Variation in medication use in cancer patients at the end of life: a cross-sectional analysis

Medical Cannabis and Utilization of Nonhospice Palliative Care Services: Complements and Alternatives at End of Life

Background and Objectives

There is a need to know more about cannabis use among terminally diagnosed older adults, specifically whether it operates as a complement or alternative to palliative care. The objective is to explore differences among the terminal illness population within the Illinois Medical Cannabis Program (IMCP) by their use of palliative care.

Research Design and Methods

The study uses primary, cross-sectional survey data from 708 terminally diagnosed patients, residing in Illinois, and enrolled in the IMCP. We compared the sample on palliative care utilization through logistic regression models, examined associations between palliative care and self-reported outcome improvements using ordinary least squares regressions, and explored differences in average pain levels using independent t-tests.

Results

115 of 708 terminally diagnosed IMCP participants were receiving palliative care. We find increased odds of palliative care utilization for cancer (odds ratio [OR] [SE] = 2.15 [0.53], p < .01), low psychological well-being (OR [SE] = 1.97 [0.58], p < .05), medical complexity (OR [SE] = 2.05 [0.70], p < .05), and prior military service (OR [SE] = 2.01 [0.68], p < .05). Palliative care utilization is positively associated with improvement ratings for pain (7.52 [3.41], p < .05) and ability to manage health outcomes (8.29 [3.61], p < .01). Concurrent use of cannabis and opioids is associated with higher pain levels at initiation of cannabis dosing (p < .05).

Discussion and Implications

Our results suggest that cannabis is largely an alternative to palliative care for terminal patients. For those in palliative care, it is a therapeutic complement used at higher levels of pain.

Prescribing practices, patterns, and potential harms in patients receiving palliative care: A systematic scoping review

Background

Patients receiving palliative care often have existing comorbidities necessitating the prescribing of multiple medications. To maximize quality of life in this patient cohort, it is important to tailor prescribing of medication for preventing and treating existing illnesses and those for controlling symptoms, such as pain, according to individual specific needs.

Objectives

To provide an overview of peer-reviewed observational research on prescribing practices, patterns, and potential harms in patients receiving palliative care.

Methods

A systematic scoping review was conducted using four electronic databases (PubMed, EMBASE, CINAHL, Web of Science). Each database was searched from inception to May 2020. Search terms included 'palliative care,' 'end of life,' and 'prescribing.' Eligible studies had to examine prescribing for adults (≥18 years) receiving palliative care in any setting as a study aim or outcome. Studies focusing on single medication types (e.g., opioids), medication classes (e.g., chemotherapy), or clinical indications (e.g., pain) were excluded. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, and the findings were described using narrative synthesis.

Results

Following deduplication, 16,565 unique citations were reviewed, and 56 studies met inclusion criteria. The average number of prescribed medications per patient ranged from 3 to 23. Typically, prescribing changes involved decreases in preventative medications and increases in symptom-specific medications closer to the time of death. Twenty-one studies assessed the appropriateness of prescribing using various tools. The prevalence of patients with ≥1 potentially inappropriate prescription ranged from 15 to 92%. Three studies reported on adverse drug events.

Conclusions

This scoping review provides a broad overview of existing research and shows that many patients receiving palliative care receive multiple medications closer to the time of death. Future research should focus in greater detail on prescribing appropriateness using tools specifically developed to guide prescribing in palliative care and the potential for harm.

Use of potentially inappropriate medication in older patients with lung cancer at the end of life

OBJECTIVES

Medications at the end of life should be used for symptom control. Medications which potential adverse effects outweigh their expected benefits are called 'potentially inappropriate medications' (PIMs). PIMs are related with adverse drug events and reduced quality of life. In this study, we investigated to what extent PIMs are dispensed to older patients with lung cancer in the last month of life.

METHODS

We selected patients with lung cancer, aged 65+, diagnosed between 2009 and 2014, and who died before April 1st 2015 from the population-based Netherlands Cancer Registry (NCR). The NCR is linked to the PHARMO Database Network, that includes medications dispensed by community pharmacies in the Netherlands. The eight PIM groups were based on the OncPal Deprescribing Guideline: aspirin, dyslipidaemia medications, antihypertensives, osteoporosis medications, peptic ulcer prophylaxis, oral hypoglycaemics, vitamins and minerals.

RESULTS

Data of 7864 patients with lung cancer were analyzed. Median age was 74 year (IQR = 70-79) and 67% was male. 45% of all patients received at least one PIM in their last month of life. Taking into account all dispensed medications, patients receiving PIMs received more different medications compared to those receiving no PIMs, respectively 10 (SD = 5) vs. 3 (SD = 4) different medications (P < 0.001).

CONCLUSION

Almost half of the older patients with lung cancer in the Netherlands received PIMs in their last month of life. Since PIM use is associated with reduced quality of life, it is important that health care professionals continue to critically assess which medication can be discontinued at the end of life.

Patterns of medication use at end of life by pediatric inpatients with cancer

OBJECTIVE

To describe medication utilization patterns by pediatric inpatients with cancer during their last week of life.

METHODS

This retrospective study used data from the Vizient Clinical Database/Resource Manager, a national compilation of clinical and resource use data from over 100 academic medical centers and affiliates. Patients (0-21 years) with malignancy who died during hospitalization (2010-2017) were included (N = 1659). Medications were categorized as opioid, benzodiazepine, gastrointestinal related, chemotherapy, anti-infectives, or vasopressors. Exposure to each group was ascertained for all patients at 1 week and 1 day prior to death. Factors associated with exposure were examined using generalized estimating equations, and summarized using adjusted odds ratios (aORs).

RESULTS

Over the last week of life, there was increased use of opioids (76% to 82%, aOR = 1.55, P < .001) and benzodiazepines (53% to 66%, aOR = 1.36, P = .02), while gastrointestinal-related medication use decreased (92% to 89%, aOR = 0.69, P = .001). Patients had decreased exposure to chemotherapy (10% to 5%, aOR = 0.46, P < .001) and anti-infectives (82% to 73%, aOR = 0.41, P = .002). Vasopressor use increased as death approached (15% to 28%, aOR = 1.67, P = .04). Factors significantly associated with exposure varied with medication category, and included age, race, length of stay, malignancy type, death in the intensive care unit, history of hematopoietic stem cell transplant, and do-not-resuscitate status.

CONCLUSION

During the week preceding death, administration of symptom management medications increased for children with cancer, but use was not universal. Potentially life-sustaining medications were often continued. Variability in utilization suggests differences in provider/family decision making that warrant further study to develop an evidence-based approach to end-of-life care.

Polypharmacy, chemotherapy receipt, and medication-related out-of-pocket costs at end of life among commercially insured adults with advanced cancer

BACKGROUND

Polypharmacy raises the risk of drug-drug interactions and adverse events among patients with cancer. Most polypharmacy research has focused on adults age 65 or older enrolled in Medicare insurance. To better inform pharmacy practice and cancer care delivery, data are needed on polypharmacy among commercially insured patients with cancer and those younger than 65.

METHODS

We performed a retrospective analysis of insurance enrollment and claims files linked to the Puget Sound Cancer Surveillance System for adults age 18 and older who were commercially insured, diagnosed with stage IV cancer, survived 30+ days after diagnosis, and did not enroll in hospice. We describe the prevalence of polypharmacy, chemotherapy use, and medication-related out-of-pocket (OOP) costs in the last month of life.

RESULTS

Of 606 patients, 390 (64%) experienced polypharmacy (i.e. 5+ medications) in the last 30 days of life. Almost half (n = 297, 49%) received chemotherapy or targeted agents; chemotherapy was associated with significantly higher odds of polypharmacy (odds ratio (OR) 2.93, 95% confidence interval (CI) 2.04-4.20). The most commonly prescribed medications at end of life were opioids, benzodiazepines and anti-emetics. Among 484 patients (80%) incurring medication-related costs in the last month of life, median total OOP cost was $82 (interquartile range $30-$200). Seven patients (1%) had total costs above $5,000. The median chemotherapy-related OOP cost was $446 (IQR $150-$1896); 32 patients (7%) had chemotherapy-related OOP costs between $1,000 and $5,000.

CONCLUSION

Most patients with advanced cancer experienced polypharmacy at end of life, although most medications observed herein are commonly used for supportive care. Patients receiving chemotherapy had higher medication-related OOP costs, and chemotherapy was significantly associated with polypharmacy at end of life. Evaluation of polypharmacy at end of life may represent an important opportunity to improve quality of life and reduce costs for patients and families.

Deprescribing in Older Adults With Cancer and Limited Life Expectancy: An Integrative Review

Polypharmacy is common in older adults with cancer and deprescribing potentially inappropriate medications becomes very relevant when life expectancy decreases due to metastatic disease. Especially preventive medications may no longer be beneficial, because they may decrease quality of life and reduction in morbidity and mortality may be futile. Although deprescribing of preventive medication is common in the last period of life, it is still unusual during active cancer treatment for advanced disease, although life expectancy is often limited to less than 1 to 2 years in that stage. We performed a systematic search of the literature in Pubmed and Embase on the discontinuation of commonly utilized groups of preventive medication and evaluated the evidence of potential benefits and harms in patients aged 65 years or older with cancer and a limited life expectancy (LLE). From 21 included studies, it can be concluded that deprescribing lipid lowering drugs, antihypertensive drugs, osteoporosis drugs and antihyperglycemic drugs is feasible in a considerable part of patients with a LLE. Discontinuation may be performed safely, without the occurrence of serious adverse events or decrease of survival. The only study that addressed quality of life after deprescribing showed that discontinuation of statins improves quality of life in patients with a LLE. Recurrence of symptoms requiring reintroduction occurred in 0-13% of patients on antihyperglycemic treatment and 8-60% of patients using antihypertensive drugs. In order to reduce pill burden and futile treatment clinicians should discuss deprescribing of preventive medication with older patients with advanced cancer and a LLE.

Polypharmacy among older advanced lung cancer patients taking EGFR tyrosine kinase inhibitors

OBJECTIVE

Polypharmacy (PP) is a common problem among the older adults and has a potential effect on health-related problems. However, the significance of PP in older advanced non-small cell lung cancer (NSCLC) patients and those on oral molecular-targeted anticancer agents is unclear.

MATERIALS AND METHODS

This retrospective, nonrandomized study reviewed the records of 334 advanced NSCLC patients who underwent epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) treatment. PP was defined as ≥ 5 concomitant medications. Potentially inappropriate medication (PIM) use was measured using the updated screening tool of older people's prescriptions (STOPP) ver. 2 criteria. We also estimated survival distributions using the Kaplan-Meier method, compared between-group differences using the log-rank test, explored potential predictors of survival using Cox regression, and performed cluster analysis to identify factors affecting multiple-medication use.

RESULTS

The PP and PIM use prevalence was 38.4% and 31.9%, respectively. The median overall survival (OS) for PP(+) and PP(-) patients was 19.4 and 27.3 months, respectively. Multivariate analysis revealed a significant correlation between PP and OS. The frequency of unexpected hospitalization during EGFR-TKI treatment was higher in PP(+) patients compared to PP(-) patients (49.4% vs. 29.4%; odds ratio = 2.34).

CONCLUSION

PP is an independent prognostic factor in older advanced NSCLC patients taking EGFR-TKIs. PP can be used as a simple indicator of such patients' comorbidities and symptoms or as a predictive marker of unexpected hospitalization during treatment.

Polypharmacy as a prognostic factor in older patients with advanced non-small-cell lung cancer treated with anti-PD-1/PD-L1 antibody-based immunotherapy

PURPOSE

Polypharmacy is a common problem among older adults. However, its prevalence and impact on the clinical outcomes of anticancer treatment, such as survival and adverse events, in older patients with advanced cancer have not been well investigated.

METHODS

We retrospectively reviewed data from Japanese patients treated with an immune checkpoint inhibitor (ICI) for advanced or recurrent non-small-cell lung cancer (NSCLC) between 2016 and 2019.

RESULTS

Among 157 older (aged ≥ 65 years) patients, the prevalence of polypharmacy, defined as ≥ 5 medications, was 59.9% (94/157). The prevalence of potentially inappropriate medication use, according to the screening tool of older people's prescription (STOPP) criteria version 2, was 38.2% (60/157). The median progression-free survival (PFS) in patients with and without polypharmacy was 3.7 and 5.5 months, respectively (P = 0.0017). The median overall survival (OS) in patients with and without polypharmacy was 9.5 and 28.1 months, respectively (P < 0.001). Multivariate analysis revealed marked associations between polypharmacy and OS, but no significant associations between polypharmacy and PFS. Polypharmacy was not associated with immune-related adverse events but was associated with higher rate of unexpected hospitalizations during ICI treatment (59.6% vs. 31.7%, P < 0.001).

CONCLUSION

Polypharmacy is an independent prognostic factor in older patients with advanced NSCLC treated with ICI. Also, polypharmacy could be utilized as a simple indicator of patients' comorbidities and symptoms or as a predictive marker of unexpected hospitalizations during ICI treatment.

Population-Based Quality Indicators for End-of-Life Cancer Care: A Systematic Review

Importance

Improving the quality of cancer care is an international priority. Population-based quality indicators (QIs) are key to this process yet remain almost exclusively used for evaluating care during the early, often curative, stages of disease.

Objectives

To identify all existing QIs for the care of patients with cancer who have advanced disease and/or are at the end of life and to evaluate each indicator's measurement properties and appropriateness for use.

Evidence Review

For this systematic review, 5 electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, and the Cochrane Library) were searched from inception through February 4, 2019, for studies describing the development, review, and/or testing of QIs for the care of patients with cancer who have advanced disease and/or are at the end of life. For each QI identified, descriptive information was extracted and 6 measurement properties (acceptability, evidence base, definition, feasibility, reliability, and validity) were assessed using previously established criteria, with 4 possible ratings: positive, intermediate, negative, and unknown. Ratings were collated and each QI classified as appropriate for use, inappropriate for use, or of limited testing. Among the QIs determined as appropriate for use, a recommended shortlist was generated by excluding those that were specific to patient subgroups and/or care settings; related QIs were identified, and the indicator with the highest rating was retained.

Findings

The search yielded 7231 references, 35 of which (from 28 individual studies) met the eligibility criteria. Of 288 QIs extracted (260 unique), 103 (35.8%) evaluated physical aspects of care and 109 (37.8%) evaluated processes of care. Quality indicators relevant to psychosocial (18 [6.3%]) or spiritual and cultural (3 [1.0%]) care domains were limited. Eighty QIs (27.8%) were determined to be appropriate for use, 116 (40.3%) inappropriate for use, and 92 (31.9%) of limited testing. The measurement properties with the fewest positive assessments were acceptability (38 [13.2%]) and validity (63 [21.9%]). Benchmarking data were reported for only 16 QIs (5.6%). The final 15 recommended QIs came from 6 studies.

Conclusions and Relevance

The findings suggest that only a small proportion of QIs developed for the care of patients with cancer who have advanced disease and/or are at the end of life have received adequate testing and/or are appropriate for use. Further testing may be needed, as is research to establish benchmarking data and to expand QIs relevant to psychosocial, cultural, and spiritual care domains.

Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission

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.

Nurses' Perspectives on Family Caregiver Medication Management Support and Deprescribing

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.

The Management of Nausea at the End of Life

The evaluation and management of nausea in patients near the end of life can be more challenging than that of nausea in patients undergoing antineoplastic therapies. Unlike in the oncology setting in which nausea is primarily managed using antiemetic regimens that have been developed with the neuropharmacology and emetogenic potentials of chemotherapy agents in mind, many patients receiving end-of-life care have nausea of multifactorial etiology. Patients also may be older with reduced physiologic ability to metabolize and clear drugs. Therefore, typical antiemetics in regimens initially selected for oncology patients may be ineffective. In this article, the prevalence, manifestation, and pathophysiology of nausea experienced by patients near and at the end of life will be reviewed, with a focus on pharmacological and nonpharmacological interventions that have been found to effectively manage this symptom in this patient population.

Adequate, questionable, and inadequate drug prescribing for older adults at the end of life: a European expert consensus

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.

Continuation of non-essential medications in actively dying hospitalised patients

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.

Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study

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.

Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: A systematic review

BACKGROUND

Opioids are the primary pharmacological treatment for cancer pain and, in the palliative care setting, are routinely used to manage symptoms at the end of life. Opioids are one of the most frequently reported drug classes in medication errors causing patient harm. Despite their widespread use, little is known about the incidence and impact of opioid medication errors in oncology and palliative care settings.

AIM

To determine the incidence, types and impact of reported opioid medication errors in adult oncology and palliative care patient settings.

DESIGN

A systematic review.

DATA SOURCES

Five electronic databases and the grey literature were searched from 1980 to August 2014. Empirical studies published in English, reporting data on opioid medication error incidence, types or patient impact, within adult oncology and/or palliative care services, were included. Popay's narrative synthesis approach was used to analyse data.

RESULTS

Five empirical studies were included in this review. Opioid error incidence rate was difficult to ascertain as each study focussed on a single narrow area of error. The predominant error type related to deviation from opioid prescribing guidelines, such as incorrect dosing intervals. None of the included studies reported the degree of patient harm resulting from opioid errors.

CONCLUSION

This review has highlighted the paucity of the literature examining opioid error incidence, types and patient impact in adult oncology and palliative care settings. Defining, identifying and quantifying error reporting practices for these populations should be an essential component of future oncology and palliative care quality and safety initiatives.

Prescription and Deprescription of Medication During the Last 48 Hours of Life: Multicenter Study in 23 Acute Geriatric Wards in Flanders, Belgium

CONTEXT

Palliative care for the older person is often limited, resulting in poor quality of dying. Pharmacological management can be one of the components to achieve better symptom control.

OBJECTIVES

To describe the anticipatory prescription of medication for symptomatic treatment and the deprescription of potentially inappropriate medication during the last days of life.

METHODS

This was a cross-sectional descriptive study between October 1, 2012 and September 30, 2013 in 23 acute geriatric wards in Flanders, Belgium. Structured after-death questionnaires were filled out by the treating geriatrician for patients hospitalized for more than 48 hours before dying.

RESULTS

Anticipatory prescription of medication was present in 65.4% of cases, 45.5% of the cases was prescribed morphine, 15.5% benzodiazepines, and 13.8% scopolamine hydrobromide. A deprescription of potentially inappropriate medication was noted in 67.9% of cases. The likelihood of anticipatory prescription was significantly higher in cases where death was expected (odds ratio [OR] 19; 95% CI 9-40; P < 0.0001) and significantly lower where dementia was present (OR 0.35; 95% CI 0.16-0.74; P < 0.006). The likelihood of deprescription was higher in cases where death was expected (OR 20; 95% CI 10-43; P < 0.0001) and in cases of patients dying from an oncological disease compared with those dying from frailty or dementia (OR 7.0; 95% CI 1.1-45.6, P = 0.042).

CONCLUSION

Anticipatory prescription of medication and deprescription of medication at the end of life in acute geriatric wards could be further optimized. A well-developed intervention to guide health care staff in patient-centered pharmacological management in the last days of life seems to be needed.

Palliative care at the end-of-life in glioma patients

The end-of-life (EOL) phase of patients with a glioma starts when symptom prevalence increases and antitumor treatment is no longer effective. During the EOL phase, care is primarily aimed at reducing symptom burden while maintaining quality of life as long as possible without inappropriate prolongation of life. Palliative care during the EOL phase also involves complex medical decisions for the prevention and relief of suffering. We discuss the prevalence and treatment of the most common EOL symptoms, decision making in the EOL phase, the organization of EOL care, and the role of the patient's caregiver. Treating disease-specific symptoms, such as impaired consciousness, seizures, focal neurologic deficits and cognitive disturbances, is a major concern during the EOL phase, as these symptoms may interfere with EOL decision making. Advance care planning is aimed at reaching consensus about possible EOL decisions between all participants, respecting the values of patients and their informal caregivers. In order to prevent the possibility that the patient becomes incompetent to make informed decisions, we recommend initiating EOL conversations at a relatively early stage in the disease course.

The characteristics of patients who discontinue their dying process - an observational study at a single university hospital centre

Background

End-of-life integrated care plans are used as structuring tools for the care of the dying. A widely adopted example is the Liverpool Care Pathway for the Dying Patient (LCP). Recently, several concerns were raised about LCP care, such as a worry that diagnosis of dying might be leading to a self-fulfilling trajectory, including hastening of death. However, data on rates of discontinuation of LCP care are lacking. In an observational study, we therefore investigated the incidence, features and trajectory of patients who were discontinued from the LCP. We hypothesised that (1) it is common to discontinue patients from the LCP, (2) quality of life does not decrease for discontinued LCP patients, and (3) discontinued patients live longer than patients who remain within LCP care.

Methods

All adult patients who were diagnosed as dying in a German university hospital specialized palliative care unit were included in 2013 and 2014. Actuarial estimation of survival prognostication tools and a number of quality of life indicators were used for data collection. Survival time was analysed using Kaplan-Meier estimates. Group differences in quality of life were tested using multivariate analysis of variance.

Results

159 patients were included in a digital version of the LCP. 15 patients (9.4 %) were discontinued later. Quality of life did not decrease for discontinued patients during LCP care (p = 0.16). LCP discontinued patients lived significantly longer than the remaining LCP subgroup (difference of means 296 hours, 95 % confidence interval 105.5 to 451.5 hours; difference of survival function estimates p < 0.0001).

Conclusions

When patients are diagnosed as dying, death is not the inevitable outcome of an end-of-life integrated care plan such as the LCP. Instead, it is common to discontinue the LCP care. Regular careful interprofessional assessments are important for identifying those patients who need to be discontinued from their end-of-life care plan. In this study, we found no evidence for harm by the LCP. We conclude that a correctly applied integrated care plan can be useful to provide good and safe care for the dying.

Trial registration

Internal Clinical Trial Register of the Medical Faculty, Heinrich Heine University Düsseldorf, No. 2015053680 (22 May 2015).

Variation in physician recommendations, knowledge and perceived roles regarding provision of end-of-life care

Background

There is high variability in end-of-life (EOL) treatments. Some of this could be due to differences in physician treatment recommendations, their knowledge/attitude regarding palliative care, and their perceived roles in treating patients with advanced serious illness (ASI). Thus, the objective of this paper was to identify potential variation in physician recommendations, their knowledge/attitude regarding palliative care and perceived roles in treating ASI patients.

Methods

A cross-sectional survey consisting of vignettes describing patient characteristics that varied by age, expected survival, cognitive status and treatment costs and asked physicians whether they would recommend life-extending treatments for each scenario, was administered to 285 physicians who treat ASI patients in Singapore. Physicians were also assessed on their knowledge/attitude in palliative care. They were administered a best-worst scaling exercise requiring them to select their most and least important role as a physician caring for an ASI patient.

Results

There was a wide variation in physician recommendations for life-extending treatments for patients with similar profiles, which can partly be attributed to physician characteristics (years of experience and place of training). Only about one-fourth of the physicians answered all knowledge/attitude questions correctly. Statements assessing knowledge/attitude regarding pain management had the fewest correct responses. The most important perceived role regarding provision of EOL care concerned symptom management.

Conclusions

Results suggest that variation in physician treatment recommendations may be partly related to their own characteristics, raising concerns regarding the EOL care being provided to patients. Efforts should be made to better understand this variation and to provide the physicians with additional training in key aspects of palliative care management.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-015-0050-y) contains supplementary material, which is available to authorized users.

End-of-life care: pathways and evidence

PURPOSE OF REVIEW

Studies in different countries and settings of care have reported the quality of care for the dying patients as suboptimal. Care pathways have been developed with the aim of ensuring that dying patients and their family members received by health professionals the most appropriate care. This review presents and discusses the evidence supporting the effectiveness of the end-of-life care pathways.

RECENT FINDINGS

Two Cochrane systematic reviews updated at June 2013 did not identify studies that met minimal criteria for inclusion. One randomized cluster trial aimed at assessing the effectiveness of the Liverpool Care Pathway in hospitalized cancer patients was subsequently published. The trial did not find a significant difference in the overall quality of care, the primary end-point, but two out of nine secondary outcomes - respect, dignity, and kindness, and control of breathlessness showed significant improvements. Afterwards, we did not find any other potentially eligible published study.

SUMMARY

The overall amount of evidence supporting the dissemination of end-of-life care pathways is rather poor. One negative randomized trial suggests the pathways have the potential to reduce the gap between hospital and hospices. Further research is needed to understand the potential benefit of end-of-life care pathways.

Medication use during end-of-life care in a palliative care centre

Background In end-of-life care, symptoms of discomfort are mainly managed by drug therapy, the guidelines for which are mainly based on expert opinions. A few papers have inventoried drug prescriptions in palliative care settings, but none has reported the frequency of use in combination with doses and route of administration. Objective To describe doses and routes of administration of the most frequently used drugs at admission and at day of death. Setting Palliative care centre in the Netherlands. Method In this retrospective cohort study, prescription data of deceased patients were extracted from the electronic medical records. Main outcome measure Doses, frequency and route of administration of prescribed drugs Results All regular medication prescriptions of 208 patients, 89 % of whom had advanced cancer, were reviewed. The three most prescribed drugs were morphine, midazolam and haloperidol, to 21, 11 and 23 % of patients at admission, respectively. At the day of death these percentages had increased to 87, 58 and 50 %, respectively. Doses of these three drugs at the day of death were statistically significantly higher than at admission. The oral route of administration was used in 89 % of patients at admission versus subcutaneous in 94 % at the day of death. Conclusions Nearing the end of life, patients in this palliative care centre receive discomfort-relieving drugs mainly via the subcutaneous route. However, most of these drugs are unlicensed for this specific application and guidelines are based on low level of evidence. Thus, there is every reason for more clinical research on drug use in palliative care.

Changes in medication profile among patients with advanced cancer admitted to an acute palliative care unit

PURPOSE

The decision-making process for medication use in the last weeks of life is complex because of patient frailty and poor prognosis. Limited literature is available on medication use in the palliative care setting, particularly in acute palliative care units (APCUs). We examined the changes in medication profile among hospitalized patients with advanced cancer before their palliative care inpatient consultation team referral, after palliative care consultation, at the time of APCU admission, and at APCU discharge or death.

METHODS

We included consecutive patients with advanced cancer who were first seen by our inpatient palliative care consultation team and subsequently admitted to the APCU. We retrieved data on all scheduled medications at the prespecified time points.

RESULTS

Among the 100 patients, the median duration of hospitalization was 10.5 days (interquartile range 8-15 days), and the median APCU stay was 5 days (interquartile range 3-7 days). The average number of medications before palliative care inpatient consultation team referral, after palliative care consultation, at APCU admission and at APCU discharge/death was 9.2 (standard deviation [SD] 4.5), 9.9 (SD 4.2), 10.3 (SD 3.8), and 10.1 (SD 3.8), respectively (P = 0.03). An increasing proportion of patients received medications for symptom control over their course of hospitalization, including systemic corticosteroids, laxatives, neuroleptics, and antiulcer agents (P < 0.05). In contrast, the frequency of several classes of medications such as antihypertensives, antilipemics, and anticonvulsants decreased over time (P < 0.05).

CONCLUSIONS

Palliative care involvement was associated with an increase in symptom control medications and decrease in medications for comorbid conditions over time.

Prescribing for comorbid disease in a palliative population: focus on the use of lipid-lowering medications

BACKGROUND

The balance of benefit versus burden of ongoing treatments for comorbid disease in palliative populations as death approaches needs careful consideration given their particular susceptibility to adverse drug effects.

AIM

To provide descriptive data regarding the medications being prescribed to patients who have a life-limiting illness at the time of referral to a palliative care service in regional Australia, with particular focus on lipid-lowering medications.

METHODS

A prospective case note review of 203 patients reporting the number of medications prescribed and, for lipid-lowering medications, the indication and level of prevention sought (primary, secondary, tertiary). Rates were compared by performance status, disease phase and comorbidity burden.

RESULTS

Mean number of regular medications prescribed was 7.2, with higher rates observed in those patients with a non-malignant primary diagnosis (rate ratio 1.28, confidence interval (CI) 1.11-1.50) or poorer performance status (rate ratio 1.37, CI 1.11-1.69) and lower rates for those in the terminal phase of disease (rate ratio 0.48, CI 0.30-0.76). Over one fifth of patients were prescribed a lipid-lowering medication, and two fifths of these prescriptions were for primary prevention of cardiovascular disease. Patients in the highest quartile of Charlson Comorbidity Index score were 4.6 (CI 2.06-10.09) times more likely to be prescribed a lipid-lowering medication than those in the lowest quartile.

CONCLUSIONS

Polypharmacy is prevalent for this group of patients, placing them at high risk of drug-drug and drug-host interactions. Prescribing may be driven by risk factors and disease guidelines rather than a rational, patient-centred approach.

A comparison of drugs and procedures of care in the Italian hospice and hospital settings: the final three days of life for cancer patients

BACKGROUND

A palliative approach at the end of life typically involves forgoing certain drugs and procedures and starting others - weighing burden against potential benefit. An assessment of the palliative approach may be undertaken by investigating which drugs and procedures are used in the dying phase, and at what frequencies.

METHODS

Drugs were classified as potentially (in)appropriate based on expert classification. Procedures were classed as therapeutic or diagnostic. 271 consecutive cancer deaths from across 16 hospital general wards and 5 hospices in Italy gathered data on drugs and procedures in the final three days of life through a standardised form. Differences between the two groups were tested using chi-square testing, and logistic regressions were performed to control for patient characteristics.

RESULTS

75.0% of patients in hospital received 3 or more potentially inappropriate drugs in their last three days of life, against 42.6% in hospice. Diagnostic procedures were carried out more frequently in hospital. Multivariate logistic regression showed that when data was controlled for patient characteristics, setting had a unique contribution to the differences found in use of drugs and procedures.

CONCLUSION

The data indicates a need for improvement in the hospital setting concerning recognising the need for palliative care, and ensuring a timely introduction of this approach.

Epilepsy in the end of life phase of brain tumor patients: a systematic review

Epileptic seizures are common in patients with primary or secondary malignant brain tumor. However, current knowledge on the occurrence of seizures during the end of life (EOL) phase of brain tumor patients is limited. Because symptom management with preservation of quality of life is of major importance for patients with a malignant brain tumor, particularly in the EOL, it is necessary to gain a deeper understanding of seizures and their management during this phase. We performed a systematic review of literature related to epilepsy in the EOL phase of brain tumor patients, based on the electronic resources PubMed, Embase, and Cinahl. The search yielded 442 unique records, of which 11 articles were eligible for further analysis after applying predefined inclusion criteria. Seizures occur relatively frequently in the EOL phase, particularly in patients with high-grade glioma. However, seizure management is often hampered by swallowing difficulties and impaired consciousness. Treatment decisions are largely dependent on expert opinion because a standardized approach for treating seizures in the terminal stage of brain tumor patients is still lacking.

Effectiveness of palliative home-care services in reducing hospital admissions and determinants of hospitalization for terminally ill patients followed up by a palliative home-care team: a retrospective cohort study

BACKGROUND

It has been demonstrated that most patients in the terminal stages of cancer would benefit from palliative home-care services.

AIM

The aim of this study was to assess the effectiveness of appropriate palliative home-care services in reducing hospital admissions, and to identify factors predicting the likelihood of patients treated at home being hospitalized.

DESIGN

Retrospective cohort study.

SETTING/PARTICIPANTS

We enrolled all 402 patients listed by the Local Health Authority No. 5, Veneto Region (North-East Italy), as dying of cancer in 2011.

RESULTS

Of the cohort considered, 39.9% patients had been taken into care by a palliative home-care team. Irrespective of age, gender, and type of tumor, patients taken into care by the palliative home-care team were more likely to die at home, less likely to be hospitalized, and spent fewer days in hospital in the last 2 months of their life. Among the patients taken into care by the palliative home-care team, those with hematological cancers and hepatocellular carcinoma were more likely to be hospitalized, and certain symptoms (such as dyspnea and delirium) were predictive of hospitalization.

CONCLUSIONS

Our study confirms the effectiveness of palliative home care in enabling patients to spend the final period of their lives at home. The services of a palliative home-care team reduced the consumption of hospital resources. This study also provided evidence of some types of cancer (e.g. hematological cancers and hepatocellular carcinoma) being more likely to require hospitalization, suggesting the need to reconsider the pathways of care for these diseases.

Managing cancer pain at the end of life with multiple strong opioids: a population-based retrospective cohort study in primary care

BACKGROUND

End-of-life cancer patients commonly receive more than one type of strong opioid. The three-step analgesic ladder framework of the World Health Organisation (WHO) provides no guidance on multiple opioid prescribing and there is little epidemiological data available to inform practice. This study aims to investigate the time trend of such cases and the associated factors.

METHODS

Strong opioid prescribing in the last three months of life of cancer patients were extracted from the General Practice Research Database (GPRD). The outcome variable was the number of different types of prescribed non-rescue doses of opioids (1 vs 2-4, referred to as a complex case). Associated factors were evaluated using prevalence ratios (PR) derived from multivariate log-binomial model, adjusting for clustering effects and potential confounding variables.

RESULTS

Overall, 26.4% (95% CI: 25.6-27.1%) of 13,427 cancer patients (lung 41.7%, colorectal 19.1%, breast 18.6%, prostate 15.5%, head and neck 5.0%) were complex cases. Complex cases increased steadily over the study period (1.02% annually, 95%CI: 0.42-1.61%, p = 0.048) but with a small dip (7.5% reduction, 95%CI: -0.03 to 17.8%) around the period of the Shipman case, a British primary care doctor who murdered his patients with opioids. The dip significantly affected the correlation of the complex cases with persistent increasing background opioid prescribing (weighted correlation coefficients pre-, post-Shipman periods: 0.98(95%CI: 0.67-1.00), p = 0.011; 0.14 (95%CI: -0.85 to 0.91), p = 0.85). Multivariate adjusted analysis showed that the complex cases were predominantly associated with year of death (PRs vs 2000: 1.05-1.65), not other demographic and clinical factors except colorectal cancer (PR vs lung cancer: 1.24, 95%CI: 1.12-1.37).

CONCLUSION

These findings suggest that prescribing behaviour, rather than patient factors, plays an important role in multiple opioid prescribing at the end of life; highlighting the need for training and education that goes beyond the well-recognised WHO approach for clinical practitioners.

Liverpool Care Pathway for patients with cancer in hospital: a cluster randomised trial

BACKGROUND

The quality of care provided to patients with cancer who are dying in hospital and their families is suboptimum. The UK Liverpool Care Pathway (LCP) for patients who are dying was developed with the aim of transferring the best practice of hospices to hospitals. We therefore assessed the effectiveness of LCP in the Italian context (LCP-I) in improving the quality of end-of-life care for patients with cancer in hospitals and for their family.

METHODS

In this pragmatic cluster randomised trial, 16 Italian general medicine hospital wards were randomly assigned to implement the LCP-I programme or standard health-care practice. For each ward, we identified all patients who died from cancer in the 3 months before randomisation (preintervention) and in the 6 months after the completion of the LCP-I training programme. The primary endpoint was the overall quality of care toolkit scale. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01081899.

FINDINGS

During the postintervention assessment, data were gathered for 308 patients who died from cancer (147 in LCP-I programme wards and 161 in control wards). 232 (75%) of 308 family members were interviewed, 119 (81%) of 147 with relatives cared for in the LCP-I wards (mean cluster size 14·9 [range eight to 22]) and 113 (70%) of 161 in the control wards (14·1 [eight to 22]). After implementation of the LCP-I programme, no significant difference was noted in the distribution of the overall quality of care toolkit scores between the wards in which the LCP-I programme was implemented and the control wards (score 70·5 of 100 vs 63·0 of 100; cluster-adjusted mean difference 7·6 [95% CI -3·6 to 18·7]; p=0·186).

INTERPRETATION

The effect of the LCP-I programme in our study is less than the effects noted in earlier phase 2 trials. However, if the programme is implemented well it has the potential to reduce the gap in quality of care between hospices and hospitals. Further research is needed to ascertain what components of the LCP-I programme might be effective and to develop and assess a wider range of approaches to quality improvement in hospital care for people at the end of their lives and for their families.

FUNDING

Italian Ministry of Health and Maruzza Lefebvre D'Ovidio Foundation-Onlus.

Concepts and definitions for "actively dying," "end of life," "terminally ill," "terminal care," and "transition of care": a systematic review

CONTEXT

The terms "actively dying," "end of life," "terminally ill," "terminal care," and "transition of care" are commonly used but rarely and inconsistently defined.

OBJECTIVES

We conducted a systematic review to examine the concepts and definitions for these terms.

METHODS

We searched MEDLINE, PsycINFO, Embase, and CINAHL for published peer-reviewed articles from 1948 to 2012 that conceptualized, defined, or examined these terms. Two researchers independently reviewed each citation for inclusion and then extracted the concepts/definitions when available. We also searched 10 dictionaries, four palliative care textbooks, and 13 organization Web sites, including the U.S. Federal Code.

RESULTS

One of 16, three of 134, three of 44, two of 93, and four of 17 articles defined or conceptualized actively dying, end of life, terminally ill, terminal care, and transition of care, respectively. Actively dying was defined as "hours or days of survival." We identified two key defining features for end of life, terminally ill, and terminal care: life-limiting disease with irreversible decline and expected survival in terms of months or less. Transition of care was discussed in relation to changes in 1) place of care (e.g., hospital to home), 2) level of professions providing the care (e.g., acute care to hospice), and 3) goals of care (e.g., curative to palliative). Definitions for these five terms were rarely found in dictionaries, textbooks, and organizational Web sites. However, when available, the definitions were generally consistent with the concepts discussed previously.

CONCLUSION

We identified unifying concepts for five commonly used terms in palliative care and developed a preliminary conceptual framework toward building standardized definitions.

The Liverpool Care Pathway for cancer patients dying in hospital medical wards: a before-after cluster phase II trial of outcomes reported by family members

BACKGROUND

Hospital is the most common place of cancer death but concerns regarding the quality of end-of-life care remain.

AIM

Preliminary assessment of the effectiveness of the Liverpool Care Pathway on the quality of end-of-life care provided to adult cancer patients during their last week of life in hospital.

DESIGN

Uncontrolled before-after intervention cluster trial.

SETTINGS/PARTICIPANTS

The trial was performed within four hospital wards participating in the pilot implementation of the Italian version of the Liverpool Care Pathway programme. All cancer patients who died in the hospital wards 2-4 months before and after the implementation of the Italian version of Liverpool Care Pathway were identified. A total of 2 months after the patient's death, bereaved family members were interviewed using the Toolkit After-Death Family Interview (seven 0-100 scales assessing the quality of end-of-life care) and the Italian version of the Views of Informal Carers - Evaluation of Services (VOICES) (three items assessing pain, breathlessness and nausea-vomiting).

RESULTS

An interview was obtained for 79 family members, 46 (73.0%) before and 33 (68.8%) after implementation of the Italian version of Liverpool Care Pathway. Following Italian version of Liverpool Care Pathway implementation, there was a significant improvement in the mean scores of four Toolkit scales: respect, kindness and dignity (+16.8; 95% confidence interval = 3.6-30.0; p = 0.015); family emotional support (+20.9; 95% confidence interval = 9.6-32.3; p < 0.001); family self-efficacy (+14.3; 95% confidence interval = 0.3-28.2; p = 0.049) and coordination of care (+14.3; 95% confidence interval = 4.2-24.3; p = 0.007). No significant improvement in symptom' control was observed.

CONCLUSIONS

These results provide the first robust data collected from family members of a preliminary clinically significant improvement, in some aspects, of quality of care after the implementation of the Italian version of Liverpool Care Pathway programme. The poor effect for symptom control suggests areas for further innovation and development.

A Favorable Course of Palliative Sedation

Objective:

Comparing characteristics of a favorable sedation course during palliative sedation to a less favorable course based on the reports Dutch physicians and nurses.

Results:

Cases identified as having a favorable sedation course less often concerned a male patient ( P = .019 nurses’ cases), reached the intended sedation depth significantly quicker ( P < .05 both nurses and physicians’ cases), reached a deeper level of sedation ( P = .015 physicians’ cases), and had a shorter total duration of sedation compared ( P < .001 physicians’ cases) to patients with a less favorable sedation course.

Conclusions:

A favorable course during palliative sedation seems more probable when health care professionals report on a (relatively) shorter time to reach the required depth of sedation and when a deeper level of sedation can be obtained.

Antiretroviral therapy at the end of life: the experience of an academic HIV clinic

INTRODUCTION

There are no guidelines regarding the discontinuation of antiretroviral therapy at the end of life.

METHODS

We retrospectively reviewed our databases and identified patients with HIV/AIDS who died over the last 12 months in our HIV clinic.

RESULTS

A total of 41 patients from our HIV clinic died in a period of 12 months. Seventy-three percent of the patients were on antiretroviral therapy during the last clinic visit. During the last 3 months of life, 32% (13 of 41) were off antiretroviral therapy, with 77% (10 of 13) of them having intermittent therapy due to noncompliance. The remaining 23% (3 of 13) decided to stop antiretroviral therapy after discussion among families, patients, and providers.

CONCLUSION

Discussions among providers, patients, and families are encouraged to establish goals of care and role of antiretrovirals during the last months of life.

Commonly prescribed medications in a population of hospice patients

Although much attention has been placed on appropriate symptom management at the end of life, little is known about the medications actually prescribed to people in hospice care. The purpose of this study was to determine the most commonly prescribed medications in a population of hospice patients. A retrospective review of a patient information database was conducted. The 6 most common drugs (acetaminophen, morphine, haloperidol, lorazepam, prochlorperazine, and atropine) were included in emergency kits provided to patients at admission. Opioid and nonopioid analgesics, anxiolytics, anticholinergics, and antipsychotics were the most commonly prescribed pharmacologic classes. This description of prescribing practices could be useful in creating more informed care plans, educating health care personnel, and anticipating the changing medication needs of patients as they enter hospice care.