Deprescribing: Discontinuing Medications Near the End of Life

How Hospice Patients May Benefit from Deprescribing

by Heather Veeder, MD, & James Wright, DO, VITAS Regional Medical Directors

Deprescribing starts with a conversation between a patient and their medical team that explores decreasing or discontinuing medications that are no longer helpful and may be harmful to the patient. This conversation should evaluate medications in the context of the patient’s goals and values, including answering medical questions and considering ethical issues involved in changing a patient’s medications near the end of life.

“Many patients are taking too many pills when they come to hospice,” says Dr. Heather Veeder, VITAS regional medical director. “While these medications and supplements have been helpful in treating or preventing disease, most of them are unhelpful or even harmful when a patient is sick enough to be in hospice care. Most of the pills end up sitting in the patient's stomach, taking up space, and our patients end up eating less than they would otherwise.”

Polypharmacy in hospice — the simultaneous use of multiple drugs by a single patient for one or more conditions — 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 as a patient nears 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?
If a medication is prescribed for specific symptom or disease benefit(s), does its effect apply ... or is it non-existent?

“When we evaluate a patient's medications, we encourage them to take only what makes them feel better,” says Dr. Veeder. “We find that many of our patients do feel better when they aren't taking as many medications. Talking with our patients about whether a medication meets their goals can be a useful approach to the conversation.”

Explanations and Questions

High-Risk Medications to Reconsider in Hospice Care:

Blood thinners
Psychotropic drugs
Statins
NSAIDs
Anticoagulants
Digoxin
Cardiovascular drugs
Hypoglycemic agents
Anticholinergic agents
NSAID + diuretic
ACE inhibitor and chronic kidney disease drugs

Factors to consider include the patient’s terminal illness, co-morbidities, current status in the disease process, physiology, goals of care and more. Is the medication related to the patient’s advanced illness terminal prognosis? Is it intended to be palliative? Does it manage symptoms, or prevent ongoing progressive disease?

“One common example is cholesterol medicines like statins,” says Dr. Veeder. “Statins are designed to be long-term preventative medications, but they also have side effects like muscle pain. Discontinuing them can alleviate that pain, improving quality of life without compromising their care.”

Another example: When someone gets older or is nearing the end of life, tight glycemic control can be dangerous rather than helpful. At this point, patients may not need to take pills, perform finger sticks or inject medications, or monitor labs. Unnecessary disease management is replaced with life enjoyment in the time the patient has left.

Consistent Reviews Address a Patient's Evolving Needs

Once a patient is referred to hospice care, a typical transition involves changes in their healthcare team and care plan. Each patient’s medication regimen should be re-evaluated as well.

VITAS relies on the admissions RN (ARN) to explain the plan of care to a new patient and their family.

“The ARN addresses these questions with the family and the physician so that there are no surprises,” says Dr. James Wright, VITAS regional medical director. “Then, during weekly VITAS team meetings, the patient’s meds are re-examined. Dying is a process and can be quite complex. A patient may experience lower blood pressure or lose the ability to swallow, for example. Throughout the process, we continue to tailor the meds to the patient’s physiology and general condition.”

Involving Patients and Families in Decisions Around Deprescribing

Deprescribing can be 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 hospice physician determines that a prescription they thought was keeping them alive or making symptoms tolerable is unnecessary.

When the decision-making process includes patients and families, the outcomes are better. This process begins with empathetic 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. We recommended these three articles:

Risk vs. Benefit of Deprescribing

“When a patient or family is anxious about discontinuing medication, we have a risk-vs-benefit discussion,” says Dr. Veeder. “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?”

Discussions about deprescribing are not reserved exclusively for patients and families. Hospice physicians consult with a patient’s primary care clinician and other specialists who have been actively engaged in managing care to provide the best possible care for the patient. Some medications that were previously deemed essential can be discontinued.

And while the concept of deprescribing medications can be unfamiliar to many clinicians, most 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, hospice 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.