Download Definitions: Anxiety, Agitation, Dementia, and Delirium

Journal
Louisiana-Mississippi Hospice & Palliative Care Organization
September 2011
in this issue
Symptom
Management
The
of the Louisiana-Mississippi Hospice & Palliative Care Organization
Pharmacotherapy
for the
Anxious
and
Agitated Patient
Definitions: Anxiety, Agitation,
Dementia, and Delirium
Curt Bicknell, PharmD
Client Relations Liaison
Hospice Pharmacia
a service of excelleRx, Inc., an Omnicare company
2525 Horizon Lake Dr., Suite 101 • Memphis, TN 38133
www.hospicepharmacia.com
[P] 901.248.3776
[C] 901-553-3827
[F] 901.384.8002
[E] [email protected]
Anxiety and
agitation are
common symptoms
experienced by hospice patients
at end of life which increases
suffering for both patient
and caregiver. Patients with
dementia and delirium are
also subject to both anxiety
and agitation, and while both
exhibit similar presentations,
they differ in their development
and pathophysiology. Quality
of life for the hospice patient
can be severely impacted by
these behavioral issues. This
article will define and contrast
anxiety, agitation, delirium
and dementia and reference
the non-pharmacological and
pharmacological management of
each.
Anxiety is an abnormal
or overwhelming sense of
apprehension and fear often
marked by physiological signs
such as diarrhea, dyspnea,
fear, insomnia, nervousness,
palpitations, uncontrolled worry, and possible
increase or decrease in appetite. Its etiological
origins stem from stress from impending death,
pre-existing mental illness, complication of
illness or treatment, or possible reactivation
of an anxiety disorder. Anxiety is most often
associated with several behavioral disorders
including obsessive-compulsive disorder,
numerous phobias, panic disorder, post
traumatic stress disorder, and GAD (general
anxiety disorder). Many hospice patients
develop general anxiety disorder
in which there is an underlying
or a general sense of anxiety on
a consistent basis. While many
anxiety disorders can be difficult
to treat, GAD responds well
to the benzodiazepine class of
medications amongst others.
Agitation is a psychotic state
characterized by restlessness,
hyperactivity, anxiety, despair
but not necessarily accompanied
by gross disorganization or
deterioration. Symptoms of
agitation include irritability,
pacing or wandering, kicking,
throwing objects, crying,
hallucinations, verbal and physical
aggression, suspiciousness, and
possible self injury. Its etiology
can stem from pain or physical
discomfort, isolation or change
in enjoinment, over stimulation,
dementia, anxiety,
—continued on page 4
Quality of life
for the hospice
patient can
be severely
impacted by
these behavioral
issues.
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The Journal • 1 • September 2011
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Louisiana-Mississippi Hospice & Palliative Care Organization
The Louisiana-Mississippi Hospice and Palliative Care Organization is a 501(c)3
non-profit organization governed by a board of directors representing all member hospice programs. It is funded by membership dues, grants, tax-deductible
donations and revenues generated by educational activities. LMHPCO exists
to ensure the continued development of hospice and palliative care services in
Louisiana and Mississippi. LMHPCO provides public awareness, education,
research, and technical assistance regarding end-of-life care, as well as advocacy
for terminally ill and bereaved persons, striving to continually improve the quality of end-of-life care in Louisiana and Mississippi.
EXECUTIVE BOARD
President, Stephanie Schedler
Glendale Healthcare
P.O. Box 650 • Mandeville, LA 70470
Phone: 985-626-3281
E-mail: [email protected]
President-Elect
VACANT
Secretary, Ann Walker
Magnolia Regional Health Center & Hospice
2034 East Shiloh Road • Corinth, MS 38834
Phone: 662-293-1405 • 800-843-7553
Fax: 662-286-4242 • E-mail: [email protected]
Treasurer, Martha McDurmond
Hospice of Shreveport/Bossier
3829 Gilbert (Madison Park)
Shreveport, LA 71104-5005
Phone: 318-865-7177 • 800-824-4672
Fax: 318-865-4077 • E-mail: [email protected]
LOUISIANA AT LARGE MEMBERS
Larry Durante, St. Joseph Hospice and Palliative Care, LLC
824 Elmwood Park Boulevard, Suite 155
New Orleans, LA 70123
Phone: 504-734-0140 • Toll-Free: 866-734-0140
Fax: 504-734-0320 • [email protected]
Kathleen Guidry
Louisiana Hospice & Palliative Care Jennings
422 Kade Dr. Ste. 4 • Jennings, LA 70546
Phone: 337-616-3482 • Fax: 337-616-9399
E-mail: [email protected]
Sherrill Phelps, Christus Cabrini Hospice
4801 Jackson Street Extention, Suite B
Alexandria, LA 71302
(318) 448-6764 • (318) 449-2568
[email protected]
MISSISSIPPI AT LARGE MEMBERS
Mike Davis
Odyssey Healthcare of Jackson
5 Old River Place, Suite 200 • Jackson, MS 39202-3449
Phone: 601-973-3550 • Toll Free: 866-973-3550
Fax: 601-973-3551 • [email protected]
Melita Miller, RN, Forrest General Hospital
1414 South 28th Avenue • Hattiesburg, MS 39402
Tel (601) 288-2421 • Fax (601) 288-2401
(800) 844-4663 • [email protected]
Cindy Clark Van Woeart
Delta Regional Medical Center Hospice
300 South Washington Avenue / PO Box 5247
Greenville , MS 38704-5247
Phone: 662-725-1200 • Toll-Free: 888-516-9229
Fax: 662-725-2309 • [email protected]
Executive Director, Jamey Boudreaux
717 Kerlerec • New Orleans, LA 70116
Phone: 504-945-2414 • Toll-Free: 888-546-1500
Fax: 504-948-3908
E-mail: [email protected]
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P.O. Box 1999 • Batesville, MS 38606
Phone: 662-934-0860 • Fax: 504-948-3908
E-mail: [email protected]
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The Journal • 2 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
With regret but with gratitude for her many year’s of service.
LMHPCO acknowledges the following coorespondence from Belinda Patterson
July 8, 2011
Jamey Boudreaux, Executive Director
Board of Directors
Louisiana Mississippi Hospice and Palliative Care Organization
717 Kerlerec
New Orleans, LA 70116
Dear LMHPCO Board of Directors;
It is with mixed emotions and regret that I ask you to accept this letter as my formal resignation
from the Board of Directors and from the Alliance. Since 2006, it has been my honor to serve on
the Board, representing providers in our two States. This organization has made many positive
strides and I’m proud to have been a part of that.
As challenges continue to arise for our industry, we will need leaders from our industry to share
their expertise and guidance for hospices in Mississippi and Louisiana, as well as a voice for
hospice in our nation. I hope that our provider members will consider serving as a member of the
Board.
Thank you for your support, your commitment and your friendships.
Sincerely,
Belinda Patterson
Executive Director
Hospice Ministries, Inc.
In consultation with the LMHPCO Board of Directors, (President) Stephanie Schedler has
decided to not appoint anyone to fill the unexpired term of Belinda Patterson, in anticipation
of the General Membership’s consideration of a By-Laws redesign proposal, to be voted on
before the next election, scheduled for May of 2012.
The Journal • 3 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Definitions — continued from page 1
depression, sleep disturbances, medications, decrease sense
of hope, and constipation/urinary retention. While patients
with agitation may be prescribed a benzodiazepine, many
will require a typical or atypical antipsychotics agent.
Sundowning, or agitation that typically occurs in late
afternoon/ night time usually responds best to antipsychotics,
risperidone in particular.
Delirium and dementia both present with a loss in
cognitive and intellectual functioning without the impairment
of perception or consciousness. Dementia is much more
progressive in nature than delirium and can take several
years to manifest. Delirium tends to be more acute in nature
and symptoms include changes in vision and possible
hallucinations. It’s etiology is different than dementia which
includes decreased sleep, metabolic/electrolyte imbalances,
decreases supply to the brain, impending death, and
infection. Medications have also been implicated as a cause
of dementia and include the following: anti-parkinsonian
medications, corticosteroids, urinary incontinence
medications, theophylline, gastric emptying medications,
insomnia, narcotics/opioids, anti-hypertensive medications,
H2 blocker antihistamines for dyspepsia, antibiotics,
NSAIDS, gerophsychiatric medications, medications with
anticholinergic properties, muscle relaxants, and anti-seizure
medications. Medications for both dementia and delirium
may target sleep disorders (benzodiazepines), infection
(antibiotics), as well as anti-psychotics and other agents for
anxiety. Many of these patients will be admitted to hospice
on medications to protect memory and cognitive functioning,
such as Aricept or Namenda. The use of these medications
in hospice is controversial due to their effectiveness in
later stages of the disease process. Due to the progressive
cognitive and functional decline associated with advances
in dementia, it is reasonable to recommend discontinuing
these medications because evidence for their benefit is
marginal at best, especially given the risk of adverse drug
reactions such as GI discomfort, syncope, and weight loss.
It is recommended to gradually taper these medications
over a 4 week period, reducing at the same rate the dose
was originally titrated upwards. As always, any medication
addition or discontinuation and its expectations should
thoroughly be discussed with the patient and caregiver in
advance.
Treatment Options- Non-pharmacological and
Pharmacological
Overall goals of therapy for the anxious and agitated
patient include reversing physical and environmental causes if
possible, improving quality of life with non-pharmacological
and pharmacological methods, and preventing harm to
patients by minimizing adverse effects. Non pharmacological
options should always be considered first. These include
a reduction in isolation, short term counseling, gentle
reassurance, appropriate lighting, calm and climate controlled
environment, music/pet/aroma/message therapy, removing
or increasing stimulation, and pastoral care. After using
non-pharmacological methods, pharmacotherapy should
be considered. Drug categories include benzodiazepines,
antihistamines, typical and atypical antipsychotics, valproic
acid, anti-depressants, and opioids.
Benzodiazepines primarily treat anxiety and sleep
disorders secondary to anxiety. Specific medications include
the short acting benzodiazepines lorazepam, diazepam,
oxazepam, alprazolam, and clonazepam for anxiety.
Temazepam is a benzodiazepine with an intermediate halflife which is used primarily to induce and maintain sleep.
All of these medications significantly enhance the effects
of naturally occurring neurotransmitter, GABA (gammaaminobutyric acid). GABA is associated with a soothing
effect on behavior, allowing one to maintain a calm
demeanor. The adverse effect potential of benzodiazepines
includes potential drowsiness, dizziness, ataxia, and
weakness. The fall risk potential is significant with
benzodiazepines, thus patients should be counseled to get
up slowly, especially when arising from a supine position.
Some patients may experience a paradoxical reaction to
benzodiazepine in which the opposite effect, aggression or
agitation, may occur. Paradoxical reactions can occur with
any benzodiazepine, thus the patient may require rotation to
another benzodiazepine or to another class of medications
such as an antihistamine. Drug interactions include combining
benzodiazepines with other medications that enhance CNS
sedation, such as phenobarbital, TCA antidepressants,
promethazine, prochlorperazine, haloperidol, chlorpromazine,
and alcohol.
Antihistamines such as diphenhydramine and
hydroxyzine are considered second line to benzodiazepines
due to intolerance or allergy. These medications compete for
histamine-1 receptors and side effects include drowsiness,
dry mouth and eyes, blurred vision, urinary retention, and
constipation. The fall risk for the elderly can be significant
and patients should be counseled to get up slowly before
standing. Drug interactions include those in which
antihistamines are combined with other CNS depressants
(sedation) as well as other anti-cholinergic medications.
The typical (haloperidol, chlorpromazine) and atypical
antipsychotics (risperidone, Zyprexa, Seroquel) primarily
treat agitation by working to decrease levels of dopamine.
The atypical antipsychotics also affect H-1 receptors, 5HT2, and adrenergic alpha -1 receptors, possibly leading to
less dopaminergic and anticholinergic side effects than
the typical ones. Adverse effects include sedation, weight
gain,hypotension, dry mouth, and neuroleptic-malignant
syndrome (especially high dose typical antipsychotics). EPS
or extrapyramidal side effects (restless leg syndrome,
—continued on next page
The Journal • 4 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Definitions — continued from previous page
slurred speech, facial ticks, muscle spasms) are present
with both categories of antipsychotics, although the chances
are much greater with the typical antipsychotics than the
atypical antipsychotics. This effect primarily occurs due
to the decrease in dopamine, and can be mitigated with
the medications diphenhydramaine or benztropine. Drug
interactions are numerous and include combinations with
medications that potentiate CNS depression or sedation,
alcohol, anti-hypertensives, and medications that inhibit
hepatic enzyme CYP3A4. It should be noted that the atypical
antipsychotics require an FDA mandated black box warning
for a possible increase in cardiovascular events.
Valproic acid (Depakene, Depakote) is an antiseizure medication that is typically used as secondary to
antipsychotics to treat agitation, especially if combined
with combative or aggressive behavior. In addition to its
neuroleptic properties, it also enhances the neurotransmitter
GABA. Adverse effect potential includes sedation, diarrhea,
anorexia, trembling, and possible hepatotoxicity. Drug
interactions include interaction with medications that enhance
sedation such as CNS depressants, warfarin, haloperidol,
TCA antidepressants, carbamazepine, and phenytoin.
Antidepressants can be used to treat anxiety related
depression, which is common in the hospice population.
Although there are many classifications of antidepressants,
SSRIs (selective serotonin reuptake inhibitors) are the most
commonly used medications to treat depression. The SSRI’s
are considered the safest antidepressants for the elderly
population. All antidepressants take 4-6 weeks of titration
to full effect, although some improvement in signs and
symptoms may take place as early as 2 weeks. The most
common side effects of SSRI antidepressants include sedation
(paroxetine), activation(all others), possible QT prolongation
in higher doses (especially citalopram), headache, dizziness,
solemnolence, impotence or decreased sexual desire, weight
loss, and fatigue. It is recommended to taper antidepressants
to prevent rebound agitation and irritation (especially
paroxetine). Drug interactions are present but are less
numerous than TCA’s (tri-cyclic antidepressants). It is
advised to check with a pharmacist for drug interactions since
they vary according to the hepatic enzyme that metabolizes
each.
Finally, opioids are used to indirectly to treat anxiety
and agitation by relieving pain and shortness of breath.
Opioids should be continued late in life, even after a patient
is experiencing difficulty in swallowing to prevent opioid
withdrawal which includes rebound anxiety and agitation.
Practioners may need to consider an alternate route of
administration, including the sublingual, rectal, transdermal,
and IV/SQ dosage forms.
In conclusion,
hospice patients have a
high risk of developing
anxiety and agitation
at some point in their
diagnosis. Dementia
and delirium only
compound the effect
of both anxiety
and agitation. Nonpharmacological and
pharmacological
therapies should be
tailored to meet the
needs of the individual.
Medications can be
most beneficial for
treatment of these
behavioral problems
and many have
adverse effects which
will require close
monitoring.
The Journal • 5 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Management of Anorexia/Cachexia
Glen Mire, MD
Medical Director,
Hospice of Acadiana
Clinical Associate Professor
LSU Family Medicine
[email protected]
Anorexia – diminished appetite; from
Greek an (negative) orexis (appetite)
Cachexia – a general weight loss and
wasting occurring in the course of a
chronic disease; from Greek kakos (bad)
hexis (condition of body)
Anorexia/cachexia occurs in 68 - 80 % of patients with a
chronic, life-limiting illness. The prevalence increases as end
of life nears.
Primary cachexia is characterized by increased
proteolysis and increased acute phase protein production;
increased resting energy expenditure; inflammation,
sympathetic activation, and hormonal abnormalities.
Weight loss occurs despite intact GI tract and “sufficient”
caloric intake. Primary cachexia is not reversed by caloric
supplementation. Primary cachexia may occur in patients with
advanced cancer, AIDS, COPD, heart failure, renal failure,
liver failure and other diseases with chronic inflammation.
Primary cachexia is usually present in end-stage dementia.
In contrast, secondary cachexia (starvation) is
characterized by insufficient caloric intake. This may be due
to reduced intake, reduced absorption or loss of nutrients. Fat
is used as an energy source in order to preserve protein. This
condition is reversible with increased caloric intake.
Assessment of patients with anorexia/cachexia
1. Is a disease process causing the symptom, or is it
secondary to other symptoms (nausea, constipation)
that can be treated? Low-grade nausea may present as
anorexia. Patients may not complain of constipation.
2. Is the patient (or the family) troubled by the symptom?
In many cases, the patient is comfortable, but the family/
caregiver(s) are very distressed by the patient’s poor
appetite. Many, if not most, cultures around the world
equate food with nurturing. The belief is that eating will
promote improved health. Unfortunately, increasing
caloric intake in patients with end-stage illness does not
reverse primary cachexia.
Management of patients with anorexia/cachexia
1. Treat the underlying cause when possible. Some
reversible causes of anorexia are nausea, vomiting,
constipation, dehydration, weakness, depression, pain,
gastritis, oral candidiasis, and dry mouth. Many of these
conditions can be ameliorated, if not completely resolved.
2. Try non-pharmacologic measures.
Remove unpleasant odors
Alcoholic drink prior to meals
Small, frequent meals
Serve meals out of bedroom
Provide companionship with meals
Involve patient with menu planning. Avoid strict
therapeutic diets. Allow food preferences.
3. Appetite stimulants have limited evidence-based efficacy.
Megestrol acetate may produce weight gain, increased
appetite, and increased sense of well-being. The greatest
effect occurs with 800mg daily and the response begins
within 2 weeks. However, weight gain is fatty tissue,
not muscle mass. Adverse effects include edema, venous
thrombosis (6%), nausea, menstrual irregularities, erectile
dysfunction, hyperglycemia, hypertension and adrenal
suppression. Megestrol is contraindicated in patients with
a history of thromboembolism.
Cochrane Review (Evidence-Based)
Megestrol acetate for treatment of anorexia-cachexia
syndrome (2007, edited 2009)
Megestrol acetate improves appetite and weight in
patients with anorexia cachexia syndrome related to cancer.
Not enough evidence to reach a conclusion about the effect
on quality of life and optimum dose. There is too little
information on AIDS patients and those patients with other
underlying pathologies. Low incidence of adverse effects was
found.
Corticosteroids may increase appetite and sense of wellbeing. Due to complications of long-term use, these agents
should be considered only for short-term use, usually less
than two months. Adverse effects include gastritis, peptic
ulcer, cushingoid syndrome, osteoporosis, myopathy, and
hyperglycemia. Corticosteroids are a reasonable choice in
patients who also have bone pain or bronchospasm.
Only the progestational agents and corticosteroids have
been shown in multiple, placebo controlled, randomized trials
to stimulate appetite.
Cochrane Review (2006, edited 2009) found insufficient
evidence to recommend use of Omega-3 fish oil.
Cannabinoids (dronabinol) can produce CNS side effects
Metoclopramide may be useful in patients with gastric stasis.
No randomized controlled trials to support the use of
cyproheptadine, thalidomide, oxandrolone, melatonin, TNF
inhibitors, and creatine.
In summary, anorexia/cachexia is nearly always present
—continued on next page
The Journal • 6 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Anorexia — continued from previous page
in patients with terminal illness. Appetite stimulants (e.g.,
megestrol acetate, corticosteroids) may provide some benefit
to patients in earlier stages of disease. Encourage patients
to eat whatever they prefer, without dietary restrictions.
Anorexia in actively dying patients who do not wish to eat
should not be treated.
References
1. UNIPAC Series, 3 Ed. 2008 American Academy of
Hospice and Palliative Medicine www.aahpm.org
2. Lipman AG, Jackson KC, Tyler LS. Evidence Based
Symptom Control in Palliative Care. The Haworth Press.
2000. www.haworthpressinc.com
3. Bruera E, Higginson IJ, Ripamonti C, von Gunten C.
Textbook of Palliative Medicine. Hodder Arnold, 2006.
www.hoddereducation.com
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Registration brochure and details at http://tinyurl.com/3m39clv
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The Journal • 7 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Methadone for pain management:
vice or virtue?
Dominique Anwar, M.D,
Palliative Care Program, Section
of General Internal Medicine and
Geriatrics
Tulane School of Medicine
[email protected]
INTRODUCTION:
Methadone, a synthetic opioid, was developed in
Germany in the late 1930s in response to the fear of
possible opium shortages during the upcoming war.1It was
subsequently given the trade name Dolophine (from the
Latin, literally “end of pain”) by Eli-Lilly, an American
pharmaceutical company. It has been stigmatized as a
“drug addict medication”, based on its frequent use as a
maintenance therapy in this patient population. It has also
been considered dangerous based on its potential side effects,
especially cardiac, as well as its complex pharmacokinetics
and pharmacodynamics, and its use as an analgesic has been
supplanted by other long-acting opioids. A recent survey of
550 pain physicians indicated that methadone was prescribed
on a very limited basis and was rarely used as a primary
analgesic.2 However, for the past 20 years, methadone
has been experiencing resurgence in the palliative care
community. Numerous case reports as well as recent studies
and reviews reemphasize its excellent efficacy on neuropathic
and/or chronic pain and take the drama out of its potential
complexity of use and side effects. The goal of this article,
illustrated by clinical vignettes, is to review these recent
evidence-based data and to assess how they may apply to the
specific palliative care and hospice context.
CLINICAL VIGNETTES:
1) A 32 year old Caucasian male is diagnosed with a
very large histiocytoma of the right thigh. After undergoing
radiation therapy and before starting a chemotherapy
regimen, he undergoes an amputation with hemipelvectomy.
Three weeks after the procedure, he presents to the Tulane
Outpatient Supportive and PC Clinic with a refractory
phantom pain syndrome which started 3 days after the
intervention and is severe enough to make him contemplate
suicide. Pain is reported as 8-10/10 on the VAS, despite
receiving very high doses of fentanyl, oxycodone, diazepam,
and gabapentin. He is started with a low dose of methadone
that is titrated up to 10 mg tid. At 48 hours, his pain level
is 5/10 and at 72 hours, it has dropped to 2/10. The other
opioids and gabapentin are weaned within one month. A
pretreatment and + 2-months EKG are normal. After 4
months, as the pain level is 0-1/10, the weaning of methadone
is initiated.
2) An 85 year old African-American male is referred
to home-based hospice care with a large ENT tumor and
chronic renal failure. The pain is refractory, with an important
neuropathic component. The patient’s pain treatment regimen
consists of fentanyl patches 125 mcg/h q 72 h, oxycodone 40
mg q 4 h, and gabapentin 600 mg tid. The pain is reported as
5/10 or greater, and the patient also presents with moderate
confusion and myoclonia, attributed to opioid-related
neurotoxicity. He is switched from oxycodone to methadone
10 mg following the M.D. Anderson conversion table, and
fentanyl is maintained. An excellent pain control is obtained
after 3 days and will be maintained. The symptoms and signs
of neurotoxicity disappear within 48 hours.
PHYSIOPATHOLOGY AND PHARMACOLOGY:
Methadone is a synthetic opioid which possesses μ
as well as δ and κ opioid receptor activity; it is also an
inhibitor of serotonin and norepinephrine reuptake, and most
important, methadone functions as an N-methyl-D-aspartate
(NMDA) receptor antagonist, with major implications for the
management of chronic and/or neuropathic pain syndrome.
Its oral and rectal bioavailability is 50% greater than that of
morphine, and its hepatic metabolism makes it an excellent
choice in patients with renal impairment.
EFFICACY:
Methadone has been shown to be as effective as
morphine for cancer pain relief.3 Several studies, focusing
mainly on cancer-related pain patients, also emphasized
the efficacy of methadone for the treatment of chronic and/
or neuropathic pain.4, 5, 6 However, a Cochrane review
conducted in 2007 failed to elaborate a meta-analysis on
the use of methadone in cancer pain based on the published
literature due to the various modes of administration and
posology of methadone as well as small sample sizes.7 More
recently, a study conducted at the M.D Anderson Cancer
Center demonstrated a success rate of 92% in patients treated
with methadone as the initial opioid and 84% in those
rotated to methadone from another opioid.8 A still-in-press
retrospective study, conducted on 13 patients treated with
high doses of the usual opioids for uncontrolled and mainly
neuropathic pain, without success, suggested that methadone
can be successfully used as a coanalgesic.9
The Journal • 8 • September 2011
—continued on next page
Louisiana-Mississippi Hospice & Palliative Care Organization
Methadone — continued from previous page
Regarding refractory neuropathic pain in non-cancer
patients, a case series with 50 consecutive patients having
failed treatment with one or more conventional opioids
and co-analgesics described 52% of patients treated with
methadone as experiencing pain relief, with improved
function in 28%.10Another author reported his positive
experience with the use of methadone for the treatment of
diabetic neuropathy.11
SIDE EFFECTS AND SAFETY:
Methadone has a side effect profile similar to that of
morphine, but due to its long half-life, it may have a higher
risk of sedation or respiratory depression in cases of high dose
administration or rapid dose adjustment. In some specific
circumstances, it may also cause an increase in the QTc
interval, with a subsequent increase in risk of arrhythmias,
especially the potentially fatal torsades de pointes. This
cardiac side effect is usually related to the use of iv and/or
very high doses of methadone (>130 mg/d) in the methadone
maintenance population, in cases of pre-existing heart disease,
and/or related to the concomitant use of medications which
have QT interval-prolonging properties or may slow the
elimination of methadone, such as those metabolized
by the cytochrome P450 isoenzymes CYP3A4
and CYP2D6.12 Although several reports
suggested that patients receiving
methadone are at increased risk for
QTc prolongation, others have not
replicated these findings. Hence, it
is not surprising that there is no
recent consensus on when and if
to perform baseline and control
electrocardiograms during
methadone administration.13
Two studies published
in 2010 provide some clues
for our daily practice. The
first one was conducted
on 100 advanced cancer
patients followed for 2
months after the initiation
of methadone (median
methadone daily dose 23
mg (range 3-90). It showed
that even though baseline QTc
prolongation was common,
significant QTc interval (500 ms
and more) very rarely occurred
during the treatment; no evidence of
clinically significant arrhythmias was
demonstrated.14 The second one, targeting
a similar patient population, focused on the
outpatient setting and assessed the efficacy and safety of a
treatment of methadone on 189 consecutive patients. The
treatment efficacy has been reported above. The frequency
of sedation, hallucinations, myoclonia, and delirium did not
increase after initiation/rotation to methadone. Interestingly,
the constipation and nausea improved (P < .005) after the
initiation/rotation.8
CONVERSION TABLES FROM OTHER OPIOIDS:
Despite the abundance of recent case reports and
literature reviews demonstrating the effective use of
methadone in patients with cancer, there is a lack of
consensus for an appropriate method for converting morphine
(and by extension, other opioids) to methadone.15 Several
tables of conversion are available and may be useful while
converting from a high dose of opioids to methadone, such as
the one used at the M.D. Anderson Cancer.3, 16
IMPLICATIONS AND RECOMMENDATIONS
SPECIFIC TO PALLIATIVE CARE AND HOSPICE
SETTINGS:
A study conducted in 2003 in the home-based hospice
setting demonstrated that methadone constituted only 1.7%
of all long-acting opioids prescribed.17 A recent study
conducted in New Zealand among 14 hospice agencies
showed that methadone was prescribed in only
10% of cases.18 To our knowledge, no
studies assessing the use of methadone in
end-of-life care have been conducted
specific to the hospice patient
population. However, based on
those studies available, conducted
mainly on the cancer patient
population, and based also on
the long and very positive
experience of the author as
well as that of a local palliative
care/ chronic pain control
expert19, methadone can be
considered a valuable option
in the palliative care and
hospice patient population:
- To improve the balance
between analgesia and side
effects (opioid rotation) thanks
to its hepatic clearance and
its lack of active metabolites,
especially in a population
frequently presenting with a renal
failure component
- To address specifically chronic or
neuropathic pain
—continued on next page
The Journal • 9 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Methadone — continued from previous page
-
In cases of morphine allergy because methadone is
synthetic and offers no cross-allogenicity
It has multiple routes of administration, a rapid onset
of action, a long half-life, and it is also an inexpensive
medication when compared to other opioids. The major
concerns regarding methadone are:
- Potential cardiac effects, which, based on recent studies,
don’t seem to be a concern at the low doses required in
this specific patient population
- Possible patient and patient family misinterpretation of
methadone prescription due to its frequent association
with drug addiction.
- Lack of evidence-based efficacy for the symptomatic
treatment of dyspnea, unlike morphine.
As it is often the case in the end-of-life period, it
is fundamental to weigh the benefits versus the risks of
methadone treatment. Based on the findings reported above,
the balance seems to be in favor of methadone.
As widely recognized treatment guidelines and
algorithms are still missing, and as for nearly all treatments in
these frail patients, our recommendations are to “start slowly
and go slowly”. We recommend to start with 5 mg bid or
tid in naive patients or if used as co-analgesic and to titrate
carefully afterwards, increasing the doses not more than q
24 or 48 h. In case of rotation from other opioids especially
with high doses, the M.D Anderson conversion table is an
excellent tool.3, 16 It is also important to provide a complete
information to patients and patients’ families to address their
potential fears regarding this stigmatized medication and to
assure good adherence, fundamental for the best efficacy and
safety.
More studies are warranted in the specific palliative
care and hospice context, as well as in the non-oncological
patient population. Other issues to explore include the role of
methadone as a first-line therapy opioid and coanalgesic, as
well as its potential usefulness for the treatment of dyspnea.
REFERENCES:
1. Angel J. Anesthesia secrets, 2nd ed. Appleton & Lange,
Norwalk, CT: 1996
2. Shah S, Diwan S. Methadone: does stigma play a role
as a barrier to treatment of chronic pain? Pain Physician
2010;13:289-293
3. Bruera E, Sweeney C. Methadone use in cancer patients
with pain. J Palliat Med 2002; 5:127-38
4. Thomas Z, Bruera E. Use of methadone in a highly
tolerant patient receiving parenteral hydromorphone. J
Pain Sympt Manage 1995; 10 (4):315-7
5. Crews J, Sweeny NJ, Denson DD. Clinical efficacy of
methadone in patients refractory to other mu-opioid
receptor agonist analgesics for management of terminal
cancer pain. Case presentations and discussion of
incomplete cross-tolerance among opioid agonist
analgesics. Cancer 1993; 72(7):2266-72
6. Morley JS, Watts JW, Wells JC, et al. Methadone in pain
uncontrolled by morphine. Lancet 1993; 342:1243
7. Nicholson AB. Methadone for cancer pain. Cochrane
Database Syst Rev 2007; (4):CD003971
8. Parson HA, de la Cruz M, el Osta B, et al. Methadone
initiation and rotation in the outpatient setting for patients
with cancer pain. Cancer 2010; 116(2):520-8
9. McKenna M, Nicholson AB. Use of methadone as a
coanalgesic. J Pain Symptom Manage. 2011 [Epub ahead
of print]
10. Moulin DE, Palma D, Watling C, Schulz V. Methadone
in the management of intractable neuropathic noncancer
pain. Can J Neurol Sci 2005;32 (3): 340-3
11. Hays L, Reid C, Doran M, Geary K. Use of methadone
for the treatment of diabetic neuropathy. Diabetes Care
2005;28(2):485-487
12. Kranz MJ, Martin J, Stimmel B, et al. QT interval
screening in methadone treatment. Ann Intern Med
2009;150:387-395
13. Cruicani RA. Methadone: to ECG or not to ECG...That is
still the question. J Pain Symptom Manage 2008;36:545552
14. Reddy S, Hui D, El Osta B, et al. The effect of oral
methadone on the QTc interval in advanced cancer
patients: a prospective pilot study. Journal of Palliative
Medicine 2010;13(1):33-38
15. Pollock AB, Teggerler EM, Morgan V. Morphine to
methadone conversion: an interpretation of published
data. Am J Hosp Palliat Care 2011.28(2): 135-40
16. Bruera E, Pereira J, Watanabe S, et al. Opioid rotation
in patients with cancer pain. A retrospective comparison
of dose ratios between methadone, hydromorphone, and
morphine. Cancer 1996;78 (4): 852-7
17. Weschules D, McMath JA, Gallager R, et al. Methadone
and the hospice patient: prescribing trends in the homecare setting. Pain Medicine 2003; 4(3): 269-276
18. Ensor BR, Middlemiss TP. Benchmarking opioids in the
last 24 hours of life. Intern Med J 2011 [Epub ahead of
print]
19. McNulty JP. Chronic pain: levorphanol, methadone, and
the N-methyl-D-aspartate receptor. Journal of Palliative
Medicine 2009; 12(9): 765-766
Acknowledgments: thanks to Dr. McNulty for his
thorough review and to N.Munshi, T3 student, for his
excellent edits
The Journal • 10 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Barriers to the Use of Opioids for Pain
Jack Mc Nulty, M.D., F.A.C.P., F.A.A.H.M.
President, Palliative Care Institute of
Southeast Louisiana
Medical Director
Hospice of St. Tammany
Assoc. Prof.
Clinical Medicine, LSUHSC
Convincing the world that opioids are an appropriate,
safe, and effective treatment for chronic pain is not an easy
task. Public misconceptions and myths about the dangers of
opioids and the risk of addiction can be formidable barriers .
True, it is a bit easier in our hospice population, but there are
barriers and misconceptions even there.
In my experience, the major barrier is the reluctance of
doctors to give up the ideas they obtained in their early years
of training. Most of these ideas are no longer correct. For
example, addiction is NOT common in chronic pain patients
who have no history of substance abuse. The incidence of
addiction is 1-3% in non-abusers treated for chronic pain.
Legitimate pain patients follow the rules; substance-abusers
bend and break the rules. 80% of addicts have a life-long
genetic brain disorder which causes them to seek a dopamine
“high” to make them feel better. Drugs, alcohol, nicotine,
gambling do NOT cause addiction; they are the tools that
addicts use because they have this brain condition.
The education that doctors and nurses receive about pain
has been woefully inadequate in school and in postgraduate
training. Projects such as EPEC (Educating Physicians on
End-of-Life Care) and ELNEC are helping to correct this.
When doctors have not been taught modern pain management
information, it is not surprising that they are slow to acquire
newer experience using opioids such as methadone and
levorphanol for neuropathic and refractory chronic pain.
Recent evidence has proven that the use of morphine
and other opioids given to relieve dyspnea and pain in
those nearing death does NOT hasten death, and is effective
and appropriate therapy. The respiratory center of patients
receiving opioids for chronic pain rapidly develop tolerance
to even large doses of opioids, and respiratory depression
very rarely occurs. But the “opioid-naïve” patient receiving
opioids for the the first time must be carefully monitored until
tolerance develops.
State medical boards NO LONGER frown on the use of
opioids for pain, as long as there is proper documentation,
and guidelines are followed. There is a wonderful and
entertaining video available from the Federation of State
Medical Boards called “Facing Fears: Pain, Medication, and
End of life Care” which costs $15 (www.fsmb.org).
The Drug Enforcement Agency (DEA) now APPROVES
the use of opioids for pain as long as there are controls to
prevent diversion. The DEA does not routinely monitor
doctor’s prescribing practices. They do investigate complaints.
In California, when the state board failed to act on a
complaint against a doctor for undertreating the pain of
a dying patient and the plaintiff family sued and won a
subsequent lawsuit, the state legislature then passed a law
that MDs MUST obtain 12 hours of CME credit on pain and
end-of-life care by 12/31/06.There is a similar law in Oregon,
requiring 6 hours of CME credit by 12/31/09. Doctors must
do more to educate themselves to avoid mandates of this kind.
By educating the public and all members of the healthcare
professions, we should be able to provide our patients and
their families with better relief of pain, less suffering, and an
improved quality of life.
What better way to honor and recognize our veterans for Veterans Day?
The LMHPCO VA-Hospice Taskforce commissioned beautiful pins to thank our
hospice veterans for their military service. LMHPCO members can now purchase
these pins to distribute throughout the year to Veterans enrolled into hospice
programs across Louisiana and Mississippi.
Pins are $1.25 each
•
Pack of 50 pins for $62.50
Proceeds from the sale of these pins benefit the LMHPCO VA-Hospice
Taskforce’s efforts to enhance hospice services to our military veterans in
Louisiana and Mississippi.
Please send checks to:
LMHPCO VA-Hospice Taskforce Pins
717 Kerlerec • New Orleans, LA 70116
The Journal • 11 • June 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Hospice/Nursing Home Care
High Percentage Hospices
also had longer lengths of service and higher Medicare
reimbursements than beneficiaries in other settings.
Cordt. T. Kassner, PhD
Hospice Analytics, Inc.
On July 22, 2011, the Office of
Inspector General (OIG) released
their Medicare Hospices that Focus
on Nursing Facility Residents report.
Why is the OIG looking at hospice care
in nursing facilities, what did they find, and what did they
recommend based on their findings?
Background
Concern about the overlap of hospice and nursing facility
services dates back to 1995, when an OIG report on nursing
facilities raised questions about hospice services provided to
these beneficiaries
A 1997 OIG report found Medicare hospice beneficiaries
residing in nursing facilities received nearly 46% fewer
nursing and aide services than hospice patients living at
home, although hospice payments were the same in either
location of care. In this report, the OIG reported 17% of
Medicare hospice beneficiaries resided in nursing facilities
in 1995, and due to growth in this location of care estimated
that hospices saw nursing facilities as an effective way of
expansion. (Apparently they were correct, as more recent
OIG reports found 28% of Medicare hospice beneficiaries
resided in nursing facilities in 2005, and 33% in 2009.) In
1997 the OIG recommended CMS modify hospice payments
for beneficiaries residing in nursing facilities (so this is a
long-standing recommendation, yet to be acted on!). This
began a series of OIG reports with several findings and
recommendations regarding Medicare hospice beneficiaries
residing in nursing facilities, including:
• 1997: Concern was raised that “some decisions about
patient care can be potentially influenced by financial
rather than clinical factors”.
•
1998: 29% of sampled Medicare hospice beneficiaries in
nursing homes failed to meet hospice eligibility criteria,
compared to 2% of patients not residing in nursing homes.
•
2007: Medicare hospice beneficiaries in nursing facilities
were more than twice as likely as beneficiaries in
other settings to have terminal diagnoses of ill-defined
conditions, mental disorders, or Alzheimer’s disease.
Medicare hospice beneficiaries in nursing facilities
•
2009: 82% of hospice claims for beneficiaries in nursing
facilities failed to meet at least one Medicare coverage
requirement (89% of claims from nonprofit hospices
failed to meet Medicare requirements, compared to 74%
from for-profit hospices); 63% of claims did not meet plan
of care requirements; 33% of claims did not meet election
requirements; 31% of claims showed hospices provided
fewer services than outlined in the plan of care; and 4%
of claims did not meet certification of terminal illness
requirements.
In addition to these OIG reports, the 2009 Medicare
Payment Advisory Commission (MedPAC) Report to
Congress includes the following recommendations, which
have been carried forward in their 2010 and 2011 reports:
The Secretary (of HHS) should direct the Office of
Inspector General to investigate:
1. The prevalence of financial relationships between
hospices and long-term care facilities such as nursing
facilities and assisted living facilities that may represent a
conflict of interest and influence admissions to hospice,
2. Differences in patterns of nursing home referrals to
hospice,
3. The appropriateness of enrollment practices for hospices
with unusual utilization patterns (e.g., high frequency of
very long stays, very short stays, or enrollment of patients
discharged from other hospices), and
4. The appropriateness of hospice marketing materials and
other admissions practices and potential correlations
between length of stay and deficiencies in marketing or
admissions practices.
Current OIG High Percentage Hospice Report:
This background provides context for why the OIG
released a recent report examining hospices with high
percentages of Medicare beneficiaries residing in nursing
facilities. The OIG’s 7/11 report noted 96% of hospices
cared for at least one beneficiary who resided in a nursing
facility; over 50% of hospices had at least a quarter of their
beneficiaries in nursing facilities; 19% of hospices had over
half their beneficiaries in nursing facilities; and almost 8% of
hospices (N=263) had two-thirds or more of their Medicare
beneficiaries residing in nursing facilities (now termed “high
percentage hospices”). Of the high percentage hospices, 72%
The Journal • 12 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
were for-profit and 22% were nonprofit, compared to hospices
overall being 56% for-profit and 39% nonprofit. This study
found:
• Medicare spending on hospice care for nursing facility
residents has grown nearly 70% since 2005.
• Hundreds of hospices had more than two-thirds of their
beneficiaries in nursing facilities in 2009; most of these
hospices were for-profit.
• High-percentage hospices received more Medicare
payments per beneficiary and served beneficiaries who
spent more time in care.
• High-percentage hospices typically enrolled beneficiaries
whose diagnosis required less complex care and who
already lived in nursing facilities.
Report recommendations included:
• CMS should target its monitoring efforts on high
percentage hospices, and should closely examine
whether these hospices are meeting Medicare
requirements. Hospice Analytics’ Comment: The CMS
concurred with this recommendation and agreed to share
this recommendation with MACs and RACs. MACs
could prioritize this recommendation by integrating it into
their medical review strategies or other interventions at
any time.
• CMS should modify the payment system for hospice
care in nursing facilities. Hospice Analytics’ Comment:
The CMS also concurred with this recommendation,
noting they will include
findings from this
analysis (and additional
analysis) to inform
their development of
alternative payment
models as part of
hospice payment reform
efforts mandated by the
Affordable Care Act, no
earlier than 10/13. We
don’t yet know if or how
this recommendation
may impact hospice
reimbursement.
hospices with high percentages of Medicare hospice
beneficiaries residing in nursing facilities include:
1. Review: Carefully review the 7/11 OIG report.
2. Documentation: Prepare for increased MAC and RAC
scrutiny through medical review and other interventions.
Review these charts for clear documentation of hospice
eligibility.
3. Financial: Consider short term budget implications if
payment is immediately postponed for claims under
medical review. Consider long term budget implications
if hospice reimbursement is reduced for Medicare hospice
beneficiaries residing in nursing facilities.
A concluding thought: CMS, OIG, and MedPAC are
not questioning the value or importance of hospice services
being provided to beneficiaries residing in nursing facilities.
However, several studies have uncovered substantial concerns
regarding hospice documentation, care planning, eligibility,
and financial conflicts of interest regarding beneficiaries
residing in nursing facilities. It is important and beneficial to
Medicare hospice beneficiaries to continue providing hospice
services in nursing facilities – however hospice services must
be provided and billed for according to regulations.
Additional Analysis &
Recommendations:
Hospice Analytics
used a methodology similar
to the OIG’s to identify
high percentage hospices
nationally, including 8
Louisiana hospices and
4 Mississippi hospices.
Recommendations for
The Journal • 13 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
We Honor Veterans
We Honor Veterans a program of the National Hospice
and Palliative Care Organization (NHPCO) in collaboration with the Department of Veterans Affairs (VA) invites
hospices, state hospice organizations, Hospice-Veteran
Partnerships and VA facilities to join a pioneering
program focused on respectful inquiry, compassionate
listening and grateful acknowledgment. By recognizing
the unique needs of America’s veterans and their families, community providers, in partnership with VA staff,
will learn how to accompany and guide them through
their life stories toward a more peaceful ending.
Become a WHV Partner
Through this program, local community hospices can
join hospice providers across the country in honoring
our Nation’s Veterans and be listed as Partners on the We
Honor Veterans website.
By becoming a We Honor Veteran Partner, hospices will
be better prepared to:
1. Build professional and organizational capacity to provide
quality care for Veterans
2. Develop and/or strengthen partnerships with VA and other
Veteran organizations
3. Increase access to hospice and palliative care for Veterans
in their community
4. Network with other hospices across the country to learn
about best practice models www.WEHonorVeterans.org
ENROLL YOUR HOSPICE:
To begin your work as a WHV Partner,
hospices can join as a “Recruit” by
clicking here to complete and submit the
Partners Commitment form. Click here:
http://www.wehonorveterans.org/files/public/WHV_Partner_Commitment.pdf
Visit the Recruit page here for additional details.
http://www.wehonorveterans.org/i4a/pages/index.cfm?pageid=3352
A MILITARY HISTORY CHECKLIST
Click here:
http://www.wehonorveterans.org/i4a/pages/index.cfm?pageid=3337
The Journal • 14 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
We Honor Veterans
Here are LMHPCO members in the process of building
their competency with regards to Veterans.
AseraCare Hospice
Corinth, MS • Level One
Hospice Ministries, Inc.
Ridgeland, MS • Recruit
Odyssey Hospice of Northwest Louisiana
Shreveport, LA • Recruit
Brighton Bridge Hospice
Oberlin, LA • Recruit
Hospice of Acadiana, Inc.
Lafayette, LA • Level Two
Christus Hospice & Palliative Care Schumpert
Shreveport, LA • Recruit
Hospice of Light
Gautier, MS • Recruit
Hospice of Natchitoches
Natchitoches, LA • Level One
Paramount Hospice
Lafayette, LA • Level One
Patient’s Choice Hospice & Palliative
Care
Tallulah, LA • Level One
Compassionate Care Hospice of Central
LA (2012 membership pending)
Alexandria, LA • Recruit
Hospice of Shreveport/Bossier
Shreveport, LA • Recruit
Deaconess Hospice
Biloxi, MS • Recruit
Hospice of South Louisiana
Houma, LA • Level Two
Deaconess Hospice
Hattiesburg, MS • Recruit
Lakeside Hospice
Metairie, LA • Recruit
Doctors Hospice - Livingston
Walker, LA • Recruit
Louisiana Hospice & Palliative Care Jennings
Jennings, LA • Level Two
Faith Foundation Hospice
Alexandria, LA • Recruit
Gentiva Hospice of Booneville
Booneville, MS • Recruit
Harmony Hospice
Metairie, LA • Recruit
HL Haydel Memorial Hospice
Houma, LA • Recruit
Hospice Care of Avoyelles
Alexandria, LA • Recruit
Hospice Compassus
Monroe, LA • Recruit
Louisiana Hospice & Palliative Care
Mamou, LA • Level One
Louisiana Hospice & Palliative Care
Monroe, LA • Recruit
Louisiana Hospice & Palliative Care
Opelousas, LA • Level One
Notre Dame Hospice
Slidell, LA • Recruit
Odyssey Hospice of Jackson, MS
Flowood, MS • Recruit
Patient’s Choice Hospice & Palliative
Care
Vicksburg, MS • Level One
Premier Hospice, LLC
Bastrop, LA • Recruit
Professional Hospice Care
Jonesboro, LA • Recruit
Professional Hospice Care
Ruston, LA • Recruit
Quality Hospice Care, Inc
Philadelphia, MS • Recruit
Richland Hospice
Rayville, LA • Recruit
St. Joseph Hospice - Acadiana
Lafayette, LA • Recruit
St. Margaret’s Hospice
Gretna, LA • Recruit
Sanctuary Hospice
Tupelo, MS • Recruit
Odyssey Hospice of Lake Charles
Lake Charles, LA • Recruit
Hospice Compassus - Slidell/New Orleans
Metairie, LA • Recruit
Odyssey Hospice of New Orleans
Metairie, LA • Recruit
The Journal • 15 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Hurricane Irene, Tropical Strom Lee and the earthquake
along the Atlantic seaboard all serve as recent reminders of
how vulnerable we are to natural disasters.
Hospice and home health agencies along the gulf coast,
have voluntarily participated in an effort to count the most
Area Code
LA 225 (17 agencies reporting)
MS 228 (11 agencies reporting)
LA 318 (17 agencies reporting)
LA 337 (23 agencies reporting)
LA 504 (18 agencies reporting)
LA 985 (18 agencies reporting)
Total (103 hospice agencies reporting)
•
•
•
•
The At Risk Patient Registry
Total Census At Risk Patient
is currently proving to be our best
(9/19/11)
Count (9/19/11) instrument to increase awareness and
L828
353
564
966
718
634
4,063
Louisiana & Mississippi Coastal *At-Risk Hospice Patients:
•
•
vulnerable patients we serve.
These reports are giving emergency mangers and state
planners new information and insights as to the potential
magnitude and challenges homecare providers have with
regards to emergency preparedness.
67
94
85
151
111
105
613
public patient safety for patients:
• living alone, without a caregiver
and unable to evacuate themselves,
or
• with a caregiver who is either
mentally or physically unable to
follow through on an evacuation
order, or
• financially unable to evacuate, or
• refusing to evacuate
To learn more about using the At
Risk Registry, contact Jamey at 888546-1500
Hospice Patients who live alone, without a caregiver and unable to evacuate themselves, or
Hospice Patients with a caregiver (physically or mentally) incapable of carrying through on
evacuation order, or
Hospice Patients/Caregivers without the financial means to carry through on an evacuation
order, or
Hospice Patients who simply refuse to evacuate.
Information compiled through emails & phone interviews conducted September 12-19, 2011 by
LMHPCO
[email protected]
[email protected]
888-546-1500
As a result of LMHPCO’s
past efforts to quantify the
at risk patient population
along the coastal regions
of both states, the Home
Care Association of LA has
decided to do the same.
For the past two hurricane
seasons LMHPCO and
HCLA have worked together
to provide state officials
with realistic numbers of At
Risk homebound patients
in the state. At Risk Home
Health patients currently
outnumber At Risk Hospice
patients by more than 4 to 1.
504-945-2414
Area Code
225
337
504
985
(28 agencies)
(52 agencies)
(33 agencies)
(35 agencies)
Totals
•
•
(148 agencies reporting)
Total Census
(9/12/2011)
At Risk Patients
(9/12//2011)
4943
615
5858
685
8416
7885
27102
942
518
2760
Louisiana Coastal *At-Risk Home Health Patients:
• Home Health Patients who live alone, without a caregiver and are unable to evacuate
themselves, or
• Home Health Patients with a caregiver physically or mentally incapable of carrying through on
an evacuation order, or
• Home Health Patients/Caregivers without the financial means to carry through on an
evacuation order, or
• Home Health Patients/Caregivers simply refusing to evacuate.
Information compiled through emails and phone interviews conducted September 6-12, 2011
by HCLA
[email protected]
[email protected]
800-283-HCLA
The Journal • 16 • September 2011
337-231-0080
Louisiana-Mississippi Hospice & Palliative Care Organization
What do you think the
hospice license plates
should
look
like?
Both the Louisiana and Mississippi Legislatures authorized specialty hospice
license platesto raise hospice awareness within our respective states. LMHPCO
is launching a design contest in each state. The winning designer will receive
hospice license plate #1. Design deadline is October 1, 2011.
Send your design ideas to [email protected]
Louisiana Car Tag design poster at http://tinyurl.com/3eyyby6
Mississippi Car Tag design poster at http://tinyurl.com/3rnoo6q
Help Us Increase
Help Us Increase
Hospice Awareness Hospice Awareness
Your Design
Here
Max. Area:
3” x 3”
Your Design
Here
Max. Area:
3” x 3”
Hospice cares at the En
d-of-Life
Hospice cares at th
e End-of-Life
LicEnSE PLATE DESign cOnTEST
LicEnSE PLATE DESign cOnTEST
ReseRve
YouR Tag
TodaY!
Winner receives license plate #1
Deadline: October 1, 2011
Email design to [email protected]
— SAMPLES FROM OTHER STATES —
ReseRve
YouR Tag
TodaY!
Winner receives license plate #1
Deadline: October 1, 2011
Email design to [email protected]
— SAMPLES FROM OTHER STATES —
The Journal • 17 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Leslie Lancon Memorial Educational
Hospice Nursing Scholarship
PURPOSE:
The annual scholarships will be awarded to support hospice and palliative care nursing excellence
and education throughout Louisiana and Mississippi.
AWARD:
Louisiana Mississippi Hospice and Palliative Care (LMHPCO) will award six educational NBCHPN certification exam scholarships to reimburse the recipients for the cost of the NBCHPN Certification
Exam. They will be awarded annually to: 1RN (CHPN); 1 LPN (CHPLN); and 1 NA (CHPNA) per state (LA and MS).
The scholarships will be offered on an annual basis running from April 1st to April 1st of each year. The recipients will be selected and notified in June; two announcements will be made the first will be in LMHPCO’s The
Journal and the second at the Annual LMHPCO Leadership Conference.
REQUIREMENTS:
All responses must be typed in the online application. The application must be submitted online. Please print
a copy of the application for your records. All recipients will be announced in the July LMHPCO Journal. Upon
notification, all recipients will be required to submit a digital photo to the education director to be used in the
announcement.
QUALIFICATIONS:
1. An employee in good standing of a LMHPCO member, with a minimum of two years of hospice experience.
2. May be a new or recertification applicant.
3. Must submit a completed NBCHPN Certification Exam Scholarship Application to the Education Chair of
Louisiana-Mississippi Hospice and Palliative Care Organization (LMHPCO) by the April 1st deadline (all supporting documentation must be postmarked by April 1st).
4. Must submit a copy of the acknowledgement letter from the testing company indicating that the individual passed the certification exam.
5. Must submit one reference letter from a professional colleague.
6. Must submit a reference letter from the employer.
DEADLINE DATE:
The completed on-line application and supporting documentation must be submitted and postmarked to
LMHPCO, by April 1. No faxed materials will be accepted. If you have any questions, please contact Nancy
Dunn, Director of Education by email at [email protected].
MAIL TO:
Nancy Dunn, Director of Education
LMHPCO Leslie Lancon Memorial Scholarship
PO Box 1999 Batesville, MS 38606.
Click here to complete the application
http://www.lmhpco.org/professionals/scholarships.shtml
The Journal • 18 • September 2011
Louisiana-Mississippi Hospice & Palliative Care Organization
Calendar
www.LMHPCO.org
September 23, 2011
LMHPCO Chaplain’s Workshop
Spirituality and End of Life
Care: Bridging the Gap for
Hospice Chaplains
Ridgeland, MS
NOTE: Session at Maximum
Capacity. Registration closed
for MS location.
Registration open for LA
location.
October 6-8, 2011
NHPCO’s 12th Clinical Team
Conference and Pediatric
Intensive
Town and Country Resort and
Convention Center, San Diego,
CA
Preconference Events: October
4-5, 2011
Main Conference: October 6-8,
2011
www.nhpco.org
October 19, 2011
504/985 Area Code Meeting
Crown Plaza New Orleans
Airport
2829 Williams Boulevard
Kenner, LA
October 27, 2011
337 Jennings Area Code
Meeting
Walker’s Cajun Dining
603 1/2 Holiday Drive
Jennings, LA
October 19, 2011
601 Area Code Meeting
Location TBD
October 27, 2011
662 North Area Code Meeting
Ryan’s
2210 S. Harper Road Corinth, MS
October 20, 2011
225 Area Code Meeting
Drusilla Seafood
3482 Drusilla Lane, Suite D
Baton Rouge, LA
October 20-21, 2011
Social Work End of Life
Education Project
Ridgeland, MS
Registration brochure and
details at http://tinyurl.
com/3o2rp7t
October 6, 2011
318 Alexandria Area Code
Meeting
Cajun Landing
2720 N. McArthur Drive
Alexandria, LA
October 25, 2011
318 Shreveport Area Code
Meeting
Zocolo’s
436 Ashley Ridge Blvd.
Shreveport, LA 71106
October 12, 2011
662 Delta Area Code Meeting
Sherman’s Restaurant
1400 South Main Street
Greenville, MS
October 26, 2011
337 Lafayette Area Code
Meeting
Abacus Restaurant
530 West Pinhook
Lafayette, LA October 13, 2011
LMHPCO Education Committee
Conference Call
The Journal • 19 • September 2011
October 28, 2011
228 Area Code Meeting
Salute Restaurant
1712 15th Street
Gulfport, MS
November 3 - 4, 2011
LMHPCO Board of Director’s
Meeting
Dunleith
Natchez, MS
November 11, 2011
LMHPCO Chaplain’s Workshop
Spiritualty and End of Life
Care: Bridging the Gap for
Hospice Chaplains
Shreveport, LA
Registration brochure and
details at http://tinyurl.
com/3m39clv
January 30-31, 2012
Social Work End of Life
Education Project
Shreveport, LA
Registration brochure and
details at http://tinyurl.
com/3o2rp7t
Louisiana-Mississippi Hospice & Palliative Care Organization
Members make the work of LMHPCO possible!
(2011 memberships received as of 8/11/2011)
2011 PROVIDER MEMBERS:
A& E Hospice, Inc, Olive Branch, MS
Agape Hospice Care of Shreveport, LA
Agape Northeast Hospice, West Monroe, LA
Agape Northwest Regional Hospice, Minden, LA
AmeraCare Family Hospice, Covington, LA
Angelic Hospice & Palliative care, Greenwood, MS
Aseracare Hospice, Corinth, MS
Aseracare Hospice, Senatobia, MS
Aseracare Hospice, Tupelo, MS
At Home Hospice Care, Fayette, MS
Baptist Hospice Golden Triangle, Columbus, MS
Baptist Memorial Homecare & Hospice of North
MS, Batesville, MS
Baptist Memorial Homecare & Hospice of North
MS, Southaven, MS
Brighton Bridge Hospice, Oberlin, LA
Camellia Hospice of East Louisiana, Vidalia, LA
Camellia Home Health & Hospice, Biloxi, MS
Camellia Home Health & Hospice, Bogalusa, LA
Camellia Home Health & Hospice, Hattiesburg, MS
Camellia Home Health & Hospice Jackson, MS
Camellia Home Health & Hospice, McComb, MS
Christopher B Epps Palliative Compassionate Care
Unit (MSP), Parchman, MS
Christus Hospice & Palliative Care – St Frances
Cabrini, Alexandria, LA
Christus Hospice & Palliative Care – St Patrick
Hospital, Lake Charles, LA
Christus Hospice & Palliative Care Schumpert,
Shreveport, LA
Circle of Life Hospice, Inc, Shreveport, LA
Clarity Hospice of Baton Rouge, LA
Comfort Care Hospice, Laurel, MS
Community Hospice, New Orleans, LA
Community Hospice, Inc, Batesville, MS
Community Hospice, Inc, Hattiesburg, MS
Community Hospice, Inc, Verona, MS
Continue Care Hospice, Cleveland, MS
Continue Care Hospice, Hollandale, MS
Continue Care Hospice, Yazoo City, MS
Crossroads Hospice, LLC, Delhi, LA
Deaconess Hospice, Biloxi, MS
Deaconess Hospice, Brookhaven, MS
Deaconess Hospice, Hattiesburg, MS
Delta Regional Medical Center Hospice, Greenville,
MS
Delta Soul Medical, LLC, Cleveland, MS
Doctors Hospice - Livingston, Walker, LA
Elayn Hunt Correctional Center End of Life Care, St
Gabriel, LA
Faith Foundation Hospice, Alexandria, LA
Forrest General Hospice, Hattiesburg, MS
Generations Hospice Service Corporation, Denham
Springs, LA
Gentiva Hospice, Booneville, MS
Gentiva Hospice, Starkville, MS
Gentiva Hospice, Tupelo, MS
Grace Community Hospice, Cleveland, MS
Guardian Hospice Care, Alexandria, LA
Harmony Life Hospice, Shreveport, LA
Harmony Hospice, LLC, Metairie, LA
Heart of Hospice, Lafayette, LA
Heart of Hospice, Lake Charles, LA
HL Haydel Memorial Hospice, Houma, LA
Hospice Associates, Baton Rouge, LA
Hospice Compassus, Alexandria, LA
Hospice Compassus, Baton Rouge, LA
Hospice Compassus, Lafayette, LA
Hospice Compassus, Mc Comb, MS
Hospice Compassus, Meridian, MS
Hospice Compassus, Monroe, LA
Hospice Compassus, Natchez, MS
Hospice Compassus, New Orleans, LA
Hospice Compassus, Shreveport, LA
Hospice Compassus, Slidell, LA
Hospice Compassus, Waveland, MS
Hospice Care of Avoyelles, Alexandria, LA
Hospice Care of Avoyelles, Marksville, LA
Hospice Care of Avoyelles, Opelousas, LA
Hospice Ministries, Brookhaven, MS
Hospice Ministries, Mc Comb, MS
Hospice Ministries, Ridgeland, MS
Hospice of Acadiana, Lafayette, LA
Hospice of Caring Hearts, LLC, Dubach, LA
Hospice of Light, Gautier, MS
Hospice of Light, Lucedale, MS
Hospice of Many, LA
Hospice of Natchitoches, LA
Hospice of St Tammany, Covington, LA
Hospice of Shreveport/Bossier, LA
Hospice of South Louisiana, Houma, LA
Infinity Care Hospice of Louisiana, LLC, Gretna, LA
Jordan’s Crossing Hospice, Shreveport, LA
Lakeside Hospice, Metairie, LA
LifePath Hospice Care Services, LLC, Shreveport,
LA
Life Source Services, LLC, Baton Rouge, LA
Louisiana Correctional Institute of Women, St
Gabriel, LA
Louisiana Hospice & Palliative Care, Jennings, LA
Louisiana Hospice & Palliative Care, Mamou, LA
Louisiana Hospice & Palliative Care, Monroe, LA
Louisiana Hospice & Palliative Care, Opelousas, LA
Louisiana State Penitentiary Hospice, Angola, LA
Magnolia Regional Medical Center Home Health &
Hospice, Corinth, MS
Mid-Delta Hospice of Batesville, MS
Mid-Delta Hospice of Canton, MS
Mid-Delta Hospice, Belzoni, MS
Mid-Delta Hospice, Charleston, MS
Mid-Delta Hospice, Clarksdale, MS
Mid-Delta Hospice, Cleveland, MS
Mid-Delta Hospice, Greenville, MS
Mid-Delta Hospice, Greenwood, MS
Mid-Delta Hospice, Indianola, MS
Mid-Delta Hospice, Lexington, MS
Mid-Delta Hospice, Yazoo City, MS
North Haven Hospice & Palliative Care, LLC,
Cleveland, MS
North Mississippi Hospice, Oxford, MS
North Mississippi Hospice, Southaven, MS
North Mississippi Medical Center Hospice, Tupelo,
MS
Notre Dame Hospice, Slidell, LA
Odyssey Hospice, Flowood, MS
Odyssey Hospice, Lake Charles, LA
Odyssey Hospice, Mandeville, LA
Odyssey Hospice, Metairie, LA
Odyssey Hospice, Shreveport, LA
Odyssey Hospice of the Gulf Coast, Gulfport, MS
Patient’s Choice Hospice, Tallulah, LA
Patient’s Choice Hospice, Vicksburg, MS
Pax Hospice, Ridgeland, MS
Pointe Coupee Hospice, New Roads, LA
Paramount Hospice Acadiana, Lafayette, LA
Premier Hospice, Bastrop, LA
Professional Hospice Care, Jonesboro, LA
Professional Hospice care, Ruston, LA
Providence Hospice South, Hattiesburg, MS
Quality Hospice Care, Philadelphia, MS
Regional Hospice & Palliative Services, SW, Baton
Rouge, LA
Regional Hospice & Palliative Services, SE,
Lafayette, LA
Regional Journey Hospice, Mandeville, LA
The Journal • 20 • September 2011
Richland Hospice, Rayville, LA
River Region Hospice, LLC, River Ridge, LA
River Region Hospice House, River Ridge, LA
St Catherine’s Hospice, LLC, LaPlace, LA
St Joseph Hospice of Acadiana, Lafayette, LA
St Joseph Hospice, Baton Rouge, LA
St Joseph Hospice of CENLA, Alexandria, LA
St Joseph Hospice, New Orleans, LA
St Joseph Hospice , Shreveport, LA
St Joseph Hospice & Palliative Care Northshore,
LLC, Covington, LA
St Margaret’s Hospice, Gretna, LA
St Teresa’s Hospice & Palliative Care, Lafayette, LA
Sanctuary Hospice House, Inc, Tupelo, MS
Serenity Hospice Services, LLC, New Orleans, LA
Serenity Premier Hospice, Vicksburg, MS
Unity Hospice Care, Oxford, MS
Unity Hospice Care, Southaven, MS
Unity Hospice Care, Tupelo, MS
Willis-Knighton Hospice of Louisiana, Shreveport,
LA
2011 ASSOCIATE MEMBERS
Accreditation Commission for Health Care, Inc,
Raleigh, NC
All Saints Hospice, Marksville, LA
American Medical Technologies, Lafayette, LA
Arthur J Gallagher, Baton Rouge, LA
AvaCare, Inc, Greensboro, NC
Calyx Pharmacy & Medical Services, Madison, MS
Deyta, Louisville, KY
First Option Infusion Pharmacy, Lafayette, LA
Gulf South Medical Supply, Hernando, MS
Hospice Pharmacia, Philadelphia, PA
HospiScript Services, Montgomery, AL
Mills & Murphy Software Systems, Inc, St
Petersburg, FL
MUMMS®Software, New Orleans, LA
Outcome Resources, Rocklin, CA
Southern Eye Bank, Metairie, LA
Staples Advantage, Baton Rouge, LA
Suncoast Solutions, Clearwater, FL
Ultimate Technical Solutions, Harvey, LA
2011 ORGANIZATIONAL MEMBERS
ALS LA-MS Chapter, Baton Rouge, LA
Palliative Care Institute of Southeast Louisiana,
Covington, LA
2011 PALLIATIVE CARE PROVIDER
MEMBERS
East Jefferson General Hospital, Metairie, LA
Our Lady of the Lake Regional medical Center,
Baton Rouge, LA
2011 PROFESSIONAL MEMBERS
Martha B Darby, R.Ph, Lafayette, LA
Susan Drongowski, RN, MA, New Orleans, LA
Deborah Guidroz, New Orleans, LA
Dr Flyda Jan Hicks, Winnsboro, LA
Gerry Ann Houston, MD, Jackson, MS
Kim McAulay, RD, LD, Petal, MS
Marilyn A Mendoza, PhD, New Orleans, LA
Susan Nelson, MD, Baton Rouge, LA
Linda Glick Schmitz, Water Valley, MS
2011 INDIVIDUAL MEMBERS
Patty Andrews, New Orleans, LA
Sandra Bishop, Long Beach, MS
Delaine Gendusa, Springfield, LA
Ronald L Marlow, New Orleans, LA
Debbie Thibodeaux, Lafayette, LA