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Psychiatric Medication-Related Issues in Hospice

Jan 16, 2020

Articles are provided as informational purposes only and are not intended to constitute medical advice.

Medication protocols are subject to patient’s medical provider’s authorization.

Medications used to treat psychiatric conditions and symptoms are commonly used in the hospice setting. It has been reported that antipsychotics are in the top 20 most frequently prescribed pharmacological class of medications in hospice patients. Adverse effects of these medications can easily be overlooked but can have significant effects on the patient. This article will examine adverse events associated with common psychiatric medications, including serotonin syndrome, neuroleptic malignant syndrome, extrapyramidal symptoms, and tardive dyskinesia.


Serotonin Syndrome

With a substantial increase in antidepressant use in the United States over the last two decades, serotonin syndrome (SS) has become an increasingly common and significant clinical concern. Serotonin syndrome can be described as a progression of serotonergic toxicity based on increasing concentration levels of serotonin affecting the central and peripheral nervous systems. The classic presentation of SS is the triad of autonomic dysfunction, neuromuscular excitation, and altered mental status. Symptoms can range from tremor, twitching, and diaphoresis in mild serotonin toxicity, to severe myoclonus, seizures and multi-organ failure in severe toxicity.

Serotonin Syndrome. Retrieved from https://www.mycpdzw.org/common-emergencies-detail/50.

 

Medications most commonly associated with SS are classified according to mechanism in the following table.

The two mainstays of serotonin syndrome management are to discontinue the serotonergic agent and to give supportive care. Symptomatic treatment with a benzodiazepine, such as lorazepam or diazepam, is often used to treat agitation and clonus. Serotonin antagonists have had some success in case reports. Cyproheptadine and chlorpromazine have been used, but require further investigation beyond individual case reports to determine their effectiveness and reliability in treating serotonin syndrome.


Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS) is a life-threatening idiosyncratic reaction to any medication that blocks dopamine, most commonly the antipsychotic drugs, but it can also happen with the rapid withdrawal of dopaminergic medications. The clinical course typically begins with muscle rigidity, also referred to as “lead-pipe” rigidity, followed by a fever within several hours of onset and mental status changes that can range from mild drowsiness, agitation, or confusion, to severe delirium or coma. See the following table of NMS symptoms.

The primary trigger of NMS is dopamine receptor blockade and the standard causative agent is an antipsychotic. Potent typical antipsychotics such as haloperidol or chlorpromazine have been most frequently associated with NMS and thought to have the greatest risk (see table at bottom for typical and atypical antipsychotics). Although atypical antipsychotics appear to have a reduced risk of developing NMS compared to typical antipsychotics, a significant number of cases have been reported with some atypical antipsychotics including risperidone and olanzapine. NMS has also been associated with non-neuroleptic agents that have antidopaminergic activity such as metoclopramide. Another cause of NMS is the abrupt cessation or reduction in dose of dopaminergic medications such as levodopa in Parkinson’s disease.


When treating NMS, typically the first step in essentially all cases is discontinuing the causative neuroleptic medication (however, if the syndrome has occurred in the setting of an abrupt withdrawal of a dopaminergic medication, then this medication is reinstituted as quickly as possible). The next step is to give supportive therapy. The two most frequently used medications are bromocriptine mesylate, a dopamine agonist, and dantrolene sodium, a muscle relaxant. Anecdotal reports have shown these agents may shorten the course of the syndrome and possibly reduce mortality when used alone or in combination. Additional pharmacologic agents that may have some utility in treating NMS include benzodiazepines, which can be helpful in controlling anxiety and agitation.


Extrapyramidal Symptoms

A variety of movement disorders have been described along the spectrum of extrapyramidal symptoms (EPS), including dystonia, akathisia, and parkinsonism. These symptoms are very debilitating for the patient, interfering with social functioning and communication, motor tasks, and activities of daily living. Dystonia most often occurs within 2-5 days of drug exposure and manifests with involuntary muscle contractions resulting in abnormal posturing or repetitive movements. Akathisia is characterized by a subjective feeling of internal restlessness and a compelling urge to move, leading to repetitive movements comprising leg crossing, swinging, or shifting from one foot to another. Drug-induced parkinsonism presents as tremor, rigidity, and slowing of motor function, or bradykinesia.


The medications most commonly associated with EPS are the centrally-acting, dopamine-receptor blocking agents, namely the first-generation (typical) antipsychotics, such as haloperidol. While EPS occurs less frequently with atypical antipsychotics, the risk increases with dose escalation. Other agents that block central dopaminergic receptors have also been identified as causative of EPS, including metoclopramide and prochlorperazine.


 Managing EPS typically involves discontinuing the offending medication, or even switching to an atypical antipsychotic. Antimuscarinic medications, such as diphenhydramine, benztropine, or trihexyphenidyl, are also used to treat these symptoms. Akathisia can also be managed by use of the beta-blocker, propranolol, and parkinsonism symptoms can be treated with use of anti-Parkinson agents, such as levodopa or amantadine.


Tardive Dyskinesia

Tardive dyskinesia (TD) is a movement disorder that causes involuntary, repetitive body movements of the face, lips, tongue, trunk and extremities. It is most commonly seen in patients who are on long-term treatment with antipsychotic medications. The most common symptoms are orofacial dyskinesia and dyskinesia of the limbs. In many patients, TD is irreversible and can persist long after the causative medications are stopped.


Typical antipsychotics are the most likely to cause TD, while atypical antipsychotics seem to be associated with a decreased prevalence. Antidepressants, such as SSRIs and MAOIs are also associated with TD, but appear to have less risk than antipsychotics. Other medications that block dopamine, including metoclopramide and prochlorperazine, can also cause TD.


Management of TD involves discontinuing the offending agent. The FDA has approved a new class of medications called the vesicular monoamine transporter 2 (VMAT2) inhibitors, which are indicated for the treatment of TD in adults.


Examples of Typical and Atypical Antipsychotics

Among our hospice patients, use of these medications to treat various conditions at end-of-life is very prevalent. Symptoms of these adverse events can easily be overlooked or misattributed to be ‘part of the dying process’. Thus, knowledge of these adverse events is critical when evaluating patient symptoms while taking these medications, to prevent further morbidity. When in doubt, a ProCare clinical pharmacist, available 24/7/365, can help assess the possibility of an adverse event from a psychiatric medication, and can assist in its management.

 

 

Written by: Kiran Hamid, R.Ph.

 

 

References

  1. Wang, R. et al. (2016, November). Serotonin syndrome: Preventing, recognizing, and treating it. Retrieved from https://www.mdedge.com/ccjm/article/120386/neurology/serotonin-syndrome-preventing-recognizing-and-treating-it/page/0/1
  2. Boyer, E. (2018, March 12). Serotonin syndrome (serotonin toxicity). Retrieved from https://www.uptodate.com/contents/serotonin-syndrome-serotonin-toxicity
  3. Berman, B. (2011, January). Neuroleptic Malignant Syndrome: A Review for Neurohospitalists. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726098/
  4. Wijdicks, E. (2019, May 31). Neuroleptic Malignant Syndrome. Retrieved from https://www.uptodate.com/contents/neuroleptic-malignant-syndrome
  5. D’Souza, R. Hooten, W. M. (2019, January 9). Extrapyramidal Symptoms (EPS). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK534115/.
  6. Jackson, N. et al. (2008, March) Neuropsychiatric complications of commonly used palliative care drugs. Retrieved from https://pmj.bmj.com/content/84/989/121.full
  7. Cornett, E. et al. (2017, July). Medication-Induced Tardive Dyskinesia: A Review and Update. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5472076/
  8. Muench, J. Hamer, A. (2010, March 1). Adverse Effects of Antipsychotic Medications. Retrieved from https://www.aafp.org/afp/2010/0301/p617.html.
  9. Ferguson, J. (2001, February). SSRI Antidepressant Medications: Adverse Effects and Tolerability. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC181155/
  10. Serotonin Syndrome. Accessed 9/25/19. Retrieved from https://www.mycpdzw.org/common-emergencies-detail/50.
  11. Neuroleptic Malignant Syndrome. Accessed 9/25/19. Retrieved from http://klossandbruce.com/video-flashcard-neuroleptic-malignant-syndrome

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Renal Impairment at End of Life: Dosing Implications for Opioids, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), and Antibiotics

21 Oct, 2022
Renal impairment is relatively common in both the elderly and hospice patients, and it can affect the way medications act in the body in several ways. Most commonly, it results in decreased clearance of renally-excreted medications, leading to accumulation of the drug and/or its metabolites and subsequent adverse or toxic effects. The absorption of oral medications may be reduced in patients with renal impairment due to increased gastric pH and gut wall edema. Uremia caused by renal impairment can increase sensitivity to medications that act on the central nervous system (CNS), as well as increase the risk of hyperkalemia due to potassium-sparing drugs. In addition, uremia can enhance the potential for NSAID-induced edema or GI bleeding. Renal impairment can also lead to edema or ascites, cachexia, dehydration, decreased albumin levels and binding capacity, and decreased tissue binding, all of which can impact the effects of medications. To compensate for these renal impairment-induced changes in drug disposition, the typical actions taken regarding medication administration are to decrease the dose, increase the dosing interval, or a combination of the two. The action that would be recommended depends on the drug and its specific characteristics. There are many medications that require dose adjustment in renal impairment, but here we’ll be discussing just those that are most often seen in hospice. The goal is to make you aware of these common medications (and categories) that often need dose adjustment so they trigger a mental alert for possible follow-up if they are ordered for your patients with decreased renal function. Opioids: Many opioids can accumulate in renal impairment as the parent drug and/or metabolites. Tramadol has a maximum daily dose in all patients, but in patients with a creatinine clearance (CrCL) less than 30 mL/minute, this maximum dose is reduced to 200 mg per day and the dosing interval should be extended to every 12 hours. Morphine renal dose reductions start with a CrCL less than 60 mL/minute, with possible extension of the dosing interval at this point as well. It is typically recommended to start considering alternatives to morphine in patients with a CrCL less than 30 mL/minute, and to avoid it altogether in patients with a CrCL less than 15 mL/minute. At end of life, the benefits of morphine can sometimes outweigh the risks. Because the presentation of renal accumulation-based adverse effects may be delayed, morphine can be used even in severe renal impairment or renal failure when the prognosis is hours to days, or in dialysis patients when death is imminent. Typically, oxycodone and hydromorphone are considered preferred alternatives to morphine in patients with significant renal impairment, although they both have metabolites that can accumulate in renal failure. As a result, the dose of oxycodone should be reduced and the dosing interval increased in patients with a CrCL less than 60 mL/minute, and oxycodone extended-release products should usually be avoided in patients with a CrCL less than 30 mL/minute. Hydromorphone dose reduction is also recommended when CrCL is less than 60 mL/minute; further dose reduction and extension of the dosing interval is recommended for hydromorphone when CrCL is less than 30 mL/minute. Although hydrocodone and its active metabolites may accumulate in renal impairment, there are no dose reductions for hydrocodone/acetaminophen according to the manufacturer’s labeling. Hydrocodone extended-release products (Hysingla ER®, Zohydro ER®) are rarely used in hospice, but dose reductions are recommended in patients with moderate to severe renal impairment. Methadone and fentanyl patch are considered among the safest opioids in renal impairment because they do not have active metabolites. However, renal impairment can still alter how fentanyl moves in the body, so dose reduction is recommended in patients with a CrCL of 50 mL/minute or less. For methadone, dose reduction is not recommended until very severe renal impairment (CrCL less than 10 mL/minute). No dose reductions are recommended for buprenorphine at any degree of renal impairment, and it is generally considered safe in this population. NSAIDs: Examples of NSAIDs that are commonly used in hospice include ibuprofen (Advil®, Motrin®), naproxen (Aleve®), and meloxicam (Mobic®), and as mentioned previously, there are some concerns regarding the use of NSAIDs in renal impairment. According to the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline, prolonged therapy with NSAIDs is not recommended if GFR is less than 60 mL/minute/1.73m² , and NSAIDs should typically be avoided in patients with a GFR less than 30 mL/minute/1.73m². As a general rule, NSAIDs should be used at the lowest effective dose for the shortest time possible in patients with renal impairment. In addition, NSAIDs should be avoided in patients with a high risk for developing acute kidney injury (e.g. volume depleted, elderly, and/or taking other nephrotoxic medications), and should be discontinued if acute kidney injury occurs during use. Antimicrobials: Many antimicrobials require dose reduction and/or extension of the dosing interval in renal impairment. Specific dosing recommendations depend on the antimicrobial in question and the type of infection being treated. When used for multiple doses, the dose of the antifungal fluconazole (Diflucan®) should be reduced in patients with a CrCL of 50 mL/minute or less. Examples of antibiotics commonly used in hospice that need dose adjustment include: sulfamethoxazole/trimethoprim (Bactrim®); fluoroquinolone antibiotics, including ciprofloxacin (Cipro®) and levofloxacin (Levaquin®); certain penicillin antibiotics, such as amoxicillin and amoxicillin/clavulanate (Augmentin®); and some cephalosporins, including cephalexin (Keflex®) and cefdinir (Omnicef®). Nitrofurantoin (Macrobid®, Macrodantin®) also has significant concerns in renal impairment. According to the manufacturer’s prescribing information, it is contraindicated in anuria, oliguria, or significant renal impairment (defined as a CrCL less than 60 mL/minute or clinically significant elevated serum creatinine). However, limited data suggest it is safe and effective for short-term use in patients with a CrCL of 30 to 60 mL/minute, although there appears to be an increased risk of pulmonary adverse events when eGFR is less than 50 mL/minute. In any case, nitrofurantoin should be avoided altogether in patients with a CrCL less than 30 mL/minute, due to the risk of pulmonary toxicity, hepatotoxicity, and peripheral neuropathy. Renal impairment can affect drug disposition in several ways, often increasing the risk of adverse and toxic effects. Whenever you have a patient with renal impairment, evaluate whether they are taking medications that may be cause for concern and require dose adjustment, and remember that hospice clinicians, pharmacists, and drug information resources can help by providing specific renal dosing recommendations. By Joelle K. Potts RPh, PharmD, BCGP REFERENCES: Aging and Kidney Disease. National Kidney Foundation. Available at: https://www.kidney.org/news/monthly/wkd_aging [accessed 8/8/2022] Aronoff GR, Bennett WM, Berns JS, Brier ME, Kasbekar N, Mueller BA, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults and Children. 5th American College of Physicians, Philadelphia, PA; 2007. Renal Impairment. Chapter in: Palliative Care Formulary, 7th Edition (PCF7). Wilcock A, Howard P, Charlesworth S, Eds. Pharmaceutical Press, London, UK. Chapter 17, added April 2017; 715-35. Drug monographs. Lexcomp Online, Lexi-Drugs Online. Waltham, MA: UpToDate, Inc. https://online.lexi.com. O’Connor NR, Corcoran AM. End-stage renal disease: symptom management and advance care planning. Am Fam Physician. 2012; 85(7): 705-10. Kidney Disease: Improving Global Outcomes (KDIGO). KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International Supplements. Jan 2013; 3(1). Available at: www.kidney-international.org Macrobid® Prescribing Information. Proctor and Gamble Pharmaceuticals, Inc. Cincinnati, OH. Revised Jan 2009. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020064s019lbl.pdf [accessed 6/13/2022] Macrodantin® Prescribing Information. Almatica Pharma Inc. Pine Brook, NJ. Revised Mar 2013. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/016620s072lbl.pdf [accessed 6/13/2022] 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 updated Beers Criteria® for potentially inappropriate medication use in older adults. JAGS. 2019; 00: 1-21

Buprenorphine for Pain Management: Pros vs. Cons in the Hospice Population

24 Aug, 2022
Buprenorphine is a unique opioid analgesic. It has several benefits (“pros”) for pain management, but it also has a few significant risks (“cons”) that prevent it from being used more frequently in hospice.  For pain management, buprenorphine is available as a buccal film (Belbuca®), a weekly transdermal patch (Butrans®), and an injection solution (Buprenex®). The forms that are most often seen in hospice patients are the buccal film and transdermal patch, which are used routinely as long-acting opioids for chronic pain, and these are the dosage forms we’ll be discussing here. Buprenorphine injection is indicated for acute pain and is not recommended for long-term use, and it is rarely used in hospice. Other dosage forms (monthly subcutaneous injection, 6-month subcutaneous implant, and daily sublingual tablet) are indicated for opioid use disorder and are not FDA-approved for pain management. What makes buprenorphine unique is the way it binds to various opioid receptors. The most commonly used opioid analgesics (e.g. morphine, oxycodone, fentanyl, and hydrocodone) are full mu-opioid receptor agonists, meaning they bind to and activate the mu-opioid receptor. In contrast, an antagonist blocks a receptor by binding to it without activating it; naloxone (Narcan®) is an excellent example of a mu-opioid receptor antagonist. Buprenorphine is a partial mu-opioid receptor agonist, which means that it binds to the mu-opioid receptor but activates it to a lesser degree than a full agonist. In addition to its effects at the mu-opioid receptor, buprenorphine has activity at three other opioid receptors: it is an antagonist at the delta- and kappa-opioid receptors, and a full agonist at the ORL-1 (opioid receptor-like 1; a.k.a. nociceptin) opioid receptor. The Pros of Buprenorphine: Effective for pain. Buprenorphine’s partial agonism at the mu-opioid receptor refers only to its activity level at the receptor, and not to its effectiveness as an analgesic. In fact, buprenorphine’s analgesic effects are comparable to full mu-opioid receptor agonists in a variety of different pain types, including moderate to severe post-operative and cancer pain, osteoarthritis, and chronic low back pain. Buprenorphine is also effective for neuropathic pain. Lower risk of certain opioid adverse effects. Because of buprenorphine’s unique activity at four opioid receptors, it is less likely to cause several common opioid adverse effects. When compared with most full mu-opioid receptor agonists, buprenorphine has a lower incidence of respiratory depression – although, as with all opioids, this adverse effect is still possible. Because buprenorphine is also less likely to produce euphoria, it has less potential for physical dependence and addiction; as such, it is classified as a Schedule III (C-III) controlled substance. In addition, when compared with the extended-release forms of oxycodone, hydromorphone, and oxymorphone, buprenorphine buccal film causes significantly less nausea, vomiting, constipation, dizziness, and somnolence. When buprenorphine is compared to morphine, the differences in adverse effect frequency are less pronounced, perhaps due to the dosage forms evaluated (or not evaluated). When comparing buprenorphine buccal film to morphine (dosage form not specified), buprenorphine appears to have just slightly lower incidences of constipation, somnolence, anxiety, and dry mouth. In a 2018 systematic review and meta-analysis of buprenorphine vs. morphine in acute pain management, the only significant difference in adverse effects identified was that buprenorphine was associated with less pruritis. The dosage forms considered in this review varied but were typically morphine injection vs. buprenorphine injection or sublingual tablet (not the patch or buccal film forms of buprenorphine that we usually see in our hospice patients). Safe in special populations. In addition, buprenorphine is considered safe in populations that we see often in hospice: those with renal impairment, including dialysis; those with mild to moderate hepatic impairment; and the elderly. The Cons of Buprenorphine: High cost. Unfortunately, buprenorphine patch and buccal film are relatively high-cost medications, which makes them much less attractive for use in hospice. Depending on the strength, the average cost for the generic weekly patch ranges from approximately $10 to $28 per day; the average cost for the brand buccal film, which is dosed once or twice a day, ranges from approximately $8 to $19 per film. Dosing limitations and cautions in severe hepatic impairment. A potential concern, especially in hospice patients, is that buprenorphine patch and buccal film both have maximum recommended doses. Also, the dose of the patch should be titrated no more frequently than every 72 hours, while the dose of the buccal film should be titrated no more frequently than every 4 days. Because buprenorphine has primarily hepatic metabolism, there are cautions regarding its use in severe liver impairment; in these patients, the dose of the buccal film should be reduced, and the transdermal patch form is not recommended. The Verdict: There are a number of reasons why buprenorphine patch and buccal film are excellent long-acting analgesics for many patients, especially those who are not approaching end of life. However, the cons can be significant, and buprenorphine is usually not preferred as a first- or second-line option for the majority of our hospice patients because other long-acting analgesics are effective and available at a much lower cost (e.g. methadone, morphine extended-release, and many strengths of fentanyl patch). In addition, the fact that buprenorphine patch and buccal film have maximum recommended doses may become an issue at end of life in patients whose pain is rapidly escalating. Of course, the pros and cons must always be weighed for each patient and their specific situation; no doubt there will be some hospice patients for whom buprenorphine patch or buccal film is an ideal choice. Written by Joelle Potts, PharmD, CGP REFERENCES: Lexicomp Online, Lexi-Drugs Online. Waltham, MA: UpToDate, Inc.; July 23, 2022. https://online.lexi.com. [last accessed 7/23/2022] Buprenorphine Practitioner Resources and Information. Substance Abuse and Mental Health Services Administration (SAMSHA), U.S. Department of Health and Human Services. Programs: Medication-Assisted Treatment (MAT). Last updated 6/24/2021. Available at: https://www.samhsa.gov/medication-assisted-treatment/practitioner-resources [last accessed: 2/5/2022] Become a Buprenorphine Waivered Practitioner. Substance Abuse and Mental Health Services Administration (SAMSHA), U.S. Department of Health and Human Services. Programs: Medication-Assisted Treatment (MAT). Last updated 6/24/2021. Available at: https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner [last accessed: 2/5/2022] Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. U.S. Department of Health and Human Services, Federal Register document number 2021-08961, pages 22439-40; 4/28/2021. Available at: https://www.federalregister.gov/documents/2021/04/28/2021-08961/practice-guidelines-for-the-administration-of-buprenorphine-for-treating-opioid-use-disorder [last accessed 2/5/2022] Pharmacist’s Manual: An Informational Outline of the Controlled Substances Act. EO-DEA154; revised 2020. Drug Enforcement Administration (DEA), Diversion Control Division. Available at: https://www.deadiversion.usdoj.gov/pubs/manuals/ [last accessed 2/28/2022] Pharmacological Treatment. Under: Opioids > Medication Assisted Recovery. Indian Health Service (IHS), Rockville, MD. https://www.ihs.gov/opioids/recovery/pharmatreatment/ [accessed 12/9/2021] Hale M, Garofoli M, Raffa RB. Benefit-risk analysis of buprenorphine for pain management. Journal of Pain Research, 2021:14; 1359-69. Gudin J, Fudin J. A narrative pharmacological review of buprenorphine: a unique opioid for the treatment of chronic pain. Pain Ther. Published online: 28 Jan 2020. Childers JW, Lou K, Arnold R. Fast Facts and Concepts #268. Low-dose buprenorphine patch for pain. October 2020. Available at: https://www.mypcnow.org Davis MP. Twelve reasons for considering buprenorphine as a frontline analgesic in the management of pain. The Journal of Supportive Oncology. Nov-Dec 2012; 10(6): 209-19. Khanna IK, Pillarisetti S. Buprenorphine – an attractive opioid with underutilized potential in treatment of chronic pain. Journal of Pain Research, 2015:8. 859-70. White LD, et al. Efficacy and adverse effects of buprenorphine in acute pain management: systematic review and meta-analysis of randomized controlled trials. British Journal of Anaesthesia. 2018; 120(4): 668-78. Morphine (systemic). Lexicomp Online, Lexi-Drugs Online. Waltham, MA: UpToDate, Inc.; July 20, 2022. https://online.lexi.com. [last accessed 7/23/2022] Butrans® (buprenorphine patch) prescribing information. Purdue Pharma LP, Stamford, CT. Revised March 2021. Available at: https://butrans.com [last accessed 3/15/2022] Belbuca® (buprenorphine buccal film) prescribing information. BioDelivery Sciences International, Inc., Raleigh, NC. Revised March 2021. Available at: https://www.belbuca.com. [last accessed 3/15/2022]

Palliative Wound Care

26 May, 2022
There are many types of chronic, non-healing wounds. These include pressure ulcers, diabetic ulcers, arterial insufficiency ulcers, venous ulcers, and malignant wounds. Pressure ulcers are the most common type of wound we encounter as patients decline, become bed bound, and approach end-of-life. Stage 1 and 2 pressure ulcers cause superficial skin changes, and Stage 3 and 4 pressure ulcers affect the deep tissue framework.¹ Pressure ulcers should be staged depending on damage and presence of certain characteristics. It is important to note that if a wound is healing, reverse staging is not done. If a patient has a stage 3 ulcer that is getting better, we would say that the patient has a “healing” stage 3 pressure ulcer.² A patient’s initial assessment should include a review of their skin and existing wounds, if any, and an assessment of the risk factors that are affecting wound healing. The Braden Scale for Predicting Pressure Sore Risk is one tool used when assessing patients. It is based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Keep in mind, most tools used to predict risk do not account for end-of-life decline, so hospice/palliative care patients may be at greater risk than the scales show.³ Other risk factors for chronic non-healing wounds include obesity, tobacco use, vascular issues, diabetes, elderly, radiation therapy, poor self-care, alcohol use, and neurological issues. After the initial assessment, a plan should be developed that aligns with the patient and family’s goals. If there are emotional or spiritual issues that are contributing to poor self-care or alcohol/substance abuse, consider calling on other members of your multi-disciplinary team (i.e., social worker or clergy) for assistance. Therapy goals, which aim to improve quality of life, should be based on patient prognosis, patient factors, heal-ability of existing wound, type of wound, and patient and family wishes. Goals should include preventing new wounds or worsening of existing wounds, prevent/relieve distressing symptoms, reduce discomfort, reduce risk of infection, bleeding, and odor.³ The TIME mnemonic can help us improve wound care.
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