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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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