VITAS Advantage: Case Study on Open Formulary for Physicians
Case Study: Patient with Advanced COPD
LH*, a 65-year-old male with chronic obstructive pulmonary disease (COPD) on chronic oxygen and with underlying diet-controlled diabetes, is referred to hospice care after losing 20 pounds in the past six months and experiencing functional decline that limits his movement to only a few steps before becoming dyspneic.
Upon admission to hospice, the RN determines that his dry-powder inhaler is no longer effective and transitions him to daily and as-needed nebulizer therapy for his COPD. Oral steroids are increased to manage inflammation, and low-dose as-needed opioids and anxiolytics are initiated for shortness of breath and anxiety.
LH’s hospice medication plan includes chronic oxygen therapy, which is supported by delivery of portable oxygen to his home, an electric hospital bed to ease breathing while sleeping, as well as a visit every other week from a respiratory therapist to educate on respiratory care equipment usage and O2 safety. A walker and wheelchair are delivered to support ambulation and safety. During one bout of exacerbated COPD, LH is prescribed antibiotics for 7 days, his oral steroid is increased, and oxygen is titrated to provide comfort.
After 12 weeks of hospice care, LH dies comfortably at home surrounded by his wife, children, and grandchildren.
*These initials represent an anonymized patient and are used for the purposes of education only.
Hospice Patients Continue to Receive Disease-Directed Medications
In a 2015 retrospective cross‐sectional medication study, staff members of nearly 700 hospices were asked the question: “What are the names of all the medications and drugs the patient was taking 7 days prior to and on the day of his or her death while in hospice? Please include any standing, routine, or PRN medications.”
The unweighted survey response rate was 71%. The average number of medications taken was 10.2, with a range of 8.5 for patients with dementia to 11.4 for patients with lung disease.
The most common therapeutic classes were:
- 98% analgesics
- 78% antiemetic and antivertigo medications
- 76% anxiolytics, sedatives, and hypnotics
- 71 % anticonvulsants
- 53% laxatives
Diagnosis-related medication patterns emerged in the data. Approximately one‐quarter of the individuals took proton pump inhibitors, anticoagulants, and antidepressants, and fewer than 20% took antacids and antibiotics.
A smaller percentage of individuals with dementia and debility than those with cancer took opioid analgesics, while a higher number of patients with dementia and debility than those with cancer and lung disease took antidepressants. Individuals with heart disease were more likely than individuals in the other clinical cohorts to take diuretics, and those with lung disease were more likely than those in the other clinical cohorts to take bronchodilators.
The authors point out that patients continue to receive disease‐focused therapies near the end of life rather than therapies exclusively for palliation of symptoms, suggesting that treatments may vary according to the person's primary diagnosis.
Write the authors, one of whom is Joseph Shega, MD, VITAS senior vice president and chief medical officer: “As the nation’s population ages and the hospice populations continue to grow, understanding the types and prevalence of medications taken near the end of life is a public health priority.”
Benefits of the VITAS Open Formulary for Physicians
The VITAS open formulary ensures that patients can continue to receive evidence-based, disease-directed therapies and medications that manage their symptoms and improve quality of life once they transition to hospice care.
In the case of LH, the VITAS hospice care plan would cover a cholinesterase inhibitor if it offered symptom relief, but would not cover it if the medication did not offer relief or might contribute to harm. If an already-prescribed cholinesterase inhibitor was not providing symptom relief or was causing harm, the care plan would attempt to discontinue the treatment.
Patients are more likely to feel comfortable about their decision to transition to hospice care if they know can continue to receive medications and therapies that focus on comfort and pain relief.
VITAS delivers medical equipment and supplies related to the hospice diagnosis to the patient, supported by VITAS nurses who oversee medication reconciliation and pillbox management.
Source: Dwyer, L. Lau, D., & Shega, J. (2015). Medications that older adults in hospice care in the United States take, 2007. Journal of the American Geriatrics society, 63(11), 2282-2289.
