Deprescribing: Discontinuing Medications at the End of Life
Would Your Hospice Patient Benefit from Deprescribing?
by James Wright DO & Heather Veeder MD, VITAS Regional Medical Directors
Deprescribing is an analytical discussion that explores medical questions, ethical issues and financial factors involved in withdrawing or continuing medications at the end of life.
When a patient is referred to hospice care, a typical transition involves changes in their healthcare team, goals of care and care plan. The location of care may change, from the hospital to home or a nursing facility. Their medication regimen should be re-evaluated as well.
Polypharmacy in hospice requires a reconciliation of all medications and products taken by the patient. Every statin and vitamin, every maintenance medication and OTC product should be assessed for appropriateness and impact at the end of life:
- Is it a high-risk medication?
- What are its benefits?
- Are its benefits important to the patient’s goals?
- Is a benefit unlikely to be realized, given the patient’s limited life expectancy?
- Is a medication’s targeted symptom or disease effect applicable or non-existent?
Explanations and Questions
High-Risk Medications to Reconsider in Hospice Care:
- Blood thinners
- Psychotropic drugs
- Cardiovascular drugs
- Hypoglycemic agents
- Anticholinergic agents
- NSAID + diuretic
- ACE inhibitor and chronic kidney disease
Factors considered include the patient’s terminal illness, any co-morbidities, the patient’s status in the disease process, the patient’s physiology, goals of care and more. Is the medication related to the terminal prognosis? Is it intended to be palliative? Does it manage symptoms, or prevent ongoing progressive disease?
“At VITAS, we rely on the admissions RN (ARN) to explain the plan of care to a new patient and their family,” says James Wright, DO, VITAS regional medical director. “The ARN addresses all these questions with the family and the referring physician so that there are no surprises.
“And then, during the team meeting, the patient’s meds are re-examined. Dying is a process. A patient may experience lower blood pressure or lose the ability to swallow. It can be quite complex. Throughout the process, we continue to tailor the meds to the patient’s physiology and general condition,” he says. “It’s about what’s best for the patient, not the cost."
Palliative medications related to a patient’s terminal disease are covered by the Medicare hospice benefit, while a patient’s prior insurer continues to cover medications unrelated to the terminal illness. If the medication is “related not palliative,” neither source is likely to cover it, as the medication does not contribute to the palliation of symptoms.
But the goal of discontinuing medication at the end of life, Dr. Wright says, is always to improve quality of life. For example, when the doctor has determined that a diabetic no longer has to avoid sweets, take pills, perform finger sticks or monitor labs, unnecessary disease management is replaced with life enjoyment in the time the patient has left.
A Personalized Evaluation
Deprescribing sometimes is an emotionally charged subject, and considerations may not be based solely on clinical data. Patients and families might feel abandoned by their doctors, for example, when a prescription they thought was keeping them alive or making symptoms tolerable is determined by a hospice physician to be unnecessary.
A better outcome is achieved when patients and families are included in the decision-making process, something that begins with empathic communication from the physician. Learning tools that help healthcare professionals talk more effectively to patients about terminal illness and goals of care can apply to deprescribing as well. Here are three articles we recommend:
- SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer
- How to deliver bad news to patients: 9 tips to do it better
- Delivering bad news to patients
Risk vs. Benefit
“When a patient or family is really anxious about discontinuing medication, we have a risk-vs-benefit discussion,” says Heather Veeder, MD, a senior medical director at VITAS. “We ask, ‘What are the risks? What are the benefits? How does the medicine make the patient feel? Is it still needed?’ Every patient is different. The bottom line is always, Is it a palliative intervention?”
The discussions of deprescribing are not reserved exclusively for patients and families. Hospice physicians consult with the patient’s other healthcare specialists who have been engaged in the active management of the patient’s health. Some medications that were previously deemed essential can now be withdrawn. The concept of deprescribing medications can be unfamiliar to many physicians. Still, most specialists understand that they are not experts in end-of-life care. They often refer and defer to the judgment of the hospice physician.
By deprescribing, physicians ensure that end-of-life medications (or the absence of them) help patients live better. In the months, weeks or days they have left, patients can experience fewer side effects, more alertness, less pain and improved quality of life.