I don’t push medications but will support you if you’re unsure, insecure, even frightened of them. I’ll guide your giving it and strengthen confidence in its helping effect, but also support your reasons for not automatically reaching for pharmaceutical solutions.
Should we take a medication, or not? Two reasons for giving medication are especially needed symptom relief or the danger of too-sudden a withdrawal once you’ve started taking something. [Yes, you must gradually reduce: corticosteroids, opioids, blood pressure medicine, gabapentin, antidepressants, anti-anxiety medicines (and others) to avoid withdrawal symptoms, or risk heart attack. Use a doctor’s direction here.]
Once starting a medication, you’re stuck with prior unknowns of consequences for having taken it. But nothing taken once or twice should cause a physical dependence (a neutral fact), often misrepresented as the fearful psychological addiction (a loaded term with negative connotations that summon unsavory images of animalistic dope fiends).
It’s up to you whether you start taking or don’t take a medication. If you decide not to, then you won’t make a medication error. Some might argue that you’re making a terrible error in judgment by withholding something that brings needed relief, but they can’t say you’ve made a medication error.
Let me point you to a website that lists 10 questions (sets of questions — the number comes closer to sixteen) everyone ought to know the answers to regarding each medication they take or administer, and the interactions between those medications. Review my comments and stories attached to these Ought-to-Knows. They may provoke your guffaw, head-shake, or surprise. Collectively considered, I hope you’ll then pause and weigh the fuller responsibility of starting a medication therapy, but not unreasonably avoid them.
BeMedwise.org starts out with such basics like, What is your medication’s name and purpose for taking it? https://www.bemedwise.org/questions-to-ask-about-the-medicines-you-take/
I infer future success or failure of a medication therapy by whether or not someone is taking notes while I’m explaining medications to them. I could hand a pen and paper to my audience before I begin teaching. After hearing the fourth distinct wrong pronunciation for the medication “lorazepam” from the same person during the same visit, I lose confidence. The daughter mocks the medication, thinks she makes it feel bad for having a difficult name, but her fight is with her father. I understand when we’re faced with new information, I tell her. Sometimes it’s too much at one time. I don’t care if we call it Some Shit in a Bottle (SSiaB), so long as you know what we’re talking about, how to give it, and when her father needs this SSiaB for his crazy-making anxiety.
Next up, know how to take the medication and the length of time it should be taken.
Medicine ‘delivery’ has different ‘routes’, which sounds as if nurses are dropping off Amazon packages.
The oral route is swallowing, and then pissing or pooping out what’s left over; some medicine is lost through sweat or the breath. As important as getting rid of the medication is, getting it down can also be a problem. If you have trouble swallowing, crushing and mixing with pudding or sauces does not disguise the bitterness of some medicine or its fillers. Changing the medication to a liquid or a transdermal formula is available (sometimes.) Towards the end of life, pill-taking is forgotten; eating, too. Don’t worry, you’d be surprised at how little a body needs during the last weeks and days before death. Late in the game, use sublingual medicine that seeps through the mouth’s mucosa and into the rich supply of blood vessels under the tongue. That’s the theory. It sort-of works. One quarter of a milliliter — about six fat drops — gets you five milligrams of morphine or a half milligram of lorazepam, enough to help with end of life upset.
Type 2/adult-onset diabetics generally know how to inject themselves subcutaneously with short, thin insulin needles, or die prematurely from faulty attempts. By the time we meet, they’ve reduced/finished with insulin because of weight loss and calorie reduction. Walk every day, lose weight, and restrict calories to see for yourself. Start low and proceed slowly.
Battery powered IV pumps keep patients’ blood pressures from causing sudden death, or manage fragile pain. The pump rates are set and locked, so the main challenge involves keeping the tubing free from kinks that sets off an annoying alarm. If I’m working on-call and our call center triage nurse refers me to a visit requiring fixing a CADD pump alarm, I know I’ll get paid mainly for driving there and not much more. All the while, I’m wondering why the triage nurse could not talk the frantic family member down sufficiently to fix the problem over the phone.
Fentanyl and a couple of other transdermal (TD) patches get absorbed through the skin, and yet are systemic medicines, potentially available to every cell in the body. Don’t put a heating pad over that fentanyl patch or you’ll overdose. Remove the spent patch and alternate sides of the upper torso every 72 hours. Mark your calendars when the next fentanyl patches are due. First thing I’ll ask you when you call me about mom’s diarrhea is, “Is she detoxing because you forgot to give her next fentanyl patch?” (Sure enough, it was due two days ago while she suffered in silence.) Tape down the thin, small-dose patches or they’ll fall off. If you’re foul with sweat, or can’t stop putting oils on your skin, or are too hairy, then TD patches are not for you.
Some medicines are meant for a limited time interval, generally antibiotics and short trials of diuretics (so-called “water pill”) to help if short-winded or retaining too much fluid at feet and legs. Take them all (if you can), on time, and then stop.
Taking antibiotics only until you feel better shows your ignorance of how they work. “Don’t be stupid, be a smarty.” — Mel Brooks. They kill enough of the too-many germs that have overwhelmed your body’s germ killer police force until you can handle the rest. Stop too early and those extra germs not yet killed will have time to adapt to the antibiotic. They’ll over-multiply again (trust me), only this time be resistant because you quit too soon. Don’t de-fund your infection police! Take all those pills, not only an amount that will just make your infection smarter and tougher. CAFO-farmed meat, eggs, and milk has loads of antibiotics in them to keep the animals from dropping dead from the constant sickening cruelty inherent in how we get fed these days. (CAFO stands for Concentrated Animal Feeding Operations. 70% of all antibiotics go into CAFO-bred animal proteins.)
If you take diuretics too late in the day, be prepared to disturb your sleep with sudden needs to urinate, or wear a diaper.
If a medicine is scheduled it generally means no stop date, i.e., keep taking it until told to stop. If it’s a pill for a chronic disease caused by overeating, like a cholesterol medication, then you’ll wait until doomsday before the prescriber calls it quits for the Big Pharma moneymaker.
If a prescription uses the words “as needed” then don’t use it until it’s required. All as-needed medicine lists the reason, the symptom it’s meant to treat, the why. If you’re not bothered by that symptom, don’t open that bottle. Hospice’s so-called “Comfort Box” of medicines, which receiving families are instructed to put in refrigerators and not open until told to by a doctor or nurse, are all as-needed medicines. I must forget every time, because it keeps happening that someone starts giving one of these medicines just because “it said to” every 4 or 6 hours, forgetting, of course, to read or understand the words that follow – “AS NEEDED”. And that no pain or nausea was ever present for which these medicines were there to treat. That’s another pitfall to warn against, as if there weren’t enough of them.
I have no idea how often, but it seems like every day I get asked when to give a pill while the literate person is holding the medicine bottle in their hand. Answer: You take it according to the times spelled out on the medicine bottle, which is where the prescription is written.
Just in case, let’s pretend no one reading this knows what constitutes a medication prescription. Five or six details enclose a legitimate Rx: What: the medicine; Who: for whom the person printed on the bottle it’s written for; How: “by mouth”, etc.; When: specified there as well; Why: “for pain” or the xyz reason, not usually included on the medicine label, for privacy reasons. I wish reasons (but they can vary) were listed on labels, but they aren’t. I must look up those I don’t know.
Also on the label, you’ll find who wrote the order and when; when this medicine was filled; the number of refills allowed before an additional Rx is required; how much liquid or how many seperate tablets or capsules are in the bottle; the name of the pharmaceutical company manufacturing the stuff and a physical description of the medicine (same medicines can look different depending on the pharmaceutical company).
Two liquid medicines commonly used in hospice – morphine sulfate concentrate and Lorazepam intensol — should not be separated from their cardboard boxes because the prescription label is on the box, not on the bottles. The bottles are too small and get too messed up with their spilt, sticky insides to secure for long a readable Rx label on them. That way you won’t give two days’ worth of an anti-psychotic when you thought you were giving a pain medication.
Are we having fun yet?
We’re only up to the Third Competency about taking or giving medication. I don’t know about you, but I’m tired already.
What are expected side effects and the solutions to possible side effects associated with taking this medicine? Which side effects are expected versus which signs or symptoms are causes for alarm?
Did you catch that? I said it twice: certain side effects are expected. That’s like saying, nuclear power waste is unstable and dangerous to humans and other living creatures for thousands of years. Crazy, isn’t it?
All medications have side effects.
How many of us have listened to those daytime Big Pharma commercials with happy smiling people holding hands while in a lower voice the announcer adumbrates the dozen or so ways you can die from taking this new blood pressure or diabetes pill? I’m doing assessments on a home patient while the TV is on and attend at the same time to these commercials. I’m thinking, No one can be listening to this! Ever read the online side effects pages, or scan the fold-out paper that comes with a package? How can one tell if it’s you who might be in that 0.003% susceptible to gastric hemorrhaging?
Let me tell you a few side effects and pass over the rest, hoping with the recent Jewish holy days in mind that we’re spared G_d’s wrath for taking that which is forbidden.
If you have a heart condition then consult a professional (doctor, pharmacist, advanced practice nurse) before taking these together: antibiotics and psych medicine like haloperidol/Haldol or quetiapine/Seroquel, especially if you’re on or starting methadone for pain. You could get a heart attack. If you take an opioid then take something for constipation if you don’t exercise, don’t drink lots of water or eat lots of fiber. Either take senna or your pick of laxative or be handy at fingering your anus to loose the stuck-dried poop you’ll soon find lodged and jammed there. If you take lots of medicine and tend to be sedentary, take a prilosec for sour stomach. I ask for omeprazole 20mg extended release. I could go on, and on. And on.
I switch off.
Samuel Beckett, “What, Where”
Do I take this on an empty stomach, or with food?
Of all the questions people have about medication, this is the one I actually do get asked, and for the most part it is irrelevant. Sure, you should take your thyroid pill on an empty stomach because other foods or pills might have calcium which can bind to it and decrease its hormone replacement effect. But if you’re used to taking it with other pills, then keep doing that. Sometimes antibiotics are pretty rough on the stomach and should be taken with a cracker. Other than that, I’m not much help. Some older psych meds used to be forbidden with grapefruit or its juice on pain of a malignant hyperthermia (brain-damaging fever) reaction. Medications are safer now. But that doesn’t mean they’re innocuous. Don’t become too blasé about medications.
What should be avoided while taking this medication: Activities/Foods/ Drinks/Alcohol/Other medications?
Don’t do anything or drink alcohol, then you’ll be fine. Have fun, though!
Alright, you’re taking an anti-platlette tablet like Plavix or even a low dose aspirin. If you fall and smack your noggin just so, you can get a sub-dural hemorrhagic stroke that can end your life after lingering in a nursing home and suffering multiple seizures; not a pretty picture. Go ahead and have your little drink too, like Don Vito Corleone says to Tom:
Don Corleone : And now you’ve had your drink. Tom Hagen : They shot Sonny on the causeway. He’s dead.
“The Godfather”
Just don’t let’s get stupid, alright? Alcohol intensifies an opioid, anti-anxiety pills (which basically act like having a stiff drink anyway), and other meds that effect the central nervous system, that cross the blood-brain barrier. Then you’ll fall. Is it worth it?
Does “Daily” mean take it in the morning, or in the evening?
Morning. Unless it makes you sleepy, then take it late if you sleep overnights. “How often should I take this daily pill?” is not a made-up question. Some have 13 pills and arbitrarily split them into groups of four or five throughout the day regardless of prescribed timing or side effects. There’s a lot of different pill takers out there doing their own thing under their own guiding stars. Yes, but studies have shown that, even while in hospitals and under licensed medical supervision, about 100,000 unnecessary deaths occur in the U.S. each year because of medication errors. What the actual number of avoidable deaths is, if you include all the civilians giving and taking medications at home, boggles the mind.
Now we come to medication interactions with: over the counter medications (OTC), vitamins, supplements, and herbals.
In hospice, too many supplements, vitamins, even cholesterol medication; and too-close monitoring of diabetes and hypertension is unreasonable and going overboard, in my opinion. OTCs for colds or pain have acetaminophen (what Tylenol is made of). Add up all the 24-hr/day’s milligrams of acetaminophen and don’t go over 3,000, to be safe. Less if you have liver disease. Vitamins are a waste of time and money if you can eat a variety of fresh vegetables and fruit. If you don’t eat fats, then fat soluble vitamins have no carrier to effect their transport into cells. Supplement-takers should be as well-informed as herbal habitués: St. John’s wort for mood interfers with several medications. The lists far exceed this blog’s capacity, look it up yourself and keep learning.
When does this start working? How will I know?
As soon as someone starts taking a medication they start feeling better because of the placebo effect. If you take something by mouth, it takes a 30 – 40 minutes. Sublingual can take 15 minutes or more. Subcutaneous or IV effects start faster, within seconds if medicine goes directly into the bloodstream. Starting transdermal fentanyl might take several to twelve hours before knowing that you’ve even put something on your skin. Keep those AS-NEEDED doses of morphine or other short-term analgesia handy for up to twelve hours when starting a new fentanyl patch. Methadone, when started multiple times a day for pain, isn’t fully effective for the first six to seven days, although one ought to feel better for having taking it after a day or so. Never miss a dose of methadone once you start taking it.
For the second part, How will I know? see “What are you taking it for?” If you don’t feel less anxious-pained-nauseous-itchy-dizzy but instead feel an added sedation and stupidity, that can be a warning sign of a bad trip. If something feels wrong or a sense of doom intrudes, speak up right away!
Storage: Worse case scenario is in the bathroom medicine cabinet. Why? Because of the bathroom’s heat and moisture, two conditions that spoil medicine. Security: Locking and child proof caps are also proof against weakened or rheumatoid arthritis fingers and hands. Hospice medicine can be deadly (suicide by respiratory depression) if gobbled or quaffed without a physical tolerance. Keep a couple boxes of naloxone/Narcan nasal applications handy if you’re likely to slip back into heroin or otherwise overdose. When someone checks on you and you’re barely breathing, we can revive you.
Directions to store the “Comfort box” of medicine in the refrigerator is meant to help in times of dire need to locate it, since not many refrigerators populate individual residences, unlike any number of cabinets and potential hideaways. However, if you have nosy children or demented or incompetent humans that may find, misuse or mishandle medicines, then use your judgment.
#10(?) Refills, extra dosings, and side effects from extra doses.
I wish people would keep track of how many days left of every medication they need and can’t miss taking. It would make life so much easier as a home health nurse. Every time I visit I must count medications: how many have been used, how many are left, how many as-needed medication doses have been taken and what this means in terms of my patient’s state of health and symptom management. I’m not anywhere close to accomplishing this: Almost never at every visit. So I get text messages on my work cell phone, on Sunday, “No more metoprolol and Ativan, please help”.
I would like to help, honestly I would. Just so happens I’m taking a few days of PTO and unavailable to respond to a special request that a physician sign off on a special pharmacy app involving twenty minutes’ work and an extended phone call to the pharmacy so John Jr. can run over to CVS and pick up a short supply to tide you over. No $230 delivery charges are approved for our courier service since your refill is not a new order.
Ask yourself until Monday these questions instead: Do I really need this medicine, and What would happen if it wasn’t available?
And one more favor, if you please: Do you really want to be remembering all these Ought-to-Knows for every medication I take, and every interaction?
Trust me, we barely scratched the surface here of what’s pertinent about the taking and safely giving of those many, many typical medications.
Maybe I’ll start taking a calcium supplement soon, like a doctor once advised me fifteen years ago. Maybe next year.
Hospice Nursing 1 Day at a Time 