As practicing community pharmacists, one of the more difficult situations we face is counseling family members about the hospice medications they are picking up for their loved one. Not only are we called upon to counsel with regards to the medications, but also be present for a few minutes in a caring and compassionate manner.
When patients are admitted into a hospice program they are usually prescribed an initial pack of "hospice care" medications. This is a standard pack of medications that a family member may pick up from a local pharmacy. Commonly, the package will contain between 3-7 days' worth of the medication from the pharmacy, then the rest will be mailed through the hospice mail order program.
Different hospice organizations will have slightly different starter packs of medications; however, they are all relatively similar. For purposes of this discussion, we will be talking about the starter pack that is prescribed to patients at the hospital where I practice.
When someone comes into the pharmacy to pick up this package, they may already be feeling overwhelmed, thinking about their family member who was just admitted to hospice care. We understand that the hospice nurse will discuss the medications with the family at home, however, we feel it is important that the family member also get a pharmacists perspective of the hospice care medications.
In our pharmacy, we like to set out each of the medications on the counter in the counseling area so that we can help the family member identify and understand what the role is of each particular medication. We encourage the family member to ask questions about anything they are unsure of. We also encourage the family to call us back with any questions they may come up with after they get home and start trying to remember what they talked about with the pharmacist at the pharmacy.
Morphine Sulfate concentrated liquid: Morphine is used both to help treat acute, sharp pain, and also to help relax the lungs of someone who is having a difficult time trying to take a breath.
Morphine is dosed with an oral syringe and is calibrated in very small increments and it is very important to help family members understand the calibration marks on the syringe. We encourage the family member to practice drawing up a dose with water to assure their proficiency with the oral dosing syringe.
We then explain that the dose is a small volume and does not necessarily need to be swallowed by the patient. The medication gets mixed in with the patient's saliva and may be absorbed through the mucous membranes directly into their blood system. The patient should see some relief within one-two minutes after receiving the dose.
Lastly, we counsel the family member to keep a piece of binder paper near the morphine so they may log each dose. It is very important to note the time, the volume of the dose, and the effectiveness of each dose. It is helpful to have this information available when they talk with the hospice nurse about the effectiveness of the current dose.
Acetaminophen tablets or suppositories: Acetaminophen is used for mild pain and for a fever > 100F. Acetaminophen works very well to help treat mild pain and is also very effective at decreasing a fever.
Lorazepam: Lorazepam is used in hospice care to help a patient relax when they are experiencing either emotional or physical anxiety.
First, if a patient is experiencing apprehension and restlessness the lorazepam will help calm them down. Second, if a patient is experiencing the physical symptoms of anxiety such as sweating, palpitations, dry mouth or dizziness the lorazepam will help treat those symptoms. It is possible that a patient will experience these physical symptoms even though they appear calm and relaxed.
Lorazepam is an oral tablet that may be dissolved under the tongue for a faster effect. The tablet is placed under the patients tongue and it takes about 30-60 seconds for the tablet to dissolve and get absorbed through the mucous membranes into the blood system. The patient should notice an effect from the medication within 5-10 minutes.
Haloperidol: Haloperidol is an antipsychotic medication used during hospice to help quiet down delirium as evidenced by increasing signs of agitation, confusion, delusions and hallucinations.
Haloperidol works in the brain to quickly decrease racing thoughts and calm the brain down. Because this medication is dispensed in liquid form, it is dosed with an oral dosing syringe. The dose may be gently squirted into the patient's mouth as directed to treat the symptoms of delirium.
Hyoscyamine Orally Dissolvable tablets: Hyoscyamine works well to help dry up excessive oral secretions and also help with the sloshing or wet lung sounds a patient may have (sometimes called rales). This tablet dissolves rather quickly simply by placing it on the patient’s tongue.
Bisacodyl rectal suppository: Bisacodyl is a stimulant laxative that is used to help a patient who is feeling the discomfort of constipation. If needed, unwrap and insert 1 suppository rectally.
Prochlorperazine suppository: Prochlorperazine works well to help decrease nausea and vomiting. The dose is unwrapped and inserted rectally as directed for the nausea and or vomiting. Please note, this medication will also make the patient feel a little sleepy.
As a pharmacist, we understand that the family member will have the hospice team available to them for questions. We also understand that this is an incredibly emotional and difficult time. Before the family member leaves, we thank them for the time we were able to spend with them and encourage them to call us back with any questions.