Journal of Palliative Medicine 2014.17:575-578. Downloaded from online.liebertpub.com by MCMASTER UNIVERSITY - LIBRARY on 01/21/15. For personal use only.
JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 5, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0364
Brief Reports
Comfort Care Kit: Use of Nonoral and Nonparenteral Rescue Medications at Home for Terminally Ill Patients with Swallowing Difficulty Richard Yap, MD,1 R. Akhileswaran, MD,1 Chong Poh Heng, MBBS,1 Angela Tan, RN,1 and David Hui, MD 2
Abstract
Introduction: We devised a comfort care kit (CCK) consisting of nonoral and nonparenteral rescue medications for caregivers to use at home for symptom control in imminently dying patients who have lost their ability to swallow. The aim of this study was to evaluate the feasibility of the CCK from the perspective of bereaved caregivers. Methods: CCKs were handed out to caregivers for patients who were entered into the care for the dying pathway (CDP). Each CCK includes morphine and haloperidol ampoules, lorazepam tablets, atropine drops, and paracetamol suppositories given either through sublingual or rectal route. We conducted a telephone survey of bereaved caregivers to assess CCK’s feasibility (proportion of use), pattern of use, perceived benefits and challenges, and need to transfer to emergency department at the end of life. Results: Forty-nine caregivers completed the survey. Thirty-three (67%) reported that they used the CCK. A majority (76%) only used one medication from the kit. Atropine drops were the most commonly used, followed by morphine and paracetamol. All family members reported that the CCK was easy to use and 98% found it to be effective for symptom management. All except one patient died at home. Conclusion: The CCK was feasible and perceived to be effective for symptom control and easy to use. Further research is necessary to optimize the use of this kit and to document related outcomes.
Introduction
A
majority of patients who suffer from a terminal illness want to die at home.1 Good symptom control and support to the caregivers are needed for home death to be possible. This could pose a challenge to the home hospice team as symptoms near the end of life are common as death approaches.2 Moreover, in the last days of life, patients often lose their ability to swallow and the medications that they used to take orally become difficult to administer. This may precipitate a crisis at home and may prompt caregivers to inadvertently bring the dying patient back to the hospital.3 To address this concern, our palliative care team devised a comfort care kit (CCK) that consists of medications specifically for nonoral and nonparenteral use. This kit is provided to family caregivers with instructions to administer the medications for various symptoms such as pain, dyspnea, nausea/vomiting, fever, delirium, and death rattle. The aim of
this study was to evaluate the feasibility of the CCK from the perspective of bereaved caregivers. Methodology
The pilot study was conducted at HCA Hospice Care in Singapore. Discussions were held to ascertain the contents of the CCK. Common symptoms at the end of life were identified4 and possible combinations of drugs within the pack were evaluated based on available literature of drugs that can be given effectively through routes other than oral and parenteral.5–7 Local practice, availability of drugs, costs, ease of administration, and safety were also considered. Five drugs were eventually chosen for inclusion in the CCK:
1
HCA Hospice Care, Singapore. MD Anderson Cancer Center, Houston, Texas Accepted November 12, 2013.
2
575
1. Morphine sulfate (10 mg/mL) injection ampoule— 0.5 mL given rectally for pain or shortness of breath; 2. Haloperidol (5 mg/1 mL) injection ampoule—0.5 mL given sublingually for agitation or nausea/vomiting;
576
YAP ET AL.
Journal of Palliative Medicine 2014.17:575-578. Downloaded from online.liebertpub.com by MCMASTER UNIVERSITY - LIBRARY on 01/21/15. For personal use only.
3. Lorazepam (1 mg) tablets—1 tablet given sublingually for agitation; 4. Atropine ophthalmic drops (1%)—2 drops given sublingually for respiratory secretions; and 5. Paracetamol (650 mg) suppositories—1 suppository inserted rectally for fever. Every CCK provides 1–2 doses of each medication in a bag. Contents of the kit were replaced during the next home visit if medications were used. Urgent home visits were made when caregivers ran out of CCK medications and another dose needed to be administered or when symptoms were not relieved after medication administration. The kit also included an instruction sheet for the caregivers regarding the use of the medications and the symptoms for which they should be used. Caregivers were further educated on how to use the kit by our palliative care team. A CCK was provided to a caregiver when a patient was entered into the care for the dying pathway based on the following criteria: (1) recognized by the palliative care team as entering the dying phase based on clinical signs, (2) lost his/her ability to swallow, and (3) had low symptom burden in the home setting. Patients with poorly controlled symptoms, on higher doses of opioids (oral morphine equivalent daily dose of more than 60 mg), or on continuous infusion of subcutaneous drugs were excluded. Caregivers who were not comfortable using the CCK were also not given the kit. As part of our quality assurance program, a telephone survey was conducted by the nurse-in-charge to the caregiver approximately 2 weeks after the death of the patient. This timeframe was chosen because we did not wish to call bereaved family members during the first week when they were often busy with funeral planning. The following questions were asked to assess the use and effectiveness of the CCK:
Table 1. Patient and Caregiver Characteristics n = 49
n = 33 who used the kits
72 (44–97)
70 (44–97)
26 (53%) 23 (47%)
20 (61%) 13 (39%)
47 (96%) 1 (2%) 1 (2%)
31 (94%) 1 (3%) 1 (3%)
42 (86%) 7 (14%)
28 (85%) 5 (15%)
Patient’s characteristics Age, median (range) Gender Male Female Race Chinese Indian Malay Diagnosis Cancer Noncancer Respondents Children Spouse Niece/nephew Parent Others (friend/helper) Median survival from time that the kit was given in days (range)
30 12 3 1 3 2
(61) (25) (6) (2) (6) (0–17)
23 8 1 0 1 4
(70%) (24%) (3%) (0%) (3%) (0–17)
1. Was the CCK used? Yes/No 2. Which of the drugs in the kit was used: morphine/ haloperidol/lorazepam/atropine/paracetamol? 3. Was the symptom relieved by the medication? Yes/No 4. Was there any difficulty using the CCK? Yes/No 5. Did they find the CCK helpful? Yes/No 6. Was the patient sent to the hospital emergency department any time after the CCK was given to them until death? Yes/No Because this is a retrospective study of the data collected during our quality improvement initiative, our institutional policy did not require us to seek Institutional Review Board approval. We analyzed the data using summary statistics including averages, proportions, percentages, and ranges. Results
Between February and August 2012, a convenient sample of 49 caregivers completed the phone survey. Most of those interviewed were children of the deceased patients. Patient and caregiver characteristics are shown in Table 1. Of the 49 CCKs issued, 33 (67%) used the kits (Table 2). A majority (76%) only used one medication from the kit. Atropine drops were the most commonly used, followed by morphine and paracetamol. Lorazepam and haloperidol were the least commonly used medications. All family members who have used at least one drug in the CCK did not find any difficulty in using the kit. Those who did not use the CCK also found it helpful knowing that a standby kit was available if and when distressing symptom developed. All respondents except one found the medications helpful in alleviating the patient’s symptoms. One family member rushed a patient to the hospital emergency department due to uncontrolled dyspnea despite rectal morphine administration. This patient passed away in the hospital, whereas the rest of the patients died at home. Discussion
In this pilot survey, we found that CCK was used by a majority of individuals given the kits. The caregivers
Table 2. Comfort Care Kit Medication Use Number of medications used per kit One drug Two drugs Three drugs Four drugs Frequency of medications used Atropine drops sublingually Morphine parenteral solution per rectum Paracetamol suppository Lorazepam tablet sublingually Haloperidol parenteral solution sublingually
n = 33 kits (%) 25 (76) 4 (12) 2 (6) 2 (6)
n = 47 medications used among the 33 kits (%) 17 (36) 11 (23) 8 (17) 7 (15) 4 (9)
Journal of Palliative Medicine 2014.17:575-578. Downloaded from online.liebertpub.com by MCMASTER UNIVERSITY - LIBRARY on 01/21/15. For personal use only.
COMFORT CARE KIT
reported it to be easy to use and useful for symptom control. Only one drug was used most of the time and atropine was the most commonly used. Almost all patients who used the kits were able to die at home. Our findings suggest that the CCK may be a useful tool to enhance the care of patients dying at home. There is a paucity of literature on the use of medication kits at home for symptom control although the practice of providing emergency boxes at home is common.8 Bishop et al.9 conducted a survey of 22 hospices and reported considerable variation in medication kit contents and practice. Walker et al.10 examined the perception of hospice managers and clinician regarding the value of medication kit use. More recently, Leigh et al.11 surveyed hospice nurses from 16 agencies regarding medication kit use. Our study is the first to examine the perception of bereaved caregivers, which provides a unique perspective of the utility of home medication kits. Our CCK is unique because it is specifically designed for terminally ill patients who are unable to swallow and it can be administered by caregivers at home. Therefore, it contains medications that can be given by routes other than the oral route, i.e., sublingually and rectally. We have purposely avoided the parenteral route as some caregivers are not comfortable administering injections at home.12 Our CCK differs from medication kits in other home care and hospice programs that were either intended for patients who were still able to swallow, or meant for health care staff to administer upon their arrival in the patient’s home.9 During the design of the kit, we considered the patient and caregiver needs, safety, costs, and local availability of drugs. The CCK was provided at no cost to family members. Thus, we used the least expensive combination of drugs without compromising the effectiveness of symptom control. Each pack costs approximately 10 SGD (approximately $8 USD). Morphine suppositories would have been preferred over morphine ampoules, however, this is not available locally. The high cost also prevented us from replacing the haloperidol ampoule with haloperidol drops. Over two-thirds of the CCKs dispensed were used. Our finding is consistent with a survey of home hospice kits in which the usage was more than half of those distributed.9 Further research is needed to examine reasons why some families did not administer the CCK. One potential explanation is that some patients were relatively asymptomatic until death. Caregivers who did not use the kit still reported that they found the CCK helpful as a backup in case any symptom arose. Palliative medication kits placed at homes of terminally ill patients have extended the period of time they were cared for at home, increased chance of home death, and lessened hospital readmissions.13 Leigh et al.11 reported that 93% of nurses surveyed believe that having a medication kit at home helped avoided emergency room stay and/or hospitalization. Our finding that almost all our patients were able to stay at home until their death is encouraging, however, it is unclear how much of a role CCK contributed in the context of other interdisciplinary palliative home care interventions. Schonwetter et al.14 reported that hospice emergency kits were associated with lower frequency of emergency room visits and/or hospitalization (odds ratio 0.33, p = 0.004). Future studies are needed to examine whether our CCK could im-
577
prove symptom control, reduce caregiver distress, and decrease emergency room visits and hospitalizations. The cost effectiveness of CCK and cost avoidance potential should also be further examined.10 Our study has several limitations. First, the results presented here are from an ad hoc survey as part of our quality improvement initiative. We did not document the number of nonresponders and were not able to contact all caregivers who received the CCK. Second, we collected data from bereaved caregivers 2 weeks from time of death. Acute grief reaction may have affected their response. Third, we surveyed a small sample of patients. Finally, this survey study does not ascertain that CCK has a direct impact on clinical outcomes such as emergency room visits. Further studies should examine this further, preferably in the setting of a randomized controlled trial. Conclusion
In summary, the CCK was perceived by bereaved caregivers to be easy to use and helpful in controlling symptoms for patients in the last days of life who were no longer able to swallow. Further research is needed to identify the optimal medications for inclusion, and to confirm the potential benefits of CCK. Author Disclosure Statement
No competing financial interests exist. References
1. Townsend J, Frank AO, Fermont D, Dyer S, Karran O, Walgrove A, Piper M: Terminal cancer care and patients’ preference for place of death: A prospective study. BMJ 1990;301:415–417. 2. Conill C, Verger E, Henrı´quez I, Saiz N, Espier M, Lugo F, Garrigos A: Symptom prevalence in the last week of life. J Pain Symptom Manage 1997;14:328–331. 3. LeGrand SB, Tropiano P, Marx JD, Davis MP, Walsh D: Dying at home: Emergency medications for terminal symptoms. Am J Hosp Palliat Care 2001;18:421–423. 4. Lichter I, Hunt E: The last 48 hours of life. J Palliat Care 1990;6:7–15. 5. Palliative Info: Clinical Guideline: Anticipating and Preparing For Predictable Clinical Challenges in The Medical Care Of The Terminally Ill Person Wishing To Die At Home. http://palliative.info/resource_material/Home_Death .pdf (Last accessed May 25, 2013). 6. Radbruch L, Trottenberg P, Elsner F, Kaasa S, Caraceni A: Systematic review of the role of alternative application routes for opioid treatment for moderate to severe cancer pain: An EPCRC opioid guidelines project. Palliat Med 2011;25:578–596. 7. Coluzzi PH, Fairbairn BS: The management of pain in terminally ill cancer patients with difficulty swallowing. Am J Hosp Palliat Care 1999;16:731–737. 8. Anderson A-K, Breen M, Sebastian N, Mycroft J: The use of emergency boxes for children with advanced cancer. Eur J Palliat Care 2010;17:80–83. 9. Bishop MF, Stephens L, Goodrich M, Byock I: Medication kits for managing symptomatic emergencies in the home: A survey of common hospice practice. J Palliat Med 2009; 12:37–44.
Journal of Palliative Medicine 2014.17:575-578. Downloaded from online.liebertpub.com by MCMASTER UNIVERSITY - LIBRARY on 01/21/15. For personal use only.
578
10. Walker KA, McPherson ML: Perceived value and cost of providing emergency medication kits to home hospice patients in Maryland. Am J Hosp Palliat Care 2010;27: 254–260. 11. Leigh AE, Burgio KL, Williams BR, Kvale E, Bailey FA: Hospice emergency kit for veterans: A pilot study. J Palliat Med 2013;16:356–361. 12. Israel F, Reymond L, Slade G, Menadue S, Charles MA: Lay caregivers’ perspectives on injecting subcutaneous medications at home. Int J Palliat Nurs 2008;14:390–395. 13. Wowchuk SM, Wilson EA, Embleton L, Garcia M, Harlos M, Chochinov HM: The palliative medication kit: An effective way of extending care in the home for patients nearing death. J Palliat Med 2009;12:797–803.
YAP ET AL.
14. Schonwetter RS, Clark LD, Leedy SA, Quinn MJ, Azer M, Kim S: Predicting emergency room visits and hospitalizations among hospice patients with cardiac disease. J Palliat Med 2008;11:1142–1150.
Address correspondence to: Richard Yap, MD HCA Hospice Care 12 Jalan Tan Tock Seng Singapore 308437 E-mail: [email protected]
JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 5, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0364
Brief Reports
Comfort Care Kit: Use of Nonoral and Nonparenteral Rescue Medications at Home for Terminally Ill Patients with Swallowing Difficulty Richard Yap, MD,1 R. Akhileswaran, MD,1 Chong Poh Heng, MBBS,1 Angela Tan, RN,1 and David Hui, MD 2
Abstract
Introduction: We devised a comfort care kit (CCK) consisting of nonoral and nonparenteral rescue medications for caregivers to use at home for symptom control in imminently dying patients who have lost their ability to swallow. The aim of this study was to evaluate the feasibility of the CCK from the perspective of bereaved caregivers. Methods: CCKs were handed out to caregivers for patients who were entered into the care for the dying pathway (CDP). Each CCK includes morphine and haloperidol ampoules, lorazepam tablets, atropine drops, and paracetamol suppositories given either through sublingual or rectal route. We conducted a telephone survey of bereaved caregivers to assess CCK’s feasibility (proportion of use), pattern of use, perceived benefits and challenges, and need to transfer to emergency department at the end of life. Results: Forty-nine caregivers completed the survey. Thirty-three (67%) reported that they used the CCK. A majority (76%) only used one medication from the kit. Atropine drops were the most commonly used, followed by morphine and paracetamol. All family members reported that the CCK was easy to use and 98% found it to be effective for symptom management. All except one patient died at home. Conclusion: The CCK was feasible and perceived to be effective for symptom control and easy to use. Further research is necessary to optimize the use of this kit and to document related outcomes.
Introduction
A
majority of patients who suffer from a terminal illness want to die at home.1 Good symptom control and support to the caregivers are needed for home death to be possible. This could pose a challenge to the home hospice team as symptoms near the end of life are common as death approaches.2 Moreover, in the last days of life, patients often lose their ability to swallow and the medications that they used to take orally become difficult to administer. This may precipitate a crisis at home and may prompt caregivers to inadvertently bring the dying patient back to the hospital.3 To address this concern, our palliative care team devised a comfort care kit (CCK) that consists of medications specifically for nonoral and nonparenteral use. This kit is provided to family caregivers with instructions to administer the medications for various symptoms such as pain, dyspnea, nausea/vomiting, fever, delirium, and death rattle. The aim of
this study was to evaluate the feasibility of the CCK from the perspective of bereaved caregivers. Methodology
The pilot study was conducted at HCA Hospice Care in Singapore. Discussions were held to ascertain the contents of the CCK. Common symptoms at the end of life were identified4 and possible combinations of drugs within the pack were evaluated based on available literature of drugs that can be given effectively through routes other than oral and parenteral.5–7 Local practice, availability of drugs, costs, ease of administration, and safety were also considered. Five drugs were eventually chosen for inclusion in the CCK:
1
HCA Hospice Care, Singapore. MD Anderson Cancer Center, Houston, Texas Accepted November 12, 2013.
2
575
1. Morphine sulfate (10 mg/mL) injection ampoule— 0.5 mL given rectally for pain or shortness of breath; 2. Haloperidol (5 mg/1 mL) injection ampoule—0.5 mL given sublingually for agitation or nausea/vomiting;
576
YAP ET AL.
Journal of Palliative Medicine 2014.17:575-578. Downloaded from online.liebertpub.com by MCMASTER UNIVERSITY - LIBRARY on 01/21/15. For personal use only.
3. Lorazepam (1 mg) tablets—1 tablet given sublingually for agitation; 4. Atropine ophthalmic drops (1%)—2 drops given sublingually for respiratory secretions; and 5. Paracetamol (650 mg) suppositories—1 suppository inserted rectally for fever. Every CCK provides 1–2 doses of each medication in a bag. Contents of the kit were replaced during the next home visit if medications were used. Urgent home visits were made when caregivers ran out of CCK medications and another dose needed to be administered or when symptoms were not relieved after medication administration. The kit also included an instruction sheet for the caregivers regarding the use of the medications and the symptoms for which they should be used. Caregivers were further educated on how to use the kit by our palliative care team. A CCK was provided to a caregiver when a patient was entered into the care for the dying pathway based on the following criteria: (1) recognized by the palliative care team as entering the dying phase based on clinical signs, (2) lost his/her ability to swallow, and (3) had low symptom burden in the home setting. Patients with poorly controlled symptoms, on higher doses of opioids (oral morphine equivalent daily dose of more than 60 mg), or on continuous infusion of subcutaneous drugs were excluded. Caregivers who were not comfortable using the CCK were also not given the kit. As part of our quality assurance program, a telephone survey was conducted by the nurse-in-charge to the caregiver approximately 2 weeks after the death of the patient. This timeframe was chosen because we did not wish to call bereaved family members during the first week when they were often busy with funeral planning. The following questions were asked to assess the use and effectiveness of the CCK:
Table 1. Patient and Caregiver Characteristics n = 49
n = 33 who used the kits
72 (44–97)
70 (44–97)
26 (53%) 23 (47%)
20 (61%) 13 (39%)
47 (96%) 1 (2%) 1 (2%)
31 (94%) 1 (3%) 1 (3%)
42 (86%) 7 (14%)
28 (85%) 5 (15%)
Patient’s characteristics Age, median (range) Gender Male Female Race Chinese Indian Malay Diagnosis Cancer Noncancer Respondents Children Spouse Niece/nephew Parent Others (friend/helper) Median survival from time that the kit was given in days (range)
30 12 3 1 3 2
(61) (25) (6) (2) (6) (0–17)
23 8 1 0 1 4
(70%) (24%) (3%) (0%) (3%) (0–17)
1. Was the CCK used? Yes/No 2. Which of the drugs in the kit was used: morphine/ haloperidol/lorazepam/atropine/paracetamol? 3. Was the symptom relieved by the medication? Yes/No 4. Was there any difficulty using the CCK? Yes/No 5. Did they find the CCK helpful? Yes/No 6. Was the patient sent to the hospital emergency department any time after the CCK was given to them until death? Yes/No Because this is a retrospective study of the data collected during our quality improvement initiative, our institutional policy did not require us to seek Institutional Review Board approval. We analyzed the data using summary statistics including averages, proportions, percentages, and ranges. Results
Between February and August 2012, a convenient sample of 49 caregivers completed the phone survey. Most of those interviewed were children of the deceased patients. Patient and caregiver characteristics are shown in Table 1. Of the 49 CCKs issued, 33 (67%) used the kits (Table 2). A majority (76%) only used one medication from the kit. Atropine drops were the most commonly used, followed by morphine and paracetamol. Lorazepam and haloperidol were the least commonly used medications. All family members who have used at least one drug in the CCK did not find any difficulty in using the kit. Those who did not use the CCK also found it helpful knowing that a standby kit was available if and when distressing symptom developed. All respondents except one found the medications helpful in alleviating the patient’s symptoms. One family member rushed a patient to the hospital emergency department due to uncontrolled dyspnea despite rectal morphine administration. This patient passed away in the hospital, whereas the rest of the patients died at home. Discussion
In this pilot survey, we found that CCK was used by a majority of individuals given the kits. The caregivers
Table 2. Comfort Care Kit Medication Use Number of medications used per kit One drug Two drugs Three drugs Four drugs Frequency of medications used Atropine drops sublingually Morphine parenteral solution per rectum Paracetamol suppository Lorazepam tablet sublingually Haloperidol parenteral solution sublingually
n = 33 kits (%) 25 (76) 4 (12) 2 (6) 2 (6)
n = 47 medications used among the 33 kits (%) 17 (36) 11 (23) 8 (17) 7 (15) 4 (9)
Journal of Palliative Medicine 2014.17:575-578. Downloaded from online.liebertpub.com by MCMASTER UNIVERSITY - LIBRARY on 01/21/15. For personal use only.
COMFORT CARE KIT
reported it to be easy to use and useful for symptom control. Only one drug was used most of the time and atropine was the most commonly used. Almost all patients who used the kits were able to die at home. Our findings suggest that the CCK may be a useful tool to enhance the care of patients dying at home. There is a paucity of literature on the use of medication kits at home for symptom control although the practice of providing emergency boxes at home is common.8 Bishop et al.9 conducted a survey of 22 hospices and reported considerable variation in medication kit contents and practice. Walker et al.10 examined the perception of hospice managers and clinician regarding the value of medication kit use. More recently, Leigh et al.11 surveyed hospice nurses from 16 agencies regarding medication kit use. Our study is the first to examine the perception of bereaved caregivers, which provides a unique perspective of the utility of home medication kits. Our CCK is unique because it is specifically designed for terminally ill patients who are unable to swallow and it can be administered by caregivers at home. Therefore, it contains medications that can be given by routes other than the oral route, i.e., sublingually and rectally. We have purposely avoided the parenteral route as some caregivers are not comfortable administering injections at home.12 Our CCK differs from medication kits in other home care and hospice programs that were either intended for patients who were still able to swallow, or meant for health care staff to administer upon their arrival in the patient’s home.9 During the design of the kit, we considered the patient and caregiver needs, safety, costs, and local availability of drugs. The CCK was provided at no cost to family members. Thus, we used the least expensive combination of drugs without compromising the effectiveness of symptom control. Each pack costs approximately 10 SGD (approximately $8 USD). Morphine suppositories would have been preferred over morphine ampoules, however, this is not available locally. The high cost also prevented us from replacing the haloperidol ampoule with haloperidol drops. Over two-thirds of the CCKs dispensed were used. Our finding is consistent with a survey of home hospice kits in which the usage was more than half of those distributed.9 Further research is needed to examine reasons why some families did not administer the CCK. One potential explanation is that some patients were relatively asymptomatic until death. Caregivers who did not use the kit still reported that they found the CCK helpful as a backup in case any symptom arose. Palliative medication kits placed at homes of terminally ill patients have extended the period of time they were cared for at home, increased chance of home death, and lessened hospital readmissions.13 Leigh et al.11 reported that 93% of nurses surveyed believe that having a medication kit at home helped avoided emergency room stay and/or hospitalization. Our finding that almost all our patients were able to stay at home until their death is encouraging, however, it is unclear how much of a role CCK contributed in the context of other interdisciplinary palliative home care interventions. Schonwetter et al.14 reported that hospice emergency kits were associated with lower frequency of emergency room visits and/or hospitalization (odds ratio 0.33, p = 0.004). Future studies are needed to examine whether our CCK could im-
577
prove symptom control, reduce caregiver distress, and decrease emergency room visits and hospitalizations. The cost effectiveness of CCK and cost avoidance potential should also be further examined.10 Our study has several limitations. First, the results presented here are from an ad hoc survey as part of our quality improvement initiative. We did not document the number of nonresponders and were not able to contact all caregivers who received the CCK. Second, we collected data from bereaved caregivers 2 weeks from time of death. Acute grief reaction may have affected their response. Third, we surveyed a small sample of patients. Finally, this survey study does not ascertain that CCK has a direct impact on clinical outcomes such as emergency room visits. Further studies should examine this further, preferably in the setting of a randomized controlled trial. Conclusion
In summary, the CCK was perceived by bereaved caregivers to be easy to use and helpful in controlling symptoms for patients in the last days of life who were no longer able to swallow. Further research is needed to identify the optimal medications for inclusion, and to confirm the potential benefits of CCK. Author Disclosure Statement
No competing financial interests exist. References
1. Townsend J, Frank AO, Fermont D, Dyer S, Karran O, Walgrove A, Piper M: Terminal cancer care and patients’ preference for place of death: A prospective study. BMJ 1990;301:415–417. 2. Conill C, Verger E, Henrı´quez I, Saiz N, Espier M, Lugo F, Garrigos A: Symptom prevalence in the last week of life. J Pain Symptom Manage 1997;14:328–331. 3. LeGrand SB, Tropiano P, Marx JD, Davis MP, Walsh D: Dying at home: Emergency medications for terminal symptoms. Am J Hosp Palliat Care 2001;18:421–423. 4. Lichter I, Hunt E: The last 48 hours of life. J Palliat Care 1990;6:7–15. 5. Palliative Info: Clinical Guideline: Anticipating and Preparing For Predictable Clinical Challenges in The Medical Care Of The Terminally Ill Person Wishing To Die At Home. http://palliative.info/resource_material/Home_Death .pdf (Last accessed May 25, 2013). 6. Radbruch L, Trottenberg P, Elsner F, Kaasa S, Caraceni A: Systematic review of the role of alternative application routes for opioid treatment for moderate to severe cancer pain: An EPCRC opioid guidelines project. Palliat Med 2011;25:578–596. 7. Coluzzi PH, Fairbairn BS: The management of pain in terminally ill cancer patients with difficulty swallowing. Am J Hosp Palliat Care 1999;16:731–737. 8. Anderson A-K, Breen M, Sebastian N, Mycroft J: The use of emergency boxes for children with advanced cancer. Eur J Palliat Care 2010;17:80–83. 9. Bishop MF, Stephens L, Goodrich M, Byock I: Medication kits for managing symptomatic emergencies in the home: A survey of common hospice practice. J Palliat Med 2009; 12:37–44.
Journal of Palliative Medicine 2014.17:575-578. Downloaded from online.liebertpub.com by MCMASTER UNIVERSITY - LIBRARY on 01/21/15. For personal use only.
578
10. Walker KA, McPherson ML: Perceived value and cost of providing emergency medication kits to home hospice patients in Maryland. Am J Hosp Palliat Care 2010;27: 254–260. 11. Leigh AE, Burgio KL, Williams BR, Kvale E, Bailey FA: Hospice emergency kit for veterans: A pilot study. J Palliat Med 2013;16:356–361. 12. Israel F, Reymond L, Slade G, Menadue S, Charles MA: Lay caregivers’ perspectives on injecting subcutaneous medications at home. Int J Palliat Nurs 2008;14:390–395. 13. Wowchuk SM, Wilson EA, Embleton L, Garcia M, Harlos M, Chochinov HM: The palliative medication kit: An effective way of extending care in the home for patients nearing death. J Palliat Med 2009;12:797–803.
YAP ET AL.
14. Schonwetter RS, Clark LD, Leedy SA, Quinn MJ, Azer M, Kim S: Predicting emergency room visits and hospitalizations among hospice patients with cardiac disease. J Palliat Med 2008;11:1142–1150.
Address correspondence to: Richard Yap, MD HCA Hospice Care 12 Jalan Tan Tock Seng Singapore 308437 E-mail: [email protected]
