hr prn for BTP *use average 4 doses per day*

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Case Study 1

She complains of significant constipation since she began morphine tablets a few months ago.

Other medications: - Multivitamins 1 tab oral TID pc

- Vitamin B complex 1 tab oral BID pc 17

Discussion Issue

1) What are your initial steps in approaching this patient?

2) Is Jenny experiencing side effects from any of her medications?

3) What medications would you recommend to control this patient’s symptoms?

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“PQRSTU” APPROACH P: Provocative Precipitating and palliative factors?

Q: Quality Burning, stabbing, dull, throbbing, tender, etc. ?

R: Region Location, radiating?

S: Severity Mild/annoying to worst possible/unbearable?

T: Timing When it occurs?

U: You How the pain interfere your life? 19

American Society of Health-System Pharmacists; 2010.

Pain Assessment

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Type of pain o Nociceptive >> Opioids, NSAIDs

o Neuropathic >> Antidepressants,

Anticonvulsants

Timing o Acute: < 6 months

o Chronic: > 6 months

Severity

U: YOU (How the pain interfere your life?) P: Physical inactivity

A: Anxiety

I: Interpersonal problem

N: No acceptance of approaching of death or distress

WHO LADDER PAIN

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Opioids Selection Selection base on pain intensity

Around the clock (ATC) plus breakthrough pain (BTP)

Constipation prophylaxis

Renal & Liver function monitoring

Avoid pethidine in chronic pain

National Comprehensive Cancer Network; Cancer Pain 2004; 10.

Pain assessment after received medication

Calculate drug dose per 24 hr Mild pain (VAS≤3): same dose Moderate pain (VAS 4-6): increase dose 25-50% Severe pain (VAS≥7): increase dose 50-100% Add breakthrough medication: 10-20% of total dose/day 22

Which of following choices would be the most appropriate regimen for Jenny’s pain?

A. MST 10 mg 1 tab oral q 8 hr + Mo Syr. 3 ml prn for BTP

B. Kapanol 20 mg 1 cap oral q 24 hr + Mo IR 10 mg ½ tab prn for BTP

C. MST 30 mg 2 tab oral morning & 1 tab oral evening + Mo Syr. 5 ml prn for BTP

D. Kapanol 20 mg 1 cap oral morning & 1 cap oral evening + Mo IR 10 mg ½ tab prn for BTP

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Ask patient about potential side effects COMMON SIDE EFFECTS • Nausea/Vomiting

• Constipation

• Itching

• Dry mouth

• Fatigue

• Sweating

• Drowsiness 24

UNCOMMON SIDE EFFECTS • Hallucinations

• Delirium/Dysphoria

• Nightmare

• Myoclonus/Seizures

• Respiratory depression

• Urinary retention

Which of following choices would be the most appropriate regimen for Jenny?

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A. Bisacodyl 30 mg oral at bedtime

B. Sennosides 7.5 mg 2 tab oral at bedtime

C. Mineral oil 30 ml oral at bedtime

D. Methylnaltrexone 8 mg SQ at bedtime

Case Study 2 Ammy is a 59-year old woman with advanced ovarian cancer who is seen in palliative care clinic reporting dyspnea for 1 week.

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Case Study 2 Vital sign: BT 36.2 C, BP 85/60 mmHg, PR 110 BPM, RR 20 BPM

PE: HEENT; marked pale, mild jaundice

CVS; normal S1S2, no murmur

RS; fine crepitation both lung [Rt.>Lt. lung]

Abdomen; soft, not tender, mass ø 4 cm, hard consistency irregular surface

Ext; no petechiae, no ecchymosis, pitting edema 1+ 27

Case Study 2

Her pain is now well-controlled on MST 30 mg per day, plus morphine syrup (2 mg/ml) 2.5 ml for BTP

Her husband reports she had chest discomfort and dyspnea about 3-4 times per day for 3 days

Other medication: Lorazepam (0.5 mg) 1xhs, Metoclopramide (10 mg) 1x3 ac, Sennosides (7.5) 2xhs 28

Discussion Issue

1) What problem list should be developed for this patient?

2) What non-pharmacologic modalities would you currently recommend?

3) What pharmacologic therapeutic modalities would you recommend?

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Non-pharmacological management Reposition upright Use fans or open windows Pursed lip/ Breathing control Minimize need for exertion Avoid strong odors Adjust temperature/humidity

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What medications would you recommend to control Ammy’s symptoms?

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A. Furosemide (40 mg) 1 tab oral prn for edema

B. Morphine syrup (2 mg/ml) 5 ml oral prn for dyspnea

C. Lorazepam (1 mg) 1 tab SL prn for dyspnea

D. Atropine 0.1% Eye drops 1-2 drop SL for dry secretion

Case Study 3 Marky is a 65-year old man with hepatocellular carcinoma.

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Case Study 3

Underlying disease: DM, HT, DLP, CKD, old CVA (left hemiparesis with facial palsy)

He admitted to an inpatient Hospice care for last days of life

He has partial bowel obstruction and on NG tube

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Case Study 3 His symptoms: pain, breathlessness and drowsiness

Current medications:

- Kapanol (50 mg) 3 cap oral OD

- Morphine syrup (2 mg/ml) 7.5 ml q 2 hr prn for BTP or dyspnea

- Lorazepam (0.5 mg) 1 tab oral hs

- Lactulose 15 ml oral hs

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Discussion Issue

1) His physician would like to switch his medication to a parenteral SQ morphine infusion, Recommendation?

2) Route of administration? 3) Drug compatibilities?

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EQUIANALGESIC OPIOID DOSING

Drug Parenteral Oral

Morphine 10 30

Codeine 100 200

Fentanyl 0.1 NA

Hydrocodone NA 30

Hydromorphone 1.5 7.5

Oxycodone 10 20

Oxymorphone 1 10

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Conversion Step

1. Calculate total daily dose of current opioids

2. Set up conversion ratio between old opioid (route) and new opioid (route)

“x” mg SQ morphine = 10 mg SQ morphine

165 mg oral morphine 30 mg oral morphine

3. X = 55 mg SQ morphine per day

4. 55/24 hours = 2.3 mg/hour

Syringe driver CSCI=Continuous sub-cutaneous infusion

Check appropriate diluent

Check drug compatibilities

Indications - Difficulty swallowing, oral or pharyngeal lesions

- Persistent nausea and vomiting, poor absorption, intestinal obstruction

- Profound weakness or cachexia

- Coma or moribund patient 37

Drug compatibilities Drug Compatibility Diluent

Morphine, Haloperidol √ NSS SWI Morphine, Metoclopramide √ NSS SWI Morphine, Midazolam √ NSS SWI Morphine, Haloperidol, Metoclopramide √ NSS SWI Morphine, Haloperidol, Midazolam √ NSS Morphine, Hyoscine butylbromide, Ondansetron √ NSS Morphine, Metoclopramide, Midazolam √ NSS Morphine, Metoclopramide, Ranitidine √ NSS Morphine, Midazolam, Octreotide √ NSS Morphine, Midazolam, Haloperidol, Metoclopramide √ SWI

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https://karunruk.com/upload/files/1460184055.pdf

Palliative Care Resources Caresearch www.caresearch.com.au

Palliative Drugs www.palliativedrugs.org

WA Cancer and Palliative Care Network www.healthnetworks.health.wa.gov.au/cancer/providers/hp_palliative.cfm#resources

Eastern Metropolitan Region Palliative Care Consortium: www.emrpcc.org.au/resources

Therapeutic Guidelines Palliative Care

http://www.aihw.gov.au/palliative-care/ The pharmacy Guild of Australia initiated steps to enhance the role of community pharmacist in palliative care 39

หลกคดส าคญในการท างาน Palliative Care

1) ชวตคอองครวม ประกอบดวยรางกาย จตใจ และจตวญญาณ

2) “การเกด” และ “การตาย” เปนธรรมดาของทกชวต

3) เปาหมายคอคณภาพชวตของผปวย และการไมทกขทรมาน

4) “การตายด” เปนสทธทมนษยทกคนพงไดรบ ตองไมเรงหรอยอเมอถงเวลา

5) การดแลทมผปวยและครอบครวเปนศนยกลาง 40

รศ. พญ. รตนา พนธพานช

Short Course Training In Palliative Care ชอหลกสตร Certificate short course Training Program in Pharmaceutical Care

ชอประกาศนยบตร Certificate in Pharmacy (Palliative Care)

หนวยงานทรบผดชอบ คณะเภสชศาสตร มหาวทยาลยขอนแกน

ศนยการณรกษ คณะแพทยศาสตรมหาวทยาลยขอนแกน

วทยาลยเภสชบ าบด สภาเภสชกรรมแหงประเทศไทย

รปแบบการฝกอบรม: ระยะเวลา 16 สปดาห (บรรยาย 2 หนวยกต, ปฏบต 14 หนวยกต) 41

Activities In Short Course Training กจกรรมหลก 1. Participate in Medical Grand Round

o Med history from patient’s record, medical reconciliation

o SOAP: assessment patients for drug efficacy and ADR

o Provide drug information

o Provide drug consultation to the health care team

o Provide instruction for safe & appropriate use of drugs

o Participate in QA round

งานมอบหมาย 2. One case presentation with 3 literatures/month

3. One journal club presentation/month

4. Fours Drug Information Write-up/month

5. Communication Diaries ไดแก Intervention, Counseling

6. One In-service presentation to the team/month

7. ในชวง 4 สปดาหสดทาย จะตองเขยนโครงรางงานบรบาลทางเภสชกรรมในผปวยประคบประคอง เพอน าเสนอกอนการด าเนน

โครงการจรง ณ หนวยงานตนสงกด

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