Bryan Prescott, PharmD, MBA, PCCA Director of Business Coaching Services

Emotional and spiritual needs are areas in which hospice care provides assistance to people who are terminally ill. Beyond those, there are the physical and therapeutic needs that are unique to hospice patients. They are often unable to tolerate many of the conventional medication dosage forms or need specialized concentrations of medications to adequately resolve their ailments. Compounding pharmacies can play a vital role in the care of these patients.

Addressing the patient’s physical needs may be the most important issue in hospice care. Since hospice strives to improve the quality of life for patients, it is important to address all symptoms they may experience. Some problems that hospice patients have are pain, constipation, nausea and vomiting, anxiety, difficult breathing (dyspnea), muscle loss and weakness (cachexia), anorexia, wounds, and terminal restlessness.

Compounding pharmacies have the ability to assist with these problems by making medications into patient-specific dosage forms and strengths. Some unique dosage forms commonly prescribed for hospice patients are capsules, sublingual drops, suppositories, oral suspensions, inhalations, sprays, troches, and topical gels and creams with permeation enhancement to deliver drugs through the skin.

Pain

Pain control is one of the best ways to comfort terminally ill patients. Pain may be overlooked or undertreated if physicians fear patients may become addicted to pain medications, but the fact is that many terminally ill patients cannot enjoy their last days with friends and family due to their uncontrolled pain.

A thorough assessment is a crucial step in achieving pain control, since pain is subjective, involves multiple aspects and can be of various origins. The three major types of pain seen in terminally ill patients are muscular, bone and neuropathic pain. These pain types differ not only in their symptoms and presentations, but also in their response to different classes of pain medications (e.g., neuropathic pain typically does not respond to opioids, while muscle pain does). When the correct type of pain is identified, treatment is based on classification of pain being responsive, semiresponsive or unresponsive to opioids.

Treatment schedules are also very important. Since most terminally ill patients have chronic pain, medications should be given around the clock instead of on an as-needed basis. Scheduled medications may reduce the incidence of “breakthrough pain,” which is a sudden increase in pain. It is better to prevent pain for hospice patients than try to control it once it starts.

Long-acting drugs are most commonly used for chronic pain while short-acting ones are used for breakthrough pain. Dosages are usually titrated up to achieve proper pain control, and then decreased as pain permits. In some circumstances, practitioners may increase patients’ medications by 25–50% to achieve proper pain management. If dosages are decreased, but the patient begins to ask for medications for breakthrough pain, the long-acting medication dose may be increased again to regain control.

Morphine, hydrocodone, fentanyl, meperidine, and methadone are some of the medications commonly prescribed to control muscular pain for hospice patients. They can be made into various dosage forms and concentrations that are specific to each patient’s need.

Bone pain is another challenge for hospice patients and is usually caused by cancer metastasis. Patients with bone pain will get the most benefit from nonsteroidal anti-inflammatory drugs (NSAIDs). Most practitioners prefer ibuprofen for bone pain; however, some prescribe other NSAIDs depending on the case.

Neuropathic pain is the third type of pain that hospice patients experience. Neuropathic pain occurs when nerves are damaged, and it is usually chronic. It is typically not opioid responsive and is usually controlled with the use of a combination of agents, including ketamine, amitriptyline, baclofen, gabapentin and clonidine.^1,2,3,4,5 These medications can be used topically directly at the site of injury or pain.

Constipation

Constipation is frequently reported in hospice patients and may be due to the use of narcotic pain medications or anticholinergics. It has been reported that up to 71% of terminal cancer patients suffer from constipation.⁶ Other causes of constipation include a low-fiber diet, reduced defecation (due to anal fissures or hemorrhoids), dehydration, depression and hypercalcemia. Treatment should include a daily stool softener and stimulant laxative (especially if a patient is on narcotic pain medications) as well as proper hydration and active movement. Bulk laxatives should be avoided since they can cause impaction. Time between bowel movements should not exceed three days.

Many patients also experience impaction with overflow, which is sometimes not seen as constipation. Some physicians see patients passing stool, so they do not recommend a laxative and stool softener, but these patients are constipated and need to have regular bowel programs.

Nausea and Vomiting

Nausea and vomiting have also been reported in patients receiving hospice care. Up to 48% of patients with terminal cancer report these symptoms. ⁶ Nausea and vomiting in hospice patients can be caused by drug side effects, oral thrush, brain metastases, anxiety, gastric irritation, intestinal obstruction, constipation, small-stomach syndrome, hypercalcemia, uremia, and low-grade urinary tract or pulmonary infections. Practitioners often prescribe drugs such as promethazine, scopolamine, lorazepam, diphenhydramine, haloperidol, metoclopramide and ondansetron for patients in these situations.^7,8,9 Compounders can provide patient-specific options as needed.

Wounds

When patients are confined to bed, as many patients in hospice care are, vascular insufficiency and subsequent tissue hypoxia may lead to bedsores (decubitus ulcers). Patients with decubitus ulcers are susceptible to severe infections, so treatment should begin as soon as possible. Practitioners commonly prescribe combination medications to help with pain and soothe the tissue, prevent or treat infection, and promote healing. They may include ketoprofen, lidocaine, bupivacaine, misoprostol, metronidazole, phenytoin or diphenhydramine.^10,11

Unfortunately, most wounds will not completely heal for hospice patients, but it is important to prevent them from progressing into more painful situations. As the necrotic tissue progresses, it will produce a foul odor that may be offensive to the patient and caregivers. For patients in this situation, the focus for wound treatment will be odor control and wound irrigation. One common way to reduce the odor is applying a eucalyptus chap stick under the nose to mask the smell.

Terminal Restlessness and Anxiety

Terminal restlessness, or agitated delirium, occurs at the end of life due to shutdown of multiple body systems. Up to 85% of dying patients are reported as having this condition.¹² Some common causes of terminal restlessness include pain, dyspnea, full bladder or rectum, nausea, unresolved concerns about death, lack of personal meaning and purpose in life, dehydration, hypercalcemia, hypoglycemia, hyponatremia, and adverse drug reactions. Patients with terminal restlessness may present with thrashing or agitation, involuntary muscle twitching or jerking (myoclonus), fidgeting or tossing and turning, yelling, or moaning. This delirium is often reversible until the last 48–72 hours of life. Appropriate assessment is important since this condition differs from regular delirium and treatments are different.

There are several treatment options for patients with terminal restlessness. One of the most commonly prescribed agents is the ABH compounded gel.⁸ It’s a topical gel with permeation enhancement that contains lorazepam, diphenhydramine and haloperidol but is known by the abbreviation of their brand names: Ativan^®, Benadryl ^® and Haldol^®. It is typically applied to the forearm every 8–12 hours and produces a rapid effect for the patient. This combination can also be compounded into a suppository.

Oral Hygiene

Patients in hospice care may also have many issues related to oral hygiene. They can deal with mouth sores from radiation treatments, dry mouth from opioids, excessive secretions due to the inability to clear lung secretions, and thrush from cancer treatments. These problems can lead to inability to eat, tooth decay and pain if not properly addressed. Compounding pharmacies can provide options for all of these issues that are customized for the individual patient.

Also on The PCCA Blog: Dental Compounding: Common Issues and Potential Treatment Options

PCCA members with Clinical Services support can find commonly requested formulas for hospice patients with pain , nausea and vomiting , wounds , and oral-hygiene needs in our formula database. They can also contact our Clinical Services team to discuss any questions about helping patients receiving hospice care.

Bryan Prescott, PharmD, MBA, PCCA Director of Business Coaching Services, currently provides business coaching for compounding pharmacies, including financial analysis, marketing and human resources expertise. Before joining the staff of PCCA in 2012, he worked at Pharmcare in Pearland, Texas, for 10 years, where he was the PIC and operations manager for the long-term care department. He has been a featured speaker at many PCCA and A4M seminars focusing on pain, palliative care, wound, scar, ENT and marketing. Bryan obtained his Doctor of Pharmacy from the University of Houston in 2001 and Master of Business Administration from Texas A&M University in 2019. He is a member of the Rho Chi Society and a lifetime member of Phi Delta Chi.

References

1. Gammaitoni, A., Gallagher, R. M., & Welz-Bosna, M. (2000). Topical ketamine gel: Possible role in treating neuropathic pain. Pain Medicine, 1(1), 97–100. https://doi.org/10.1046/j.1526-4637.2000.00006.x

2. Genevois, A. L., Ruel, J., Penalba, V., Hatton, S., Petitfils, C., Ducrocq, M., Principe, P., Dietrich, G., Greco, C., & Delmas, P. (2021). Analgesic effects of topical amitriptyline in patients with chemotherapy-induced peripheral neuropathy: Mechanistic insights from studies in mice. The Journal of Pain, 22(4), 440–453. https://doi.org/10.1016/j.jpain.2020.11.002

3. Kopsky, D. J., Keppel Hesselink, J. M., & Casale, R. (2015). Walking with neuropathic pain: Paradoxical shift from burden to support? Case Reports in Medicine, 2015. https://doi.org/10.1155/2015/764950

4. Hiom, S., Patel, G. K., Newcombe, R. G., Khot, S., & Martin, C. (2015). Severe postherpetic neuralgia and other neuropathic pain syndromes alleviated by topical gabapentin. The British Journal of Dermatology, 173(1), 300–302. https://doi.org/10.1111/bjd.13624

5. Wrzosek, A., Woron, J., Dobrogowski, J., Jakowicka-Wordliczek, J., & Wordliczek, J. (2015). Topical clonidine for neuropathic pain. The Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010967.pub2

6. Morita, T., Tsunoda, J., Inoue, S., & Chihara, S. (1999). Contributing factors to physical symptoms in terminally-ill cancer patients. Journal of Pain and Symptom Management, 18(5), 338–346. https://doi.org/10.1016/s0885-3924(99)00096-2

7. Bassani, A. S., Banov, D., & Lehman, P. A. (2008). Evaluation of the percutaneous absorption of promethazine hydrochloride, in vitro, using the human ex vivo skin model. International Journal of Pharmaceutical Compounding, 12 (3), 270–273. https://ijpc.com/Abstracts/Abstract.cfm?ABS=2782

8. Bleicher, J., Bhaskara, A., Huyck, T., Constantino, S., Bardia, A., Loprinzi, C. L., & Silberstein, P. T. (2008). Lorazepam, diphenhydramine, and haloperidol transdermal gel for rescue from chemotherapy-induced nausea/vomiting: Results of two pilot trials. The Journal of Supportive Oncology, 6(1), 27–32.

9. Moon R. B. (2006). ABHR gel in the treatment of nausea and vomiting in the hospice patient. International Journal of Pharmaceutical Compounding, 10 (2), 95–98. https://ijpc.com/Abstracts/Abstract.cfm?ABS=2351

10. Mahoney, J., Ponticello, M., Nelson, E., & Ratz, R. (2007). Topical misoprostol and wound healing in rats. Wounds, 19(12), 334–339. https://www.hmpgloballearningnetwork.com/site/wounds/article/8076

11. Shaw, J., Hughes, C. M., Lagan, K. M., & Bell, P. M. (2007). The clinical effect of topical phenytoin on wound healing: A systematic review. The British journal of dermatology, 157(5), 997–1004. https://doi.org/10.1111/j.1365-2133.2007.08160.x

12. Brajtman S. (2003). The impact on the family of terminal restlessness and its management. Palliative Medicine, 17(5), 454–460. https://doi.org/10.1191/0960327103pm779oa

These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The information contained herein is not intended to replace or substitute for conventional medical care, or encourage its abandonment.