How to Counsel Family Members About Hospice Care Medications

JUNE 30, 2015
One of the most difficult situations practicing community pharmacists face is counseling family members about hospice medications for their loved ones. Such counseling requires not only medication information, but also compassion and empathy.
 
Patients admitted to a hospice program are usually prescribed an initial pack of "hospice care" medications that a family member may pick up from a local pharmacy. The standard package will typically contain between 3 and 7 days' worth of the medication from the pharmacy, with the remainder being provided through the hospice organization's mail-order program.
 
Different hospice organizations will have slightly different medication starter packs, but they are all relatively similar. Here, I will discuss the starter pack prescribed to patients at the hospital where I work.  
 
When someone comes into the pharmacy to pick up this starter package, he or she may already be feeling  overwhelmed in thinking about the 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 gets a pharmacist's 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 the role of each particular medication. We encourage family members to ask questions during this counseling session, and we also encourage them to call us back with any questions they may come up with after they get home and try to remember what they talked about with the pharmacist.

Here are the medications we routinely discuss:
 
Morphine sulfate concentrated liquid

Morphine is used to help treat acute, sharp pain and also relax the lungs of a patient having difficulty in trying to breathe.   
 
The drug is dosed with an oral syringe and calibrated in very small increments, so 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 ensure proficiency with the device. 
 
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 the blood system. The patient should experience some relief within 1 to 2 minutes of receiving the dose.
 
Lastly, we counsel the family member to keep a piece of binder paper near the morphine in order to log each dose. It is very important to note the time, volume, and effectiveness of each dose. It is helpful to have this information available when speaking with the hospice nurse about the efficacy of the current dose.
 
Acetaminophen tablets or suppositories

Acetaminophen is used for mild pain and for a fever >100 degrees F. Acetaminophen can help treat mild pain and it is also effective at decreasing fever. 
 
Lorazepam

Lorazepam is used in hospice care to help a patient relax during either emotional or physical anxiety. 
 
If patients are experiencing apprehension and restlessness, then the lorazepam will help them calm down. If they are experiencing the physical symptoms of anxiety, such as sweating, palpitations, dry mouth, or dizziness, then the lorazepam will help treat those symptoms. It is possible that a patient will experience these physical symptoms even when appearing calm and relaxed. 
 
Lorazepam is an oral tablet that may be dissolved under the tongue for a faster effect. It takes about 30 to 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 to 10 minutes. 
 
Haloperidol

Haloperidol is an antipsychotic medication used during hospice to help quiet down delirium evidenced by  increasing signs of agitation, confusion, delusions, and hallucinations. 
 
Haloperidol quickly decreases racing thoughts and calms 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 can dry up excessive oral secretions and also helps with the sloshing or wet lung sounds a patient may have, which is sometimes called rales. This tablet dissolves rather quickly, simply by placing it on the patient's tounge.
 
Bisacodyl rectal suppository

Bisacodyl is a stimulant laxative that is used to help a patient feeling the discomfort of constipation.  If needed, unwrap and insert 1 suppository rectally.
 
Prochlorperazine suppository

Prochlorperazine can help decrease nausea and vomiting.  The dose is unwrapped and inserted rectally as directed. However, this medication will make the patient feel a little sleepy.
 
Pharmacists understand that the hospice team is available to answer any family members' questions, but also know that this is an incredibly emotional and difficult time for them. Before family members leave the pharmacy, thank them for their time and encourage them to call back with any questions.


Steve Leuck, PharmD
Steve Leuck, PharmD
Steve Leuck, PharmD, has been practicing both hospital and community pharmacy for over 30 years. He founded AudibleRx, in 2011, which provides Consumer Medication Information which is both Useful and Accessible. Content designed to meet health literacy guidelines. Format designed to "read along" with the audio presentation in a simple to use web application. More information at AudibleRx.org.
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