Hospice Care/Drugs and gout

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Question
Hello.  My 89 year family member has CHF and is on hospice.  They have him on morphine for pain for the gout and he is still in pain. He also takes colchinfine for gout.   Also, he is on Feroquel for anxiety.  Some of us are concerned about the euthanize effect of the morphine and Feroquel.  Are there alternatives drug?  Thanks for any help!

Answer
Dear Jan:

Thank you for writing to me.  I will try to answer your questions.

First, the two drugs you mention are "Seroquel" and "Colchicine."  Both are fairly old drugs (which is a good thing) with well known side effects.  Taken together, Seroquel and morphine can make a person dizzy and make thinking a little less clear, or both, but not under usual doses.  They wouldn't have any "euthanizing" (death-causing) effects.  You mention that the patient still has pain.  Pain should be addressed.  If the pain is related to the CHF (which is extremely unlikely), the hospice should provide more medication and other interventions. If it is related to his gout, his pain should be addressed by primary care provider or whichever physician (or nurse practitioner or physician's assistant) usually cares for his gout.

There are other drugs for pain and anxiety, although morphine is the best pain reliever and helps a lot with anxiety, especially if the anxiety is caused or made worse by pain.  Seroquel is a little unusual for anxiety, but this is a medication given more often for things like certain mental illnesses.  If someone has been taking it for a while, for example to help with symptoms of a mental illness, it's not a good idea to stop it.  Another consideration is also whether there are people in the family or among the caregivers (who might be friends, for example) who might enjoy sharing a patient's medication.  Many medications that are very effective for anxiety also have a high street value.  Seroquel is not all that pleasant, though it is effective--and it has no street value at all.  Colchicine has no street value at all, either.  So these are some reasons why these drugs are being prescribed.

No one in hospice ever intends to shorten life or delay death.  Hospice is all about quality of life, and therefore about management of symptoms like pain.  If we must choose between being pain free or living a day longer, we will always choose to prevent pain.  For one thing, we cannot know whether the patient will die a day sooner or a day later, but we certainly know if they are hurting.  Hospice also doesn't worry about whether a patient will become "addicted" to the medications we give--to be very direct, they aren't going to be around long enough for that to be a problem!

Patients with breathing problems severe enough to qualify for hospice services often feel breathless and that can make them anxious, which is why anti-anxiety medications are prescribed.  Gout and pain, however, are not usually associated with CHF.  In hospice, the medications that are covered are those associated with the hospice diagnosis (in this case, CHF).  Morphine can make breathing easier, so that makes sense.  However, the colchicine doesn't fit.  The one exception where medication for pain is covered, no matter what the source of the pain is, is cancer.  If a hospice patient has little pain, falls and breaks a leg, and has more pain from the broken leg, hospice will provide the extra pain medication.

Receiving hospice care doesn't mean patients don't get care for their other problems, it just means that their primary care provider or other physician would provide the care (including prescriptions) for those problems that are not related to the hospice diagnosis.  Primary care providers and hospice physicians typically maintain a close working relationship because of the potential for side effects if each prescribes but doesn't know what the other doctor has ordered.

Here is my suggestion: Discuss your concerns with the family who in turn, along with the patient, if they agree and they are concerned, they should talk with the hospice nurse about medication interactions.  If the patient and the family aren't concerned, or disagree with you, they have "veto" power, so to speak.  In that case, if you truly have concerns, you have two options.  One, you can call and speak with the hospice physician yourself.  They will not and should not even say if the person is a patient there, unless there is a signed release that says they can talk to you.  But that doesn't prevent you from expressing your concerns.  They can receive all kinds of information.  They just can't give any out.  Two, you can call your local office of Adult Protective Services.  They can take down the information you provide.  I must stress, the second option is if you feel that the patient is being hurt or neglected.  Those are the issues that concern APS.

Bottom line: if the patient and immediate family are worried, they should talk to the hospice nurse. In any case, the continued pain must be soothed.

Thank you for writing.  I hope I've helped.  Good luck to you!

Peace,
Christine

Hospice Care

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Christine Johnson

Expertise

I can give suggestions, encouragement and direction on what hospice is and is not, when it is appropriate, and how to go about getting it. I am familiar with Medicaid and Medicare hospice benefits. I can answer general questions about disease process, what dying looks like, how hospice handles pain and other symptoms, what to expect from a hospice when end of life nears. I can provide support, direction and encouragement related to spiritual matters and psychological matters related to death and dying.

Experience

I am a certified hospice and palliative care nurse, and have been the director of nurses for three hospice centers, under two different companies. I have also worked as a contract hospice nurse for a large American hospice company. On a personal level, my father died without benefit of hospice (it was not popular then). I have taken care of dying patients in hospitals and recognize that for most of us, it is preferable to die at home (or in our residence, wherever that may be), comfortably and without anxiety. Also I had no support when my father died; hospice clients are the whole family (however that is defined by the "patient"), and support is provided at least a year after the patient passes. These are the sorts of things (and probably others) that I can help with.

Organizations
HPNA (Hospice and Palliative Nurses Association)

Publications
none yet

Education/Credentials
Registered Nurse (TX), Licensed Marriage and Family Therapist (TX) ADN Nursing, Excelsior College, Albany, New York (2004) 4.0 GPA BA, Psychology (minor Social Work), Oklahoma University, Norman, OK (1986) 3.67 GPA MHR (MA) Human Relations, Oklahoma University, Norman, OK (1988) 3.5 GPA

Awards and Honors
Phi Beta Kappa (and others)

Past/Present Clients
Unable to name as this would violate their privacy (and HIPAA....)

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