Hospice care often includes the addition of medications that support comfort and symptom relief. However, it’s also a time to consider reevaluating and/or discontinuing medications, also known as deprescribing. Deprescribing can improve overall quality of life in several ways, including:
- Lower risk of drug-drug interactions and other adverse drug events
- Reduced pill burden, particularly important for patients with diminished ability to swallow
- Relief from side effects associated with certain medications
Deprescribing decisions should be guided by the goals and prognosis of each patient, as well as input from prescribers and pharmacists. Enclara Pharmacia’s list of the top five treatments to reevaluate can help guide a deprescribing strategy that improves care while managing costs.
#5 Acid Reflux Medications
Proton pump inhibitors (PPIs) such as omeprazole and H2 agonists such as famotidine are widely used to prevent heartburn. Many patients are initiated on therapy during a hospital admission, get discharged on them and then take them for years without reevaluating their need. Some research has associated PPI use with greater susceptibility to C difficile infections and pneumonia. Although the overall risk is low, these medications are still worth reevaluating, particularly when patients are no longer consuming food or drink likely to trigger heartburn.
#4 Diabetic Medications
Oral glucose-lowering medications like metformin may place patients at higher risk of low blood sugar as their food intake declines. Meanwhile, high blood sugar is typically asymptomatic in the short term. Based on these factors, guidelines from the American Diabetes Association support the discontinuation of oral hypoglycemic medications for Type II Diabetes patients nearing the end of life. However, patients with Type I Diabetes or symptomatic hyperglycemia may still benefit from treatment.
#3 Inhalers
Inhalers are a convenient delivery device, but they aren’t right for all patients, especially at the end of life. If a patient can’t inhale deeply enough or hold in a breath for 10 seconds, the drug is more likely to end up in the throat than deep in the lungs where it’s needed. Nebulized therapy is often preferred for greater symptom relief. Oral opioids may also provide relief from breathlessness.
#2 Dementia Medications
Dementia medications such as donepezil and memantine can improve mental functioning, but their effects are typically subtle. In some cases, they may even worsen symptoms such as depression, confusion, and aggression. For patients with advanced dementia, the risk of side effects typically outweighs any benefits. Use of these medications may still be appropriate for higher-functioning patients but if desired effects are not realized within 12 weeks of starting the medication, discontinuation is recommended.
#1 Statins
Cholesterol-lowering medications can reduce the risk of heart attack and stroke over time but are associated with side effects such as muscle pain, brain fog and poor digestion. Drug-drug interactions are another concern, as is the risk of kidney and liver problems. Additional support for deprescribing this medication class came in the findings of a randomized controlled trial of hospice patients: Those who discontinued statins lived longer and enjoyed better quality of life.1
Deprescribing is a Process
This top five list is far from comprehensive. Any medication with long-term effects that a hospice patient is unlikely to benefit from is recommended for regular reevaluation – these include antithrombotics (anticoagulants, antiplatelet agents) and high blood pressure medications. Some treatments may be appropriate early in hospice enrollment but become less so as the patient approaches the end of life.
The ever-changing balance between risk and benefit is one reason deprescribing is best thought of as a process, not an event. Another is that building trust and rapport with patients and caregivers is essential for success and that doesn’t happen overnight. When it comes to initiating deprescribing conversations, here are a few tips:
- Discuss your process for medication review with patients and families during admissions and patient change of status
- Provide options that may include gradual dose reduction, based on the patient’s goals
- Talk about the potential positive outcomes such as greater comfort, reduced pill burden and greater safety
Learn More about Hospice Deprescribing Strategy
- Download Enclara’s whitepaper, Benefits of Deprescribing for Patients Nearing End-of-Life
- Read Palliative Pearls case studies on polypharmacy management and discontinuing dementia medications.
- Take Enclara’s free course, Achieving Better Outcomes through Deprescribing in Hospice, at The Enclara Learning Academy via Relias Learning
- Browse NHPCO’s Hospice Medication Deprescribing Toolkit (PDF)
References
- Kutner JS, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: A randomized controlled trial. JAMA Intern Med. Published online 2015 Mar 23.
