Comments on GeriPal - Geriatrics and Palliative Care Blog: Inappropriate Medications in the Hospice Setting

Okay I have a little tidbit of information we rece...

2011-09-12T10:27:33.649-07:00

Okay I have a little tidbit of information we recently found out completely by accident in hospice care for my father who has bladder ca. He has and extensive history of CHF and complete renal faluire causing him to have to dialysis 3 times a week. When the pain got so bad that transport to dialysis and the procedure itself became intolerable we decided for his comfort to stop dialysis. Over the next week he began to get lower extremity edema and diffultly breathing from fluid overload, not to mention abdominal distention for stood accumulation. He said he felt like he was sufficating from the fluid and we were considering initiating dialysis again. He hadn't had a bowel movement in 7 days so we gave a small dose of miralax with what small amount water he was able to consume. Two days later he had a BM and we noticed his edema and difficulty breathing was gone. The miralax pulled the extra body water fluid out of his body from his lower extremities and lungs to his rectum, which allowed him to have a BM, get ride of the stool and extra body fluid, and relieved his CHF symptoms abdominal pressure pain from the stool. So in certain cases I wouldn't rule out using miralax. It has made his end of life much more comfortable.

1) 'Miralax' or PEG. It's not an inap...

2009-08-10T18:00:01.441-07:00

1) 'Miralax' or PEG. It's not an inappropriate drug in EOL/hospice settings - just used inappropriately all too often. I see patients weekly who have complicated medical issues, poor performances statuses, and are on opioids, who are getting miniscule doses of stimulant laxatives who are prescribed 17gm of PEG daily. 17gm is the FDA approved OTC dose for healthy adults with chronic idiopathic constipation, and in the trials got them to poop 3 times a week up from 2. Oh and it took most people at least a couple days to laxate. I have a sense that because it's PEG, and can be cathartic in the 100s md/day range, that people think it's a Big Gun.

2) re: Rabob (RMA is that you?) who I can't tell if left a comment or a new post - there have been at least 2 studies indicating that people are much more willing to give patients higher (equianalgesic) doses of hydromorphone than morphine. I think it's a number thing just as you suggest. 2mg of hydromorphone 'feels' a lot better than 10 mg of morphine for some.

I agree that the above are bad. My number one p...

2009-08-06T15:12:05.272-07:00

I agree that the above are bad.

My number one pet peeve on IDT rounds:

1) Alpha blockers in patients with a foley when there is no intent to remove the foley. I find no medication more irritating in a palliative setting.

2) Tight Glucose control: This is exceedingly irritating. We probably shouldn't even be doing this in normal elderly folks.

3) Bisphosphonates for osteoporosis: Particulary if the patient has been on these for some time. There is data that alendronate hangs out in your bones for years anyway.

I agree with the statins and docusate. I feel less strongly about the MVI - you have to pick your battles.

I agree that the above are bad. My number one p...

2009-08-06T15:12:01.771-07:00

My top three are 1)Colace (how many times a day d...

2009-08-04T21:34:19.412-07:00

My top three are
1)Colace (how many times a day do I find soft fecal impactions and 'terns prescribing docusate syrup?? I think I wil have them all taste the stuff the next lunch talk I give)

2) Statins- overrated in the frail elderly and no evidence for continued use as Eric states.

3)Tough call between the tight control of blood glucose in the failing frail adult who is losing weight, MVIs and all such ilk (Loved the tern who thought weekly bisphosphonates would benefit the 94 yo bedbound male) and benzos for sleep or agitation in frail elders.

OK, I'll bite. ;-) 1. DSS/Colace - give me a b...

2009-08-03T18:02:36.136-07:00

OK, I'll bite. ;-)
1. DSS/Colace - give me a break (just don't break open the capsule). In addition to the good reasons Eric cited, pts, nurses, docs, and families actually believe it's needed to have a BM!
2. Statin - agreed, just silly
3. Aspirin - Risks of GI bleed are too great (hospice patients' po intake is likely decreasing, use of meds effecting the GI tract is likely increasing [NSAIDS, steroids]and benefit too small (NNT is about 100, with only 2.5% chance of reduction of stroke, heart attack over 2 years).