Deprescribing: Discontinuing Medications near 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 a patient’s medications near 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 as well, from the hospital or care facility to the patient’s home, a nursing facility, or assisted living community.

Each patient’s medication regimen should be re-evaluated as well.

Polypharmacy in hospice — the simultaneous use of multiple drugs by a single patient for one or more condition — 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 intended effect apply ... or is it non-existent?

Explanations and Questions

High-Risk Medications to Reconsider in Hospice Care:

• Blood thinners
• Opioids
• Benzodiazepines
• 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?

“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.

“Then, during each weekly VITAS team meeting, the patient’s meds are re-examined. Dying is a process and it 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,” he says. “It’s about what’s best for the patient, not the cost."

The Cost

Palliative medications related to a patient’s advanced illness and hospice diagnosis are covered by the Medicare hospice benefit; a patient’s prior insurer continues to cover medications unrelated to the hospice diagnosis. If a medication is “related but 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 near the end of life, Dr. Wright says, is always to improve quality of life. For example, when a physician has determined that a patient with diabetes no longer has to avoid sugar, 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 is sometimes 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, which 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. We recommended these three articles:

• 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 regional 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?”

Discussions about deprescribing are not reserved exclusively for patients and families. Hospice physicians consult with a patient’s primary care physician and other specialists who have been actively engaged in managing care. Some medications that were previously deemed essential can be withdrawn. And while the concept of deprescribing medications can be unfamiliar to many physicians, 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.