DOCSLIB.ORG

Promoting Excellence in Symptom Management Case Series Case Study: a New Intervention for Rapid End-Of-Life Symptom Control in the Home Setting

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Promoting Excellence in Symptom Management Case Series Case Study: a New Intervention for Rapid End-Of-Life Symptom Control in the Home Setting Symptom Management Series Promoting Excellence in Symptom Management Case Series Case Study: A New Intervention for Rapid End-of-Life Symptom Control in the Home Setting Kathryn Paez, BSN, RN, CHPN ƒ Meegan Gregg, NP, CHPN ƒ Charlea T. Massion, MD ƒ Brad Macy, BSN, BA, RN, CHPN The oral route is compromised for nearly all patients at can be used to ensure rapid symptom management and the end of life (EOL). This article reviews the benefits decreased burden of care by facilitating immediate and and burdens of the usual alternative routes of medication easy use of medications already present in the home. delivery when the oral route fails and presents a case study on the use of a new innovation for the rectal delivery of medication to control EOL symptoms. A 62-year-old KEY WORDS male hospice patient with end-stage metastatic prostate Macy Catheter, rectal medication, sublingual cancer presented with severe symptoms (Face, Legs, medications, suppository, symptom management Activity, Cry and Consolability scale score, 9/10) that were uncontrollable with medications given via oral or lmost every hospice patient loses the ability to sublingual routes. The patient goals were to remain at swallow medications in the last hours to days of home with optimal symptom management. Rapid relief of Alife. For most of these patients, symptoms are well symptoms was accomplished by the administration of managed with the administration of sublingual (SL) medi- medications already present in the home delivered with a cations. However, the SL route is ineffective for many pa- new rectal catheter that provides discreet access for tients in controlling symptoms. Whereas the precise ongoing medication administration. Significant relief was percentage of hospice patients who die with poorly con- noted within 20 minutes of dosing. The patient died trolled symptoms is unknown, symptom control chal- peacefully 18 hours later, meeting his EOL goals, and the lenges at the end of life (EOL) are well known and family was empowered to provide effective care for the documented. patient at home. The family found the intervention easy to use. This case demonstrates how this new innovation A comprehensive literature review done by Kehl and Kowalkowski1 evaluated the prevalence of symptoms in the last 2 weeks of life. Of the 2416 patients in this review, Kathryn Paez, BSN, RN, CHPN, is case manager, Hospice of Santa Cruz the authors found that pain was present in 52.4%, dyspnea County, Scotts Valley, CA. was present in 56.7%, and confusion was present in 50.1% Meegan Gregg, NP, CHPN, is nurse practitioner and case manager, Hos- of patients. Another literature review on symptom manage- pice of Santa Cruz County, Scotts Valley, CA. ment in palliative care between 2004 and 2012 found that Charlea T. Massion, MD, is chief medical director, Hospice of Santa Cruz pain and other symptoms were inadequately assessed and County, Scotts Valley, CA. managed at the EOL.2 A survey performed specifically on Brad Macy, BSN, BA, RN, CHPN, is president and co-founder, Hospi 3 Corporation, Newark, CA. hospice patients by Coyle et al found that between 5% and Address correspondence to Brad Macy, BSN, BA, RN, CHPN, Hospi Corpo- 35% of hospice patients described their pain as ‘‘severe’’ in ration, 39655 Eureka Dr, Newark, CA 94560 ([email protected]). the last week of life and that 25% of the patients described Mr Macy is a 25-year veteran hospice nurse and inventor of the Macy their shortness of breath as ‘‘unbearable.’’ Catheter (MC) and is a stockholder of Hospi Corporation, which has When oral and SL routes are unavailable or ineffective developed and commercialized the MC. All other authors have no con- flicts of interest to disclose. and symptoms are active, establishing an alternative deliv- This is an open-access article distributed under the terms of the Creative ery route is essential. This article reviews the benefits and Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY- burdens of the common alternatives to oral delivery and NC-ND), where it is permissible to download and share the work provided it presents a case study on the use of a new technology for is properly cited. The work cannot be changed in any way or used commer- cially without permission from the journal. rectal delivery to control symptoms at the EOL. This is the Copyright B 2016 by The Hospice and Palliative Nurses Association. first case study published in the hospice and palliative care All rights reserved. literature on the use of a catheter designed for administer- DOI: 10.1097/NJH.0000000000000298 ing ongoing medications via the rectum (Macy Catheter 498 www.jhpn.com Volume 18 & Number 6 & December 2016 Symptom Management Series [MC]; Hospi Corporation, Newark, CA). The article demon- manage pain are typically unmanageable via the SL route. strates how this relatively new mode of medication deliv- If a patient is receiving large doses of an opioid analgesic ery can offer a rapid and effective solution that is easy to and loses the ability to swallow, these doses cannot be use by both clinicians and caregivers. effectively absorbed on the relatively small SL mucosa. In addition, hydrophilic opiates such as morphine, oxycodone, Alternative Routes of Medication Delivery in and hydromorphone are poorly absorbed sublingually. For the Home Setting example, the bioavailability of SL morphine is very low When oral and SL routes fail to control symptoms, the in- compared with those of other routes. In one study, mean terdisciplinary team (IDT) is challenged to find a route that (SD) SL morphine absorption was demonstrated to be only is safe, rapid, effective, and easy for caregivers in the home 9% (11.9%) compared with an intramuscular dose.8 setting. The National Consensus Guidelines (2013) state If dose volumes are too high or too frequent, silent as- that the goal of symptom management in the hospice piration can occur because medication administered in and palliative setting is the safe and timely reduction of very low volumes will not always stimulate a swallow re- symptoms to a level that is acceptable to the patient or pa- flex, especially in patients with altered levels of conscious- tient’s surrogate if the patient is unable to self-report dis- ness. Furthermore, when a patient transitions to an actively tress.4 Therefore, the choice of an optimal alternative dying state, the swallowing reflex may be impaired, esca- medication route must consider the speed and extent of ab- lating the risk of aspiration. When aspiration occurs, pa- sorption, safety and comfort in the home setting, and ease tients often have respiratory distress and more secretions, of use by lay caregivers. The speed of initiating an alterna- which increase patient discomfort and caregiver angst at tive route is important because patients may have severe the EOL. The clinician should assess for silent aspiration symptoms with little time before death. Waiting for medi- by asking caregivers whether they are noting any coughing cations to arrive while watching a patient suffering with or gurgling sounds after SL dosing. symptoms can be a great burden to caregivers, especially If a patient requires adjuvant pain medications such as if medications do not arrive in time to help, leading to a nonsteroidal anti-inflammatory medication, dexametha- poor death outcome. Routes of medication administration sone, antiseizure medications, or antidepressants, either available when the oral route fails include SL, rectal, subcu- these medications must be stopped, or another route must taneous (SQ), intravenous (IV), transdermal, transmucosal, be found when swallowing fails because they are not epidural, and intrathecal.5 The more common alternatives absorbed sublingually. For patients with severe or complex used in the hospice setting are reviewed hereinafter. pain management needs, abruptly stopping these medica- tions when the oral route fails can result in a pain crisis. An- The SL Route other route of delivery may be needed to continue these The SL route is most frequently used in hospice care. Ease medications. Therefore, a patient who has a history of com- of access, simplicity for the caregiver, and the relatively low plex or severe pain should be monitored carefully, and the cost of medications make this route highly desirable. How- IDT team should have a plan in place for how to deliver ever, often, the SL route is ineffective or unfeasible in a pa- adjuvant pain medication quickly to patients when the oral tient’s final days. Clinicians must recognize when to switch route fails. to more effective routes of delivery. Skilled clinical assess- Terminal agitation is another symptom in which the SL ment and an understanding of the limitations of the SL route often fails. Agitation is one of the most common EOL route will allow the clinician to anticipate when a patient symptoms and one of the most distressing for caregivers to will need an alternate route before symptom crises. witness. Agitated patients commonly will not cooperate Some medications for EOL comfort are poorly absorbed with taking orally administered medications. Severe dys- sublingually. Dose volumes of approximately 1 mL or less pnea or pulmonary crises requiring larger doses of narcotic are optimal. Larger volumes can be too large for the limited analgesics or sedatives for palliative sedation are also poorly surface area of the SL and buccal mucosa and are many managed via the SL route. Other examples of symptoms times swallowed or aspirated or may drip out of the mouth. that are difficult to manage with SL medications include The SL absorption of medications is also highly dependent seizures, fever, nausea, and vomiting. on oral pH, the amount of time in contact with the muco- sal surface, and the moisture and secretions within the Parenteral Route (IV and SQ) oral cavity.6,7 Once IV access is established and medications are avail- able, IV therapy is the most rapid delivery method avail- Assessment of Patient Types for Whom the SL able and allows for quick titration of medication to Route Is Ineffective control severe symptoms.
Load more

Recommended publications
  • Rectal Administration of Aid-In-Dying Medications
    Rectal Administration of Aid-in-Dying Medications (NOTE: This is a medical procedure and requires a trained clinician who can evaluate the patient for this procedure, do a rectal exam to be sure that the procedure can be safely accomplished, and be responsible for potential complications. We do not recommend that this be done by families alone without significant direct clinician participation.) by Thalia DeWolf, RN, CHPN For questions and/or information, email [email protected] An Essential Warning: Aid-in-dying medications are a thick suspension of powders. They can clog a Macy Catheter. So while Macy Catheters are indeed wonderful and useful devices for end-of- life care, they should not be used for medical aid in dying. See below for proper materials. Pre-care: An intact, empty, warm, moist, well-perfused rectum assures thorough absorption of rectally administered aid-in-dying medications. Be sure your patient has good bowel care in the 72 hours before aid in dying. A daily soft BM is recommended. The best practice is to do an enema the day before or the morning of aid in dying. Within 24 hours of the procedure (or at the time of the procedure) a digital rectal exam must be performed by an experienced clinician (RN or physician) The clinician must ascertain that the lumen is patent and will accept the catheter; that the rectal vault is not filled with stool (small amounts of stool will not interfere with absorption of medications, large amounts, especially of thick, pasty stool, are likely to bind the medications and prevent absorption; that tumor has not invaded the rectum; that the rectum is warm and well-perfused).
    [Show full text]
  • A Cost and Quality Analysis of Utilizing a Rectal Catheter for Medication Administration in End-Of- Life Symptom Management
    Journal of Pain & Palliative Care Pharmacotherapy ISSN: 1536-0288 (Print) 1536-0539 (Online) Journal homepage: http://www.tandfonline.com/loi/ippc20 A Cost and Quality Analysis of Utilizing a Rectal Catheter for Medication Administration in End-of- Life Symptom Management Natalie M. Latuga, Mary Gordon, Paula Farwell & Megan O. Farrell To cite this article: Natalie M. Latuga, Mary Gordon, Paula Farwell & Megan O. Farrell (2018): A Cost and Quality Analysis of Utilizing a Rectal Catheter for Medication Administration in End-of-Life Symptom Management, Journal of Pain & Palliative Care Pharmacotherapy, DOI: 10.1080/15360288.2018.1500509 To link to this article: https://doi.org/10.1080/15360288.2018.1500509 © 2018 Natalie M. Latuga, Mary Gordon, Paula Farwell, and Megan O. Farrell Published online: 31 Dec 2018. Submit your article to this journal Article views: 41 View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ippc20 JOURNAL OF PAIN & PALLIATIVE CARE PHARMACOTHERAPY https://doi.org/10.1080/15360288.2018.1500509 ARTICLE A Cost and Quality Analysis of Utilizing a Rectal Catheter for Medication Administration in End-of-Life Symptom Management Natalie M. Latuga, Mary Gordon, Paula Farwell and Megan O. Farrell ABSTRACT ARTICLE HISTORY Technology that can improve the ability to provide quick symptom control while decreasing Received 14 December 2017 the cost and burden of care could help hospice agencies deal with current hospice industry Revised 8 June 2018 challenges. This paper describes how the use of a new rectal medication delivery technol- Accepted 9 July 2018 ogy at a large hospice in western New York has improved patient care and nursing effi- KEYWORDS ciency while at the same time decreasing the cost of care.
    [Show full text]
  • Field Notes from the Frontline of a COVID-19 Outbreak
    Feature Article Field Notes From the Frontline of a COVID-19 Outbreak Dyspnea Management for Hospitalized Patients at End-of-Life 12/05/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= by https://journals.lww.com/jhpn from Downloaded Dawn Pavlu, MSN, APN, AGACNP-BC, ACHPN, CCRN ¦ Katherine DeMarco, DNP, MSHS, APN, FNP-BC, ACHPN ¦ Downloaded Yusimi Sobrino-Bonilla, MSN, APN, ANP-BC, ACHPN, CCRN from https://journals.lww.com/jhpn Northern New Jersey was inside one of the worst initial dyspnea are described. These accounts include Lessons coronavirus disease 2019 pandemic epicenters in the Learned in order to assist others who may need to quickly United States. At the peak of the pandemic surge in mid- implement changes in the future due to pandemic April 2020, New Jersey saw 8045 hospitalized patients resurgence or second-wave events. with severe coronavirus disease 2019 symptoms, of which by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= 2002 were in intensive care unit beds (86.3% of statewide capacity), including 1705 requiring mechanical ventilation. Because of the severity of pulmonary dysfunction/hypoxia, the unprecedented numbers of KEY WORDS critically ill patients, the national opioid shortage, and air hunger, COVID-19, dyspnea, end of life, opioids, transmission prevention measures for standard palliative palliative, pandemic, refractory dyspnea, care treatment protocols in place for refractory and/or shortness of breath end-of-life dyspnea were found to be ineffective in providing adequate symptom relief. The aim of the n the early months of 2020, as the coronavirus disease following Notes From the Field is to provide concise, 2019 (COVID-19) pandemic reached the shores of the pragmatic, and experiential reflection by 3 palliative care United States, New Jersey became one of the worst advanced practice nurses from 3 different hospital I epicenters in the nation.
    [Show full text]
  • 4/6/2017 1 Pediatric Palliative Care Where Passion and Compassion Merge Session Objectives Pediatric Palliative Care
    4/6/2017 Pediatric Palliative Care Where Passion and Compassion Merge Kimberly Battle‐Miller, MD, MBA, MS System Medical Director, Palliative Care and Hospice Advocate Health Care Session Objectives • Expand participants knowledge of similarities and differences in palliative care versus hospice in pediatric patients • Improve participants knowledge of how to identify pediatric patients who would benefit from Palliative medicine • Enhance participants appreciation for a team approach to patient care • Improve participants knowledge of pain and symptom management in pediatric palliative care Pediatric Palliative Care 101 • Similarities and differences in palliative care versus hospice in pediatric patients • Identifying pediatric patients who would benefit from Palliative medicine • Appreciation for a team approach to the care of the pediatric patient 1 4/6/2017 Statistics • 81 million children in the United States • Children represent 25% US population • United States 2.5 million deaths annually • About 50,000 deaths are pediatric 0‐19 (2.2%) • Half of childhood deaths are in first year of life • Half of infant deaths are in the first month of life Symptoms in Dying Children • 89% suffered from at least one symptom in their last month of life, most with 4‐5 symptoms • Most common reported symptoms: • Pain • Fatigue • Dyspnea • Constipation • Nausea/Vomiting • Poor appetite Wolfe, NEJM, 342:5; 2000 Causes of Deaths Infants with Complex Chronic C0nditions 1. Cardiovascular (32%) 2. Congenital / genetic (26%) 3. Respiratory (17%) 4. Neuromuscular (14%) www.nhpco.org, Facts & Figures on Pediatric Palliative Care and Hospice 2 4/6/2017 Causes of Death Children 1‐19 with Complex Chronic Condition 1. Malignancy (43%) 2.
    [Show full text]
  • Hospi Fact Sheet 122315
    THE MACY CATHETER® A New Option for Patient Comfort • RAPID, EASY FACILITATES RAPID SYMPTOM RELIEF AND SAFE • An immediate way to administer medications when the oral route is compromised • Utilizes medications already in the home; no waiting for delivery • COMFORTABLE of compounded or parenteral medications1 AND DIGNIFIED • Suspensions or solutions are generally absorbed more quickly than suppositories2 • COST EFFECTIVE PR MEDICATION ADMINISTRATION IS COMMONLY USED IN SYMPTOM MANAGEMENT FOR3: • Pain, Agitation, Anxiety, Dementia • Dyspnea, Terminal Fever • Acute Nausea, Vomiting MINIMIZE ADDITIONAL MEDICATION COSTS ELIMINATE DELIVERY CHARGES DECREASE FREQUENCY OF NURSE VISITS FDA INDICATION: “The Macy Catheter truly enhances the care experience for patients and families coping with serious or advanced illness, helping To provide rectal patients to remain comfortable in the setting of their choice.” access to administer Brad Macy RN, BSN, CHPN Co-founder of Hospi, Recipient of 2013’s National Hospice liquids/medications and Palliative Care Nurse of the Year Award 4 EASY STEPS FOR MACY CATHETER PLACEMENT LUBRICATE INSERT INFLATE SECURE FACTORS AFFECTING RECTAL ABSORPTION THE MACY CATHETER STORY The Macy Catheter was invented by • Mucosa is highly vascularized Brad Macy, RN, a practicing hospice • High % absorptive cells nurse for 20 years. One night Brad had a patient who was terminally agitated • Small, dry surface area and not responding to a solid form of • Increased bioavailability Inferior a rectally delivered medication. He vena cava administered the same medication in Inferior a semi-liquid form with a small tube mesenteric vein inserted into the rectum. Brad saw his patient's agitation rapidly diminished, and the patient was sleeping within 30 minutes.
    [Show full text]
  • OPTIONS for CLIENTS WHO CANNOT SWALLOW Gastric/Jejunal Tubes and Rectal Administration of Aid-In Dying Medications
    OPTIONS FOR CLIENTS WHO CANNOT SWALLOW Gastric/Jejunal Tubes and Rectal Administration of Aid-In Dying Medications Suggestions from EOLWA Using materials from Thalia DeWolf, RN, CHPN at ACAMAID, Nancy Simmers, RN at EOLWA, Bob Wood, MD Volunteer Medical Advisor and Carol Parrot, MD, Clinical Consultant End of Life Washington (Rev. 2/21/2021) Death with Dignity is legal even if a person cannot swallow or can no longer eat. The Washington Death with Dignity Act was written and passed with the expectation that those who qualify for and decide to take life-ending medicines would simply swallow (ingest) the medicine, then fall asleep and die. Some of our clients are unable to swallow1. If the medicine is administered into the food ‘tract’ (medically known as the ‘gastrointestinal or GI’ tract – which starts at the mouth and ends at the rectum), patients can take life-ending medications at either end, or through a tube somewhere in-between. Gastric Tubes or Jejunal tubes: Using medicines to end life does require a segment of the GI tract long enough for medicines to be administered and well absorbed. Patients unable to swallow can be provided tubes inserted into the GI tract to administer fluids, nutrition, and medications. A ‘nasogastric’ (through the nose into the stomach) tube might be used for this purpose. A PEG (Percutaneous Endoscopic Gastrostomy) tube can be placed through the abdomen into the stomach. Or, a ‘J’ tube can be placed through the abdomen into the jejunum (the small intestine). Any of these tubes can be used by clients to self-administer life-ending medications.
    [Show full text]
  • Giving Meds by Alternate Routes
    −This Clinical Resource gives subscribers additional insight related to the Recommendations published in− August 2017 ~ Resource #330823 Giving Meds by Alternate Routes Off-label routes of drug administration are considered when patients can’t take a medication by the usual route. Other reasons for using an alternative administration route include minimization of side effects, dosing accuracy, improved efficacy, or cost savings. Examples include administration of oral or injectable medications rectally, or injectables orally. Consider injectables orally when an oral solution is needed, but isn’t available or is unsuitable. Rectal administration of tablets, capsules, oral liquids, or injectables may be the best route at the end of life. Ophthalmic drops can generally be used in the ear to save money.11 But ear drops cannot be used in the eye; their preservatives may harm the eye, they aren’t buffered for eye use, and they aren’t always sterile.11-13 Evidence supporting off-label administration routes is often anecdotal and from experience in end- of-life patients. Use your knowledge of physiology, pharmacokinetics, pharmacodynamics, and pharmaceutics to avoid mishaps. Avoid oral use of injectable meds if the drug isn’t stable in the GI tract or is poorly absorbed orally. Ensure patients or caregivers know how to administer the drug by the alternative route, and give specific instructions for the label instead of writing “as directed.” The table below provides information on alternative routes for certain medications. For important information specific to rectal administration, see footnote “a.” For important information specific to intranasal administration see footnote “b.” Medication Alternative Comments Route Acetylcysteine injection Oral Dilute the 20% solution with three parts diet soda to one part acetylcysteine injection.
    [Show full text]
  • Gilchrist Quality and Patient Safety Plan FY2018 EXHIBIT F
    EXHIBIT F Gilchrist Quality and Patient Safety Plan FY2018 Gilchrist - Quality and Patient Safety Plan FY18 Page 1 of 12 EXHIBIT F Page Table of Contents 3-5 Plan Summary 6-7 Dashboard for FY 2018 Glossary 8-11 Gilchrist - Quality and Patient Safety Plan FY18 Page 2 of 12 EXHIBIT F Plan Overview Each element of the FY2018 Gilchrist Quality Plan is intended to guide hospice and end-of-life care performance in accordance with the CMS Quality Strategy for hospice and the GBMC “Quadruple” AIM: Better Health, Better Care, Least Waste and More Joy. The ultimate goal of hospice care is to help the patient and family receive care aligned with their preferences, while improving quality of life as death nears. Defining and measuring the quality of hospice care is challenging given its strong ties to patient preferences, the terminal health status of patients, and the challenges of an interdisciplinary team delivering services in various settings, including patients’ homes and residential care settings. National data gathering and public reporting are in their initial stages and as a result the consumer currently has limited information about the quality of hospice care to help them select a provider. Efforts to reach consensus on defining hospice quality –including the National Consensus Project for Quality Palliative Care – has generated the measures currently implemented in The Centers for Medicare and Medicaid Services (CMS) Hospice Quality Reporting Program. The first of these CMS measures is the Hospice Item Set (HIS), a patient-level instrument administered as part of the hospice admissions process. It is used to gather data on seven quality measures.
    [Show full text]
  • Rectal Administration and the Macy Catheter® February 2018 Patient
    Rectal Administration and The Macy Catheter® February 2018 Patient Case JK is a 68 year old male with a primary diagnosis of lung cancer metastatic to bone, brain, and liver. He also has a history of cardiac disease and no known allergies. JK lives at home with his wife who is his primary caregiver. Current Medications: • Morphine extended release (MS Contin®) 60mg tablet; Take two tablets (120mg) by mouth every 12 hours for pain • Oxycodone 40mg/ml compounded oral solution; Take 0.5ml (20mg) by mouth every 4 hours as needed for pain • Dexamethasone (Decadron®) 4mg/ml suspension; Take 1ml (4mg) by mouth daily for cerebral edema • Lorazepam (Ativan®) 1mg tablet; Take one tablet by mouth every 4 hours as needed for anxiety • Haloperidol (Haldol®) 2mg/ml oral solution; Take 0.5ml (1mg) by mouth every 4 hours as needed for agitation JK has a strong desire to remain at home and refused inpatient care in the past when his symptoms worsened. His wife and family support his decision to stay at home and are working closely with the hospice team to aggressively manage his pain, occasional seizure activity, and agitation. When first admitted to hospice, JK’s pain control was acceptable. However, during the first week, JK had a seizure that was controlled with a diazepam suppository. He was continued on lorazepam 1 mg, but the order was changed from PRN to every 6 hours around the clock for seizure prevention and to manage his anxiety and restlessness. JK was having periods of unconsciousness, rendering him unable to swallow routine liquid medications.
    [Show full text]
  • Anticonvulsants and Rectal Use: Best Practices | April 2021
    Anticonvulsants and Rectal Use: Best Practices | April 2021 SEIZURES AT END OF LIFE: AN OVERVIEW Seizures are a rare but serious complication at end of life. The incidence of seizure occurrence in hospice patients is not known. Patients at an increased risk for seizures are those with brain cancer, cerebrovascular disease, metabolic abnormalities, certain genetic disorders and/or pre-existing seizure disorders.1 Anticonvulsant therapy should continue, if possible, for patients with a history of seizures, brain tumors with experience of seizures, or a history of status epilepticus. Up to 40% of patients with brain tumors have a seizure at the time of diagnosis. Another 20% develop seizures during the course of the illness. In the past, anticonvulsants were commonly started at the time of brain tumor diagnosis, however they have not been found to prevent seizures. Guidelines published by the American Academy of Neurology do not support seizure prophylaxis. Based on the lack of evidence for benefit, anticonvulsants can be safely discontinued in patients with brain tumors who have never had a seizure.1,2 Most acute seizures are short-lived and terminate spontaneously. The exception is status epilepticus (SE), defined as a crisis in which seizure activity is abnormal, prolonged and refractory to management. Guidelines for managing SE recommend the use of intravenous medications and suggest that neurological, respiratory and cardiovascular monitoring be available. Considering many hospice patients reside at home, these resources may not always
    [Show full text]
  • Decreasing Hospital Transfers in the Skilled Nursing Setting Utilizing a Rectal Administration Catheter for Treatment of Changes in Patient Condition
    Decreasing Hospital Transfers in the Skilled Nursing Setting Utilizing a Rectal Administration Catheter for Treatment of Changes in Patient Condition: A Preliminary Case Series Study Summary: In this case series review, a specialized rectal administration catheter provided eff ective short term hydration in all patients. The catheter intervention was successful in avoiding emergency room or hospital transfers in 7 of the 9 (78%) patients with conditions deemed serious enough to mandate hospitalization if not treated within the facility. The 6 patients able to self-report comfort of the hydration procedure reported hydration via the catheter as very comfortable (5 on a scale of 1 – 5). Staff reported high satisfaction using the catheter in all cases. Bob Parker, DNP, RN, CENP, CHPN Chief Clinical and Compliance Offi cer | Hospice and Palliative Care Siegfried Kreis, MD, CMD Internal Medicine Hospice & Palliative Medicine (Board Certifi ed) Medical Director, Interim Hospice Data included in this white paper was presented in a poster by Bob Parker entitled, “Managing Changes in Condition in the SNF with a Rectal Administration Catheter to Prevent ED and Hospital Utilization,” at the AAHPM/HPNA Annual Assembly, Boston, MA, March 15 2018. The poster won the fi rst place research poster award. Unless otherwise indicated, all materials on these pages are copyrighted. All rights reserved. No part ofthese pages, either text or image may be used for any purpose without the express written permission.Reproduction, modifi cation, storage in a retrieval systemor retransmission, in any form or by anymeans, electronic, mechanical or otherwise, is strictly prohibited without prior written permission. Hospi-10124-v4 1 Introduction Skilled nursing facilities (SNFs) are facing numerous chal- lenges in today’s changing healthcare climate.
    [Show full text]
  • Pharmacokinetics of Phenobarbital in Microenema Via Macy Catheter Versus Suppository Y
    Vol. - No. --2016 Journal of Pain and Symptom Management 1 Original Article Pharmacokinetics of Phenobarbital in Microenema Via Macy Catheter Versus Suppository Y. W. Francis Lam, PharmD, FCCP, Ansom Lam, MD, and Brad Macy, RN, BSN, BA, CHPN Department of Pharmacology (Y.W.F.L.), University of Texas Health Science Center at San Antonio, San Antonio, Texas; WCCT Global (A.L.), Cypress, California; and Hospi Corporation (B.M.), Newark, California, USA Abstract Context. The oral route is compromised for nearly all patients approaching death. When agitation, seizures, or other intractable symptoms occur, a quick, discreet, comfortable, and effective alternate route for medication delivery that is easy to administer in the home setting is highly desirable. Objectives. To characterize the early absorption profile, variability, and comfort of phenobarbital given in microenema Ò suspensions delivered via the Macy Catheter (MC) vs. the same dose given via suppository. Methods. This was a randomized, open-label, crossover study comparing the early absorption profile of equal doses of phenobarbital administered rectally in three treatment phases: phenobarbital suppository and two different microenemas with phenobarbital tablets crushed and suspended in 6 mL (MC-6) or 20 mL (MC-20) of tap water. Results. Mean plasma phenobarbital concentrations at 10 minutes were 12Â higher for MC-20 and 8Â higher for MC-6 compared to suppository. Concentrations achieved in 30 minutes via MC-20 took almost three hours to achieve with suppository. Mean AUC values were higher for MC-20 and MC-6 (82% and 46%, respectively) vs. suppository (P < 0.05). There was less variability in absorption for MC-20 and MC-6 (1.4- to 1.9-fold difference) compared to a 4.4-fold difference via suppository.
    [Show full text]