1. Evergreen Hospice Rotation Ted Williams PharmD Candidate 2009 PHAR 744

2. About the Tie Yes, I wear a bow tie to work Yes, I wore a bow tie to my rotations No, it is not a clip on, I tie them myself every time My sister got this for me for Christmas

3. Outline What is Hospice Pharmacy role in hospice Case Study

4. What is Hospice Palliative care for terminally ill patients Must have a terminal diagnosis with <6mo life expectancy Must demonstrate gradual decline Evaluation period of 90 days

5. Economics of Hospice Medicare Part B Flat rate for all care services and medications

6. Care in Hospice Counseling Services Patient Familiy Medication Management More to come Direct Care Services Set up and maintenance of durable medical equipment Medication administration Bathing and feeding General nursing care

7. Pharmacy in Hospice Discontinuation of most maintenance meds Hypertension Thyroid Osteoporosis Life sustaining meds like insulin are continued Introduce and/or continue pain management medications Opioids Steroidal and non-steroidal anti-inflammatory meds

8. Special Considerations for Pharmacy Management Long term side effects are of little consequence Short to mid term side effects are an issue Nausea/Vomiting e.g. opioids Constipation/Diarrhea e.g. opioids Desensitization e.g. Steroids

9. Case Presentation Subjective Patient: OM Age: early 60s PMH Long history of minor CVD Long history of minor CVA 5 months prior to visit patient had a massive CVA

10. Massive CVA 3 months a UCSF MC Several weeks at skilled care facility in Vancouver, WA Several weeks at home under Hospice Care Patient is semi comatose and generally unresponsive, but does visually track and has some limited reactions

11. Hospice Care Patient’s previous cardiologist and neurologist ended care after major CVA Patient’s only option for care was Hospice Wife is not willing to accept prognosis and continues to shop for a physician Hospice trial period was to end in January 2007

12. Objective Feeding Tube Condom style urinary catheter Rectal catheter Patient is bed bound Has a pronounced 6cm diameter 1-2 cm deep ulcer over the coccyx Vital signs stable, but poor (I did not collect actual numbers)

13. Objective Thyroid and Hypertension medications have been discontinued Patient’s wife administers natural supplements with Ensure feeding regime

14. Assessment Patient is terminal, but the wife refuses to accept this diagnosis Hospice cannot support long term care of the patient Without a primary care physician, the patient will have a very difficult time receiving any care

15. Plan Patient will attempt to locate a PCP, Neurologist, or Cardiologist Hospice will attempt to document a steady decline in patient’s health

16. Conclusion Positives Valuable service for dying patients Creative pharmacy practice and problem solving Drawbacks Emotionally taxing