In this episode of “Reimagining Hope,” Dr. Rachel Jordan is joined by Dr. Sonja Richmond, a physician specializing in hospice and palliative care at Hospice of the Chesapeake. They delve into the critical topic of medication management for aging and chronically ill loved ones. The conversation focuses on the importance of re-evaluating the purpose and necessity of medications, particularly for those in hospice or palliative care, and how to empower families to navigate this challenging process.
Dr. Rachel Jordan
Welcome to our podcast. Today we’re discussing an important topic. Managing Mom’s and Dad’s medications. And when is it too much? Joining us today is Dr. Sonja Richmond, a physician specializing in hospice and palliative medicine at hospice of the Chesapeake. Thank you for being here, Dr. Richmond.
Dr. Sonja Richmond
Thank you.
Dr. Rachel Jordan
So, tell us a little bit more about yourself, and I’m glad that you’re here to discuss this critical issue in this aspect of care.
Dr. Sonja Richmond
Thank you, Dr. Jordan. Rachel, my friend, my sister. As you shared in your introduction, you’re a mom, you’re a daughter, you’re a sister, and most importantly, you’re a friend and an advocate. I too am an advocate. Born and raised in Miami, Florida, did all my training in the Washington, DC, metropolitan area. I see a great need for education and information for the population that we serve. And happily, Hospice of the Chesapeake allows me to do just that. I serve as the vice president of medical affairs and hospice medical director with Hospice of the Chesapeake.
Dr. Rachel Jordan
Good stuff. Well, before we get started, I want to be clear that we’re not here to tell you what medicines are good or bad. It’s important. You know, our focus here today is just to highlight the influx of medications that are prescribed to adults, especially those that are chronically unwell or maybe even aging. How many times we go into a home and there is a medicine cabinet full of pills, all prescriptions, new prescriptions, some that conflict, some that don’t. And so, we want to give families and listeners the tools they need to know when is too much enough, or how do they even begin to unpack all of these things that they see. Because, you know, every prescription is a good prescription, right? The doctor told me to take it. So let you know. Let’s dive into that and see what we can do for our listeners today to help their families and their loved ones.
Dr. Sonja Richmond
Yeah, I would say first and foremost, the most important thing is the inquiry. Are these too much. So, when you ask that question, you’re opening up a window, you’re opening up a door and an opportunity to engage and talk about yourself with your healthcare provider. My first recommendation is to always ask, to always seek that information and knowledge in an environment that’s supportive.
Dr. Sonja Richmond
And that starts with your healthcare provider. The goal is that you’ve formed a relationship with your health care provider, thus far. So, an opportunity to sit back and discuss these cabinets full of overflowing medications, expiration dates through the roof, can’t even read what’s on the label or you’re reading what’s on the label. And your question is, does it still even apply to me where I am today in my life?
And it’s an opportunity to reset. It’s an opportunity to clean house, and it’s an opportunity to have a quality of life. Medications serve their purpose, oftentimes in a certain time frame when you are recovering from a certain illness or setback. But the goal ultimately is not this longstanding. Forget about this medication and all of the possible implications of side effects.
All the possible implications of just not feeling your best self when you have been diagnosed with a chronic illness, when you have been diagnosed with a terminal illness, or when you’re in your day-to-day management of your life, looking at these meds and asking yourself, are they still helping me or are they holding me back? Is it a burden for me?
Dr. Rachel Jordan
Yeah, so important, especially in the patient population that we serve. Right. So why is medication management so important particularly for hospice and palliative care patients. You spoke about the relationship, but you know, why it is so important in, in this particular area of medicine.
Dr. Sonja Richmond
What I have found in this arena, when bringing someone on or under care at Hospice of the Chesapeake, you’re going through pages and pages and pages of medications. And studies have found that as we are approaching end of life, there are a set of a few medications that are here and available to help with symptom burden.
So, we change the switch. There’s a different focus and a reset. And no longer is your disease guiding this train or guiding the show. It’s you and your symptoms and alleviating those symptoms managing those symptoms. So, it’s an opportunity to peel away especially when you’re not feeling your best self. And I have often found that as you peel away with many of these medications that can be weighing your loved one down, you see a different person. You see someone who is alive, who is engaged oftentimes and often no longer burdened by the laborious medications and the schedule that it comes with it.
Dr. Rachel Jordan
Absolutely. You know, there’s nothing more liberating than to walk into a patient’s home and you start that visit in their own 18 medications. And then at the end, you’re like, I’m just going to leave you with five medications because think about how much time that takes for a mom or dad to have to wake up. And I have six medicines to take, but I must make sure I have food on my stomach, and I can’t take this one with coffee or dairy.
Dr. Sonja Richmond
I have to be up right, or my legs have to be down, or one eye has to be open…
Dr. Rachel Jordan
I can’t have grapefruit, right? And then you’re like, well, I’m on this antidepressant. Can I take this medication? Or, you know, I have to take this antibiotic. And that’s the other thing. Sometimes we get into that hoarding, right, where you they’re like, you know what, this antibiotic worked for this. And I’m going to store it in my cabinet until, you know, I have something else coming.
Dr. Rachel Jordan
I’m like, please don’t do that. So, you know, we have to have this open conversation about when the medication is no longer necessary. It’s okay to let it go.
Dr. Sonja Richmond
Oh, okay. Yeah. And it’s empowering people to understand that it’s okay. One secret I want to share as a physician, I love engaging with the people that I care for. Yeah. My role is not to stand here and be a dictator and tell you what’s best for your life. My goal is to be a source and a resource in helping you navigate the best way you can, and to walk with you not in front of you, but alongside with this journey.
And it is such a liberating feeling when you can walk out of someone’s home after you’ve not only scaled back on the meds, but you’ve scaled in with the education and the information and you.
Dr. Rachel Jordan
Know they’re going to feel better.
Dr. Sonja Richmond
Right? Absolutely.
Dr. Rachel Jordan
Let’s talk about some of the common medicines that we use in hospice, because you probably get this all the time because I do, too. The moment we mention hospice everybody jumps. You’re just going to prescribe me morphine. And I’m like, I have so many other medicines in my toolkit. Well, let’s talk about some of the more common things that we use in hospice.
Dr. Rachel Jordan
You talked about how the focus is symptom management. So, what are some of the more common medications.
Dr. Sonja Richmond
When we talk about symptom management we focus on domains of decline. We focus on repetitive information that we share when we’re caring for people. Studies that have shown aspects that’s affecting someone’s quality of life. Pain. Huge. Yes. Agitation. Anxiety. Huge bowel regimen. Huger than huge. Nausea. Vomiting. Absolutely important. Even respiratory distress. Some people even encounter sleeping issues.
The list can go on and on, but the ones I started with are the main medications, the main foundation of symptom management. And if we keep it to that core. Notice I didn’t say multivitamin, I didn’t say a multivitamin. And oftentimes we hold that multivitamin with so much I would say tightness. And afraid to let go that we may be impacting an opportunity to feel better.
So, when we stick to the core, those core medications that help alleviate symptoms, that help me along my journey of treatment, that help me along my journey of end-of-life care. We see a new way of focusing on the patient in their family and keeping them at that nucleus.
Dr. Rachel Jordan
Yeah, absolutely. I couldn’t agree more. You know, I always tell my patients, your best source of nutrition and vitamins is from the food you eat. Yeah. Think about it. I can give you a vitamin. You ever wonder why your urine turns so yellow after you take it? It’s because your body can’t accept all of that at one time.
So, you waste it off, and sometimes you don’t feel well after you take it. Sometimes you get a little bit of a headache. You get this taste in your mouth. Now, not all vitamins are bad, but there comes a time and a place where it may not be the best to take it at that time.
Dr. Sonja Richmond
At that time in your life, if you are already, for instance, battling issues with challenges with swallowing your meds as a whole, am I doing you a disservice by continuing to encourage you to take medications that are no longer serving you? Or is my goal as “do no harm”, taking that oath, looking at these medications and resetting your journey for quality of life?
Dr. Rachel Jordan
One of the things that I find most interesting as a nurse practitioner is, you know, I walk into the home, and I see 20 medications that I have to make that decision of what to stop. Okay. Right. So, help our listeners understand what we kind of go through. What’s our process when we look at medicines as a whole and, and how we begin to discontinue or talk about medications that are no longer beneficial.
So let me give you an example. Right. We know that dementia is very prevalent in this area and say we walk into a home in our patients with dementia, end stage dementia, they’re not eating as much. They’re not walking as much. They’re losing weight because we sort of expect these things as a part of the disease trajectory. And they’re on medicines for cholesterol and their on dementia medications, you know, memantine or donepezil.
What’s your thought process? How do you start to de-escalate that regimen?
Dr. Sonja Richmond
So, I first ask the patient and their families their thoughts. What is your observation? As much as I have letters behind my name, I am in no way, shape or form better than the people who are right there in that home witnessing what their loved one is going through and encountering. And so, what I find is that oftentimes you’re empowering not only the patient, but also their family who’s caring for them in helping to navigate this new aspect in your loved one’s life.
And so, looking at someone who has advanced dementia, the cognitive impairment, the inability to eat, to drink, to engage, to mobilize as they once were doing. Are these medications still helping my loved one? For example, my mom was given a diuretic furosemide, Lasix, because she has preexisting heart disease or swelling in her legs or feet. However, you’ve acknowledged that mom lost 35 to 40 pounds.
Mom’s not eating or drinking. This is an opportunity for me to provide education about a medicine like the Furosemide or Lasix. The brand name. This medication is intended to remove excess fluid off of a patient to help stabilize or manage someone’s blood pressure. But how is it that you can continue taking this medication in this new setting, when you’ve already demonstrated severe weight loss? Severe fluid loss? Is this medication still warranted today?
And so, we leave it at that. We leave it with empowerment. We leave it with consideration and information. So that you can make an informed decision for what’s best for mom, dad, brother or sister or whomever you’re caring for. And it’s that stepwise approach. The cholesterol medications…At one point, I even read a study that all cholesterol medication should be in the water.
It’s beneficial for us. It helps with the hypercholesterolemia. But if mom is already battling issues with swallowing this medication and she’s already at an end stage, how impactful is this particular medication in helping her from a symptom management standpoint?
Dr. Rachel Jordan
And that’s so important because you talked about the relationship you have with your patient and family. And I often tell them I’m here to be your partner. Right. I’m 50%. You’re the other 50%. This is a partnership. And if either one of us sort of fail to show up, how successful can we be? Right. And so, knowing your patient, really knowing their health history, those are the things that we do.
We look at their health history. We look at the medications. We look at them physically. You know, we look at all of their conditions. And then like you said, guide provide that education to walk them through their journey. But it’s also important that patients and families understand it’s okay to ask questions.
Dr. Sonja Richmond
Right.
Dr. Rachel Jordan
I’m not going to bite you if you ask me questions.
Dr. Sonja Richmond
And if someone bites.
Dr. Rachel Jordan
You, find another provider.
Dr. Sonja Richmond
Find another provider.
Dr. Sonja Richmond
I tell them that all the time. Find another provider. And bite can come in words, bite can come in mannerisms, dismissal. Yeah. The goal is to be seen, to be heard, to be felt. Our job, because we are specialists at end-of-life care, is to share what we know. But also, to understand the lens in which the other side, the people that we’re caring for, is coming from, no one knows how to pass away.
Dr. Rachel Jordan
And everyone’s journey is different.
Dr. Sonja Richmond
Everyone’s journey is different and should be different. And so we don’t have a script for patients. We treat everyone as an individual. Absolutely. And we meet you where you are. And the goal is that whomever it is that’s in your repertoire of healthcare providers, they meet you where you are. And no biting.
Dr. Rachel Jordan
Yeah, no. No biting. You know, you can easily shut down that relationship. When a family member or a patient feels scolded. Yeah, they sort of just shut down. Right. And that is not therapeutic at all. So how important is communication with patients and their families regarding medication management. So, at every point, you know, I may see you today. Right? I’m going to come back and see you next week or next month. I’ve started a medication. You know, we’ve talked about the symptoms that are common at end-of-life –pain, anxiety, shortness of breath. How important is it to keep reviewing those medications?
Dr. Sonja Richmond
That’s the key: review revisit. The goal is to see is this medication efficacious? Is it effective in the outcome that we all desire? Our goal of care is quality of life. Has it helped to minimize the pain, the anxiety the agitation. Has it helped the nausea. Has it alleviated the constipation. Is mom resting because when mom, dad, brother and sister, whomever it is that the caregivers caring for is resting, it allows the caregiver to rest.
Dr. Rachel Jordan
Yeah. And you know that that’s it’s so important. And people, you know, sometimes patients, they’re like, well, they prescribe me this medicine. I just have to stick it out. If it’s not working for you, if it’s not working for your loved one, if you see a change and you’re not comfortable with that change, speak up about it. You know, how many times do we prescribe maybe an antidepressant and then the patient becomes more withdrawn, right?
Or a lot quieter? Or we prescribe a medication for pain, and they become sleepy. Now we have intended side effects, but if something is not right. The thing I love about hospice, there’s a nurse available 24/7.
Dr. Sonja Richmond
24/7.
Dr. Rachel Jordan
So, if something’s not right, don’t be afraid to call. And so, what are your thoughts whether you’re in hospice or you’re in palliative care, what would you tell your patient if you’re starting a new medication in their concerns? Do you tell them stick it out. Wait, what do you tell them?
Dr. Sonja Richmond
Tell them this is a journey, and your feedback is key in helping reach the goal. The intended goal of care. So, it’s a dialog. It’s not a “I prescribed. I shut the door; I move on.” It’s an opportunity to engage and reengage because we’re constantly going back to the source, who is that person we’re caring for, not the disease.
We’re caring for the person because that person is driving the bus now, driving the train, directing where we all fit in as healthcare providers. So, you pick up the phone because hospice is here for you 24/7, because you can’t always anticipate what symptoms will arise or what side effect to the new medication will arise. But what we can do is say we will be here with you.
Dr. Rachel Jordan
Absolutely. So, so important. And that’s why I love my job. You know, it’s never that I’ve closed the door. It’s I’ll talk to you when you need me. I’ll be there when you need me.
Dr. Rachel Jordan
But, in the essence of our podcast series, we thank you. Thank you for bringing this information to our listeners so that they can better understand how to manage Mom and Dad’s medication when it’s too much, you know, when is it too much, when is enough, and also empowering them to feel comfortable saying, you know what?
We’ve got too many medicines in the cabinet. Let’s talk about deep prescribing or feeling comfortable knowing that it’s okay to let go of some medicines. It’s actually normal and expected because not everything is supposed to be around permanently, right?
Dr. Sonja Richmond
Nothing stays the same.
Dr. Rachel Jordan
Exactly. So, thank you for helping our listeners along this journey. We also wanted to provide these real time tools to our listeners and the caregivers in the patients. So now, you know, our hope is that someone’s going to query their provider and say, do I really need this? Or when would be the best time to discontinue this medicine?
Dr. Sonja Richmond
Exactly. And it’s pearls. We’re sharing pearls. And hopefully our listeners pick up on something that that moves them that works with them, that brings them to pick up the phone and have that conversation with the provider or go into the doctor’s office with all of the medication.
Dr. Rachel Jordan
Yes.
Dr. Sonja Richmond
Oftentimes people have many doctors from different places, and unbeknownst to them, they don’t know all the meds that you are on. This is your life. We own it, we share the information, and we seek the guidance and help from those that are willing to walk with us.
Dr. Rachel Jordan
Absolutely. And your pharmacist. The pharmacist can be your friend.
Dr. Sonja Richmond
Oh my gosh. Oh my gosh. Yes! Got to know your pharmacist. Yes, because the conversations are deep. They are impactful. And it helps get the message across.
Dr. Rachel Jordan
Yeah absolutely. Well thank you so much again. And you know we we’ve developed these lists of resources. And our listeners can visit Hospice of the Chesapeake or Hospicechesapeake.org and click on the podcast episode where they can listen to this as many times as they want, and they can find resources. Anything else that you would recommend to our listeners?
Dr. Sonja Richmond
I would say advocate, advocate, advocate for yourselves, your loved ones.
Dr. Rachel Jordan
Absolutely. And rest.
Dr. Sonja Richmond
Yes.
Dr. Rachel Jordan
Rest because you’re only as good as a caregiver as you are to yourself. So, make sure you empower yourself. So, this has been a wonderful podcast.
Dr. Sonja Richmond
Thank you so much Rachel. Can’t wait to do this again.
Dr. Rachel Jordan
I know looking forward to the next one. Take care.
