Rev. Candace McKibben, M. Div.Director of Faith OutreachBig Bend Hospice, Tallahassee, FloridaFebruary 25 – 8:00- 9:30 AM

I do not have (nor does any immediate family member have) a vested interest in or affiliation with any corporate organization offering financial support or grant money for this continuing education program, or any affiliation with an organization whose philosophy could potentially bias my presentation.

Upon completion of this CPE activity, pharmacists should be able to:

Describe the philosophy and services of Palliative and Hospice Care

Objectives

• Explain the differences and similarities in palliative care and hospice care

• Name key players in both the hospice care movement and the palliative care movement

• List hospice services available to patients, family members and the community

• State how hospice services are financed• Define the hospice team and interdisciplinary approach

Upon completion of this CPE activity, pharmacists should be able to:

Describe the advantages of Palliative and Hospice Care

Objectives

• Identify positive outcomes in hospice stories shared and told

• Review the four tasks, four conversations, and four gifts of dying

• Name the value of facing mortality and identifying preferences for health care at the end of life

• List the benefits of acknowledging grief

Upon completion of this CE activity, the pharmacist should be able to:

Identify palliative care management strategies in the geriatric population

Objectives

• Describe patient-centered pharmacological care plans to improve the experience of the terminally-ill elderly patient

• Discuss opportunities and barriers in providing palliative care therapies for elderly patients with advanced diseases.

Upon completion of this CE activity, pharmacy technicians should be able to: Describe the philosophy and services of Palliative and Hospice Care Objectives

• Explain the differences and similarities in palliative care and hospice care

• Name key players in both the hospice care movement and the palliative care movement

• List hospice services available to patients, family members and the community

• State how hospice services are financed• Define the hospice team and interdisciplinary approach

Upon completion of this CE activity, pharmacy technicians should be able to: Describe the advantages of Hospice and Palliative Care

Objectives• Identify positive outcomes in hospice stories shared

and told• Review the four tasks, four conversations, and four

gifts of dying• Name the value of facing mortality and identifying

preferences for health care at the end of life• List the benefits of acknowledging grief

Upon completion of this CE activity, pharmacy technicians should be able to:

Describe palliative care plans in the geriatric population

Objectives:• Identify medications used to improve the experience

of the terminally ill elderly patient• Discuss opportunities and obstacles in providing

palliative care therapies for elderly patients with advanced disease

Which came first?

Hospice or Palliative Care?

Founder of the Modern Hospice Movement –She started Saint Christopher’s Hospice in 1967

in South London linking expert pain and symptom control, compassionate care, teaching and clinical

research in caring for the dying.

Canadian Physician known as the Father of Palliative Care – bringing expert pain and symptom control, emotional, and spiritual support through the compassionate care of an interdisciplinary team to those living with chronic, life- limiting illness, even while receiving curative treatment. Palliative Care was named a medical sub-specialty in 2008.

Total pain not just physical but also psychosocial, existential, and spiritual

Symptom management The patient and family as the unit of care Goals of care in keeping with the patient’s values

and preferences Interdisciplinary team care Open communication between the patient and

family and the care team Bereavement care of family and friends

Anytime along the trajectory of a serious illness.

Palliative means “to improve the quality of.”

Palliative Care when two or more physicians believe that the serious illness will result in death in six months if the disease follows its anticipated trajectory

And (in the United States), when the patient elects symptom management rather than curative treatments

When a serious illness is believed to be terminal.

Hospice comes from the same linguistic roots as “hospitality.”

Medicare benefit established in 1982 to provide Medicare beneficiaries with access to high-quality end-of-life care

The United States government requires that the total number of hours that hospice volunteers contribute must equal at least 5% of the total number of patient care hours provided by paid hospice employees and contract staff

Medicare

Private Insurance Companies/HMOs

Medicaid

Charity Care

Four Levels of Care

1. Routine Home Care:Higher payment for first 60 days of care

2. Inpatient Respite Care

3. General Inpatient Care

4. Continuous Home Care

• People services

• Medications related to the primary diagnosis and those secondary conditions that contribute to the terminal diagnosis

• Medical supplies and equipment related to the primary diagnosis and secondary conditions

Pain and symptom control

Meeting of basic physical needs

Emotional well-being

Spiritual strength

Quality of life

Dignity

Relationships restored

Love of self reclaimed

A sense of worth developed

Families able to reclaim family role

Comfortable and at peace

A sense of serenity in doing what was best and desired by the patient

You matter to the last moment of your life, and we will do all we can not only to help you die

peacefully, but to live until you die.”-Dame Cicely Saunders

The need to find meaning in life

The need to heal relationships

The need to understand the meaning of suffering

The need to understand what death is

Please forgive me…

I forgive you…

Thank you…

I love you…

Pondering life’s meaning

Contemplating what comes next

Finding acceptance

Letting go

When a person dies, at least six people will be significantly impacted by the death.

All hospices have written resources to support those who are grieving.

Some have individual and group counseling for bereavement.

Some hospices are becoming involved in the movement to help more people

consider what they want and do not wantfor themselves regarding health care

at the end of life.

Greater scrutiny on length of stay and the four levels of care

Greater definition to allowable admissions –terminal not chronic

Late admissions

Live discharges

Where is hospice care provided? How is hospice care acquired? Is calling hospice giving up hope? Can a person get other medical care while under

hospice care? Can a person discontinue hospice care?

Concerns such as:◦ Physiological changes of aging

◦ Multiple chronic diseases

◦ Seniors using more medications than any other age group◦ Impaired memory, and hearing and vision loss

among seniors compromising medication compliance

◦ Social isolation and fixed income

Reviewing medications for drug toxicity, fall risks, drug-drug interactions

Educating on non-pharmacological therapies

Advising regarding insurance/generics

Advising regarding sound alike look alike (SALA) meds to reduce potential medical errors

Advising regarding substitutions for drug shortages

Educating on medical adherence for pain control

Compounding products for individual needs –e.g. doses, flavor, routes of administration, alternate ingredients for allergies

Vomiting – Haldol

Uncontrolled vomiting – ABHR(D) suppository -

Ativan; Benadryl; Haldol; Reglan or

Dexamethasone

Hiccups – Thorazine

Secretions – Atropine Ophthalmologic Drops

Pain and Fatigue and Poor Appetite – Steroids

Neuropathic Pain - Antidepressants

Seizures for someone who can no longer swallow

– Scheduled Ativan

Dyspnea – Morphine (prior to activity)

◦ Person-centered – related to patient goals

◦ Empathetic toward patient, family, and caregiver

◦ Aware of cultural factors at play in medicine choices

◦ Aware of complementary and alternative medications

◦ Aware of religious concerns related especially to pain medications

Listening to patients and alerting pharmacist

Asking pertinent questions

Confirming the understanding of the patient/caregiver about the medications

Completing home medication lists

Medication reconciliation

Prescription delivery programs in hospitals

Pharmacists have long served as volunteer consultantsto hospice care services, but increasingly they are

becoming integrated into the interdisciplinary team as employees or on contract.

Pharmacists add value by:

Counseling the patient in care

Updating and educating the team regarding medications

Working with the team and in particular nurses to monitor therapeutic responses

Working with the agency to find the best pharmaceutical or alternative solutions for common symptoms

Assisting in determining related and unrelated

medications

Education about the use of pain medications

Facts and Figures, Hospice Care in America, 2016 Edition, National Hospice and Palliative Care Organization.

Help Older Adults Manage their Meds with These Resources and Tips, Pharmacy Today, October 2017.

ASHP Guidelines on the Pharmacist’s Role in Palliative and Hospice Care, AM J Health Syst Pharm, Vol 73, 17, September 1, 2016 www.ashp.org

Pharmacist Involvement in Hospice and Palliative Care, Tammie Lee Demler, BS, PharmD, MBA, BCPP, US Pharm. 2016; 41 (3); HS2-HS5

Byock, Ira, The Four Things that Matter Most, Atria Books, Simon and Schuster, 2014.

Gwande, Atul, Being Mortal: Illness, Medicine and What Matters in the End, Picador, 2017.

Kalanithi, Paul, When Breath Becomes Air, Random House, 2016.

Longaker, Christine, Facing Death and Finding Hope, Random House, 1997.

Nouwen, Henri, Our Greatest Gift: A Meditation on Dying and Caring, Harper and Collins, 1994.

Thank you for your time.

For more information contact:

Rev. Candace McKibben, Big Bend Hospice 1723 Mahan Center Blvd.

Tallahassee, Florida850-671-6029

candace@bigbendhospice.org

or

Capstone Center, LLC(a subsidiary of Big Bend Hospice)

850-219-8985