HP Newsletter - Hospice Pharmacia

Passionate for the Appropriate Use of Medication 

Volume 7 | Issue 3 

HOSPICE PHARMACIA 

News & Views 

Current Information and Topics from the Market Leader in Hospice Pharmacy 

IN THIS ISSUE 

2 

3 

4 

Increasing Public Awareness 

of Hospice and Hospice Care 

Education Corner 

Medication Related 

Problem Advisory 

5 

The Evolution of Open 

Access in Hospice 

6 

Dear Laura: Frequently 

Asked Questions 

7 

Pediatric 

Pharmacotherapy 101 

8 

Discontinuing Hospice 

Medications 

Medication Disposal & Destruction 

[ Catherine J. Woods, JD, Associate Counsel & Sr. Director, Regulatory Affairs ] 

The issue of unused and wasted medications 

and the best way to dispose of them in the 

homecare setting is a topic of interest for 

many hospices and their nurses. 

Traditionally, the 

common practice is 

to dispose of medications 

through the 

household water 

system by flushing 

or pouring them 

down the drain. 

One reason for this is to minimize the risk of diversion 

of Controlled Substances (CS), which are often 

prescribed for patients with chronic disease states 

and severe pain. Additionally, because nurses are 

required to account for any CS remaining in the 

home at the time of death, disposal through the water 

system allows the nurse to record the amounts 

of unused CS and dispose of them quickly, leaving 

more time to focus on the needs and questions of 

the patient’s family and other final duties. 

However, evidence increasingly suggests that 

the disposal of medications through flushing may 

cause adverse environmental effects in fish and 

wildlife and may also negatively impact our drinking 

water supplies. 

Numerous stakeholders have an interest in solving 

the dilemma of how to best dispose of unused and 

wasted medications. Recently, greater focus has 

been placed on this issue by the federal government, 

individual states, and even local municipalities. 

Many hospices are also attempting to create 

and follow best practices for medication disposal. 

Everyone is trying to do the right thing. But what 

exactly does “doing the right thing” mean in reference 

to the disposal of a hospice patient’s medications, 

which often include Controlled Substances? 

Consider for a moment that creating a sound policy 

and procedure on medication waste disposal in the 

homecare setting will often be a matter of deciding 

between two “rights” instead of a right and a wrong. 

The question of what constitutes proper disposal 

may frequently come down to weighing the immediate 

potential for diversion of a certain medication 

against its probable long-term environmental 

impact. Such a decision is a matter of choosing to 

protect the immediate health needs of individuals 

by limiting access to medications with high diversion 

potential or protecting the long-term health of 

(continued on page 2) 

COMING SOON: HP’s QAPI tools for hospice! 

Learn more by visiting Hospice Pharmacia at Booth #105 

during NHPCO’s 8th Clinical Team Conference 

www.hospicepharmacia.com 

newsletter1007(f).indd 1 

11/14/07 4:31:31 PM


CONTINUED FROM PAGE 1 

individuals by minimizing environmental pollution 

and thereby increasing quality of life. If 

the decision seems simple now, read on. 

In an attempt to address the growing concern 

of medication waste in our water systems, in 

February of this year the federal government issued 

the Suggested Guideline for the Disposal 

of Medications. These guidelines offer helpful 

tips for how to dispose of medications through 

household solid waste. They include instructions 

for diluting medications, removing protected 

health information (PHI), and even ways 

to disguise the contents of the bottle. The original 

guidelines strongly advised against flushing 

any medications. Less than one month later, a 

revised set of Suggested Guidelines was issued. 

What changed? Upon further consideration, 

it was determined that some medications were 

still best disposed of through flushing. The current 

Suggested Guidelines now include helpful 

tips, advice, and a separate boxed section listing 

certain high diversion potential medications 

still advised for flushing. 

Individual states are also attempting to solve 

this problem. More and more states continue 

to enact legislation or create regulations 

regarding the ways and means by which 

either healthcare professionals or private 

citizens may properly dispose of household 

medication waste. Even better, voluntary 

medication take back programs are increasingly 

being sponsored at both state and local 

levels so that concerned individuals can 

dispose of medications through incineration 

rather than flushing or dumping in household 

solid waste. 

What does this mean for hospice? Since every 

hospice must create and follow a policy and 

procedure for disposing unused medications 

it means there are a lot of facts to gather and 

information to pay attention to. Federal rules 

are universal but individual state rules will vary. 

HP will hold a presentation on The Necessity 

for Medication Waste Management in the 

Hospice Homecare Setting during NHPCO 

which will help answer many questions nurses 

may have about the various relevant guidelines, 

regulations, voluntary programs, and issues to 

NHPCO SESSION 

Title: The Necessity for 

Medication Waste Disposal 

Management in the Hospice 

Homecare Setting 

Session No: 11D 

Time: Saturday, December 1st, 

2007 (9:30 – 11:00am) 

Presenter: 

Catherine J. Woods, JD 

consider when creating and implementing a Best 

Practice Medication Disposal Policy for their 

hospice. There is an answer to the communal 

problem of unused and wasted medications. 

Together, we will find it. 

Increasing Public Awareness of 

Hospice and Hospice Care 

[ Nick Baranowski, Marketing Project Manager ] 

One of the many challenges facing hospices throughout the United States is the lack of knowledge 

and public awareness about what hospice is and what hospice care has to offer patients and 

families. After having learned about this challenge from hospices, Hospice Pharmacia (HP) 

created www.hospicepatient.com. This site is intended to provide an overview of hospice 

services and dispel common myths about hospice. HP and the National Hospice Foundation 

(NHF) joined together to create an informational brochure about hospice and hospice care. 

In honor of National Hospice Month, HP is distributing this brochure throughout the month 

of November. The brochure is included in HP’s medication packages and will reach 120,000 

residences in the United States. HP is proud to work with the NHF to increase awareness of 

hospice and enhance overall hospice care. 



11/14/07 4:31:32 PM


 

EDUCATION 

CORNER 

[ Laura Scarpaci, PharmD, Clinical Education Manager ] 

Hospice Pharmacia is committed to providing 

high quality, educational programs focused on 

palliative and end-of-life care. Although our 

programs are developed for the beginner to 

advanced clinician, all medical directors, nurses, 

social workers, and pharmacists of our partnering 

hospice organizations are invited to participate. 

During the Fall, HP offered two national webteleconference 

continuing education programs. 

Our September program, “Quality Assurance/ 

Performance Improvement (QAPI) Programs in 

Hospice: Preparing for New Quality Standards,” 

presented by Terri Maxwell, PhD, APRN, BC- 

PCM, Vice President of Research, excelleRx, 

Inc, described what the proposed changes to 

the current Conditions of Participation reflect, 

which includes a significant emphasis on quality 

improvement and the requirement for hospices 

to incorporate an outcomes-oriented Quality 

Assessment Performance Improvement (QAPI) 

program. It furthermore described performance 

measurement systems that can be used in hospice 

programs to evaluate and improve care. Over 

100 hospice programs participated! 

Our November program, “Controlling Common 

Symptoms in the Patient with End-Stage COPD,” 

was presented by Jennifer Johansen, PharmD, 

BCPS, Medical Intelligence Pharmacist, 

excelleRx, Inc. This program reviewed 

pharmacotherapeutic treatment options for the 

management of common symptoms in patients 

with end-stage COPD, including the following: 

dyspnea, anxiety, depression, cough, secretions, 

insomnia, weight loss, and delirium. 

If you missed either of these great programs… 

Don’t worry! Stay tuned as they will be added to 

our current list of home study offerings! 

HP offers bimonthly CNE programs via webbased 

teleconferences. Also, Hospice Pharmacia 

partners can participate in self-study CNE 

programs online. To do so, log into Xeris ® and 

click the Education Materials icon on the left 

navigation bar. 

Thank you to those 

who completed 

our 2008 Hospice 

Pharmacia Nurses Needs 

Assessment Survey! 

We are busy tabulating 

the results and will be 

announcing the 2008 

Continuing Education 

Web Teleconference 

Schedule soon! 

AVAILABLE SELF-STUDY PROGRAMS INCLUDE 

Minimizing Fall Risk through Appropriate Medication Management 

Managing Heart Failure in the Hospice Setting 

It’s Not Always Alzheimer’s: A Look at Other Dementing Illnesses 

The Use of Hospice to Improve End of Life Care in Dementia 

Managing Pain: A Focus on the Appropriate Use of Methadone 

Management of Common GI Complaints at the End of Life 

The Safety and Efficacy of Psychotropics in the Elderly: Weighing the Risks vs. Benefits 

Introduction to Non-opioid and Opioid Pain Therapy 

Pain Management: The Role of Adjuvant Drug Therapy 

*Visit www.hospicepharmacia.com and log into Xeris to access these CNE programs. 



11/14/07 4:31:33 PM


Medication Related Problem (MRP) Advisory: 

Your Patient’s Safety 

[ Jennifer Johansen, PharmD, BCPS, Clinical Pharmacist, Medical Intelligence ] 

Many hospice patients are at risk for 

medication related problems (MRPs). An 

MRP is “an event or circumstance involving 

medication therapy that actually or potentially 

interferes with an optimum outcome for a 

specific patient.” 1 In the elderly, MRPs have 

been shown to have a negative impact on 

hospitalization and mortality as well as selfperceived 

health status. 2, 3 

In a recent retrospective review of 1315 

consecutively admitted home care patients 

to Hospice Pharmacia (HP), we found that 

more than 70% of patients were identified as 

having one or more potential or actual MRP 

upon admission. Of those patients, 35% had 

a total of 3 or more MRPs. 

MRPs include (but are not limited to): 

• Untreated indication – e.g. missing 

bowel regimen while on an opioid 

• Actual or potential adverse drug event 

– e.g. patient with a history of low 

platelets prescribed an anticoagulant 

• Potentially improper drug selection 

– e.g. use of propoxyphene (Darvon®, 

Darvocet®) in the elderly 

• Dose may be too high or too low – e.g. 

use of high dose ranitidine (Zantac®) or 

famotidine (Pepcid®) in the elderly 

HP pharmacists help identify patients 

who are at risk for MRPs 

and work with the hospice team 

for optimal medication therapy 

management thereby ensuring 

quality outcomes and appropriate 

pharmacotherapy plans for 

all patients. We look forward 

to keeping you informed about 

new findings regarding MRPs 

and how HP is working to ensure 

your patients’ safety. 

1. American Society of Hospital Pharmacists. 

ASHP statement on pharmaceutical care. Am 

J Hosp Pharm 1993; 50:1720-3. 

2. Fu AZ, Liu GG, Christensen DB. Inappropriate 

medication use and health outcomes in the 

elderly. J Am Geriatric Soc 2004;52:1934-9. 

3. Cohen JS. “Avoiding adverse reactionseffective 

lower-dose drug therapies for older 

patients.” Geriatrics 2000;55(2): 54-64. 


Title: Performance 

Improvement! Avoid 

Medication-Related Problems 

and Keep your Hospice 

Patients Safe 

Location: HP’s Hospice 

Appreciation Lunch, Ballroom 

C on 2nd floor 

Time: Thursday, 

November 29th, 2007 

(11:45am – 1:30pm) 

Presenter: Kevin Bain, PharmD, 

BCPS, CGP, FASCP 



11/14/07 4:31:35 PM


 

The Evolution of Open Access in Hospice 

[ Terri Maxwell, PhD, APRN, BC-PCM, Vice President of Research ] 

The number of non-debilitating palliative 

chemotherapy agents is rising, making continuing 

therapy more palatable for those 

with advanced cancer and in turn, contributing 

to delays in hospice enrollment. In order 

to improve access, some hospice programs 

are developing “open access programs”. 

Open access has been part of some hospice 

programs for over 20 years, as part of 

a commitment to care for all who seek hospice 

services, regardless of their diagnosis, 

care setting, or ability to pay. However, the 

growth in the number and types of palliative 

chemotherapies, has forced many programs 

that did not allow patients receiving chemotherapy 

to enroll in hospice to reconsider 

their policies so that patients would not wait 

until they had only weeks or days to live before 

accessing hospice care. 

Providing chemotherapy and other similar 

agents presents many challenges, as well as 


Title: The Evolution of Open 

Access in Hospice 

Session: 5G 



(4:00pm – 5:00pm) 

Presenter: Terri Maxwell, PhD, 

APRN, BC-PCM 

opportunities to hospice programs. Difficulties 

include decisions regarding appropri- 

family expectations. It is important to have a 

goals of care, treatment plans and patient/ 

ateness of therapies 

in hospice, costs 

associated with 

open access in relation 

to the Hospice 

Medicare Benefit, 

training personnel 

to safely provide 

Benefits of open access programs include 

improved access to hospice, longer length of stay, 

encouraging relationships with the community, 

and possible referral advantages. 

and monitor these therapies, and obtaining 

board buy-in. Benefits of open access at a future time. 

plan in place to re-assess treatment efficacy 

programs include improved access, longer 

length of stay, encouraging relationships During the NHPCO Clinical Conference, 

with the community, and possible referral Terri Maxwell, PhD, APRN, BC-PCM, Vice 

advantages. 

President of Research, a pharmacist, a nurse 

researcher, and an oncologist/hospice medical 

director will provide an overview of open 

A national study of 544 hospices to identify 

hospice-level factors associated with the access, describe the current state of chemotherapy 

provision in hospice, and identify 

provision of oral palliative chemotherapy 

was undertaken in 2006. Forty-three percent 

of the hospices in the sample provided use to determine appropriate chemotherapy 

policies and procedures that hospices can 

chemotherapy to over 1100 patients in use in their open access programs. 

2005. Patients who received chemotherapy 

in hospice were enrolled on average 2 weeks 

longer, were less likely to have short stays 

of a week or less, and were more likely to be 

enrolled for at least 2 months, compared to 

those not receiving chemotherapy. Large 

hospices and not-for-profit programs were 

more likely to provide chemotherapy, compared 

to small and for-profit organizations. 

Hospices are increasingly developing standardized 

approaches to guide admission 

staff in the appropriate selection of open 

access patients. Hospice Medical Directors 

and oncologists frequently must confer on 



11/14/07 4:31:36 PM


Dear Laura 

Dear Laura, 

Dear Laura, 

3. Click Edit My Profile 

When I call into the Medication 

Management Support Center I am 

sometimes given the option to use 

the virtual hold system. Other 

times I am not. Are there certain 

I am the Xeris Administrator for 

my hospice. Am I able to assign 

PINs to my nurses? 

Roberta 

times that this feature is available? 

Bailey 

Bailey, 

Yes. The virtual hold option is available 

when the estimated wait time for a 

pharmacist is greater than five minutes. 

This option is available when wait 

times are highest so that hospice 

staff may keep their virtual place in 

line but go about their daily activities. 

They will then receive an inbound call 

from the first available HP pharmacist. 

In addition to this, the virtual hold 

option is not available after 7:00pm 

Eastern Time. This ensures that all calls 

are addressed before the Next Day 

delivery cut-off time. 

Roberta, 

No. The individual user must login 

as themselves in order to establish a 

PIN. PIN numbers are used to verify 

a nurse’s identity and expedite the 

call process. I have listed the steps for 

doing this below and included some 

screen shots for your convenience. 

1. Login to Xeris by going to 


2. Click on My User Profile on the 

toolbar 

4. Click on the four XXXX 

5. Enter a 4-digit number in the 

bottom two fields 

Thanks! 

Laura 

6. Click Save 



11/14/07 4:31:37 PM


 

A Primer on Pediatric 

Pharmacotherapy for Symptom 

Management 

[ Tom McCool, RPh, Pharmacist Leader ] 

HP Newsletter Staff 

EDITOR: 

Rebecca Lewis, PharmD, MBA 

Senior VP, Marketing 

and Corporate Accounts 

rlewis@excelleRx.com 

ASSISTANT EDITOR: 

Nick Baranowski 

Marketing Project Manager 

nbaranowski@excelleRx.com 

LAYOUT AND DESIGN: 

Melissa Morris Ivone 

Director, Creative Services 

mivone@excelleRx.com 

To request additional copies 

of this newsletter, please email 

HPnewsletter@excelleRx.com. 

While managing children with lifethreatening 

illnesses has always been a part 

of the health care system, it is only recently 

that palliative care has been recognized as 

a specialty within the pediatric population 

and that an integrated vision towards care 

has emerged. 

There are many barriers to pediatric hospice 

care that prevent the proper utilization of 

palliative care. Barriers include those related 

to healthcare professionals (physician, 

nurse, and pharmacist), the child’s parents, 


Title: Primer on Pediatric 

Pharmacotherapy for Symptom 

Management 

Session: 5C 



(4:00pm – 5:00pm) 

Presenter: Tom McCool, RPh 

and Jeannine Winsness, PharmD 

obstacles within the design of the hospice 

program, and communication. 

Pharmacotherapy for a pediatric hospice 

patient is invariably the most significant 

factor in managing the symptoms associated 

with the end of life. While it is true that 

pediatric patients can be prescribed most 

medications used for adult patients in lower 

doses, we should not treat our pediatric 

patients like “little adults”. It is important 

to understand that absorption, distribution, 

metabolism and elimination of medications 

in the pediatric population are different than 

that of adults and will vary according to age. 

Hospice providers face unique challenges 

when providing pediatric palliative care, 

including difficulties in pain and other 

symptom assessment and finding appropriate 

solutions to these problems. Tom McCool, 

RPh will be giving a presentation entitled 

“Primer on Pediatric Pharmacotherapy for 

Symptom Management” at NHPCO which 

will increase participants’ confidence and 

skills in prescribing and administering 

pharmacotherapy to palliate common 

symptoms in the pediatric hospice population 

with an overall goal of improving care for 

children at the end of life. 



11/14/07 4:31:39 PM


Evaluating Medication Utility in the 

Context of Medication Discontinuation 

[ Kevin Bain, PharmD, BCPS, CGP, FASCP, VP, Chronic Care Outcomes ] 

Patients enrolled in hospice frequently need to 

have medications discontinued due to changing 

goals of care, clinical deterioration, financial 

burden, and to avoid the unnecessary distress of 

continuing with a medication when no clear benefit 

can be gained from its use. In addition, stopping 

certain medications becomes increasingly 

important in the hospice care setting as a means 

to help prevent adverse drug reactions and other 

medication related problems when medications 

for symptom management are added to an already 

complex drug regimen. Decisions about 

medication discontinuation occur as a continuous 

process in hospice, beginning at enrollment 

and continuing throughout the dying process, 

yet little has been published about the medica- 

tion discontinuation process. With little guidance 

from the available literature, hospice and 

palliative care clinicians are faced with a daunting 

task of deciding which medications to stop and 

when and how to stop them. 

Kevin Bain, PharmD, BCPS, CGP, FASCP, will 

be holding a session at the NHPCO CLC Conference. 

This session will describe a conceptual 

model for evaluating the usefulness of medications 

in hospice patients, defined as medication 

utility. The model is discussed as part of a larger 

process leading to the decision to discontinue 

medications in hospice patients. By attending 

this presentation the participant will be able to 

apply this process in their practice. 


Title: Evaluating Medication 

Utility in the Context of 

Medication Discontinuation 

Session No: 9O 

Time: Friday, November 30th, 

2007 (3:00 – 4:00pm) 

Presenters: Kevin Bain, PharmD, 

BCPS, CGP, FASCP 

Holly Holmes, MD 

Mary Lynn McPherson, PharmD 

Florida Hospices Names 

Hospice Pharmacia (HP) Patron 

Associate Member of the Year 

Florida Hospices and Palliative Care, Inc. has unanimously agreed to honor Hospice Pharmacia 

as their Patron Associate Member of the Year. This Award is presented to a Corporation who has 

a record of exceptional partnership within the state organization of Florida Hospice and Palliative 

Care, Inc. This corporation must also demonstrate leadership and motivational abilities to encourage 

others to become involved. HP is honored to receive such an award and looks forward to the future 

partnership with Florida Hospice and Palliative Care. 

Hospice Pharmacia Highlights newsletter has a new look. Let us know what you think! Email your opinions to mivone@excelleRx.com 

Hospice Pharmacia is a service of excelleRx, Inc. 

Copyright © 2007, excelleRx, Inc., All rights reserved. Medication Use Guidelines (MUGs), and all Xeris products and services and their respective logos are trademarks of excelleRx, Inc. MUGs ® and Xeris ® are 

registered trademarks of excelleRx, Inc. No part of the information contained herein may be reproduced, duplicated, or copied without permission. Please inquire if you are not sure. 



11/14/07 4:31:40 PM

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