Variable Patterns of Continuous Morphine Infusions at End of Life

Ching, Andrea; Edmonds, Kyle P; Roeland, Eric; Revta, Carolyn; Joseph, D.; Atayee, Rabia S.

doi:10.1089/jpm.2015.0008

Cited by 12 publications

(10 citation statements)

References 16 publications

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“…Areas of focus include but are not limited to the prescription of fentanyl patches, patient-controlled analgesia, gabapentinoids, ketamine oral and intravenous infusion, lidocaine intravenous infusion, mexiletine, methadone, and naloxone [23,[28][29][30][31][32][33][34][35][36]. Guidelines for the appropriate use of end-of-life opioids were developed [37]. Early access to the inpatient palliative care pharmacist resulted in a shortened length of stay, shortened length from admission to palliative care consult, and a positive impact on time from consult to discharge or death [25].…”

Section: Ucsdh Pain and Palliative Carementioning

confidence: 99%

Advancing Pharmacist Collaborative Care within Academic Health Systems

et al. 2019

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Introduction: The scope of pharmacy practice has evolved over the last few decades to focus on the optimization of medication therapy. Despite this positive impact, the lack of reimbursement remains a significant barrier to the implementation of innovative pharmacist practice models. Summary: We describe the successful development, implementation and outcomes of three types of pharmacist collaborative care models: (1) a pharmacist with physician oversight, (2) pharmacist–interprofessional teams and (3) physician–pharmacist teams. The outcome measurement of these pharmacist care models varied from the design phase to patient volume measurement and to comprehensive quality dashboards. All of these practice models have been successfully funded by affiliated health systems or grants. Conclusions: The expansion of pharmacist services delivered by clinical faculty has several benefits to affiliated health systems: (1) significant improvements in patient care quality, (2) access to experts in specialty areas, and (3) the dissemination of outcomes with national and international recognition, increasing the visibility of the health system.

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Section: Ucsdh Pain and Palliative Carementioning

confidence: 99%

Advancing Pharmacist Collaborative Care within Academic Health Systems

et al. 2019

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“…In contrast, our data regarding the association between the label palliative and continuous infusions also demonstrate the risk of using continuous infusions by default for every palliative patient. This problem has also been identified by a previous smaller study in general palliative care, and various recommendations emphasize to avoid starting continuous infusions as a matter of routine at the end of life 1,5,34 . Symptom control should be adjusted as needed for the individual, and sedation should only be considered after exploiting other measures of symptom control 1,24,34,35 .…”

Section: Discussionmentioning

confidence: 91%

“…Several studies on medication at the end of life in general hospital departments suggest that drugs are frequently administered via continuous infusion in these circumstances. 2 , 4 , 5 Used correctly, continuous infusions are an appropriate and effective measure for symptom control. 6 However, some reports, predominantly from the United Kingdom, raised concerns regarding misuse of continuous infusions in end-of-life care in general hospital departments.…”

Section: Introductionmentioning

confidence: 99%

“Palliative Syringe Driver”? A Mixed-Methods Study in Different Hospital Departments on Continuous Infusions of Sedatives and/or Opioids in End-of-Life Care

et al. 2022

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ObjectivesContinuous infusions of sedatives and/or opioids (continuous infusions) are frequently used in end-of-life care. Available data indicate challenges in nonspecialist palliative care settings. We aimed to assess the use of continuous infusions during the last week of life in different hospital departments.MethodsIn a sequential mixed-methods design, a retrospective cohort study was followed by consecutive qualitative interviews in 5 German hospital departments. Medical records of 517 patients who died from January 2015 to December 2017 were used, and 25 interviews with physicians and nurses were conducted. Recorded sedatives were those recommended in guidelines for “palliative sedation”: benzodiazepines, levomepromazine, haloperidol (≥5 mg/d), and propofol. Exploratory statistical analysis (R 3.6.1.) and framework analysis of interviews (MAXQDA 2018.2) were performed.ResultsDuring the last week of life, 359 of 517 deceased patients (69%) received continuous infusions. Some interviewees reported that continuous infusions are a kind of standard procedure for “palliative” patients. According to our interviewees’ views, equating palliative care with continuous infusion therapy, insufficient experience regarding symptom control, and fewer care needs may contribute to this approach. In addition, interviewees reported that continuous infusions may be seen as an “overall-concept” for multiple symptoms. Medical record review demonstrated lack of a documented indication for 80 of 359 patients (22%). Some nurses experienced concerns or hesitations among physicians regarding the prescription of continuous infusions.ConclusionsContinuous infusions seem to be common practice. Lack of documented indications and concerns regarding the handling and perception of a “standard procedure” in these highly individual care situations emphasize the need for further exploration and support to ensure high quality of care.

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“…22,23 It is important to add that there is a formal indication of preventive analgesia to symptoms after extubation, that the dose of morphine may be related to the patient's previous conditions, and that higher doses of this drug are associated with a longer time until death. 24 Sedative medications, such as midazolam and propofol, isolated or associated with opioids, were found in only six (26%) prescriptions of the last 48 hours of life among the 23 patients studied.…”

Section: Discussionmentioning

confidence: 99%

Palliative extubation: case analysis in an Intensive Care Unit

Rebelatto¹,

Moritz²

2017

Mundo da Saúde

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Current technological advancements have allowed for the prolongation of the dying process, especially in Intensive Care Units (ICU). This has increased the need for decisions on the limitation of therapeutic effort (LTE), such as the use of palliative extubation that, although difficult from an emotional standpoint, has legal and ethical justifications, and has increased family acceptance. The objective was to evaluate the clinical and demographical profile of patients submitted to palliative extubation (PT) in the ICU of the University Hospital of the Universidade Federal de Santa Catarina (HU/ UFSC), Brazil. This was a historical cohort whose data were obtained from forms filled out by critical care doctors from the Hospital Death Commission at the HU/UFSC. Patients submitted to LTE that died between January 2011 and December 2014 were included in the study. The use of PT and clinical and epidemiological data were collected. LTE was indicated in 374 (53.8%) patients, with 23 (6.1%) receiving PT. Average age of patients undergoing PT was 73.8 years; 10 patients were over 60, and 9 were over 80 years of age. Ten (43.4%) patients had been previously in the ICU. The average time from checking in at the ICU and extubation was 4.4 days, and between extubation and death it was 2.5 days. Neurological disease was the main cause of death of patients subjected to PT. All family members were aware of the extubation. Family members from 2 families witnessed the extubation. Morphine was the most common analgesic prescribed. It is concluded that patients submitted to PT were older, with neurological diseases, and the average time from extubation to death was 2.5 days ResumoO desenvolvimento tecnológico do mundo atual tem permitido o prolongamento do morrer, principalmente em unidades de terapia intensiva (UTI). Torna-se crescente a necessidade de decisões de limite de esforço terapêutico (LET), do qual se destaca a extubação paliativa (EP), que embora difícil de ser aceita do ponto de vista emocional, tem respaldo ético-legal e aumenta a satisfação familiar. O estudo teve como objetivo avaliar o perfil clínico-demográfico dos pacientes extubados paliativamente (ExPl) na UTI do HU/UFSC. Trata-se de coorte histórico, cujos dados foram coletados através das fichas preenchidas por médicos intensivistas que constituem a Comissão de Óbito da instituição. Foram incluídos os pacientes que morreram na UTI/HU/UFSC, após indicação de LET, entre janeiro/2011 e dezembro/2014. Foram selecionados os pacientes que foram ExPl, sendo anotados seus dados clínicos e epidemiológicos. LET foi apontado em 374 (53,8%) pacientes, sendo 23 (6,1%) ExPl. A média da idade dos ExPl foi de 73,8 anos, 10 tinham mais de 60 e 9 mais de 80 anos. Dez (43,4%) pacientes já haviam sido internados previamente em UTI. O tempo médio entre a internação-extubação foi 4,4 dias e entre extubação-morte foi de 2,5 dias. Doença neurológica foi a principal causa da morte dos pacientes ExPl. Todos os familiares estavam cientes da EP. Familiares de 2 pacientes acompa...

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Variable Patterns of Continuous Morphine Infusions at End of Life

Abstract: Hospitalized patients at EOL had a much higher 24-hour IV morphine equivalents and CMI rates at time of death compared to CMI initiation. Variability was observed in the number of CMI rate adjustments and the number of bolus doses administered.

Cited by 12 publications

References 16 publications

Advancing Pharmacist Collaborative Care within Academic Health Systems

Advancing Pharmacist Collaborative Care within Academic Health Systems

“Palliative Syringe Driver”? A Mixed-Methods Study in Different Hospital Departments on Continuous Infusions of Sedatives and/or Opioids in End-of-Life Care

Palliative extubation: case analysis in an Intensive Care Unit

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