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Huisman BAA, Geijteman ECT, Dees MK, Schonewille NN, Wieles M, van Zuylen L, Szadek KM, van der Heide A. Role of nurses in medication management at the end of life: a qualitative interview study. BMC Palliat Care 2020; 19:68. [PMID: 32404166 PMCID: PMC7222510 DOI: 10.1186/s12904-020-00574-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/07/2020] [Indexed: 11/13/2022] Open
Abstract
Background Patients in the last phase of their lives often use many medications. Physicians tend to lack awareness that reviewing the usefulness of medication at the end of patients’ lives is important. The aim of this study is to gain insight into the perspectives of patients, informal caregivers, nurses and physicians on the role of nurses in medication management at the end of life. Methods Semi-structured interviews were conducted with patients in the last phase of their lives, in hospitals, hospices and at home; and with their informal caregivers, nurses and physicians. Data were qualitatively analyzed using the constant comparative method. Results Seventy-six interviews were conducted, with 17 patients, 12 informal caregivers, 15 nurses, 20 (trainee) medical specialists and 12 family physicians. Participants agreed that the role of the nurse in medication management includes: 1) informing, 2) supporting, 3) representing and 4) involving the patient, their informal caregivers and physicians in medication management. Nurses have a particular role in continuity of care and proximity to the patient. They are expected to contribute to a multidimensional assessment and approach, which is important for promoting patients’ interest in medication management at the end of life. Conclusions We found that nurses can and should play an important role in medication management at the end of life by informing, supporting, representing and involving all relevant parties. Physicians should appreciate nurses’ input to optimize medication management in patients at the end of life. Health care professionals should recognize the role the nurses can have in promoting patients’ interest in medication management at the end of life. Nurses should be reinforced by education and training to take up this role.
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Affiliation(s)
- Bregje A A Huisman
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, Netherlands. .,Hospice Kuria, Amsterdam, Netherlands.
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands.,Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marianne K Dees
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Noralie N Schonewille
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, Netherlands.,Department of Gynaecology, OLVG West, Amsterdam, the Netherlands
| | | | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Karolina M Szadek
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
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52
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Wilson E, Caswell G, Latif A, Anderson C, Faull C, Pollock K. An exploration of the experiences of professionals supporting patients approaching the end of life in medicines management at home. A qualitative study. BMC Palliat Care 2020; 19:66. [PMID: 32393231 PMCID: PMC7216477 DOI: 10.1186/s12904-020-0537-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 03/03/2020] [Indexed: 12/01/2022] Open
Abstract
Background The management of medicines towards the end of life can place increasing burdens and responsibilities on patients and families. This has received little attention yet it can be a source of great difficulty and distress patients and families. Dose administration aids can be useful for some patients but there is no evidence for their wide spread use or the implications for their use as patients become increasing unwell. The study aimed to explore how healthcare professionals describe the support they provide for patients to manage medications at home at end of life. Methods Qualitative interview study with thematic analysis. Participants were a purposive sample of 40 community healthcare professionals (including GPs, pharmacists, and specialist palliative care and community nurses) from across two English counties. Results Healthcare professionals reported a variety of ways in which they tried to support patients to take medications as prescribed. While the paper presents some solutions and strategies reported by professional respondents it was clear from both professional and patient/family caregiver accounts in the wider study that rather few professionals provided this kind of support. Standard solutions offered included: rationalising the number of medications; providing different formulations; explaining what medications were for and how best to take them. Dose administration aids were also regularly provided, and while useful for some, they posed a number of practical difficulties for palliative care. More challenging circumstances such as substance misuse and memory loss required more innovative strategies such as supporting ways to record medication taking; balancing restricted access to controlled drugs and appropriate pain management and supporting patient choice in medication use. Conclusions The burdens and responsibilities of managing medicines at home for patients approaching the end of life has not been widely recognised or understood. This paper considers some of the strategies reported by professionals in the study, and points to the great potential for a more widely proactive stance in supporting patients and family carers to understand and take their medicines effectively. By adopting tailored, and sometimes, ‘outside the box’ thinking professionals can identify immediate, simple solutions to the problems patients and families experience with managing medicines.
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Affiliation(s)
- Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK. .,Nottingham Centre for the Advancement of Research in End of life care (NCARE), B302 School of Health Sciences, Medical School, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
| | - Glenys Caswell
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Asam Latif
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Claire Anderson
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | | | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
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53
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Puente-Fernández D, Roldán-López CB, Campos-Calderón CP, Hueso-Montoro C, García-Caro MP, Montoya-Juarez R. Prospective Evaluation of Intensity of Symptoms, Therapeutic Procedures and Treatment in Palliative Care Patients in Nursing Homes. J Clin Med 2020; 9:jcm9030750. [PMID: 32164342 PMCID: PMC7141278 DOI: 10.3390/jcm9030750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 02/04/2023] Open
Abstract
The aim of the study is to evaluate the intensity of symptoms, and any treatment and therapeutic procedures received by advanced chronic patients in nursing homes. A multi-centre prospective study was conducted in six nursing homes for five months. A nurse trainer selected palliative care patients from whom the sample was randomly selected for inclusion. The Edmonton Symptoms Assessment Scale, therapeutic procedures, and treatment were evaluated. Parametric and non-parametric tests were used to evaluate month-to-month differences and differences between those who died and those who did not. A total of 107 residents were evaluated. At the end of the follow-up, 39 had (34.6%) died. All symptoms (p < 0.050) increased in intensity in the last week of life. Symptoms were more intense in those who had died at follow-up (p < 0.05). The use of aerosol sprays (p = 0.008), oxygen therapy (p < 0.001), opioids (p < 0.001), antibiotics (p = 0.004), and bronchodilators (p = 0.003) increased in the last week of life. Peripheral venous catheters (p = 0.022), corticoids (p = 0.007), antiemetics (p < 0.001), and antidepressants (p < 0.05) were used more in the patients who died. In conclusion, the use of therapeutic procedures (such as urinary catheters, peripheral venous catheter placement, and enteral feeding) and drugs (such as antibiotics, anxiolytics, and new antidepressant prescriptions) should be carefully considered in this clinical setting.
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Affiliation(s)
- Daniel Puente-Fernández
- Doctoral Program of Clinical Medicine and Public Health, University of Granada, 18071 Granada, Spain;
| | - Concepción B. Roldán-López
- Department of Statistics and Operational Research, Faculty of Medicine, University of Granada, 1016 Granada, Spain;
| | | | - Cesar Hueso-Montoro
- Department of Nursing, Faculty of Health Sciences, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Spain; (C.H.-M.); (M.P.G.-C.); (R.M.-J.)
| | - María P. García-Caro
- Department of Nursing, Faculty of Health Sciences, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Spain; (C.H.-M.); (M.P.G.-C.); (R.M.-J.)
| | - Rafael Montoya-Juarez
- Department of Nursing, Faculty of Health Sciences, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Spain; (C.H.-M.); (M.P.G.-C.); (R.M.-J.)
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54
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Walter KS, Gillespie H, Moqbel D, Choe HM, Smith MA. The Impact of Palliative Care Interventions on Medication Regimen Complexity. J Palliat Med 2020; 23:156-157. [PMID: 32023191 DOI: 10.1089/jpm.2019.0229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Krysta S Walter
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Heather Gillespie
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Darene Moqbel
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Hae Mi Choe
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan.,University of Michigan Medical Group, Ann Arbor, Michigan
| | - Michael A Smith
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan.,Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan
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Abstract
The aim of deprescribing in end-of-life care is to improve the patient's quality of life by reducing their drug burden. It is essential to engage the patients and enable them to make choices about medications by discussing their preferences and implement a pharmacy management plan. Withdrawing medications during the end stages of life is extremely complex because the period of care varies substantially. The aim of this article is to address polypharmacy within end-of-life care. It will review which medications should be stopped by examining the non-essential and essential drugs. The intention is to encourage an approach to care which provides an equal balance between treatment and patient expectation.
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Affiliation(s)
- Emma Gardner
- Community Nurse Practitioner, Dorset HealthCare NHS, University NHS Foundation Trust Westminster Memorial Hospital, Dorset
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56
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Zueger PM, Holmes HM, Calip GS, Qato DM, Pickard AS, Lee TA. Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission. J Gen Intern Med 2019; 34:2029-2037. [PMID: 31346909 PMCID: PMC6816724 DOI: 10.1007/s11606-019-05152-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 02/06/2019] [Accepted: 05/01/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND The use of medications not relieving symptoms or maximizing quality of life should be minimized following hospice enrollment. OBJECTIVE To evaluate the frequency of and predictive factors for continuation of medications with limited benefit after hospice admission among those admitted for cancer- and non-cancer-related causes. DESIGN Cohort study using the Surveillance, Epidemiology and End Results-Medicare linked database. PATIENTS Medicare Part D-enrolled beneficiaries 66 years and older who were admitted to and died under hospice care between January 1, 2008, and December 31, 2013 (N = 70,035). MAIN MEASURES Patients were followed from hospice enrollment through death for Part D dispensing of limited benefit medications (LBMs) they had used in the 6 months prior to hospice admission, including anti-hyperlipidemics, anti-hypertensives, oral anti-diabetics, anti-platelets, anti-dementia medications, anti-osteoporotic medications, and proton pump inhibitors. The proportion of patients continuing an LBM after hospice admission was evaluated. Adjusted relative risks (RRs) were estimated for factors associated with LBM continuation. KEY RESULTS Overall, 29.8% and 30.5% of patients admitted to hospice for a cancer- and non-cancer-related cause, respectively, continued at least one LBM after hospice admission. Anti-dementia medications were continued most frequently (29.3%) while anti-osteoporotic medications were continued least often (14.1%). Compared to home hospice, LBM continuation was greater in hospice patients residing in skilled nursing (RR 1.25, 95% CI 1.20-1.29), non-skilled nursing (RR 1.29, 95% CI 1.25-1.32), and assisted living facilities (RR 1.28, 95% CI 1.24-1.32). Patients with hospice stays ≥ 180 days were more likely to continue at least one LBM compared to those with stays of 1 week or less (RR 13.11, 95% CI 12.25-14.02). CONCLUSIONS A substantial proportion of Medicare hospice beneficiaries continued to receive LBMs following hospice enrollment. Providers should evaluate the necessity of continuing non-palliative medications at the end of life through a careful, patient-centric consideration of their potential risks and benefits.
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Affiliation(s)
- Patrick M Zueger
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, UTHealth McGovern Medical School, Houston, TX, USA
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Dima M Qato
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - A Simon Pickard
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA.
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.
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57
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Morin L, Wastesson JW, Laroche ML, Fastbom J, Johnell K. How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study. Palliat Med 2019; 33:1080-1090. [PMID: 31172885 PMCID: PMC6691599 DOI: 10.1177/0269216319854013] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care. AIM To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions. DESIGN Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden. SETTING Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria. RESULTS A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75-84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results. CONCLUSION A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.
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Affiliation(s)
- Lucas Morin
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden.,2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas W Wastesson
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden.,2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie-Laure Laroche
- 3 Centre de pharmacovigilance et de pharmaco-épidémiologie, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, CHU Limoges, Limoges, France.,4 INSERM 1248, University of Limoges, CHU Limoges, Limoges, France
| | - Johan Fastbom
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Johnell
- 2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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58
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Abstract
In the United States, the adult population that will need hospice and palliative care is expected to double in the next 40 years. In primary care, providers are often faced with tough decisions on how to manage patients' medications at the end of life. This article describes how to deprescribe in the last year of life.
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59
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Roux B, Morin L, Papon A, Laroche ML. Prescription and deprescription of medications for older adults receiving palliative care during the last 3 months of life: a single-center retrospective cohort study. Eur Geriatr Med 2019; 10:463-471. [PMID: 34652792 DOI: 10.1007/s41999-019-00175-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Near the end of life, drugs to ensure comfort and improve quality of life should be prioritized, and unnecessary drugs should be avoided. The aim was to assess the evolution and quality of drug therapy throughout the last 3 months of life of older adults in need of palliative care. METHODS A single-center retrospective cohort study included older adults (≥ 65 years) who died in a teaching hospital between 1 January 2014 and 30 June 2014 and had been identified as patients in need of palliative care in their last 3 months of life. Drugs were collected from electronic medical records and defined as 'unnecessary' or 'essential' based on a review of the literature. RESULTS A total of 149 patients were included [age: 82.1 (SD 8.6) years, women: 46.3%]. The mean number of medications varied from 6.7 (SD 3.3) drugs 90 days before death, to 7.5 (SD 4.1) 7 days before death, to 5.6 (SD 3.6) on the day of death. During the final week of life, one additional prescription of essential drugs was observed for 75.2% of patients and 79.3% of patients had at least one unnecessary drug deprescribed. The most prescribed and deprescribed drug classes were, respectively, analgesics (56.4%) and antithrombotic agents (38.2%) during the last week of life. CONCLUSIONS Near the end of life, medication therapy is adapted to the goals of palliative care. However, this only occurs during the last week of life. Earlier transition to palliative care is necessary to avoid exposure to unnecessary drugs.
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Affiliation(s)
- Barbara Roux
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France. .,INSERM UMR 1248, University of Limoges, Limoges, France.
| | - Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Arnaud Papon
- Department of Geriatric Medicine, University Hospital of Limoges, Limoges, France
| | - Marie-Laure Laroche
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France.,INSERM UMR 1248, University of Limoges, Limoges, France
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60
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Nurses' Perspectives on Family Caregiver Medication Management Support and Deprescribing. J Hosp Palliat Nurs 2019; 21:312-318. [PMID: 31033645 DOI: 10.1097/njh.0000000000000574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Nurses who care for patients with life-limiting illness operate at the interface of family caregivers (FCGs), patients, and prescribers and are uniquely positioned to guide late-life medication management, including challenging discussions about deprescribing. The study objective was to describe nurses' perspectives about their role in hospice FCG medication management. Content analysis was used to analyze qualitative interviews with nurses from a parent study exploring views on medication management and deprescribing for advanced cancer patients. Ten home and inpatient hospice nurses, drawn from 3 hospice agencies and their referring hospital systems in New England, were asked to describe current practices of medication management and deprescribing and to evaluate a pilot tool to standardize hospice medication review. Analysis of the 10 interviews revealed that hospice nurses are receptive to a standardized approach for comprehensive medication review upon hospice transition and responded favorably to opportunities to discuss medication discontinuation with FCGs and prescribers. Effective framing for discussions included focus on reducing harmful and nonessential medications and reducing caregiver burden. Results indicate that nurses who care for hospice-eligible and enrolled patients are willing to discuss deprescribing with FCGs and prescribers when conversations are framed around medication harms and their impact on quality of life.
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61
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Schenker Y, Park SY, Jeong K, Pruskowski J, Kavalieratos D, Resick J, Abernethy A, Kutner JS. Associations Between Polypharmacy, Symptom Burden, and Quality of Life in Patients with Advanced, Life-Limiting Illness. J Gen Intern Med 2019; 34:559-566. [PMID: 30719645 PMCID: PMC6445911 DOI: 10.1007/s11606-019-04837-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/13/2018] [Accepted: 12/19/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Polypharmacy may be particularly burdensome near the end of life, as patients "accumulate" medications to treat and prevent multiple diseases. OBJECTIVE To evaluate associations between polypharmacy, symptom burden, and quality of life (QOL) in patients with advanced, life-limiting illness (clinician-estimated, 1 month-1 year). DESIGN Secondary analysis of baseline data from a trial of statin discontinuation. PARTICIPANTS Adults with advanced, life-limiting illness. MAIN MEASURES Polypharmacy was assessed by summing the number of non-statin medications taken regularly or as needed. Symptom burden was assessed using the Edmonton Symptom Assessment Scale (range 0-90; higher scores indicating greater symptom burden) and QOL was assessed using the McGill QOL Questionnaire (range 0-10; higher scores indicating better QOL). Linear regression models assessed associations between polypharmacy, symptom burden, and QOL. KEY RESULTS Among 372 participants, 47% were age 75 or older and 35% were enrolled in hospice. The mean symptom score was 27.0 (standard deviation (SD) 16.1) and the mean QOL score was 7.0 (SD 1.3). The average number of non-statin medications was 11.6 (SD 5.0); one-third of participants took ≥ 14 medications. In adjusted models, higher polypharmacy was associated with higher symptom burden (coefficient 0.81; p < .001) and lower QOL (coefficient - .06; p = .001). Adjusting for symptom burden weakened the association between polypharmacy and QOL (coefficient - .03; p = .045) without a significant interaction, suggesting that worse quality of life associated with polypharmacy may be related to medication-associated symptoms. CONCLUSIONS Among adults with advanced illness, taking more medications is associated with higher symptom burden and lower QOL. Attention to medication-related symptoms and shared decision-making regarding deprescribing are warranted in this setting. NIH TRIAL REGISTRY NUMBER ClinicalTrials.gov Identifier for Parent Study - NCT01415934.
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Affiliation(s)
- Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA.
| | - Seo Young Park
- Center for Research on Healthcare Data Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kwonho Jeong
- Center for Research on Healthcare Data Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer Pruskowski
- Department of Pharmacy and Therapeutics, UPMC Palliative and Supportive Institute, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA
| | - Judith Resick
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA
| | | | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Kadoyama KL, Noble BN, Izumi S, Fromme EK, Tjia J, McPherson ML, Candrian CB, McGregor JC, Ku IY, Furuno JP. Frequency and Documentation of Medication Decisions on Discharge from the Hospital to Hospice Care. J Am Geriatr Soc 2019; 67:1258-1262. [DOI: 10.1111/jgs.15860] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/06/2019] [Accepted: 02/06/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Kirsten L. Kadoyama
- Department of Pharmacy Practice; Oregon State University/Oregon Health & Science University College of Pharmacy; Portland Oregon
| | - Brie N. Noble
- Department of Pharmacy Practice; Oregon State University/Oregon Health & Science University College of Pharmacy; Portland Oregon
| | - Shigeko Izumi
- Oregon Health & Science University School of Nursing; Portland Oregon
| | - Erik K. Fromme
- Department of Psychosocial Oncology and Palliative Care; Dana-Farber Cancer Institute; Boston Massachusetts
- Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health; Boston Massachusetts
| | - Jennifer Tjia
- Department of Quantitative Health Sciences; University of Massachusetts Medical School; Worcester Massachusetts
| | - Mary Lynn McPherson
- Department of Pharmacy Practice and Science; University of Maryland School of Pharmacy; Baltimore Maryland
| | - Carey B. Candrian
- Division of General Internal Medicine, Department of Medicine; University of Colorado School of Medicine; Aurora Colorado
| | - Jessina C. McGregor
- Department of Pharmacy Practice; Oregon State University/Oregon Health & Science University College of Pharmacy; Portland Oregon
| | - In Young Ku
- Department of Pharmacy Practice; Oregon State University/Oregon Health & Science University College of Pharmacy; Portland Oregon
| | - Jon P. Furuno
- Department of Pharmacy Practice; Oregon State University/Oregon Health & Science University College of Pharmacy; Portland Oregon
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63
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Paque K, Elseviers M, Vander Stichele R, Pardon K, Vinkeroye C, Deliens L, Christiaens T, Dilles T. Balancing medication use in nursing home residents with life-limiting disease. Eur J Clin Pharmacol 2019; 75:969-977. [DOI: 10.1007/s00228-019-02649-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 02/11/2019] [Indexed: 12/13/2022]
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64
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Paque K, De Schreye R, Elseviers M, Vander Stichele R, Pardon K, Dilles T, Christiaens T, Deliens L, Cohen J. Discontinuation of medications at the end of life: A population study in Belgium, based on linked administrative databases. Br J Clin Pharmacol 2019; 85:827-837. [PMID: 30667540 DOI: 10.1111/bcp.13874] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 12/17/2022] Open
Abstract
AIMS The aim of this study was to examine the use of potentially inappropriate medication (PIM) in relation to time before death, to explore whether PIMs are discontinued at the end of life, and the factors associated with this discontinuation. METHODS We conducted a retrospective register-based mortality cohort study of all deceased in 2012 in Belgium, aged at least 75 years at time of death (n = 74 368), using linked administrative databases. We used STOPPFrail to identify PIMs received during the period from 12 to 6 months before death (P1) and the last 4 months (P2) of life. RESULTS Median age was 86 (IQR 81-90) at time of death, 57% were female, 38% were living in a nursing home, and 16% were admitted to hospital between 2 years and 4 months before death. Overall, PIM use was high, and increased towards death for all PIMs. At least one PIM was discontinued during P2 for one in five (20%) of the population, and 49% had no discontinuation. Being hospitalized in the period before the last 4 months of life, living in a nursing home, female gender and a higher number of medications used during P1 were associated with discontinuation of PIMs (respective aOR [95% CI]: 2.89 [2.73-3.06], 1.29 [1.23-1.36], 1.26 [1.20-1.32], 1.17 [1.16-1.17]). CONCLUSION Initial PIM use was high and increased towards death. Discontinuation was observed in only one in five PIM users. More guidance for discontinuation of PIMs is needed: practical, evidence-based deprescribing guidelines and implementation plans, training for prescribers and a better consensus on what inappropriate medication is.
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Affiliation(s)
- Kristel Paque
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.,Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Robrecht De Schreye
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Monique Elseviers
- Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium.,Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (NuPhaC), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Robert Vander Stichele
- Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Tinne Dilles
- Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (NuPhaC), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Thierry Christiaens
- Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
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O’Leary J, Pawasauskas J, Brothers T. Adverse Drug Reactions in Palliative Care. J Pain Palliat Care Pharmacother 2019; 32:98-105. [DOI: 10.1080/15360288.2018.1513435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Paque K, Vander Stichele R, Elseviers M, Pardon K, Dilles T, Deliens L, Christiaens T. Barriers and enablers to deprescribing in people with a life-limiting disease: A systematic review. Palliat Med 2019; 33:37-48. [PMID: 30229704 DOI: 10.1177/0269216318801124] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND: Knowing the barriers/enablers to deprescribing in people with a life-limiting disease is crucial for the development of successful deprescribing interventions. These barriers/enablers have been studied, but the available evidence has not been summarized in a systematic review. AIM: To identify the barriers/enablers to deprescribing of medications in people with a life-limiting disease. DESIGN: Systematic review, registered in PROSPERO (CRD42017073693). DATA SOURCES: A systematic search of MEDLINE, Embase, Web of Science and CENTRAL was conducted and extended with a hand search. Peer-reviewed, primary studies reporting on barriers/enablers to deprescribing in the context of explicit life-limiting disease were included in this review. RESULTS: A total of 1026 references were checked. Five studies met the criteria and were included in this review. Three types of barriers/enablers were found: organizational, professional and patient (family)-related barriers/enablers. The most prominent enablers were organizational support (e.g. for standardized medication review), involvement of multidisciplinary teams in medication review and the perception of the importance of coming to a joint decision regarding deprescribing, which highlighted the need for interdisciplinary collaboration and involving the patient and his family in the decision-making process. The most important barriers were shortages in staff and the perceived difficulty or resistance of the nursing home resident's family - or the resident himself. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: The scarcity of findings in the literature highlights the importance of filling this gap. Further research should focus on deepening the knowledge on these barriers/enablers in order to develop sustainable multifaceted deprescribing interventions in palliative care.
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Affiliation(s)
- Kristel Paque
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Robert Vander Stichele
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Monique Elseviers
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,3 Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium
| | - Koen Pardon
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Tinne Dilles
- 3 Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium.,4 Department of Nursing and Midwifery, Thomas More University College, Lier, Belgium
| | - Luc Deliens
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,5 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Thierry Christiaens
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
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Wilson E, Caswell G, Turner N, Pollock K. Managing Medicines for Patients Dying at Home: A Review of Family Caregivers' Experiences. J Pain Symptom Manage 2018; 56:962-974. [PMID: 30217417 DOI: 10.1016/j.jpainsymman.2018.08.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/29/2018] [Accepted: 08/29/2018] [Indexed: 12/20/2022]
Abstract
CONTEXT Increased life expectancy, technical advances in treatment and symptom control, and the extension of palliative care in community settings not only lengthen life but also make it possible for many patients to be cared for, and to die, at home. Moreover, death increasingly occurs in late old age and after a prolonged period of comorbidity and/or frailty. This has far-reaching consequences for the way that professional services are resourced and organized and for the informal carers who are often responsible for providing the greater part of patient care, including management of complex medication regimes. OBJECTIVES To explore the literature focused on family caregivers' (FCGs) experiences of medication management for patients being cared for and dying at home. METHODS This literature review takes a critical interpretive synthesis approach to the review of 15 identified articles. RESULTS Findings show that FCGs can struggle to manage medications for someone who is dying at home, yet there is an expectation that they will take on these roles and are often judged by professional standards. Five key themes identified particular issues around administration, organizational skills, empowerment, relationships, and support. CONCLUSION As increasing demands are placed on FCGs, there remains limited acknowledgment or understanding of the challenges they face, how they cope, or could be best supported. Alongside training, FCGs need access to 24 hours of support and medication reviews to rationalize unnecessary medications. Furthermore, the ethical challenges arising from administering medicines at the end of life also need to be acknowledged and discussed.
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Affiliation(s)
- Eleanor Wilson
- Nottingham Centre for the Advancement of Research in End of Life Care (NCARE), School of Health Sciences, University of Nottingham, Medical School, Queen's Medical Centre, Nottingham, United Kingdom.
| | - Glenys Caswell
- Nottingham Centre for the Advancement of Research in End of Life Care (NCARE), School of Health Sciences, University of Nottingham, Medical School, Queen's Medical Centre, Nottingham, United Kingdom
| | - Nicola Turner
- Nottingham Centre for the Advancement of Research in End of Life Care (NCARE), School of Health Sciences, University of Nottingham, Medical School, Queen's Medical Centre, Nottingham, United Kingdom
| | - Kristian Pollock
- Nottingham Centre for the Advancement of Research in End of Life Care (NCARE), School of Health Sciences, University of Nottingham, Medical School, Queen's Medical Centre, Nottingham, United Kingdom
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Ersoy S, Engin VS. Risk factors for polypharmacy in older adults in a primary care setting: a cross-sectional study. Clin Interv Aging 2018; 13:2003-2011. [PMID: 30410317 PMCID: PMC6197244 DOI: 10.2147/cia.s176329] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Purpose Polypharmacy (PP) is a clinical challenge in older adults. Therefore, assessment of daily drug consumption (DDC) and its relationships is important. First-line health services have a crucial role in monitoring and preventing PP. In this study, we aimed to assess DDC and investigate the risk factors for higher DDC among older adults in a primary care setting. Patients and methods A total of 1,000 patients aged ≥65 years who visited Melek Hatun Family Practice Center between December 1, 2014, and August 1, 2017, were enrolled in the study. All patients were seen either at the center or in their homes, and informed consent was obtained. Comprehensive geriatric assessment was performed for each subject. Data were analyzed using SPSS software (version 17). The daily number of medicines that each patient used (DDC) regardless of whether they were prescribed was the dependent variable. Relationships between DDC and other continuous variables were examined using Pearson's correlation. For between-group comparisons of DDC, Student's t-tests were performed. Results Univariate tests showed relationships between DDC and various demographic and clinical parameters. The variables that remained significant at the last step of a stepwise linear regression analysis were metabolic syndrome, chronic pain, incontinence, increased serum creatinine level, increased Geriatric Depression Scale scores, reported gastric disturbances, and neutrophil/lymphocyte ratio. Conclusion Along with certain chronic conditions, depressive symptoms and an inflammatory marker (neutrophil/lymphocyte ratio) were significantly and independently related to higher DDC. Longitudinal and larger studies are needed to further explore the multifaceted relationships of PP.
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Affiliation(s)
- Suleyman Ersoy
- Department of Family Medicine, Faculty of Medicine, Karabuk University, Karabuk, Turkey,
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Geijteman EC, Huisman BA, Dees MK, Perez RS, van der Rijt CC, van Zuylen L, van der Heide A. Medication Discontinuation at the End of Life: A Questionnaire Study on Physicians' Experiences and Opinions. J Palliat Med 2018; 21:1166-1170. [DOI: 10.1089/jpm.2017.0501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Eric C.T. Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bregje A.A. Huisman
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Marianne K. Dees
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roberto S.G.M. Perez
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Carin C.D. van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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Saletti P, Sanna P, Gabutti L, Ghielmini M. Choosing wisely in oncology: necessity and obstacles. ESMO Open 2018; 3:e000382. [PMID: 30018817 PMCID: PMC6045771 DOI: 10.1136/esmoopen-2018-000382] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 05/25/2018] [Accepted: 05/26/2018] [Indexed: 12/25/2022] Open
Abstract
In the last decades, the survival of many patients with cancer improved thanks to modern diagnostic methods and progresses in therapy. Still for several tumours, especially when diagnosed at an advanced stage, the benefits of treatment in terms of increased survival or quality of life are at best modest when not marginal, and should be weighed against the potential discomfort caused by medical procedures. As in other specialties, in oncology as well the dialogue between doctor and patient should be encouraged about the potential overuse of diagnostic procedures or treatments. Several oncological societies produced recommendations similar to those proposed by other medical disciplines adhering to the Choosing Wisely (CW) campaign. In this review, we describe what was reported in the medical literature concerning adequacy of screening, diagnostic, treatment and follow-up procedures and the potential impact on them of the CW. We only marginally touch on the more complex topic of treatment appropriateness, for which several evaluation methods have been developed (including the European Society for Medical Oncology-magnitude of clinical benefit scale). Finally, we review the possible obstacles for the development of CW in the oncological setting and focus on the strategies which could allow CW to evolve in the cancer field, so as to enhance the therapeutic relationship between medical professionals and patients and promote more appropriate management.
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Affiliation(s)
- Piercarlo Saletti
- Medical Oncology Clinic, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.
| | - Piero Sanna
- Palliative and Supportive Care Clinic, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Luca Gabutti
- Internal Medicine Department, Ente Ospedaliero Cantonale (EOC), Choosing Wisely EOC, Bellinzona, Switzerland
| | - Michele Ghielmini
- Medical Oncology Clinic, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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Adequate, questionable, and inadequate drug prescribing for older adults at the end of life: a European expert consensus. Eur J Clin Pharmacol 2018; 74:1333-1342. [PMID: 29934849 PMCID: PMC6132505 DOI: 10.1007/s00228-018-2507-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/14/2018] [Indexed: 01/01/2023]
Abstract
Background Clinical guidance is needed to initiate, continue, and discontinue drug treatments near the end of life. Aim To identify drugs and drug classes most often adequate, questionable, or inadequate for older people at the end of life. Design Delphi consensus survey. Setting/participants Forty European experts in geriatrics, clinical pharmacology, and palliative medicine from 10 different countries. Panelists were asked to characterize drug classes as “often adequate,” “questionable,” or “often inadequate” for use in older adults aged 75 years or older with an estimated life expectancy of ≤ 3 months. We distinguished the continuation of a drug class that was previously prescribed from the initiation of a new drug. Consensus was considered achieved for a given drug or drug class if the level of agreement was ≥ 75%. Results The expert panel reached consensus on a set of 14 drug classes deemed as “often adequate,” 28 drug classes deemed “questionable,” and 10 drug classes deemed “often inadequate” for continuation during the last 3 months of life. Regarding the initiation of new drug treatments, the panel reached consensus on a set of 10 drug classes deemed “often adequate,” 23 drug classes deemed “questionable,” and 23 drug classes deemed “often inadequate”. Consensus remained unachieved for some very commonly prescribed drug treatments (e.g., proton-pump inhibitors, furosemide, haloperidol, olanzapine, zopiclone, and selective serotonin reuptake inhibitors). Conclusion In the absence of high-quality evidence from randomized clinical trials, these consensus-based criteria provide guidance to rationalize drug prescribing for older adults near the end of life. Electronic supplementary material The online version of this article (10.1007/s00228-018-2507-4) contains supplementary material, which is available to authorized users.
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Pype P, Mertens F, Helewaut F, D’Hulster B, De Sutter A. Potentially inappropriate medication in primary care at the end of life: a mixed-method study. Acta Clin Belg 2018; 73:213-219. [PMID: 29199905 DOI: 10.1080/17843286.2017.1410606] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
CONTEXT Polypharmacy results in adverse drug interactions, high pill burden, and medication costs. Stopping or diminishing potentially inappropriate medication (PIM), is complex . Data on the use of PIM in a primary care context are scarce and deprescribing barriers for general practitioners (GP) are underexplored. OBJECTIVE Describing the use of PIM in primary care at the end of life, and exploring the barriers for GPs to deprescribe. METHODS Retrospective chart review of 210 consecutive patients referred to a palliative home care service and semi-structured interviews with 11 GPs. Percentages were calculated on medication use, linear regression was done to evaluate the effect of diagnosis on PIM use. Thematic analysis was used to analyze the interviews. RESULTS In total 83 % of patients took at least one PIM. The proportion that continued taking PIMs at the time of referral, one week prior to death and at the day of dying: varies between 6% and 45% according to drug category. Linear regression showed a statistical significant (p < 0.001) higher number of PIM use with non-cancer patients (mean 3,1-SD 1,5) than with cancer patients (mean 1,6-SD 1,6). Participants reported being aware of the PIM use, making efforts to deprescribe. Main issues GPs are taking into account are medical, communicative, and collaborative in nature. CONCLUSION This study confirms the high level of PIM use in primary care at the end of life. The views of GPs inspire support strategies for deprescribing focusing on shared decision-making with patients and on interprofessional collaboration.
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Affiliation(s)
- Peter Pype
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Fien Mertens
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Fleur Helewaut
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Bert D’Hulster
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - An De Sutter
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
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Garfinkel D, Ilin N, Waller A, Torkan-Zilberstein A, Zilberstein N, Gueta I. Inappropriate medication use and polypharmacy in end-stage cancer patients: Isn't it the family doctor's role to de-prescribe much earlier? Int J Clin Pract 2018; 72:e13061. [PMID: 29359381 DOI: 10.1111/ijcp.13061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 12/22/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Elderly patients are exposed to increased number of medications, often with no proof of a positive benefit/risk ratio. Unfortunately, this trend does not spare those with limited life expectancy, including end-stage cancer patients who require only palliative treatment. For many medications in this subpopulation, the risk of adverse drug events outweighs the possible benefits and yet, many are still poly-medicated during their last year of life. AIM To describe the extent of polypharmacy among end-stage cancer patients, at the time of admission to homecare hospice. METHODS A retrospective chart review of 202 patients admitted to Homecare Hospice of the Israel Cancer Association and died before January 2015. RESULTS Average lifespan from admission until death was 39.2 ± 5.4 days. 63% died within the first month, 89% within 3 months. Excluding oncological treatments, 181 (90%) and 46 (23%) patients were treated with ≥ 6 and ≥ 12 drugs for chronic diseases, respectively. Two months before death, 32 (16%) patients were treated with ≥ 3 blood pressure lowering drugs, 62 (31%) with statins and 48 (23%) with aspirin. CONCLUSION Though not representative of the whole end-stage cancer patient population, our study demonstrates that these patients are exposed to extensive polypharmacy. Most of these medications could have probably been safely de-prescribed much earlier in the course of the malignant disease. Considering the prolonged trust-based relationship with their patients, the family physicians are those who should be encouraged to implement the palliative approach and reduce polypharmacy much before reaching hospice settings.
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Affiliation(s)
- Doron Garfinkel
- Geriatric-Palliative Service, Wolfson Medical Center, Holon, Israel
- Homecare Hospice, Israel Cancer Association, Ramat Gan, Israel
- IGRIMUP - International Group for Reducing Inappropriate Medication Use and Polypharmacy, Israel
| | - Nataly Ilin
- Homecare Hospice, Israel Cancer Association, Ramat Gan, Israel
| | | | | | | | - Itai Gueta
- The Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel
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Paque K, Elseviers M, Vander Stichele R, Pardon K, Hjermstad MJ, Kaasa S, Dilles T, De Laat M, Van Belle S, Christiaens T, Deliens L. Changes in medication use in a cohort of patients with advanced cancer: The international multicentre prospective European Palliative Care Cancer Symptom study. Palliat Med 2018; 32:775-785. [PMID: 29243546 DOI: 10.1177/0269216317746843] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Information on medication use in the last months of life is limited. AIM To describe which medications are prescribed and deprescribed in advanced cancer patients receiving palliative care in relation to time before death and to explore associations with demographic variables. DESIGN Prospective study, using case report forms for monthly data collection. Medication included cancer treatment and 19 therapeutic groups, grouped into four categories for: (1) cancer therapy, (2) specific cancer-related symptom relief, (3) other symptom relief and (4) long-term prevention. Data were analysed retrospectively using death as the index date. We compared medication use at 5, 4, 3, 2 and 1 month(s) before death by constructing five cross-sectional subsamples with medication use during that month. Paired analyses were done on a subsample of patients with at least two assessments before death. SETTING/PARTICIPANTS We studied the medication use of 720 patients (mean age 67, 56% male) in 30 cancer centres representing 12 countries. RESULTS From 5 to 1 month(s) before death, cancer therapy decreased (55%-24%), most medications for symptom relief increased, for example, opioids (62%-81%) and sedatives (35%-46%), but medication for long-term prevention decreased (38%-27%). The prevalence of chemotherapy was 15.5% in the last month of life, with 9% of new courses started in the last 2 months. With higher age, chemotherapy and opioid use decreased. CONCLUSION Medications for symptom relief increased in almost all medication groups. Deprescribing was found in heart medication/anti-hypertensives and cancer therapy, although use of the latter remained relatively high.
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Affiliation(s)
- Kristel Paque
- 1 Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium.,2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Monique Elseviers
- 1 Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium
| | - Robert Vander Stichele
- 1 Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium
| | - Koen Pardon
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Marianne J Hjermstad
- 3 European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,4 Regional Advisory Unit for Palliative Care, South Eastern Norway, Oslo University Hospital, Oslo, Norway
| | - Stein Kaasa
- 3 European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,5 Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tinne Dilles
- 6 Department of Nursing and Midwifery Sciences, Centre for Research and Innovation in Care (CRIC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Martine De Laat
- 7 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Simon Van Belle
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,7 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Thierry Christiaens
- 1 Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium
| | - Luc Deliens
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,7 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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Narayan SW, Nishtala PS. Population-based study examining the utilization of preventive medicines by older people in the last year of life. Geriatr Gerontol Int 2018; 18:892-898. [DOI: 10.1111/ggi.13273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/02/2017] [Accepted: 12/21/2017] [Indexed: 01/28/2023]
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Phung E, Triantafylidis L, Zhang H(M, Yeh IM. New Media, Part 5: Online Deprescribing Tools. J Palliat Med 2018. [DOI: 10.1089/jpm.2017.0688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Elizabeth Phung
- Division of Geriatrics and Palliative Care, New England GRECC - Geriatric Research Education and Clinical Center, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Laura Triantafylidis
- Department of Pharmacy, VA Boston HealthCare System, New England GRECC - Geriatric Research Education and Clinical Center, Boston, Massachusetts
| | - Haipeng (Mark) Zhang
- Department of Psychosocial Oncology and Palliative Care, Dana Farbar Cancer Institute, Boston, Massachusetts
| | - Irene M. Yeh
- Department of Psychosocial Oncology and Palliative Care, Dana Farbar Cancer Institute, Boston, Massachusetts
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Arevalo JJ, Geijteman EC, Huisman BA, Dees MK, Zuurmond WW, van Zuylen L, van der Heide A, Perez RS. Medication Use in the Last Days of Life in Hospital, Hospice, and Home Settings in the Netherlands. J Palliat Med 2018; 21:149-155. [DOI: 10.1089/jpm.2017.0179] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Jimmy J. Arevalo
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Eric C.T. Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bregje A.A. Huisman
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Marianne K. Dees
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wouter W.A. Zuurmond
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
- Hospice Kuria, Amsterdam, the Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto S.G.M. Perez
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
- Hospice Kuria, Amsterdam, the Netherlands
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78
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Viswanath V, Palat G, Chary S, Broderick A. Challenges of Using Methadone in the Indian Pain and Palliative Care Practice. Indian J Palliat Care 2018; 24:S30-S35. [PMID: 29497252 PMCID: PMC5806303 DOI: 10.4103/ijpc.ijpc_168_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Palliative care providers across India lobbied to gain access to methadone for pain relief and this has finally been achieved. Palliative care activists will count on the numerous strengths for introducing methadone in India, including the various national and state government initiatives that have been introduced recognizing the importance of palliative care as a specialty in addition to improving opioid accessibility and training. Adding to the support are the Non-Governmental Organizations (NGOs), the medical fraternity and the international interactive and innovative programs such as the Project Extension for Community Health Outcome. As compelling as the need for methadone is, many challenges await. This article outlines the challenges of procuring methadone and also discusses the challenges specific to methadone. Balancing the availability and diversion in a setting of opioid phobia, implementing the amended laws to improve availability and accessibility in a country with diverse health-care practices are the major challenges in implementing methadone for relief of pain. The unique pharmacology of the drug requires meticulous patient selection, vigilant monitoring, and excellent communication and collaboration with a multidisciplinary team and caregivers. The psychological acceptance of the patient, the professional training of the team and the place where care is provided are also challenges which need to be overcome. These challenges could well be the catalyst for a more diligent and vigilant approach to opioid prescribing practices. Start low, go slow could well be the way forward with caregiver education to prescribe methadone safely in the Indian palliative care setting.
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Affiliation(s)
- Vidya Viswanath
- Department of Palliative Care, Homi Bhabha Cancer Hospital and Research Centre, A Unit of Tata Memorial Centre, Visakhapatnam, Andhra Pradesh, India
| | - Gayatri Palat
- Consultant, Pain and Palliative Medicine, MNJ Institute of Oncology and RCC, Hyderabad, India
| | - Srini Chary
- Department of Oncology and Family Medicine, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
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79
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Williams BR, Amos Bailey F, Kvale E, Steil N, Goode PS, Kennedy RE, Burgio KL. Continuation of non-essential medications in actively dying hospitalised patients. BMJ Support Palliat Care 2017; 7:450-457. [PMID: 28904011 DOI: 10.1136/bmjspcare-2016-001229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 05/30/2017] [Accepted: 07/18/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The objective of this analysis was to examine the use of 11 non-essential medications in actively dying patients. METHODS This was a planned secondary analysis of data from the Best Practices for End-of-Life Care for Our Nation's Veterans trial, a multicentre implementation trial of an intervention to improve processes of end-of-life care in inpatient settings. Supported with an electronic comfort care decision support tool, intervention included training hospital staff to identify actively dying patients, communicate the prognosis to patients/families and implement best practices of traditionally home-based hospice care. Data on medication use before and after intervention were derived from electronic medical records of 5476 deceased veterans. RESULTS Five non-essential medications, clopidogrel, donepezil, glyburide, metformin and propoxyphene, were ordered in less than 5% of cases. More common were orders for simvastatin (15.8%/15.1%), calcium tablets (8.4%/7.9%), multivitamins (11.6%/10.8%), ferrous sulfate (9.1%/7.6%), diphenhydramine (7.2%/5.1%) and subcutaneous heparin (29.9%/27.5%). Significant decreases were found for donepezil (2.5%/1.3%; p=0.001), propoxyphene (0.8%/0.1%; p=0.001), metformin (0.8%/0.3%; p=0.007) and multivitamins (11.6%/10.8%; p=0.01). Orders for one or more non-essential medications were less likely to occur in association with palliative care consultation (adjusted OR (AOR)=0.64, p<0.001), do-not-resuscitate orders (AOR=0.66, p=0.001) and orders for death rattle medication (AOR=0.35, p<0.001). Patients who died in an intensive care unit were more likely to receive a non-essential medication (AOR=1.60, p=0.009), as were older patients (AOR=1.12 per 10 years, p=0.002). CONCLUSIONS Non-essential medications continue to be administered to actively dying patients. Discontinuation of these medications may be facilitated by interventions that enhance recognition and consideration of patients' actively dying status.
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Affiliation(s)
- Beverly Rosa Williams
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - F Amos Bailey
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, Denver Health Medical Center, University of Colorado, Denver, Colorado, USA
| | - Elizabeth Kvale
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Neal Steil
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Palliative Care Section, Birmingham VA Medical Center, Birmingham, Alabama, USA
| | - Patricia S Goode
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Richard E Kennedy
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathryn L Burgio
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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80
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How Medicine Has Changed the End of Life for Patients With Cardiovascular Disease. J Am Coll Cardiol 2017; 70:1276-1289. [DOI: 10.1016/j.jacc.2017.07.735] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/13/2017] [Accepted: 07/19/2017] [Indexed: 12/20/2022]
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81
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Narayan SW, Nishtala PS. Discontinuation of Preventive Medicines in Older People with Limited Life Expectancy: A Systematic Review. Drugs Aging 2017; 34:767-776. [DOI: 10.1007/s40266-017-0487-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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82
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Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study. Am J Med 2017; 130:927-936.e9. [PMID: 28454668 DOI: 10.1016/j.amjmed.2017.02.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/01/2017] [Accepted: 02/01/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The burden of medications near the end of life has recently come under scrutiny, because several studies suggested that people with life-limiting illness receive potentially futile treatments. METHODS We identified 511,843 older adults (>65 years) who died in Sweden between 2007 and 2013 and reconstructed their drug prescription history for each of the last 12 months of life through the Swedish Prescribed Drug Register. Decedents' characteristics at time of death were assessed through record linkage with the National Patient Register, the Social Services Register, and the Swedish Education Register. RESULTS Over the course of the final year before death, the proportion of individuals exposed to ≥10 different drugs rose from 30.3% to 47.2% (P <.001 for trend). Although older adults who died from cancer had the largest increase in the number of drugs (mean difference, 3.37; 95% confidence interval, 3.35 to 3.40), living in an institution was independently associated with a slower escalation (β = -0.90, 95% confidence interval, -0.92 to -0.87). During the final month before death, analgesics (60.8%), anti-throm-botic agents (53.8%), diuretics (53.1%), psycholeptics (51.2%), and β-blocking agents (41.1%) were the 5 most commonly used drug classes. Angiotensin-converting enzyme inhibitors and statins were used by, respectively, 21.4% and 15.8% of all individuals during their final month of life. CONCLUSION Polypharmacy increases throughout the last year of life of older adults, fueled not only by symptomatic medications but also by long-term preventive treatments of questionable benefit. Clinical guidelines are needed to support physicians in their decision to continue or discontinue medications near the end of life.
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83
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Grande G, Morin L, Vetrano DL, Fastbom J, Johnell K. Drug Use in Older Adults with Amyotrophic Lateral Sclerosis Near the End of Life. Drugs Aging 2017; 34:529-533. [PMID: 28536907 PMCID: PMC5488113 DOI: 10.1007/s40266-017-0469-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS), with its certain prognosis and swift progression, raises concerns regarding the adequacy of pharmacological treatment, including the risk-benefit profiles of prescribed drugs. OBJECTIVE Our objective was to evaluate the use of prescription drugs over the course of the last year of life in older adults with ALS. METHODS We conducted a nationwide retrospective cohort study of older adults who died with ALS in Sweden between 2007 and 2013. The primary outcome was the number of prescription drugs to which individuals were exposed during the last 12 months before death. RESULTS The overall proportion of individuals receiving ten or more different prescription drugs increased from 19% at 12 months before death to 37% during the last month of life. Institutionalization was independently associated with polypharmacy near the end of life (odds ratio 1.84; 95% confidence interval 1.42-2.39). CONCLUSION Future research is needed to assess the time to benefit of treatments and to develop guidelines for medication discontinuation in advanced ALS.
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Affiliation(s)
- Giulia Grande
- Aging Research Center, Department of Neurobiology, Care Sciences, and Society (NVS), Karolinska Institutet and Stockholm University, Gävlegatan 16, 11330, Stockholm, Sweden.
- Center for Research and Treatment on Cognitive Dysfunctions, Biomedical and Clinical Sciences Department, "Luigi Sacco" Hospital, University of Milan, Milan, Italy.
| | - Lucas Morin
- Aging Research Center, Department of Neurobiology, Care Sciences, and Society (NVS), Karolinska Institutet and Stockholm University, Gävlegatan 16, 11330, Stockholm, Sweden
| | - Davide Liborio Vetrano
- Aging Research Center, Department of Neurobiology, Care Sciences, and Society (NVS), Karolinska Institutet and Stockholm University, Gävlegatan 16, 11330, Stockholm, Sweden
- Department of Geriatrics, Catholic University of Rome, Rome, Italy
| | - Johan Fastbom
- Aging Research Center, Department of Neurobiology, Care Sciences, and Society (NVS), Karolinska Institutet and Stockholm University, Gävlegatan 16, 11330, Stockholm, Sweden
| | - Kristina Johnell
- Aging Research Center, Department of Neurobiology, Care Sciences, and Society (NVS), Karolinska Institutet and Stockholm University, Gävlegatan 16, 11330, Stockholm, Sweden
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84
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Campbell CL, Kelly M, Rovnyak V. Pain management in home hospice patients: A retrospective descriptive study. Nurs Health Sci 2017; 19:381-387. [PMID: 28612352 DOI: 10.1111/nhs.12359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 03/14/2017] [Accepted: 03/24/2017] [Indexed: 01/14/2023]
Abstract
The development and evaluation of evidence-based, safe, and effective home-based pain management models for caregivers implementation is receiving greater attention in the literature because of international initiatives intended to increase the number of people who receive end-of-life care in home-based settings. The purpose of this "retrospective descriptive design" study was to describe pharmacological pain management and outcomes for 40 cancer and non-cancer patients receiving hospice care at home. While the median pain score was higher at admission in the cancer group than in the hospice care at home group, the difference was not significant at or within 48 hour of admission. Overall, there was a significant decrease in pain from the first measurement to the second. Within the last seven days of life, the majority of participants were not able to provide a pain severity score when asked to evaluate the effectiveness of pain management, thus their caregiver provided a proxy evaluation. Pain management was effective in the home setting. More research is needed on the best methods to teach lay caregivers to assess pain and evaluate the effectiveness of pharmacological modalities to manage pain.
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Affiliation(s)
- Cathy L Campbell
- University of Virginia School of Nursing, Charlottesville, Virginia
| | - Meghan Kelly
- University of Virginia School of Nursing, Charlottesville, Virginia
| | - Virginia Rovnyak
- University of Virginia School of Nursing, Charlottesville, Virginia
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85
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Morin L, Vetrano DL, Grande G, Fratiglioni L, Fastbom J, Johnell K. Use of Medications of Questionable Benefit During the Last Year of Life of Older Adults With Dementia. J Am Med Dir Assoc 2017; 18:551.e1-551.e7. [PMID: 28431913 DOI: 10.1016/j.jamda.2017.02.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 02/28/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the prevalence and factors associated with the use of medications of questionable benefit throughout the final year of life of older adults who died with dementia. DESIGN Register-based, longitudinal cohort study. SETTING Entire Sweden. PARTICIPANTS All older adults (≥75 years) who died with dementia between 2007 and 2013 (n = 120,067). MEASUREMENTS Exposure to medications of questionable benefit was calculated for each of the last 12 months before death, based on longitudinal data from the Swedish Prescribed Drug Register. RESULTS The proportion of older adults with dementia who received at least 1 medication of questionable benefit decreased from 38.6% 12 months before death to 34.7% during the final month before death (P < .001 for trend). Among older adults with dementia who used at least 1 medication of questionable benefit 12 months before death, 74.8% remained exposed until their last month of life. Living in an institution was independently associated with a 15% reduction of the likelihood to receive ≥1 medication of questionable benefit during the last month before death (odds ratio 0.85, 95% confidence interval 0.88-0.83). Antidementia drugs accounted for one-fifth of the total number of medications of questionable benefit. Lipid-lowering agents were used by 8.3% of individuals during their final month of life (10.2% of community-dwellers and 6.6% of institutionalized people, P < .001). CONCLUSION Clinicians caring for older adults with advanced dementia should be provided with reliable tools to help them reduce the burden of medications of questionable benefit near the end of life.
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Affiliation(s)
- Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.
| | - Davide L Vetrano
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden; Department of Geriatrics, Catholic University of Rome, Rome, Italy
| | - Giulia Grande
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden; Center for Research and Treatment on Cognitive Dysfunctions, Biomedical and Clinical Sciences Department, "Luigi Sacco" Hospital, University of Milan, Milan, Italy
| | - Laura Fratiglioni
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Johan Fastbom
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Kristina Johnell
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
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86
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Abstract
Hospice is a model of care for patients nearing the end of their lives that emphasizes symptom management, quality of life (QOL), and support of the patient and caregiving family through the death of the patient and the family's bereavement. It is associated with high patient and caregiver satisfaction and appears to not shorten lifespan for appropriately referred patients. Patients with advanced heart failure are being referred to hospice care more often than in the past, but the majority of deaths occur without this benefit. Hospice care in the USA is defined by the Medicare Hospice Benefit and associated regulations. Hospice is appropriate for patients with an expected survival prognosis of 6 months or less, and multiple predictive factors and tools are available to assist in prognostication. Management of symptoms and specific drug therapy options are discussed. For many patients, deactivation of electronic cardiac devices is appropriate when the goals of care are comfort and QOL. Ongoing collaboration of the referring physician with the hospice agency and staff offers opportunities for seamless and quality care.
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87
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Geijteman ECT, Dees MK, Tempelman MMA, Huisman BAA, Arevalo JJ, Perez RSGM, van Zuylen L, van der Heide A. Understanding the Continuation of Potentially Inappropriate Medications at the End of Life: Perspectives from Individuals and Their Relatives and Physicians. J Am Geriatr Soc 2016; 64:2602-2604. [DOI: 10.1111/jgs.14519] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Eric C. T. Geijteman
- Department of Public Health; Erasmus University Medical Center; Rotterdam the Netherlands
- Department of Medical Oncology; Erasmus MC Cancer Institute; Rotterdam the Netherlands
| | - Marianne K. Dees
- Radboud Institute for Health Sciences; IQ Healthcare; Radboud University Medical Center; Nijmegen the Netherlands
| | | | - Bregje A. A. Huisman
- Department of Anesthesiology; VU University Medical Center; Amsterdam the Netherlands
| | - Jimmy J. Arevalo
- Department of Anesthesiology; VU University Medical Center; Amsterdam the Netherlands
| | - Roberto S. G. M. Perez
- Department of Anesthesiology; VU University Medical Center; Amsterdam the Netherlands
- Hospice Kuria; Amsterdam the Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology; Erasmus MC Cancer Institute; Rotterdam the Netherlands
| | - Agnes van der Heide
- Department of Public Health; Erasmus University Medical Center; Rotterdam the Netherlands
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Joven MH. Should the Treatment of Hypothyroidism Be Withdrawn in Hospice Care? J Pain Symptom Manage 2016; 52:e3-4. [PMID: 27401512 DOI: 10.1016/j.jpainsymman.2016.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 04/25/2016] [Accepted: 05/22/2016] [Indexed: 11/20/2022]
Affiliation(s)
- Mark H Joven
- Clinical Fellow in Geriatric Medicine, Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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