Compounding for Hospices Offers Rewards, Challenges
"You're making something that is unique," said Nancy Nystrom, Ph.D., compounding pharmacist for Portland Professional Pharmacy Inc. in Portland, Maine. "The commercial products have all been tried at this point, so you're really the last resort on how you can help somebody."
Hospice services provide care to patients who have a terminal illness and are expected to live six months or less. Rather than cure the patient, hospice care is designed to relieve pain and make the patient's last days as peaceful as possible.
Mary Moore, R.N., director of admissions for Hospice Care Network in Westbury, New York, said hospice patients suffer from a variety of deadly illnesses.
"It ranges from cancer patients to end-stage renal failure, cardiac disease, dementia, failure to thrive," Moore said. She noted that not all hospice patients are elderly: "We have some pediatric patients with genetic malformations," she said.
Moore said her organization relies as much as possible on manufactured drug products to keep patients comfortable.
"For pain management, there's a whole host of things we use," she said. Products that Moore said come to mind include "fentanyl patches, [patient-controlled analgesia] pumps with Dilaudid or morphine, and Percocet."
"We have patients that do require high-tech pain management," she said. In these cases, a specialty pharmacy will compound medication for the patient.
"We get called in at the very last stage, when someone's in their last three of four days of life," Nystrom said.
Nystrom said getting medications into a hospice patient can present problems. "They're tired of being poked with needles," she said. Another difficulty, she said, is that "some of these terminally ill patients just don't want to open their mouths every couple of hours to take medications."
When a hospice patient gets to what Nystrom described as "the very uncomfortable stages," the pharmacy may be asked to prepare lorazepam gel for transdermal administration. The compounded gel, she said, "works very well in keeping [patients] not so agitated and keeping them comfortableconscious, but lightly sedated."
Nystrom said that, because the topical route of administration for lorazepam has been used for several years, much of the preparation procedure is standardized. "You can make the cream at one concentration, but you may be able to apply a very small amount and then titrate to the effect that you need," she said.
Concentrated hydromorphone is another product that Nystrom said the pharmacy prepares for hospice patients.
"We make [it] in a very concentrated oral-drop form, so that it comes down to a very small volume of medication," Nystrom said. "Giving three teaspoons or three tablespoons of medication is not real acceptable, but if you can give a couple drops onto the side of the cheek or under the tongue, then you've got very quick effects and very small volumes. We do a lot of hydromorphone drops."
Harold Embry, a pharmacist and the owner of Home Pharmaceutical Services Inc. in Midland, Texas, said that an "ABH suppository" is one of the more common specialty products he provides for hospice patients.
"That has Ativan, Benadryl, and Haldol in it," Embry said, adding that the drug combination relieves symptoms such as anxiety and itching.
Embry said the suppositories are particularly useful for patients with diseases that affect the gastrointestinal tract. "Generally, they're so nauseated they can't keep anything down," he noted.
Because absorption of the medication from the suppository varies with each patient, Embry said he starts with a standard combination, sees how the patient responds, and then adjusts the ratio of the components.
Nystrom said that patients' families seem to appreciate the pharmacy's role in hospice care. "What you're doing is basically keeping the patient comfortable, so that it's easier for the family and it's easier for the patient in the last few days."
According to the Centers for Medicare & Medicaid Services (CMS), nearly a half million Americans received care from CMS-certified hospices in 1999. Hospice care, including drug therapy for pain relief, is reimbursable under Medicare Part A and is also covered by some state Medicaid programs.