Preventing Adverse Drug Events in Hospice Care

Documentation errors and a fragmented health system pose the greatest risks for adverse drug events among hospices.

Evaluating these risks involves having solid medication reconciliation processes in place — both at the time of a patient’s admission and throughout their end-of life care experience, according to Mary Lynn McPherson, professor and executive program director of advanced post-graduate education in palliative care at the University of Maryland’s School of Pharmacy. McPherson also serves on the board of the American Academy of Hospice and Palliative Medicine (AAHPM).

Another key to reducing adverse events is increasing education around medication management at the end of life, McPherson stated.

“It’s very important to have good medication reconciliation processes at the point of hospice admission,” McPherson told Hospice News. “It’s challenging when a patient is in a facility-based setting, because they keep their own medical records and sometimes the medication changes don’t transfer to the hospice side. Another really important intervention is making sure patients, families and informal caregivers have sufficient understanding of the medications. They also need to know which side effects are more concerning and should prompt a call to the hospice.”

A vulnerable population

Adverse drug events are among the eight most common medication-related issues in chronically ill patients, McPherson indicated. Others include overdoses, underdoses (failure to receive or take medications) and drug interactions with both prescribed and prescribed substances, she added.

These events are frequently associated with cognitive symptoms such as confusion and irritability, as well as nausea, constipation and dizziness, among others, according to Ryan Krout, vice president of clinical management at Enclara Pharmacia.

Common pain and symptom management medications used in the hospice space can be particularly “problematic” in terms of overlapping risk factors for adverse effects, he said.

“[Adverse drug events (ADEs) present on a spectrum from discomfort to medical emergency, so the impacts can range widely,” Krout told Hospice News in an email. “The likelihood of an ADE increases with each new medication or dose change, so polypharmacy is often going to be your biggest risk factor. There’s also what we call the ‘prescribing cascade,’ in which one drug causes a side effect and another drug is added to manage it. We are in many cases using medications differently and dealing with changes in the body’s ability to metabolize medications due to disease progression, hydration and nutrition.”

Adverse drug reactions (ADRs) can have an impact on mortality and morbidity among seriously ill patients, according to researchers of a 2019 study published in the Journal of Pain & Palliative Care Pharmacotherapy.

Close to 60% of 440 hospital-based palliative patients experienced an adverse drug reaction over the span of a one-year period, the study found. Nearly half (45.7%) of these patients had more than one adverse drug event. Almost two-thirds were of “moderate severity.”

About 81.5% of these drug reactions were considered to be “potentially preventable,” and most commonly came with gastrointestinal and neurological effects, researchers found.

“Palliative care patients constitute a vulnerable population due to the complexity of their care and treatments,“ researchers wrote. “ADRs are commonly experienced in palliative care patients and are often preventable. Identification of risk factors for ADRs may prevent occurrences in the complex palliative care patient.”

Impacts on quality, compliance

Adverse drug reactions can detract from the overall experience of hospice care for patients and their families, Krout said. These negative experiences can impact quality scores for providers and ultimately may lead to more hospice revocations and higher emergency care utilization and rehospitalizations, he added.

Hospice providers have been closely evaluating how they prescribe and deprescribe medications for patients. Hospices have come under closer scrutiny in recent years as the U.S. Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health & Human Services Office of the Inspector General (OIG) continue to take a hard look at issues such as recertifications and billing for services outside the hospice benefit, including medications.

Greater staff training around adverse drug risks is a large part of curbing these instances and improving quality outcomes, according to Krout.

“Raising awareness about ADEs is really where it starts,” Krout said. “It’s also important for clinicians to engage pharmacists as part of their interdisciplinary teams to maximize patient safety and comfort.”

Building strong care collaborations with pharmacists is an important part of ensuring that hospice patients avoid falling into a risk zone for adverse drug reactions, according to McPherson.

Improved medication management involves open lines of communication around patient’s care plans and goals of care, she said. This includes coordinating on which medications are no longer providing therapeutic benefits and which are bringing symptom management, McPherson added.

“There is a role for everyone on the team in supporting patients and caregivers in medication management. It’s important that everybody on the interprofessional collaborative team knows the patients’ goals of care, because that can drive so many things, including drug interventions,” McPherson said. “Interprofessional collaboration means all the team members are very aware of each other’s knowledge and skills, and this collaboration leads to improved decision-making, including about drug therapy.”