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Evergreen Hospice Rotation

Ted Williams PharmD Candidate 2009 PHAR 744. Evergreen Hospice Rotation. 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. Outline. What is Hospice

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Evergreen Hospice Rotation

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

  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

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