Meeting the Needs of the Hospice Patient

The goals of a good hospice program are simple: first, to increase quality of life; and second, to guide loved ones through the difficult transition. Hospice patients face special challenges with regard to medication administration, and there are times when commercial medications may not meet those unique needs. Patients entering a hospice program often have several medical conditions, and, in many cases, pain relief is a primary concern. The potential for drug interactions increases, and adverse effects may be more pronounced. In some patients, the disease state can affect metabolism and excretion, whereas in others swallowing is compromised, rendering the oral route of administration impossible.¹ The patient?s comfort and quality of life are foremost in every case, and the pharmacist must be sensitive to those objectives, in addition to considering each patient?s individual needs. A compounding pharmacist may be the best candidate to meet some of these specialized needs.

Medication administration is often an issue. Multiple medications may be needed for treatment of symptoms such as pain, nausea, anxiety, and depression. Topical administration can be a convenient, cost-effective, and successful alternative for hospice patients. Medications can often be combined into transdermal gels, which can result in enhanced relief with lower doses than are required orally. Additionally, topical routes of administration often have a faster effect than oral routes.¹ A commonly used preparation to treat nausea and vomiting is known as ABHR gel and consists of lorazepam, diphenhydramine, haloperi-dol, and metoclopramide. ABHR gel works by blocking the 4 pathways in the brain that trigger and cause nausea and vomiting.² A host of articles and case reports have been published to demonstrate the effectiveness of this particular combination as well as several similar preparations.^2,3 Components can be substituted and may include any of the following:

• Alprazolam
• Diphenhydramine
• Droperidol
• Haloperidol
• Lorazepam
• Meclizine
• Metoclopramide
• Phenothiazines

For localized neuropathic pain, a medication such as transdermal keta-mine may be applied directly to the affected site.⁴ Recent studies have indicated that ketamine may be an effective tool in the treatment of chronic neuropathic pain.⁵ The appropriate topical dose will vary widely according to the patient and the severity of the pain, but the formula can easily be customized once titration is done.

In addition to transdermal gels, other compounds such as suppositories, troches, nasal sprays, and rapid-dissolving tablets can be effective alternatives to traditional oral administration. These dosage forms can accommodate a wide range of medications and allow for easy administration by caregivers. Unit-dose packaging for hospice patients may be ideal to increase compliance and take the guesswork out of administration by rotating caregivers.

Compounding for hospice patients may not always involve treating symptoms such as pain or nausea. Other preparations can be particularly helpful in increasing comfort and quality of life. For example, many hospice patients suffer from dry mouth, either as a result of the disease state or as a side effect of medications. A dry mouth spray formulated from sodium carboxymethyl-cellulose, sodium chloride, glycerin, and preserved water can be prepared and flavored to the patient?s liking.⁶ Aroma-therapy has long been used for medicinal purposes and can be helpful in treating hospice patients. These specially blended oils may increase energy and mental clarity and elevate the mood of a hospice patient. They can be misted into the air as needed.^7,8 Hospice patients face many challenges during their final days. Sensitivity to these needs is paramount, and pharmacists must work closely with physicians, caregivers, and family members to come up with solutions to these problems. Where the commercial market falls short, a caring compounding pharmacist can often fill the gap. Ms. Fields is with the International Journal of Pharmaceutical Compounding and is a pharmacy technician at Innovative Pharmacy Services in Edmond, Okla.

References

1. Carling MA. Hospice and the role of the compounding pharmacist. IJPC. 2000;4(4):246-249.

2. Moon RB. ABHR gel in the treatment of nausea and vomiting in the hospice patient. IJPC. 2006;10(2):95-98.

3. Boomsma D. Nausea and vomiting in hospice patients. IJPC. 2000;4(4):250-251.

4. Wood R. Ketamine for pain in hospice patients. IJPC. 2000;4(4):253-254.

5. Backonja M, Arndt G, Gombar K, Check B, Zimmerman M. Response of chronic neuropathic pain syndromes to ketamine: a preliminary study. Pain. 1994;56:51-57.

6. Horwitz R. Custom-making medications for the hospice patient. IJPC. 2000;4(4):255-256.

7. Soden K, Vincent K, Craske S, Lucas C, Ashley S. A randomized controlled study of aromatherapy massage in a hospice setting. Palliat Med. 2004;18(2):87-92.

8. Allen LV Jr. Aromatherapy and the hospice patient. IJPC. 1997;1(1):18-21.