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Hospice Articles

Hospice Story: Psychosocial Support & Medications – Permission

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org
 

When pharmacy is consulted on a hospice patient the knee jerk response is let’s give them medications! That’s an understandable response considering the role of the pharmacist and often where the inquiry begins. However, I have always asked and taught, though the pharmacist isn’t often the one preforming psychosocial support, they must inquire, understand, and encourage its place in the hospice journey. So, it’s not uncommon to hear me ask things like, is the spiritual counselor or social worker visiting? What’s their take on the situation. The mind is powerful and can sometimes overcome a medication regimen. In this next mini-series, I’ll touch on some cases where the relationship between psychosocial support and medications are showcased.

It was approximately around 7pm when my cell phone rang. It was a dear friend who I’ve known for years and taught with at The Ohio State University. I knew their family had a parent on hospice and was at the local inpatient unit, so the call didn’t surprise me. The conversation didn’t start with typical pleasantries, but instead was met with panic and stress in their voice. The conversation went like this: “Dad’s just not responding to medications. They are giving him stuff, but it’s just not working. He seems so uncomfortable, was hoping I could pick your brain on what we might try next.” After some history gathering and getting up to speed, we discussed the current regimens and I asked this question, “Has everyone in the family visited? Anyone from out of the area you’re waiting on?” Clearly, this question was not expected as the silence on the other end made me think the phone call had dropped. Nonetheless, their response was everyone was or had been there, except one brother who was on his way right now. He would probably arrive within the next couple of hours. My response was your medication regimen seems appropriate and you’ve done the right titrations. Based on what you’re saying and how you’re chasing these symptoms, if I can be honest, it sounds like emotional discomfort and I have to wonder if it’s not related to the brother who has not arrived yet. My dear friend paused and said “well maybe, they are close”. I suggested since he was enroute let’s regroup after he arrives and see what, if anything, changes. They agreed.

We stayed in touch over the next day and my friend’s father had settled down greatly after the brother visited, no major medication changes had been needed and everything was stable. Now with this new found calmness, the family started to wonder how long would their father ‘hang on’. My friend called and said “hey, we just spoke with the social worker here in the inpatient unit and they said dads on his journey and could be any time now, but it’s been two days without any meaningful connection/response. It seems like he’s just hanging on. Do you have any thoughts?”

We talked about their dad settling down quickly once all the family was there. I reminded them how close of a family they are and asked the following “has everyone given him permission to go? Let him know you all love him and the family will stick together and take care of each other and cherish all he has taught the family?” My friend said no they haven’t done that. I suggested they get together, discuss it, and decide if they felt comfortable doing that.

I received a phone call later that day. My friend said their dad passed away 30 minutes after they all gave him permission to go. The family was at peace and so was their dad.

Note: This is part 1 of the psychosocial support & medications mini-article series.

Hospice Case: George’s Pain Pump

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org
 

George was a fiery gentleman residing in the nursing home. He had come to the nursing home after his last hospital admission where he had a recent setback from his end stage lung cancer. You see, George was a veteran, pretty stoic and had stopped his cancer treatment a while ago when electing hospice care.

George had ongoing pain issues and had been treated with various different regimens over the year and they all left him feeling his pain wasn’t controlled. While he was in the hospital this last time, they started him on a morphine continuous infusion of 0.5mg/hr basal and 0.5mg every 2 hours as needed for breakthrough pain, which seemed to provide a lot of relief.

Fast forward a couple of weeks, George’s nurse reports he’s just mad. Not like disease progression agitated, more like I’m mad at the world agitated. The nurse reported she had been discussing with George the idea of moving off the morphine continuous infusion and back to oral medications. George wasn’t hearing that. After so many trials and failures that’s the last thing he wanted to hear. In addition, he was extremely upset with the IV pole he had to roll around the nursing home.

I asked George if he would talk to me. Yes, he was afraid to make a change to his pain medications. Yes, being tethered to the IV pole caused extreme frustration. I think George saw that IV pole as a constant reminder to him and everyone else he was sick. But I saw something interesting, his total morphine dose was pretty small in the grand scheme of things. So, was it that the IV morphine was magic or were his previous failed regimens maybe just not optimized very well?

Upon some digging and talking with George, it was clear that his previous pain regimens were not consistent. Lots of PRNs, chasing the pain, max number of pills and worry about acetaminophen max doses and do this, but not that. His goals were to be as alert as possible and his words were: “if I have to be in this damn nursing home, I sure want to be able to do stuff… Not half asleep and tethered to this pole!”

I suggested we discuss with his physician making a change to methadone. He was reluctant, but agreed to the trial. I explained that the methadone would be twice a day and would cause less drowsiness than other medications. I also knew George was going to have difficulty swallowing soon, his decline was showing and he already had some bouts with dysphagia, so methadone gave us that flexibility to crush and/or use a liquid and still be long acting.

About a week after George’s conversion to methadone my phone rang. I answered and the nurse on the other end was laughing. I said, well I’ve clearly missed the joke, but what’s going on? She just says he, (George), wants to talk to you. He gets on the phone and says: “hey medicine man, I’m not sure what games you’re playing, but this is the best I’ve felt in a long time! That dumb IV pole is gone, I can dance around this nursing home. I’m not sure why no one suggested this months ago, just know in my eyes, you’re alright.” I chuckled; we conversed and ended the call.

After hanging up, I sat there for a minute and laughed at what he said…. ‘you’re alright’- I’ll take it!

Hospice Case: Steven’s Agitation

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org
 

Steven was a charismatic gentleman who had been admitted to hospice about three months ago for end stage Parkinson’s Disease. Steven lived at home with his wife Bea, who also served as his primary caregiver.

Overall, Steven had been steadily declining and had experienced some recent bouts of confusion, but he was still able to ambulate some and was still taking some of his Parkinson’s medications. During the IDG team meetings, it always felt like Steven was up on the screen for a short time, little was changed and often “no change” was communicated by the team. So, it was a little bit of shock when his wife called and reported things were not going well. Steven had not slept for the past three nights and was very confused.

Now I’m a big proponent of teaching the following:

1) Understand the likely symptoms that each patient might have based on their hospice diagnosis or diagnoses. If you know what these are, you can plan.

2) Recognize and understand the difference between acute vs gradual change and reversible and irreversible causes of agitation/delirium.

With the above in mind, this is an acute change for Steven, though common to see increased confusion and agitation with end stage Parkinson’s and he could be declining towards the end, it didn’t seem to fit and warranted a rule out. In addition, the chief complaint is no sleep, agitation and confusion, which go hand in hand.

Reminding ourselves of possible causes of delirium, we know that lack of sleep with hospice patients is a major cause. The hospice case manager and I immediately start working through what’s likely to happen in Parkinson’s and where we should look. Constipation, urinary retention, infection (UTI and aspiration pneumonia), dehydration/electrolyte abnormality, pain, and medications typically float to the top. For Steven, his bowel and bladder were unchanged, no signs of infection were present, skin turgor was unremarkable, no changes in non-verbal signs of pain. We briefly discussed that Parkinson’s medications towards the end provide limited benefit and often can start to produce agitation, confusion and hallucinations, but overall, that wasn’t what caught my attention.

Bea had said something to the nurse that sparked a thought. She was talking about how Steven had been getting worse and his “freezing of gait” (FOG) with door thresholds had become a challenge despite his medications. She had to make the hard decision to move Steven from the bedroom to the dining room where there was just more room and a direct path to the restroom.

Change in location, like moving from a bedroom to the dining room, is on the list of causes of delirium, but it was Bea’s next comment that solidified the cause.  Bea states: “I just want everyone to be safe, so I added these nightlights”.  Adding nightlights is common and what any person would do to prevent falls, but what this can sometimes do in Parkinson’s patients is cause shadows. “Parkinson’s Shadows” can lead to hallucinations and fear and can be a common cause of insomnia. The timeline fits with the location change and nightlight addition.

So instead of increasing the dose of quetiapine (Seroquel) and attempting to “force” sleep with antipsychotics, which is not best practice and usually fails, we removed the low light nightlights and added a brighter light in the room, discussed with the medical director about using trazodone to reverse the sleep deprived delirium and after 48 hours the agitation and delirium subsided.

Cases like these remind us the importance of walking through a differential and looking for causes of our patient’s symptoms, sharing with the IDG team, and the importance to always be listening for clues.

Hospice Case: Billy’s Ewing Sarcoma

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org
 

Bill, aka Billy as he preferred, was a young 24-year-old that had been diagnosed with Ewing’s Sarcoma, a painful type of bone cancer. Billy arrived in the inpatient unit at the hospice program in Texas.

Flashback about one week. I was asked by this hospice program to travel to Texas and present at each of their home hospice locations, inpatient units and at a physician’s dinner later that evening. After a successful trip, I arrived back home when the phone rang.

Hello Jason… This is the Executive Director of the hospice and I know you were just here, but I have our medical director and our nurse with us and we need your help. The primary nurse spoke up and said we have a patient named Billy who arrived in our inpatient unit over the weekend and we started him on hydromorphone 1mg/hr infusion with 1mg IV every 20 minutes for breakthrough pain. We’ve since had to increase his pain meds from 1mg/hr to 40mg/hr and he’s used 240mg of breakthrough in the last 24 hours. The medical director chimes in at this point saying they’re thinking palliative sedation with midazolam and we need a second opinion.

It is not uncommon before palliative sedation is started to request an ethics consult or get a second opinion from a colleague. I was officially the second opinion, which to be honest is perfectly fine as I have been the second opinion or expert witness for many patient care activities over the years.

I preceded to ask some questions about the pain, more specifics about the Ewing’s Sarcoma and other treatments that had been tried. After conversing for a bit, we concluded that it would be best to try some other options before palliative sedation and monitor for the next 24-72hrs. We started methadone, we began to slowly decrease the hydromorphone, started dexamethasone and added chlorpromazine strategically since we discovered he was having rectal spasms that were contributing to a significant amount of his pain. Chlorpromazine is a hospice clinical pearl for rectal tenesmus. Over the next 72 hours he improved greatly and was able to spend quality time with his family. At that point Billy was stable so I ended my daily check-in and let them know I was available should the need arise.

A year had past and the hospice had asked me to visit them again for some educational training. Upon arriving at the inpatient unit, one of the nurses came out to meet me and as we chatted, she asked did you ever hear what happened with Billy? I responded I had not. She proceeded to tell me he passed away peacefully. I was sad to hear he had passed, but happy it was peaceful.  She stopped mid-sentence and said, “oh you don’t know the other half”. I paused and listened very carefully. The nurse informed me that one week after Billy had passed, his mother and father came to the hospice and requested a meeting with the leadership. The mother preceded to let the hospice know that Billy had a brother who was two years younger. Billy’s brother also had the genetic abnormality that causes Ewing’s Sarcoma and had begun to develop the disease. They went on to say that when the hospice couldn’t get Billy’s pain under control, they were really struggling emotionally and went home every night thinking their son would die in pain and his brother would die in pain in a couple of years. The mother said, “you don’t know the gift you gave us when Billy died peacefully, as we know our son is in a better place and we know his brother, our other son, will also be able to die peacefully”.

I wanted to share this case as every so often when people ask, are you happy working in hospice, I pause and remember Billy- remembering the amazing journey we all play in the lives of people every day.

Recognizing a Hospice Prescribing Cascade

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org
 

Every medication choice in hospice is crucial. Keeping therapies streamlined to those that offer multi-symptom benefits and truly align with the patient’s goals of care is key.

A prescribing cascade illustrates how a single medication can lead to a domino effect of new prescriptions. A classic example starts with amlodipine:

Amlodipine –> Increased Ankle Edema –> Furosemide Added –> Increased Urine Output & Bathroom Visits –> Fall & Injury –> Opioid Started –> Constipation –> Laxative Started –> GI Upset –> PPI Started….

This cascade shows how a common side effect, lower leg edema with amlodipine, can lead to a complex and dangerous cycle of polypharmacy. Hospice patients are already at high risk for falls, pain, and constipation. By adding more medications, we compound these risks.

When faced with a new symptom, ask yourself these questions:

  • Is this symptom a side effect of a medication we recently added, stopped, or changed?
  • If we add a new treatment, what other effects could it have and how do we monitor for those?
  • Are we able to remove a medication while adding this new one?

For this particular scenario, understanding the patient’s blood pressure history, including a sitting to standing measurement since the patient appears to be ambulating. Asking the question why do we treat blood pressure to begin with and what are we targeting as a goal in hospice. Understanding the general lack of evidence on the use of amlodipine as a treatment. Checking the skin turgor to see how “hydrated” the patient is despite the edema. Hospice Clinical Pearl: Checking skin turgor in hospice patients on the clavicle area is one of the best spots. Understanding that lower leg edema in hospice is not uncommon due to decline in mobility, decreased intake leading to low albumin levels and malnutrition and ultimately third spacing etc. Even if the amlodipine isn’t the sole cause of the edema, deprescribing it when appropriate will often improve the symptoms or at least allow for a reduced dose of the furosemide, lessening the risk of continuing the cascade.

Building a deprescribing mindset into your routine is a fundamental part of hospice care. It helps eliminate unnecessary medications and reduces the cumulative effects of polypharmacy in a frail population, ultimately improving comfort and quality of life.

Why does hospice use haloperidol (Haldol) for nausea?

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org
 

We’ve all heard we should use, but why? Well, the answer is multifactorial, just like the drug. Let’s first start with the idea that as patients decline limiting the number of medications is always a goal, especially when we know swallowing will become more difficult. Picking a medication that we can use for nausea and agitation/delirium just makes practical sense.

Now pharmacology wise if we look way back into the archives, we find that everyone was looking for medications to treat schizophrenia and haloperidol was highly successful, but it was also discovered that patients in those studies didn’t have nausea… Well, another drug, prochlorperazine (Compazine) was trying to enter the space as a schizophrenia drug, but it didn’t really work as well. So, marketing said “ok haloperidol you can have schizophrenia, we’ll go after nausea”. And as you sit here today reading this, you realize that marketing (yes before Google and Social Media ads), played a role into drug selection. But in all seriousness let’s talk chemistry for a minute. The reason prochlorperazine was good for nausea and not as good for schizophrenia is because even though the both have binding affinity for the dopamine receptors, prochlorperazine binds then releases, binds then releases. Haloperidol likes to bind and hang on. That binding and hanging on is what gives haloperidol that bad rap for extrapyramidal side effects especially over long treatment courses, which you have with schizophrenia. Flash back to hospice, most of end-of-life nausea is dopamine mediated at the chemoreceptor trigger zone (CTZ) and guess what… it’s not going away. Their cancer, end stage renal disease, liver, etc. will be here tomorrow. So, unlike transient nausea, we benefit from the binding and holding on at the receptor. We need the medication to stay around to keep nausea at bay. This is often why haloperidol is given in small doses like 0.5mg twice a day and then as needed for breakthrough. If we keep the doses under 2mg, then our likelihood for extrapyramidal side effects, combined with shorter life expectancy, makes haloperidol’s risk equivalent similar to the other antipsychotics like risperidone (Risperdal) and olanzapine (Zyprexa).

So, there you have it. Why does hospice use haloperidol for nausea? It targets the most common cause of nausea at end-of-life, helps us limit medication administration by providing flexibility with dosing, treats multiple symptoms, can be crushed, used rectally, comes in a concentrated liquid, injectable that can be given subcutaneous, and has equivalent efficacy and risk.

Clinical Peal: In general, if you find you’re needing more than 2mg of haloperidol for nausea regularly, pause and go through the causes of nausea. You will often find the nausea to be multifactorial too, like CTZ and anticipatory nausea.

Lastly, we all know that extended care facilities/nursing homes F-Tag antipsychotic use, not just haloperidol, but all of them. We also know there is extra excitement about haloperidol. There is no magic bullet for this hurdle other than education and developing a working relationship with the consulting pharmacist assigned to that facility on the best management for patients at end of life.

Morphine’s History in Hospice

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org
 

In order to appreciate the present and prepare for the future, you must understand the past. If we look back in time, we see Dame Cicely Saunders as the modern-day founder of hospice. The journey begins with the death of David Tasma in 1948 and Saunders opening of St. Christopher’s Hospice in 1967. During that time, we see the rise of many “cocktail” creations for the treatment of end-of-life symptoms, including the Brompton Cocktail. The Brompton Cocktail contained a variety of ingredients, such as Morphine/Cocaine/Alcohol/Chloroform/Heroin etc. and we see Cicely Saunders praising this cocktail in the 1950’s for easing suffering at end of life.

We flash forward to the 1970’s and early 80’s, a physician by the name of Robert Twycross asks the question, is the idea of a cocktail needed or are all of these ingredients causing too much sensory impairment. This idea of “keeping people comfortable” vs. “symptom control, with quality of life” came into question. Sensory impairment was high with these cocktails, I mean they contain cocaine & chloroform! Twycross set out to do research on this topic and discovered in multiple studies that using morphine alone was therapeutically equivalent to the cocktails, but caused less impairment and more quality of life. In response to these studies, Cicely Saunders in an interview said “everyone changed from heroin to morphine and the only impact was the prescriber who had to write the order”. Here the concept of Morphine Elixir was born.

That led to the transatlantic hospice movement, where knowledge sharing between Europe and the west (United States) began and you start to see influence from the likes of Elisabeth Kubler-Ross ‘On Death and Dying’ 1969, Connecticut Hospice 1974 etc. That transatlantic movement walks us up to 1978 where a pharmaceutical company by the name of Roxane Labs had just been purchased and then onto the 90’s where this idea that ‘concentrated solutions’ could replace elixirs and could be given sublingually, a real benefit at end if life. With wind in the sail, Roxane Labs gave birth to their first child and named them “Roxanol”. That family grew and gave us many other siblings, two popular concentrates, Lorazepam 2mg/mL & Haloperidol 2mg/mL.

So, at least at a very high level, you know how Morphine Concentrate 20mg/mL (Roxanol) came to be the backbone medication for hospice, a medication that you probably find yourself talking about, educating on, ordering, each and every day.

Note: This is part 1 of the morphine mini-article series.

Morphine Myths in Hospice

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org
 

We’re going to tackle five common morphine myths that tend to circulate around the internet. Let’s dive right in!

Myth #1: Hospice gives morphine because it kills people. Reality is lots of things can kill people and yes that includes morphine. However, this notion that hospice uses morphine for this reason is just not true. Morphine, along with every other opioid, is dosed using equianalgesic dosing, meaning one opioid is dosed equivalent to another. So, if one takes a hydrocodone/acetaminophen (Vicodin) for a dental procedure, taking an equivalent dose of morphine yields the same result. Now that is vastly different than taking an entire bottle of morphine, or even Vicodin for that matter. It’s extremely helpful to remember these opioid steps. As the dose of an opioid goes up you generally get analgesia; then sedation; then loss of consciousness; then respiratory depression; then death. So as long as morphine, or any opioid for that matter, is being dosed and titrated appropriately, then hastening death with opioids is just a myth.

Myth #2: I have to reserve morphine for the end. This myth stems from fear. As we noted above, equianalgesic dosing is standard practice so this should never be the worry. Tolerance on the other hand, can occur with all opioids, and opioid rotations are very effective. So, this idea of leaving morphine on the sidelines till the last play in the game doesn’t clinically hold any weight; morphine can be used to manage symptoms at any time.

Myth #3: We increased their morphine from 5mg to 10mg and they took their last breath. Did we end their life? Absolutely not! If you remember from the steps above in the opioid path from analgesia to death, incremental titrations that are clinically appropriate will not hasten a patient’s death. It goes without saying, inappropriate dosing i.e. morphine 5mg then next dose you gave 1000mg, that is an overdose and separate from this conversation. Overall, we find that it is not uncommon for a patient to “let go” during a stage of relief (pain, anxiety, shortness of breath etc.). So that bump in opioid yielded some symptom relief and allowed the patient to pass away peacefully.

Myth #4: Morphine is more addicting than other opioids. This is not true, addiction is a complex medical process, far more than can be discussed here. However, in the face of true physical pain, development of addiction is very rare and would not be a concern with a patient at end of life.

Myth #5: Morphine will slow my breathing causing me to die. No this is not true. It is true that morphine is used at end of life for shortness of breath/dyspnea. We also know that the sensation of dyspnea at end of life does not always correlate to a low oxygen (O2) saturation. The mismatch that the body produces centrally between drive to breath harder and faster vs. the actual oxygen exchange is at play here. Morphine does calm the body’s ability to perceive the need i.e. central mediated drive and brings it back into line with the physical needs of oxygen exchange. Remember from above, the opioid steps from analgesia to death and remind yourself under normal dosing guidelines you are not treating dyspnea in someone who entered the sedation and loss of consciousness phase, and you need to enter those before respiratory depression and death.

Note: This is part 2 of the morphine mini-article series.

Morphine a Hospice Medication

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org
 

We’ve covered some history and some myths in previous articles, so let’s spend a little time on morphine the medication.

Morphine is a really effective pain reliever and is still considered to be first line by the world health organization (WHO) for end-of-life symptom management. There is no data that globally supports one opioid is better than another. Granted there are patient considerations which may make one agent a better choice, hence hospices number one principal for creating individualized plans of care. Morphine currently holds that #1 spot as a ‘pure opioid’, meaning it is not mixed with another agent like acetaminophen etc.

Many ask, and you often see this echoed by patients and families on social media, why does hospice jump right to morphine? Frankly, it has to do with the idea it’s a pure opioid and you are not limited in dosing, aka a ceiling, like you get with combination products- example things that contain acetaminophen where there is a max dosing limit. The goal in hospice is to manage symptoms and create comfort as quickly as possible, so avoiding that messy aspect of having to change medications, begs one to just start with the end in mind. Morphine also comes in multiple dosage forms (tablets, liquids, injectables, short acting, long acting), various strengths, well tolerated orally, rectally, via PEG, subcutaneous, intravenous, etc. and is generally very cost effective.

Like all medications there are some known concerns, one being the use of morphine long term and in renal impairment due to the metabolites M3G and M6G. M3G is the one that more often leads to myoclonus, neuroexcitation and hyperalgesia, though all opioids can produce hyperalgesia, with methadone being one of the least likely. Remember besides just the metabolite, time and dose plays a role here. Often, someone might be concerned even though they already have morphine in the home, the patient has renal insufficiency so therefore morphine shouldn’t be used. Remember, if your patient is in the active stages of decline and not expected to live for more than a couple of weeks or is not on a trajectory to use high doses, the acute/short term use of morphine will be fine. However, if your patient has significant renal insufficiency and months to live and you’re starting an opioid, then picking another agent could be warranted. Oxycodone, Fentanyl, & Methadone are better choices with renal impairment, remembering that Hydromorphone (Dilaudid) is metabolized similar to morphine to the D3G and D6G metabolite and is associated with similar concerns.

Note: This is part 3 of the morphine mini-article series.

Nebulizing Morphine in Hospice for Dyspnea

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org

Nebulizing morphine has been a topic of debate in hospice over the years. The use seems cyclical, where it garners lots of attention, then the use rapidly falls out of favor only to show back up again. I’ll attempt to explain why that cyclical phenomena occurs.

The data on the use of morphine nebulized is weak. Larger studies showcased that morphine nebs are no more effective than nebulized normal saline. Small case studies have shown some possible benefit, however as previously discussed, morphine is hydrophilic and typically you need more of a lipophilic substance to readily get across the membrane surface and be absorbed. So, the amount of morphine absorbed systemically via the lungs is lower than if given orally or parentally. This makes sense since we often see little to no sedation with nebulized morphine. Herein lies the problem. Dyspnea at end of life is often centrally mediated in the brain, so if you can’t achieve a blood level high enough via nebulization, you are probably fighting an uphill battle.

Some studies theorized a mechanism of action via opioid receptor binding in the lungs that might impact smooth muscles and help with shortness of breath. The data however is pretty sparse to make a solid conclusion for morphine. Also keep in mind, relaxation of smooth muscle in the airway would most likely benefit those having dyspnea non-centrally mediated. There is actually more data to support that nebulized furosemide (Lasix) and its binding affinity for a different set of receptors might be a better option. So, if you’re practicing evidenced based medicine, morphine nebs would be reserved for last line therapy.

My general recommendations over the years for end-of-life dyspnea are: use opioids via the oral route first with the alternative being subcutaneous/parental, manage anxiety with use of a benzodiazepine, then try adding in normal saline nebs (don’t sleep on the value of nebulized normal saline especially in COPD patients), then a bronchodilator like albuterol or furosemide nebs, then morphine nebs or fentanyl nebs. Fentanyl being more lipophilic may actually be more readily absorbed.

Clinical pearl wise, the biggest challenge with all of this data is you have to normalize for various patient conditions, in addition to the medications used. For example, a patient with dyspnea who has COPD, a disease that causes damage to the lungs, might not absorb at the same rate as someone who has dyspnea and dementia and no lung impairment. Alternatively, those with lung diseases might actually express more or less of these alternative receptors making their use and results questionable.

These and many other factors have led us here to the present where we have the occasional case report of success aka the ‘one off’, but on the other hand many reported treatment failures. That case report phenomena can be contributed to the cyclical response we see in the hospice space, but due to wide variability and study bias the results are hard to be extrapolated to hospice in general. One such bias that is important to understand is when nebulizing morphine, you bring the volume up to 3mls with normal saline and normal saline alone has shown benefit in dyspnea. So are morphine nebs wrong to use, not necessarily, but best practice would be to not use as first line or second line, keeping in mind this is in general and there can always be patient level exceptions.

If morphine nebs are to be used, the best recommendation would be to use injectable morphine. Preservative free morphine has been suggested to reduce risk of bronchospasms, but in clinical practice the preservative free often is not necessary. Some use the oral liquid morphine concentrate mixed with normal saline. This is not recommended as the oral solution, even the sugar free, is formulated for oral administration and contains other ingredients that actually do increase the risk of bronchospasms, cough, etc.

Note: This is part 4 of the morphine mini-article series.

Hospice Story: Psychosocial Support & Medications –
Safety & Sleep 

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org


This was just your ordinary Wednesday afternoon, patients were being seen, medication orders were being written, and patients and families were working through tough transitions.

Meet Debbie. Debbie was an elderly woman who had suffered a stroke and had vascular dementia. She was receiving hospice care in her home, as she had multiple hospitalizations for UTIs and aspiration pneumonia and the goal wasn’t to go back to the hospital anymore. Between her stroke and vascular dementia, she didn’t speak much, often communicating with simple eye movements.

It seemed recently that Debbie was really struggling with insomnia. It was reported that she couldn’t fall asleep and would just lay in bed with her eyes wide open. The hospice nurse reported she was concerned that if this continued much longer Debbie would begin to have some delirium. The hospice nurse reported that they had tried the lorazepam already in the home, using varying doses. The medical director ordered some trazodone a couple of nights ago, with repeat and titrating doses, all of which didn’t seem to do anything.

So, the question was what should we try now? There were endless choices it seemed, as ideas were tossed around among the interdisciplinary team. The conversation landed back on me and they said… so what do you think?

I resisted the urge to throw out another option, instead I said something felt off. Debbie hadn’t had any reports of insomnia until these past couple of weeks and it wasn’t happening every night. I think we need to poke around more. What’s Debbie’s home life like and has anything changed? Come to find out Debbie’s husband had passed away years prior and she had no family. She resided in her home and had paid caregivers who stayed with her during the day and at night. Upon inquiring with the caregiver agency, they said Debbie always has the same caregiver at night, up until recently. Bingo! That change corresponded with new onset insomnia. Let’s think about it, if you had a stranger in your house, would you sleep well at night? That explains the up-all-night and eyes-wide-open. This was confirmed by Debbie using eye blinking to let us know she was scared when new caregivers stayed overnight.

So why did the medications not work? Well, the mind is a powerful thing and it’s not uncommon for the mind to overcome medications. The repeat and titrating doses weren’t going to muster enough to get Debbie to sleep- she was resisting. Even if they did work, it’s short ten-minute sleep cycles, leading to exhaustion. So, the resolution required some work between the hospice and the caregiving agency, but stopping the rotation of new caregivers each night and doing some ‘introductions’ between new night caregivers and Debbie helped create more of a team that could rotate through, easing that stress and allowing Debbie to rest.

Sometimes when things don’t make sense it is imperative that we reminder ourselves to pause, remembering that psychosocial and spiritual elements can carry just as much power as medications found in our hospice toolkits.

Note: This is a part 2: Psychosocial Support & Medications – Safety & Sleep

Hospice Case: Mary’s Weekend Surprise

By: Jason Kimbrel, PharmD., BCPS
Chief Operating Officer Yellow Leaf Consulting | www.yellowleafconsulting.org
 

It was an early Saturday morning. Nothing exciting was happening besides some routine admissions and new medication orders for common hospice medications.

That all changed at 10:09 AM. Meet Mary. Mary lived in a nursing home and didn’t really have any family close; most were out of state. Mary had been on hospice for about three months with uterine cancer that had metastasized to her bone. Mary slept the majority of the time and had been declining for the last couple of weeks. The nursing home had called the hospice to report that Mary had become nauseated and was vomiting a little bit of blood. The hospice nurse quickly headed to the nursing home to assess Mary. Both Mary and her family had previously made it very clear they did not want any more hospitalizations.

Upon arrival, the hospice nurse (Anne) completed her assessment and reached out to me. She said, “Jason, I’m here and Mary’s nauseated. She’s vomiting a little like the nursing home reported, but frankly it doesn’t look like blood. It looks and smells like stool. Could she be obstructed?”

After a little more back and forth on the physical assessment (bowel sounds etc.), we concluded that it was a very high likelihood she was fully obstructed. Now one of the many skills that hospice clinicians have is we use history, physical assessments, likelihood percentage, etc., to guide next steps, as we often don’t have things like lab values, or in the case of a full bowel obstruction, imaging. The family was clear they didn’t want any more trips to the hospital, so Anne was like, “What do we do?”

We talked through possible plans with the attending physician. I discussed at this stage we were going to need injectable glycopyrrolate (Robinul), haloperidol (Haldol), and dexamethasone (Decadron). We were going to want to place a couple of subcutaneous butterflies to control the symptoms, as changing her intake status to nothing-by-mouth (NPO) was needed and appropriate. We shared with the family that bowel obstructions can often occur when tumors rapidly grow in the abdominal cavity pushing on the intestines and creating widespread inflammation. Since no more hospital visits was her plan, and they did not want any surgical intervention to repair the obstruction, it was about symptom control and comfort. They were on board with the plan, understanding that it would be wise if they headed into town now to see Mary. The plan was to get the gastrointestinal (GI) tract shut down quickly, stopping the pain, spasms, and vomiting of stool with glycopyrrolate; haloperidol to help combat the nausea; and dexamethasone acutely to reduce some of the tumor burden/inflammation. Our goal was to allow morphine concentrate sublingually for pain and, if tolerated, even move back over to oral liquid concentrated haloperidol and dexamethasone, while keeping the glycopyrrolate subcutaneous.

After starting treatment, her symptoms subsided rather quickly. Upon her family’s arrival, she was well-controlled and comfortable; Mary was reaching the end of her journey.

Sometimes calm Saturday mornings flip rather quickly to vomiting stool and mild panic, but with solid training and an interdisciplinary team, even scenarios like this can be effectively managed in the place where the patient calls home, honoring their wishes.

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