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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. Not yet a Member? Get more information about LMHPCO at www.LMHPCO.org Membership next month: 2012 Kick-off 717 Kerlerec, N.O., LA 70116 Toll Free 1-888-546-1500 The Journal • 1 • September 2011 (504) 945-2414 Fax (504) 948-3908 www.LMHPCO.org 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] Education Director, Nancy Dunn P.O. Box 1999 • Batesville, MS 38606 Phone: 662-934-0860 • Fax: 504-948-3908 E-mail: [email protected] F F F The Journal is produced monthly by Noya Design, Inc. Newsworthy submissions are encouraged. Please contact Glenn Noya with questions, comments and submissions at ph: 504-455-2585 • Em: [email protected] HEN Courses on Symptom Management COURSECODE Advanced Symptom Management....................1198 ELNEC Core Curriculum: Symptom Management in Palliative Care.........................818 ELNEC for Veterans: Symptom Management....1534 ELNEC Geriatric Palliative Care: Non-pain Symptoms......................................................1334 ELNEC Pediatric Palliative Care: Symptom Management..................................................1309 HFA: Pain Management at the End of Life.........417 Pain Hurts Everyone: Managing and Understanding Pain.........................................208 Principles of Pain & Symptom Management......196 Become a Hero. . . by providing educational support for the continued development of End-of-Life Care within Louisiana and Mississippi Correctional facilities. Your donations fund scholarships for continuing educational opportunities among hospice professionals within corrections. Send donations to: LMHPCO-Hero Fund, 717 Kerlerec • New Orleans, LA 70116 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 Make Your Plans to Attend Social Work or Chaplain C ! Seminars! Spirit k r o ALL ATTENTION ORKERS! SOCIAL W ATTENTION CHAPLAIN ALL S! ay Dse oo ntsg afoTrwth rease PC rin ve si n te u In Waorrk ed for s Sowcihaol c Prease nts rin ga e oDse foO ay r nth Cwhhao placin Con ared ferreunsce fo ! Social W e End-of-Lif Education Project ualit End of Life yCaand Bridging there: Gap for Hospic Chaplains e ecially for Designed Esp ealing in rs d Social Worke care fe li f-o end Designed Esp ecially for Hospice Cha plains -21, 2l 011 er 20ite te Octobba ssy Su s Ho September Em ip Place 200 Townsh 39157 MS Ridgeland, 12 (601) 607-71 2 30-31po,rt201 JanuaHiry lton Shreve Street 104 Market LA 71101 Shreveport, 00 (318) 698-09 ONS 1-800-HILT 23, 2011 Hospice M inistries 450 Towne Center Boul evard Ridgeland, MS 39157 November Christus Sc 11, 2011 humpert Au ditorium 1 St Mary Pl ace Shreveport, LA 71101 Se Work ptember 2 shop Full & 3 Close d LMHPCO’s Chaplains’ Workshops scheduled for September 23, 2011 in Ridgeland, MS and November 11, 2011 in Shreveport, LA. Registration brochure and details at http://tinyurl.com/3m39clv Social Work End of Life Education Project is returning to Ridgeland, MS (October 20-21, 2011) and Shreveport, LA (January 30-31, 2012). Registration brochure and details at http://tinyurl.com/3o2rp7t 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