Development of Guidelines for Palliative Care Pharmacotherapy

Preventive medication use among persons with limited life expectancy

Persons with limited life expectancy (LLE) – less than 1 year – are significant consumers of health care, are at increased risk of polypharmacy and adverse drug events, and have dynamic health statuses. Therefore, medication use among this population must be appropriate and regularly evaluated. The objective of this review is to assess the current state of knowledge and clinical practice presented in the literature regarding preventive medication use among persons with LLE. We searched Medline, Embase, and CINAHL using Medical Subject Headings. Broad searches were first conducted using the terms ‘terminal care or therapy’ or ‘advanced disease’ and ‘polypharmacy’ or ‘inappropriate medication’ or ‘preventive medicine’, followed by more specific searches using the terms ‘statins’ or ‘anti-hypertensives’ or ‘bisphosphonates’ or ‘laxatives’ and ‘terminal care’. Frameworks to assess appropriate versus inappropriate medications for persons with LLE, and the prevalence of potentially inappropriate medication use among this population, are presented. A considerable proportion of individuals with a known terminal condition continue to take chronic disease preventive medications until death despite questionable benefit. The addition of palliative preventive medications is advised. There is an indication that as death approaches the shift from a curative to palliative goal of care translates into a shift in medication use. This literature review is a first step towards improving medication use and decreasing polypharmacy in persons at the end of life. There is a need to develop consensus criteria to assess appropriate versus inappropriate medication use, specifically for individuals at the end of life.

Medication inappropriateness for older adults receiving hospice care: a pilot survey

OBJECTIVE

To test the feasibility and reliability of a tool and methodology for evaluating expert clinicians' perceptions about the application of the Beers criteria in hospice.

DESIGN

A pilot survey.

SETTING

A national medication therapy management provider specializing in hospice care.

PARTICIPANTS

Thirty-five participants from a multidisciplinary panel were invited to complete the survey. They were selected to represent acute, long-term care, and community practice settings with various levels of experience and judgment.

INTERVENTION

Respondents were asked to complete the survey by rating their agreement or disagreement with the inappropriateness of the medications or medication classes for hospice patients, using a five-point Likert scale from strongly agree (1) to strongly disagree (5), with the midpoint (3) expressing equivocation.

MAIN OUTCOME MEASURES

Feasibility as measured by the percentage of returned and completed surveys. A secondary aim was to measure inter-rater reliability and response.

RESULTS

Twenty-four clinicians (69%) completed the survey, including 13 clinical pharmacists, 6 nurses, and 5 physicians. Twenty-nine responses (2%) were furnished by imputation methods. The intraclass correlation for medication inappropriateness for hospice patients was 0.89 (0.81-0.95), indicating "good" inter-rater reliability. Short-acting benzodiazepines, gastrointestinal antispasmodics, anticholinergics, and antihistamines were considered appropriate for use in older hospice patients, but they are considered inappropriate according to the Beers criteria.

CONCLUSION

We established a viable methodology for evaluating clinician judgment about medication inappropriateness in older hospice patients. Some medications routinely considered to be inappropriate may be appropriate at end of life; different criteria may be needed to determine medication inappropriateness in hospice care.