Hello, everyone, as you start getting kind of set up here, we'll give it about another minute and then we'll get started. So glad to see you all here to see you. Okay. Well, as people continue coming into the event, we'll get started. It's great to see you all. I'm Bruce Hammond. I serve as HMDCB's Executive Director, and I'd like to welcome you all to our second Coffee Chat of 2023. It's great to be here with you here in April for our second Coffee Chat of the year. So before we kick off today's event, and I'll introduce our moderator for the session in just a moment, but have a couple of announcements of some upcoming events that are important for you to be aware of. As we usually do at the beginning of these, I'll just run through these briefly, and then you can always go to our website to learn more about them. Tomorrow is the April edition of the Hospice Physician Compliance Conference. Tomorrow, April 21st. As you can read on the screen, it focuses on hospice regulations and compliance, and you can receive a 10% discount code for registering by reaching out to Gina, and she can give you that code. Sometimes the term register today is marketing speak for register soon, but this literally means register today because the session is tomorrow. So make sure if you are interested in attending, please register for that today. HMDCB's May webinar, part two of our dementia care series is on May 16th at 10 a.m. Central Time. Part one was very, very well attended. We actually had an overflow for being able to attend. So if you're interested in participating in part two of the dementia care webinar series, please register online for that at hmdcb.org slash webinars. Our next coffee chat will take place on June 21st, so we look forward to hopefully seeing you again for that one in a couple of months. We're holding these every other month here in 2023. We heard from you all that you wanted to have a few more of these, and last year we were doing them quarterly. This year, we're doing them every other month, so we'll hold the next one June 21st. And again, more information on the website. And as you're probably aware, our initial application window is currently open. So for anybody that you know who is not yet certified but should be, please feel free to encourage them to learn more about HMDCB and to apply at hmdcb.org slash apply. So without taking up much more of your time, your precious time here, I'll introduce today's moderator for the session, our Education Committee Chair, Dr. Robin Turner from Duke University. Dr. Turner, I will give it off to you and take it away, please. Thanks so much. All right, thank you so much and welcome, everyone. Thank you for joining. So I think many of you have done these chats before. This is really all about you, all about the conversation that will help you learn and be better in your role as hospice providers and medical directors. And so with that, I would like to kind of propose a couple of options as to how to maybe run this meeting today. First off, I wanted to share with you all, I told Gina and Bruce right before we started that at the academy, were a lot of you at the academy? You can kind of let me know in the chat. At the academy, I went to the hospice homeroom and I've been to the academy meetings many, many years and there were so many of you all at this homeroom and the conversation was so robust. I realized how important conversations amongst us are, the support that we need, because many of us who are doing hospice are often the only ones in our hospices and so support is so needed. So I can really say that these kinds of conversations are so important and I think everybody's voice needs to be heard. So I'm really glad that we're doing them more frequently this year through the medical board. So with that, I have two options. I thought I would propose something. Last month, two months ago now, I guess, Dr. Riddle had sent a case about complex pain management in a hospice patient. I have that case and we can start with that and review that and have conversation about it. Or I also can open it up to any questions that you are burning in your minds that you would like to discuss. And I have three submitted questions that we would want to get to by the end of the session anyway. So does anyone have a preference? Should we open it up for questions or talk about a case? Hi, Robin. Go ahead, Carolyn. I was just going to say let's do the case maybe first. Okay. Everybody else good with that? All right. So I'll read it here. Gina, would you want to share it maybe? Yeah. So this is a 66-year-old gentleman who was referred to hospice. His primary diagnosis is chronic respiratory failure. His PCP says that he has progressive respiratory failure due to interstitial lung disease. He has significant weakness and aspiration pneumonia due to his secondary diagnosis, which is Parkinson's disease. He's been hospitalized several times in the past few months with pneumonia. His other conditions, as you can see, include dysphagia, probably all the usual suspects, CAD, interstitial lung disease, recurrent aspiration. And he has a final diagnosis of CLL, which doesn't seem to be his main problem. He has a long history of chronic pain that he describes as never-ending headache with every joint in his body hurting and with a back that is always killing him. His pain is always nine out of 10, which is normal for him, but he no longer wants to suffer. He has been managed with high doses of oxycodone. He's now at 30 milligrams every four hours, as confirmed by his PCP. And he states that he sometimes takes it more often and sometimes doubles the dose when the pain is too bad. So upon admission to hospice, he's given only one week's worth of medication at a time. He states his biggest, and I think that was happening beforehand as well, he states that his biggest fear is that hospice will come in and stop his medications. So upon assessment, he's at the admission to hospice, he reported that he was out of his oxycodone and, oh, by the way, he's also on Valium. He states that he wants to be pain-free. He doesn't want to suffer anymore. And he informed us that he did not want his current doctor to be responsible for prescribing his pain medications any longer and agreed to have, of course, this transferred over. He's not eating much. He's really not eating much at all, less than 25% of his meals. He does not want a feeding tube as he's had one in the past. And his PCP thinks that he's chronically aspirating. This is supported by his weight loss, his recurrent pneumonias. He's definitely sleeping more. His physical exam, he looked the part, cachectic, mildly short of breath at rest, first lip breathing. He is ambulatory, but very weak. He's unsteady, probably what everyone would expect advanced COPD, interstitial lung disease patient to look like. He uses oxygen six to nine liters when he feels like he needs it. He can drop as low as 60% on his oxygenation. So, we can stop here and talk for a minute. This is a patient who uses a fair amount of oxycodone and they want hospice to supply it. It is a chronic pain issue and not really related to his dyspnea. Does anyone have any concerns about this dose or providing this medication to this chronic COPD, chronic respiratory failure patient? Hi, this is Dr. Thomas DeGregory. I had to call in audio. I'm not on the computer. Can you hear me? We sure can. Thank you. Okay. I'm giving my opinion. I'm a full-time 20-year hospice doc boarded and I'm also a certified director and I do this all day. It's only my opinion. This is my 49th year of geriatrics. I see these patients like this frequently and I've been getting a lot of referrals from pain clinics to the palliative division that doesn't want to do the pain anymore and we don't like to accept just chronic pain patients. But my opinion is you could probably triple his oxycodone and it wouldn't work any better. Oxycodone, they become dependent. They become very tolerant and I've just found no matter if they get to three, four, 500 milligrams, it doesn't work. At the last board review, we talked about that. You know, Dr. McPherson, Dr. McMethadone at Maryland. I think you have to do opiate rotation. A lot of people are resistant when they hear dolephine, methadone, fentanyl, all this. I don't think you'll get anywhere with this type of patient just doubling, tripling, increasing his oxycodone. Personally, I know one of the lectures of her about a year or two ago and I've been doing this. She said, you have these patients, do something and sit back and watch. If the patients are accepting, if you take a methadone and I know it takes training and cautiousness with methadone, just adding five mil instead of going through the whole litany of P-glycoprotein, inducers, inhibitors, all that stuff. If you take this five milligrams twice a day, she said, add it and sit back and watch. I don't think you'll get anywhere with this patient with oxycodone. You got to do something else. You got to opiate rotate. I'm a big methadone fan. Do I use it every day? No. Have I used it zillions of times successfully? Yes. But just going the oxycodone road, I don't think you'll get anywhere. Ellen, I saw you had something in the chat. Thank you so much. Yes, I think you know, what you're saying is so true. I'm sure we've all seen that. Alan Rosen is saying in the chat how he agrees with you. Tell me your name again. Tom DeGregory. I'm an old man, but I've been doing a lot of time. Every day, I get a new case. We just did a methadone conversion from Suboxone. The toughest cases are these terminally ill patients with chronic pain that have had years of opiates. You got your hands full. The oxycodone, I think, I would rotate, control the pain with an alternative agent and start weaning that down. I know people get really reliant on hearing oxycodone more and more and more and more it won't work. Preferably, in this case, the first thing I personally would try is methadone before I would use fentanyl, buprenorphine, all that stuff. That's one approach. Hey, this is Tom Browning. I'm actually struck by the fact that he fired his PCP and expects the hospice to provide him medication and also says that he's afraid that we'll cut him off. That's going to be a challenge right there because he's feeding right into what it is we do the best. Similar to the cholera, I've had these patients routinely. I agreed to either leave him as is and encourage the PCP to continue to be his prescriber and not feed into this issue or contract and switch to or add methadone and then taper the oxycodone. I'm amazed he can be on an elliptical with respiratory compromise and hypoxia and so forth. That strikes me. I think I would also invite all my team members to come visit my chaplain and social worker and so forth to explore all the other pain mechanisms, things feeding into his pain. Definitely. David has his hand up. Chris, is it okay for David? Sure, go ahead. Thank you. Thanks, everyone. Thanks for joining. This is a case that I often get involved with many outside providers, particularly oncologists. For some reason, the oncology world believes the only way to treat pain is oxycodone, at least in the areas where I work. That's the only thing they ever prescribe. It's been a number of years ago now that I undertook the study of this pretty intently to figure out what some of the issues were with oxycodone. The first thing is oxycodone is a prodrug. When it's taken, it has to be metabolized into its active form. Now, most of you probably know that, but the two enzymes in the P450 system that does that is 3A4 and 2D6. Those are the two primary enzymes that metabolize oxycodone into its oxymorphone active form. So, when you take it, it's not active. It has to be activated. There's two classes of medicines that interfere with that that I find many, many patients on. The first is beta blockers. So, beta blockers have a higher affinity for the CYP2D6 pathway than oxycodone, and if they take beta blockers at all outside of atenolol, that conversion can't take place, or it's really, really slowed down. And I've seen this happen where patients will be prescribed oxycodone, and their primary oncologist will keep escalating the dose. They're not getting much more effect, and then they miss their beta blocker, and now they can't wake them up. I've seen that, I don't know, like a dozen times or more, where I don't think doctors understand, oncologists or others understand that mechanism and how important it is to pay attention to that. The other class of medicines are proton pump inhibitors, all of them except protonics. And so, if I see this all the time, especially in the geriatric population too, where providers are prescribing both those classes of medications, they're trying to give someone oxycodone, and that doesn't work. And their pain's not controlled, and they're in the cycle of trying to give them more, or how do we deal with that, with the risk of not, you know, overdosing them, but causing them over sedation if they miss a dose of one of those other medicines, or if they take them too close together. The other two meds that I see the same problem with all the time, and they're both pro-drugs, is hydrocodone and tramadol. Both of those have to be metabolized into their active form in those same CYP2D638 pathway. And so, and then the other thing I've discovered over my years of working in geriatric populations and doing pharmacogenomic testing on that population, is about 40% of the population has some aberrancy in those two pathways, in terms of the alleles they get from their mom and dad, in terms of being able to functionally metabolize meds through those two pathways. And so, I just see lots of problems all the time with oxycodone, and as others of you have mentioned, I'm always rotating patients off of those meds, because they're just not, it's hard to control. You don't know what their genomics are, and you, if they're taking other medicines, it's totally interfering with that. And so, this is a great case and illustration that's probably related to some of that. Yeah, thanks for that pharmacology lecture and update. And I think we all knew the pathway, but we aren't taught in any of our palliative care training about medications that actually do interfere with that. We know it probably like the back of our hands for methadone, but we don't often think about it for oxycodone. So, good reminder, and I'm going to remember protonics, because I definitely didn't know that. So, Chris, did you want to say something? Yeah, I would just want to get a little bit more history about what's performed in the past, if he has, if he's been on steroids in the past, would this be something that's been helpful, and he's not used for a while? You know, you get a hit off, you get, you feel better with it. Methadone is, I like methadone, it's great, except it's not a very good as, as, as, Chris, can you kind of adjust your either phone or speak, microphone, because we're having a little trouble hearing you. How is that? Is that better now? Yeah, better. Okay. Anyways, with methadone, as I'm blocking out her name, McPherson, says that it's her favorite girlfriend, but it doesn't really help well with breathing problems. And so, this patient will probably need some sort of other opioid to help with breathlessness on top of the methadone, which I think would be good. Another agent that I've been using quite a bit is ketamine for these chronic pain patients. And you can, you know, start that out at 10 milligrams a couple of times a day with your IV formulation. I have them flavor it so that it goes well, but you can start there. And that sometimes really works well too. Yeah, we used to give oral ketamine, and the hospital I used to work in, and they used the cherry syrup they use for kids. Nobody ever missed their ketamine dose, that's for sure. Right. Very good. Yeah, those are all, you know, really good thoughts. And, you know, I did a lot of work in North Philly, some of my training and a lot of my practice in the North Philadelphia area. So, I worry about the street value of oxycodone, honestly. So, I'm going to throw that out there, and hopefully that's not one of the worries here, but it's always something to remember. And we've said before, even in hospices, sometimes when we stop prescribing these medicines because we are worried about diversion, that we are taking away their grocery money. But obviously we cannot, you know, we have to make sure that we are not supporting diversion for sure. Allen, I see your hand up. Yeah, I agree with everyone's comments so far. I would also offer one other thing. When someone said consider continuing the present regimen, I would disagree with that or push back, and a couple reasons. One, I go off of what a patient is saying, but if he's saying in this case so far, taking every four hours, there's no period where the pain improves, then it's hard to really justify the ongoing current regimen. I agree with David's point and Tom, the first speaker's point that I'd really question what's more important to this patient, continuing the regimen or seeking relief which would involve changes. And personally, I'd be reluctant to add to that don't methadone and perpetuate this oxycodone because I don't think there's sufficient benefit right now. And so instead of clouding the picture and helping clarify what are the goals, he was saying he didn't want to be in discomfort. Now he may be afraid of changing but being afraid and being open to trying and if there are any adverse outcomes, then perhaps GIP. But I have a concern perpetuating what he himself says doesn't work and creates a lot of risk for the provider, for the organization, for this patient. Remember says he's having multiple falls. If he is taking the pills around the clock, how often is he getting up at night? Is he walking? And when's the last time anyone's done a urine on him? Yeah, wait. Questions and curiosities to best help him. Yeah, yeah. All right. So great conversation. Yeah, Kristen, do you have something to say? Hi, Robin. Thanks for the great conversation. Yeah, I think to piggyback on Alan and just a slightly different take, I feel like in a case like this when we should have at least chronic pain on, right? As one of his listed problems, right? Like if we read the case, it's the primary diagnosis is chronic respiratory failure, secondary Parkinson's. We have these other conditions. There's a sense that I see this all the time in our hospice patients that chronic pain gets kind of, you know, talked about in the discussion and the HPI kind of built, it's kind of hovering around in places up front on the problem list and dealt with as a distinct problem because that's what this team, now this team has two things they have to do, right? They have to negotiate a care plan for the chronic pain that's gonna work on both sides. They're gonna have to, in my hospice, we would have to negotiate a contract and really just kind of work with the psychosocial interventions and structure that we know can help kind of hold a chronic pain situation, right? And then we have to deal with the possibility that his dyspnea will get worse, right? But I find in these situations, if we're not careful to distinguish the two and really kind of regimented with ourselves and distinguishing the two, that we get confused and we're escalating opioids for chronic pain that has been mentioned really has never been opioid responsive in the first place, right? But we're escalating opioids for their requests because of pain, but then we're not even really assessing the dyspnea or talking about the dyspnea. So I think that was just one thing I wanted to add that I feel I work with my teams to really just label chronic pain or history of substance use disorder or whatever the true history is. And then to really lay out what our pain contract is, how we're therapeutically trying to address that chronic pain. And then also how we will juggle the need for escalating opioids for dyspnea, which is going to be difficult, but at least we're kind of talking with the patient about it that way too, right? Like the only way we're really gonna be able to help you with this dyspnea is if we can have a agreement and kind of a plan of how we're gonna manage your chronic pain and your opioids, you know? So I'm not sure if that makes sense to others. Tom. Browning. Yeah, so thanks. So I think everybody's saying a similar thing. What I really think is I smell a rat and what just the most recent speaker is saying is that this is an example where this person will get into the team and we'll spend, you know, hours worrying about this, a lot of splitting with elevating practitioners and cutting them off and he's firing his PCP and telling us we're gonna be his savior and don't stop my medication. So I think Kristen is absolutely right, is that you have to isolate the chronic pain. So far, I haven't heard the patient actually say that they want their dyspnea treated in any other way than the oxygen. So they're mostly worried about this chronic pain. And so I agree, I think it's a wonderful thing to use that as a particular problem and work with that problem and not exclude the PCP. I think that's actually the wrong thing to do, that we have to say that we admire the PCP, that they've been doing this for a long time, keep them engaged because they know the patient best. This is a case where I'll make a first phone call to the PCP to find out what their impression is of what actually is going on. One other thing I can add as an operational point, I don't know if people on this call might be leaders, hospice medical directors or team physicians, but one of the things, if I can put out there that's been helpful in other scenarios as an operational point, making sure your EMR, whatever it is, you have an alert, you have something with what your team consensus is because if you're in an organization, you have different hospice teams and that doctor working with that team may know this, do a favor for your colleagues and your organization that you have in a prominent place. So in some EMRs, you can have an alert, there's a dog in the home that's aggressive before you show up, call and make sure the dog's away. Or another thing, who can call or what else, but it's almost like an interdisciplinary communication. And if you have others that are participating in your call schedule, that they know where to look in the chart to find this. Don't have it buried in your IDT notes that someone has to scroll through a few pages. These patients that might be more challenging also warrant a higher level of coordination, especially if we're the leaders, how do we coach our newer docs or those that might be part-time in this? And what should we expect for that communication among teams? If you have a separate on-call or after hours call center, how are you preparing them or over the weekend? And these are all dynamics that can improve your quality of life, not to mention our patients. Yeah, all really great points. I don't know if anyone has anything else to add. I was trying to think of a summary before we get to the end of this case, because I think there may be some more considerations once we kind of get them on hospice. But basically what I hear from this team is that it's probably a good idea and basically what I hear from this team is that it's probably worthwhile to identify chronic pain as a specific diagnosis, which there is an ICD-10 code for. Perhaps consider this a complex case and pay higher, more attention during a team or maybe even outside team to the care of this patient and certainly involving the entire IDT always and making sure that even on-call is aware. And maintaining the contact with the PCP sounds like we're pretty much all in agreement with that. And that makes a lot of sense because to me, it makes us take a step back, think about the patient's problems independently and also helps that poor admission nurse who's gonna go in there and probably feel really overwhelmed with this guy. So anyone else have anything to add to that? Does that seem pretty fair? Summary of our conversations, I'm seeing some nods on those people on. So here's the, yeah, sorry, Tom, on the phone. Yeah, I agree, that's a wonderful conversation. The two issues we really didn't do a lot to is dyspnea, the methadone's not gonna help that. The oxytocin is failed. So working with the team is doctor eventually winning that down doing a substitute pain management. Is the guy, is he at his maximum dose of steroids, et cetera, et cetera. What the hell, he'll still need something to treat his dyspnea with. And really, really a tough case, really a tough case. The guy seems like he's more interested in his pain than he is in his sickness and breath. So that's a tough one. But I wouldn't continue on the same route with his oxytocin and keep refilling that and just adding it to it, I don't think that'll work. Yeah, so I'm shaking my head to everything you're saying, Tom, for sure. And I think other people are in agreement. But we're all seeing these patients now. This is not an atypical hospice patient, unfortunately. I actually, I wanna float this out because I had a patient not too dissimilar like everybody has said. I actually did not relate the chronic pain issue. That's how bad the chronic pain. It was a very specific failed back syndrome and I didn't relate it until we got to the point where all symptoms needed a different approach to care. So I don't know if anyone else has taken that approach but I feel like that was the right thing to do for the patient. The nurses would not have been able to manage this. So I don't know, I unrelated it. I don't know if, I'll let that sink in. Robin, do you mean that you let another, the MD-1 continue or another physician continue to manage it? Is that like a pain clinic continue to manage? Yes, I did not relate it to the prognostic diagnosis and said that this was not contributing to their decline which it really wasn't. And so Tom just put in the chat that he's kept it unrelated as well. And that way you don't have to partner with the PCP in this case or the pain clinic. You just simply say this person is going to that provider for management of this problem which is not related to the hospice diagnosis. There's a challenge in that though from the regulations because under, and it depends who the payer is but under the CMS Hospice Medicare Benefit they do expect the hospice to manage pain. And even if you say it's unrelated that may be a challenge depending on your MAC, your fiscal intermediary and perhaps getting some clarification from your regulatory person, your compliance and asking a question, then it becomes an issue. Do you contract with them and have them manage? And that I think is totally great. We've done that with implantable pain pumps and those types of things. But you get into some issue, the symptoms and I'm just going off top of my head. I can be wrong if someone can clarify for me but I think it's pain. I think it's nausea. I think it's constipation and bowel. And I'm thinking there's one other perhaps breathing. Right. Thanks Heidi, Dyspnea. But with breathing that regardless of the etiology there is the expectation and responsibility of hospice to coordinate it. I'm sure we could talk another hour on that. And it's an approach and certainly I don't do it every time. I'm gonna bet Tom Browning doesn't do it every time. I think, you know, again, case by case and chronic pain, if they truly have that diagnosis it's a diagnosis. And so you're only required, right? I mean, so you can use that argument. You're only required to manage things that are related to diagnoses that are related to the prognosis. And you're right. I mean, there's no question that you have to justify it and make sure that you're doing the right thing. In this case, I thought it was the right thing for the patient. I didn't think our, Kristen I'll hand it over to you but I just didn't think our nurses and that our hospice would be able to manage this in a way that would be fair to the patient and appropriate for the patient. So that's why that decision was made. I'll hand it over to you, Kristen, sorry. Oh no, I think you've done a good job describing a case where that was the way you could best manage it and interest of the patient and the team and trying to be as true to the regulatory process as possible by unrelating it even to Alan's point that that could come back to bite you. But I think you give a good example of you have to make these decisions case-by-case in the context of how the team is doing, what resources you have on the team, what resources you have as an outside prescriber and who this patient is. So no, yeah, I think that's, you're right. We could come, we could ask a hundred prescribers this question, get a hundred different answers, right? Because we have to be creative in these situations. Yeah, and the right thing for the patient for sure. So if everyone's okay, let's just go back and Gina, you don't need to pull up the case. It's just a few comments about what happened once the patient got on to hospice. As previously, the patient was given a seven day supply of medication. The patient went through it in three days, well, the oxy was gone in three days. So was the Roxanol bottle, which he said the nurse spilled on the floor. They changed to daily delivery of medications and the patient began reporting that the medications he received was less than what he was supposed to, the number, and asked for more, a higher dose. And that of course it wasn't controlling his pain. And he refused a trial of buprenorphine. And the last comment was that they're considering now switching to methadone. So, the end of the case is that, no surprise, we see some aberrant behaviors. And I guess the question is, okay, now what do we do? Maybe we didn't have our beautiful plan outlined for him when our nurse went out there. So now, are there any new concerns and what would people do at this point? Crying? Yeah, this is Tom again. That is so classic that this is a classic oxycodone. They will take all you give them. It's not working. You're treating a dependent problem. It's a separate case. Pulmonary fibrosis, et cetera, et cetera, is not a painful disease. It's a dyspnea disease. And I just don't know. You have to set the rules. You have to pill count, do all that stuff. They deliver them once a week, the lock boxes, et cetera. I've had to do this a few times. And who lives in the house with them? Is there any abuses or diversion? Is there this? When I hear these doses of oxycodone, I just think of all the nightmares I've had with these patients. I don't really know. I have even had the discharges patients that are non-compliant, but I hate to do that. Somebody has got to this level. And we have, I'm in Pittsburgh, Pennsylvania, and somebody was talking about letting the pain, people manage the pain and somebody else do the dyspnea. A lot of the pain centers now don't like to take on hospice patients. That contract is a good idea. I'm gonna talk to the bosses about that. I don't have a lot of problems such as this, but it only takes two or three cases to make it crazy. If he's totally non-compliant, it's not working in the first place, even when he goes from 30 to 60, he's still nine out of 10. So where are we going? If something else has to be done, I'm not sure exactly what that would be, but it's not what we're doing when he gets on the hospice. The nightmare. This is Alan. I agree with what Tom was just saying. I also wanna say one other thing besides caring for the patient, we as leaders need to care for members of our staff and team. This raises concerns for me that the nurse should not go in alone, that there should be a tag team. Another reason is you now have a patient for whatever reason making allegations that the medicine's controlled substances are different than prescribed. That may be a felony. That may be other types of questions. And with that type of scenario, I would be concerned putting a staff member, there's also an undercurrent of some aggression, hostility, belligerence, and I may be reading into this, but as leaders, we should also be sensitive to it and have protocols to respond accordingly. And likewise, cautioning. So again, put in the note that you may not have a music therapist who just joined hospice two months ago and is going out there on their own, or a brand new social worker or chaplain. These may be new scenarios for them. Those of us on this call are aware, but we have to coach our colleagues, our team members, as well as, unfortunately, be prepared. Yeah, Chris. Thanks, Alan. Yeah. We always have to be wary of your team members. Readjust your microphone, not your microscope, your microphone again. Yeah. Sorry. You always have to be aware of your team members and wanting them to be protected. We often will have two people out when we have patients like this that we are concerned, two members of the team going out. But the other, his refusal and these complaints, we would put him immediately on a pain contract, which is our step for going through the meds. And this is the way it's going to be put out. And this is, we're going to put you on methadone. And if they don't agree to these things or they violate the pain contract, then you have cause for discharge. So these are ways that you need to be able to set it up for that, and so that's how we would plan on handling a patient like this. And our pharmacist, well, I can do these things. You'd find something challenging. I've never gone to everyday delivery, but I've had every three days, and it wasn't delivery. The patients, somebody would have to go to the pharmacy and sign for the medicine, and therefore it would be validated right then and there, how many you're getting. So there's no, he said, she said. So I've done that. And also in our provisional is what we would call. So we do the pain contract on admission, on every single admission, no matter who you are. Agreement, not a contract. Then if there's a problem, then we do what's called a provisional, where we remind all these things of what you say, you know, what we say we will do and what you will do. And if there's a discrepancy, we're gonna come back and revisit this in one week. And if something is not quite right, so like a pill count or whatnot, then that could be, could be cause for discharge. But, and then we also tell them if there is a discrepancy, we're not the police, but we'll call the police and we'll let them figure it out. So. Perfect. Yeah. I agree. Yeah. Well, certainly safety of staff is utmost important. Protecting the license of the organization and our prescribing licenses, also of utmost importance. But Kristen in the chat brings up an important point that discharging for cause when we're the prescribing providers, you have to find somebody who will write for the opioids. And so that could be a challenge unless we have contracted with a pain clinic, of course, or maintain the relationship with the PCP. So, yes. And Tom, good point. Protecting our communities from these drugs. You know, certainly a plan for this patient sounds like a contract. I mean, this is where I would call it a contract. The agreement is one thing, a contract is a contract. You know, if you do this, we do this. And we have to be willing to uphold that contract. On our part, we can't be the, you know, the kind hospice people that we tend to be. And so we really have to uphold that. I would argue, or have people consider, and maybe you guys do this, but I think he needs a drug screen and maybe a quantitative one and see if he's actually taking his, well, maybe just a screen would tell us if he's taking his opioid, but maybe he's taking some of it, not all of it. So, and, you know, and then moving forward, you know, if he is not adhering to the behavioral contract that you've devised, then, you know, he, you either have to stop provide, I think stop prescribing as step number one, the opioid, and then just keep him on hospice for the reason that he's on hospice and then look at discharge for cause. So I don't know if anybody else has a different kind of approach, but I think we've shied away from agreements and contracts and holding our patients accountable. But now that we're seeing these patients where the opioid isn't critical to the care of his symptoms related to his hospice diagnosis, we are put in this position and we do have to have a plan on how to manage it. Thoughts, follow-ups? Tom is asking about drug disposal at time of death. We do in North Carolina because it, I guess it's true everywhere. It is the patient's meds. We can't touch it without them asking us to help. Anybody else? Tom, go ahead. You're muted. You're muted. Okay, I'd like to review the case. And am I gonna accept this case? Do I think that I can help you get the case straight? Lately, over the last month, these referrals for chronic pain, and just like you said, not related to the hospice diagnosis. They were in a pain clinic and they have another disease that's not painful. And I just got one the other day that I didn't accept. He's on 150 one milligram Ativan tablets a month. And those cases are monsters. And I just, I don't personally know if I were to study the case you're discussing, would I admit it to hospice with pulmonary fibrosis with such a long drug history? And now you saw the discrepancies in the pill counts and et cetera, et cetera. They only get worse. And I agree with sending my nurse into that house alone because they do get angry, they do get combative. And I hate to use the word addict, whether it's dependence, whether it's addiction, I have to study that case. And I do study my cases before I certify them to receive the hospice benefits. Actually, that's more of a drug problem, a case like that, because you haven't even talked about it. It's an oxytocin case that would scare me away. Unless they're willing to try other modalities to control their pain, other than just getting more and more and more oxytocin. Yeah, it's definitely a tough case. And certainly opioid use disorder, not sure we could help him at this point, but does need to be considered for sure. Tom Browning. You're muted still. So you don't have to listen to me dog bark. So drug disposal at the time of death is actually really interesting because the patient and the healthcare proxy control the medications when the patient is alive, but when the patient dies, then it's actually whoever is their executor. So the estate becomes the owner of the medication. So we still don't own it, but I mean, this has been a huge issue in our area. So I've been very kind of reminded my staff how important it is. And I've told them to remind the families of people who refuse to give up particularly the opiates that whoever, that the estate owns the drugs at this point. And if somebody takes those drugs and does something with them, they're criminal, that's a criminal act now because they've stolen the drugs from the estate and done something with them. For example, taking them themselves. Really gotten any traction with it, but it is a reminder to families that this is a big issue and that even the healthcare proxy no longer owns those drugs because at the time of death, the healthcare proxy goes away and the estate becomes administered by either the state or an executor. Hmm. That's a challenge. We own and take everything else back in hospice. We take the equipment, take the oxygen, we take everything else back, but we can't take the opioids back even though we pay for them. So this has been a great conversation. We're moving towards the end of time. My hope was to discuss this case for the first 45 minutes and maybe get to some questions, but it's obviously a very challenging case and one that we face on a more regular basis than maybe when we first started in hospice. Are there any other comments or thoughts we've got some good resources now in the chat. Put it in the chat as recently, and this was through the Academy just on Tuesday, that when Joe Schrager and others gave the opioid in service, even though the FDA, the DEA, screwing up my acronyms, even though the DEA still has an official allowance and even guidance for flushing some medications, I wanna caution you, it may be illegal in your locale. You may have heard, it was a couple years ago, it got a lot of traction, but city water supplies have been contaminated in some areas with opioids in their water. And that is something that locales have passed their own regulations, do not flush. And if they trace back, whatever else. So as we need to adapt best practices that may be in conflict locally, nationally, and again, making sure you follow what's right in your area. Yeah, thank you for that. So I don't think we have time to get to any questions. I was gonna ask, does everyone know that the DEA is now requiring for your next renewal or initial application to, you're gonna be asked to affirm that you've had eight hours of opioid or other substance abuse training. So that is required starting this year. So anyone who's up for that. So we're gonna look into that here to see what kind of training that we need to do. And maybe it's something this group can talk about at some point or provide. I think the Academy is providing as well as CAP-C is providing some training that will meet these requirements. If anybody knows anything about that. Yeah. And then Gina just put in the chat about one that HMDCB is planning as well. It has to be a total of eight hours. You can piece together from various places. So great to know about different resources. Thanks. It's a good way, good end to the session, Robin, to remind us that this is lifelong learning. And now the DEA wants us to continue lifelong learning as well in this regard. So exactly, exactly. So. Do we have a hospice discipline only annual training get together any longer? Like there was, I can't remember the name of it, but it was some sort of maybe a one day CME event back in the summertime. I can't remember, years ago. And I guess that kind of went away. And of course COVID then and so on and so forth. But is there anything that I'm not seeing that's just hospice centric? You mean through the Academy or just- Well, yeah. I know that the Academy did some summertime sessions, yeah. Yeah. But it's a nice point- The disappointing thing. It's a nice point, Gina, for us to think about collecting resources like that to share with people about opportunity. Yeah, that is, thank you for that suggestion. I don't think, and Dave Wenzel's on the phone, who may know, I think they can be used to offer that. I don't know if they do anymore. Though I can look into it, but to my knowledge, I don't think there's any. Who did you say? At least not this year. What was that? Who did you say? The AHPM, I think you should ask for hospice only sessions. I don't know, Dave, if Dr. Wenzel knows if those are still being offered. Not currently, Gina. I think they, the first time this past year at the Academy meeting, they were providing the sessions in like shorter, 15, 30 minute, like much shorter sessions. So they had a lot more of them and there were some marked specific for hospice. But I know what Carolyn's asking and I don't think there is anything like that currently. Okay. I guess what I'm missing is back in late nineties and so forth, when the meetings were truly hospice-centric, it's really before palliative care was up and running. And now of course it's together, which is fine, but I'm feeling, because I'm a hospice medical director and that's all I do. I don't do any palliative care in the now traditional sense. So I just feel like I wish I had some sort of two day, something where medical directors get together and truly engage and have our questions and cases and this and that. And I have burning questions and I wish I had somebody else to talk about it with. And so that's what I'm asking for. You're raising a really great point in that I've been a member of the Academy for that many years too. And I remember back at the meetings in the nineties where there was only a few hundred people there and they were all hospice medical directors. But I will say that the creation of this board came out of that discussion of how do we not only provide a place for mid to late career hospice providers to get certification, but a community for hospice providers. And as some of you have mentioned, there was the hospice homeroom at the Academy that was another part of what they're trying to do to promote and support hospice medical directors. But maybe this is something we could think about like in terms of submitting something for a pre-conference workshop at the next Academy meeting or something that's very hospice specific. I mean, that's a great idea. I'm always open to finding places where our certificates and hospice medical directors can come together. That would be good. It's a board review course in Kentucky. I was sort of disappointed. I took the course in August in Louisville and found out when I got there, going on at the same time, because I know Joe Shega gave us a lecture and then he said he was doing the advanced pain management meeting that they also had, which I didn't know. I would have liked to taken both, but to my knowledge, they were given at the same time in Louisville. Now that would have been a great course to go to, but you couldn't go to both. Well, these are great suggestions. And yes, I think this group definitely agrees that having a place for the hospice medical directors to get together is really important, so. Yeah, great. A new effort for you, David and Gina. Yes, thank you, everyone, for sharing. I know, so it's 4.04, anyone who needs to leave. Thank you so much, everyone. But Chris, you have a comment, and please share with us. Yeah, I agree that this is, I'm an old timer, I'm 72, and I've been doing this forever. Me too. And the original hospice group was back in the early 90s, and then palliative wanted to get involved. So then we had a discussion about, should we become hospice and palliative medicine? And now it's rotated to palliative a lot, and primarily because of the people going through the fellowship program only get about a month of hospice. So they don't, there's not a lot of us, but you need a strong basis of primary care medicine to manage chronic disease states in hospice. And that's part of the issue that we need to look at to help train people coming through, because everybody is so siloed now in their practices. In the present day, we really need to open up and try to teach people chronic disease management, which is what hospice medicine really is. And so anyway, that's my two cents on that. And we did get together, like whether we would have before the conference, a regulation, bootcamp regulation. And so that was often part of that. And so that would be all hospice people. So that was one way that we could do that. So anyway, that's my history on that. Mm-hmm. So those are, yeah, great thoughts. And we hear the need. And so hopefully we can think about a pre-course and maybe think about some other ways to provide a forum for conversation amongst medical directors. I think that would be great. And there's eight weeks required, sorry, 10 weeks of hospice required for ACTME, Hospice and Palliative Medicine Fellowship. And the experience is variable because of relationships with hospices. And so here at Duke, part of the reason that I wanted to be a part of this is that there's a good connection with the hospice. And so the eight weeks is very defined. And it's not so defined. I see Leslie Sutton is on the phone and I know that they worked hard to partner with UNC. And so they have a pretty defined experience now for their hospice. But I think one of the things the board, the education portion of the board, the committee of the board, we're gonna look at relationships with Hospice and Palliative Medicine Fellowships and see how we can strengthen that training. So Chris, thank you for bringing that up. It's really important. And I think everybody acknowledges that we could broaden and do a better job of hospice education within the fellowship programs. All right. Anything else? Thanks, Robyn. Thank you so much, Robyn. Thank you so much. Have a great couple of months. We'll see you in a couple of months. Bye. Bye-bye. Thank you.

hospice patient

chronic pain

respiratory failure

oxycodone

rotate opioids

methadone

pain control

medication refusal

drug diversion

pain contract