VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.
"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.
It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.
A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.
Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.
A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.
The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.
Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).
They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.
Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.
"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.
Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.