Prescribing in palliative care as death approaches

Cross-sectional study to evaluate patients' medication management with a new model of care: incorporating a pharmacist into a community specialist palliative care telehealth service

BACKGROUND

Patients receiving palliative care are often on complex medication regimes to manage their symptoms and comorbidities and at high risk of medication-related problems. The aim of this cross-sectional study was to evaluate the involvement of a pharmacist to an existing community specialist palliative care telehealth service on patients' medication management.

METHOD

The specialist palliative care pharmacist attended two palliative care telehealth sessions per week over a six-month period (October 2020 to March 2021). Attendance was allocated based on funding received. Data collected from the medication management reviews included prevalence of polypharmacy, number of inappropriate medication according to the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy criteria (STOPP/FRAIL) and recommendations on deprescribing, symptom control and medication management.

RESULTS

In total 95 patients participated in the pharmaceutical telehealth service with a mean age of 75.2 years (SD 10.67). Whilst 81 (85.3%) patients had a cancer diagnosis, 14 (14.7%) had a non-cancer diagnosis. At referral, 84 (88.4%, SD 4.57) patients were taking ≥ 5 medications with 51 (53.7%, SD 5.03) taking ≥ 10 medications. According to STOPP/FRAIL criteria, 142 potentially inappropriate medications were taken by 54 (56.8%) patients, with a mean of 2.6 (SD 1.16) inappropriate medications per person. Overall, 142 recommendations were accepted from the pharmaceutical medication management review including 49 (34.5%) related to deprescribing, 20 (14.0%) to medication-related problems, 35 (24.7%) to symptom management and 38 (26.8%) to medication administration.

CONCLUSION

This study provided evidence regarding the value of including a pharmacist in palliative care telehealth services. Input from the pharmacist resulted in improved symptom management of community palliative care patients and their overall medication management.

Polypharmacy and Potentially Inappropriate Medications in Patients With Advanced Cancer: Prevalence and Associated Factors at the End of Life

Background: Polypharmacy and potentially inappropriate medications (PIMs) impose a burden on patients with advanced cancer near the end of their lives. However, only a few studies have addressed factors associated with PIMs in such patients. Objective: To examine polypharmacy and factors associated with PIMs in end-of-life patients with advanced cancer. Design: Retrospective chart review. Setting/Subjects: We analyzed 265 patients with advanced cancer who died in a palliative care unit (PCU) or at home in a home medical care (HMC) from April 2018 to December 2022 in Japan. Measurements: Sociodemographic, clinical, and prescription data at the time of PCU admission or HMC initiation were collected from electronic medical records. PIMs were assessed using OncPal Deprescribing Guidelines. Results: Patients with advanced cancer with an average age of 76.3 years and median survival days of 20 were included in the analyses. The average number of medications was 6.4 (standard deviation = 3.4), and PIMs were prescribed to 50.2%. Frequent PIMs included antihypertensive medications, peptic ulcer prophylaxis, and dyslipidemia medications. A multivariate logistic regression analysis revealed that age ≥75 years (adjusted odds ratio [aOR] = 2.30, 95% confidence interval [CI] = 1.30-4.05), referral from an outpatient setting compared with inpatient setting (aOR = 2.06, 95% CI = 1.12-3.80), more than two comorbidities (aOR = 1.88, 95% CI = 1.08-3.29), and more than five medications (aOR = 1.84, 95% CI = 1.03-3.28) were associated with PIMs. Conclusions: Medication reconciliation is recommended at the time of transition to a PCU or HMC, especially for older patients with advanced cancer who were referred from an outpatient setting and present more comorbidities and prescriptions.

Impact of palliative care at end-of-life Covid-19 patients - a small-scale pioneering experience

BACKGROUND

In March 2020, the outbreak caused by the SARS-CoV-2 virus was declared a pandemic, resulting in numerous fatalities worldwide. To effectively combat the virus, it would be beneficial to involve professionals who specialize in symptom control for advanced illnesses, working closely with other specialties throughout the illness process. This approach can help manage a range of symptoms, from mild to severe and potentially life-threatening. No studies have been conducted in Portugal to analyse the intervention of Palliative Medicine at the end of life of Covid-19 patients and how it differs from other specialties. This knowledge could help determine the importance of including it in the care of people with advanced Covid-19.

OBJECTIVES

The objective of this study is to examine potential differences in the care provided to patients with Covid-19 during their Last Hours and Days of Life (LHDOL) between those who received care from Palliative Medicine doctors and those who did not.

METHODS

This is a retrospective cohort study spanning three months (Dec 2020 to Feb 2021), the duration of the Support Unit especially created to deal with Covid-19 patients. The database included clinical files from 181 patients admitted to the Support Unit, 27 of which died from Covid-19.

RESULTS

Statistically significant differences were identified in the care provided. Specifically, fewer drugs were administered at the time of death, including drugs for dyspnoea, pain and agitation, suspension of futile devices and use of palliative sedation to control refractory symptoms.

CONCLUSIONS

End-of-life care and symptomatic control differ when there's regular follow-up by Palliative Medicine, which may translate less symptomatic suffering and promote a dignified and humane end of life.

Understanding the Extent of Polypharmacy and its Association With Health Service Utilization Among Persons With Cancer and Multimorbidity: A Population-Based Retrospective Cohort Study in Ontario, Canada

Background: Cancer often co-occurs with other chronic conditions, which may result in polypharmacy. Polypharmacy is associated with adverse outcomes, including increased health service utilization. Objectives: This study examines the overall prevalence of polypharmacy (5 or more medications) among adults with cancer and multimorbidity, as well as the association of both minor polypharmacy (5-9 medications) and hyper-polypharmacy (10 or more medications) on high use of emergency room visits and hospitalizations, while controlling for age, sex, and type and stage of cancer. Methods: This retrospective longitudinal study used linked health administrative databases and included persons 18 years and older diagnosed with cancer between April 2010 and March 2013 in Ontario, Canada. Data on the number of health service utilizations at or above the 90th percentile (high users), was collected up to March 2014 and multivariate logistic regression was used to determine the impact of polypharmacy. Results: The prevalence of polypharmacy was 46% prior to cancer diagnosis, and 57% one year after diagnosis. Polypharmacy prior to and after cancer diagnosis increased with the level of multimorbidity, increasing age, but did not differ by sex. It was also highest in persons with lung cancer (52.4%) and those diagnosed with stage 4 cancer (51.3%). Minor polypharmacy increased the odds of being a high user of emergency rooms (1.16; 99% CI: 1.09-1.24) and hospitalizations (1.03; 0.98-1.09) and the odds of high use was greater with hyper-polypharmacy (1.41; 1.33-1.51) and (1.23; 1.17-1.29) respectively. Conclusion: Polypharmacy is highly prevalent and is associated with high health service utilization among adults with cancer and multimorbidity.

Are Australian Cancer and Palliative Care Nurses Ready to Prescribe Medicines? A National Survey

OBJECTIVES

Registered nurse prescribing has been put forth, for decades, as an innovative approach to meet growing healthcare needs, particularly in areas of care where medications are essential and highly controlled such as for patients requiring cancer and palliative care. However, the adoption of innovative health delivery models requires acceptance by key stakeholders. This study explores cancer and palliative care nurses' attitudes toward nurse prescribing and their perceptions about educational requirements for a nurse prescriber.

DATA SOURCES

A cross-sectional survey was distributed to Australian nurses between March and July 2021. Data were collected using the Advancing Implementation of Nurse Prescribing in Australia online survey. Pearson χ2 tests were used to examine associations between nurses in cancer care, palliative care, and all other specialties on demographics, attitudes to nurse prescribing, and educational perspectives to become prescribers. Of the 4,424 nurses who participated in the survey, 161 nurses identified they worked in cancer care and 109 in palliative care settings.

CONCLUSION

Although nurses have a common set of core capabilities, their work contexts and their professional experiences shape their attitudes toward practice. Nurses in cancer care were significantly less certain than nurses in palliative care [χ2(2) = 6.68, P = .04], and nurses from all other specialties [χ2(2) =13.87, P = <.01] of the benefits of nurse prescribing (ie, nurse prescribing would decrease health care system costs, reduce patient risk). Nurses in cancer care were more certain that successfully implementing nurse prescribing requires strong support from their medical and pharmacy colleagues. In addition, nurses working in cancer and palliative care agreed that improving patient care was their primary motivator for becoming a prescriber.

IMPLICATIONS FOR NURSING PRACTICE

Open to expanding their role and responsibilities, nurses in cancer and palliative care settings reported that successfully adopting nurse prescribing must be supported by their other healthcare colleagues within the same environment, which demands strong interprofessional collaborative efforts.

Potential Drug Interactions in Terminally-Ill Cancer Patients, a Report from the Middle East

This study aims to evaluate the epidemiology of potential drug interactions in terminally-ill cancer patients receiving exclusively supportive care. In this cross-sectional study, during a 6-month follow-up, we considered the medical record of terminally-ill cancer patients referred to palliative care at the cancer center in Isfahan, Iran. Potential drug-drug interactions (DDIs) were assessed by Lexi-Interact ver.1.1 online software. During the study period, 133 terminally-ill cancer patients were recruited. We detected 1678 DDIs with moderate or major severity levels. Among them, 330, 219, 32, 1075, and 51 interactions were categorized in B, C, D, and X drug interactions categories, respectively. One hundred and twenty-two patients (91.73%) encountered at least one potential drug-drug interaction during the end of life care. Mechanistically, most drug-drug interactions (64.5%) were pharmacodynamics. The most frequent pharmacological class of drugs responsible for DDIs were quetiapine (91 cases), oxycodone (87 cases), and sertraline (55 cases). Interaction between oxycodone and sertraline was found to be in the top 10 detected DDIs (13.7%). Our results showed that potentially moderate or major drug-drug interactions often occur among terminally-ill cancer patients and the clinical significance of DDIs should be considered meticulously in the palliative care cancer setting.

How Safe Do Dying People Feel at Home? Patients' Perception of Safety While Receiving Specialist Community Palliative Care

BACKGROUND

There is a research gap regarding safety concerns of patients at the end of life. The aim of this study was, therefore, to explore whether patients under specialist community palliative care feel safe at home and which factors affect the perceived safety. Furthermore, we investigated if perception of safety is associated with different aspects of subsequent care.

METHODS

Using a standardized questionnaire, a cross-sectional survey was conducted among 100 specialist community palliative care patients. Logistic regression was used to examine the strength of the association between clinical and socio-demographic variables and the perception of safety. After a 6-month follow-up period, we analyzed differences in various care-related outcomes between patients with unaffected and impaired perceptions of safety.

RESULTS

In our study, one in five patients receiving specialist community palliative care expressed safety concerns. Subdomains of safety that were reported most frequently were physical disability (60%), physical symptoms (30%), psychological symptoms (26%), and side effects/complications of drug therapy (19%). Of the participants surveyed after the initial COVID-19 lockdown, 35.1% reported that they felt their safety had been adversely affected by the pandemic. Compromised safety perception was associated with higher levels of palliative care-related problems, and proximity to death.

CONCLUSIONS

Our study uncovered relevant safety concerns of palliative care patients receiving specialist community palliative care. The insights gained into patient-reported problems may help healthcare professionals to identify situations where patients feel unsafe. Further research should address primary and secondary prevention measures to improve the quality of end-of-life care in the home environment.

Perspectives on deprescribing in palliative care

INTRODUCTION

Pharmacotherapy plays a critical role in the delivery of high-quality palliative care, but the intersection of palliative care and deprescribing has received little attention.

AREAS COVERED

We conducted a scoping review of English language articles using PubMed to identify relevant publications between 1 January 2000 to 31 July 2022 using search terms of deprescribing, palliative care, end of life, and hospice. We summarize current definitions and developments in palliative care and deprescribing from both clinical and research perspectives. We highlight key challenges and outline proposed solutions and needed research.

EXPERT OPINION

The future of deprescribing in palliative care requires the development and adoption of individualized approaches to medication management, including a reconsidered approach to communication about deprescribing. Evidence from high-quality clinical outcomes studies is lacking, and the field needs new approaches to coordination of care delivery. This review article will be of interest to both clinical and research-based pharmacists, physicians, and nurses interested in improving care for patients with serious illness.

Potential clinical benefits of warfarin in end-stage cancers: A retrospective analysis

Background and Aims

Coagulopathy and thromboembolism are common comorbidities in cancer, and anticoagulants, such as warfarin, are needed in specific situations. This study aimed to determine the clinical relevance of prothrombin time (PT) monitoring and the clinical usefulness of warfarin in patients with malignancy.

Methods

We retrospectively investigated patients with PT lower than 10% treated in our hospital between April 2006 and March 2013. Cases of false coagulopathy, including those due to technical errors during blood sampling, were excluded. The cause of coagulopathy was determined or estimated by physicians.

Results

This study included 338 cases comprising 155 females and 183 males with a median age was 68 (0-97) years. Among them, 89 (26.3%) had cancer, and 163 (48.2%) received warfarin at a median dose of 2.23 (0.5-8.0) mg/day. PT prolongation caused by warfarin overdose and malignancy exacerbation were observed in 75 (22.2%) and 64 (18.9%) patients, respectively. The leading reasons for warfarin administration were arterial fibrillation, chronic heart failure, and deep vein thrombosis. Univariate analysis revealed that the overall survival was higher in the warfarin and nononcology groups than in the nonwarfarin and oncology groups (both p < 0.001). In multivariate analysis, survival was significantly decreased in older adults (p = 0.049), those with malignancy (p < 0.001), and those without warfarin therapy (p < 0.001). Early mortality (within 3 days after PT prolongation) was observed in 65 patients and was mostly related to emergent diseases (36.9%, 24/65) and end-stage malignancy (32.3%, 21/65).

Conclusion

Patients with malignancy may experience subclinical PT prolongation upon disease progression. Warfarin treatment mitigates panic PT values in patients with malignancy. Conversely, those not treated with warfarin have poor survival, suggesting that coagulopathy without warfarin treatment can lead to death. Warfarin enhances hemostatic conditions, thereby preventing malignancy-related lethal hemorrhagic or thromboembolic events.

Potentially inappropriate prescribing in older adults with cancer receiving specialist palliative care: a retrospective observational study

BACKGROUND

Older adults (≥ 65 years) with cancer receiving palliative care often have other health conditions requiring multiple medications.

AIM

To describe and assess the appropriateness of prescribing for older adults with cancer in the last seven days of life in an inpatient palliative care setting.

METHOD

Retrospective observational study of medical records for 180 patients (60.6% male; median age: 74 years; range 65-94 years) over a two-year period. Medication appropriateness was assessed using: STOPPFrail, OncPal deprescribing guideline and criteria for identifying Potentially Inappropriate Prescribing in older adults with Cancer receiving Palliative Care (PIP-CPC).

RESULTS

94.5% of patients had at least one other health condition (median 3, IQR 2-5). The median number of medications increased from five (IQR 3-7) seven days before death, to 11 medications on the day of death (IQR 9-15). The prevalence of PIP varied depending on the tool used: STOPPFrail (version 1: 17.2%, version 2: 19.4%), OncPal (12.8%), PIP-CPC (30%). However, the retrospective nature of the study limited the applicability of the tools. Increasing number of medications had a statistically significant effect on risk of PIP across all tools (STOPPFrail (version 1: 1.29 (1.13-1.37), version 2: 1.30 (1.16-1.48)); OncPal 1.13 (1.01-1.27); PIP-CPC 0.70 (0.61-0.82)).

CONCLUSION

This study found that the number of medications prescribed to older adults with cancer increased as time to death approached, and the prevalence of PIP varied with the application of different tools. The study also highlights the difficulties of examining PIP in this patient cohort.

Temporal Change in the Use of Laboratory and Imaging Tests in One Week Before Death, 2006–2015

BACKGROUND

To analyze the trends in laboratory and imaging test use 1 week before death among decedents who died in Korean hospitals, tests used per decedents from 2006 to 2015 were examined by using the National Health Insurance Service-Elderly Sample Cohort (NHIS-ESC) dataset.

METHODS

The study population consisted of decedents aged ≥ 60 years old with a history of admission and death at a hospital, and tests recorded in the payment claims for laboratory and imaging tests according to the Healthcare Common Procedure Coding System codes were examined. Twenty-eight laboratory and 6 imaging tests were selected. For each year, crude rates of test use per decedents in each age and sex stratum were calculated. Regression analysis was used to examine the temporal changes in the test use.

RESULTS

During the follow-up period, 6,638 subjects included in the sample cohort died. The number of total laboratory and imaging tests performed on the deceased increased steadily throughout the study year from 10.3 tests/deceased in 2006 to 16.6 tests/deceased in 2015. The use of tests increased significantly in general hospitals, however, not in nursing hospitals. Laboratory tests showed yearly increase, from 9.46/deceased in 2006 to 15.57/deceased in 2015, an annual increase of 7.39%. On the other hand, the use of imaging increased from 0.86/deceased in 2006 to 1.01/deceased in 2015, which was not statistically significant.

CONCLUSION

The use of tests, especially laboratory tests, increased steadily over the years even among those elderly patients at imminent death. Reducing acute healthcare at the end of life would be one target not only to support the sustainability of the health care budget but also to improve the quality of dying and death.

Prescription Trends in Hospice Care: A Longitudinal Retrospective and Descriptive Medication Analysis

BACKGROUND

In hospice and palliative care, drug therapy is essential for symptom control. However, drug regimens are complex and prone to drug-related problems. Drug regimens must be simplified to improve quality of life and reduce risks associated with drug-related problems, particularly at end-of-life. To support clinical guidance towards a safe and effective drug therapy in hospice care, it is important to understand prescription trends.

OBJECTIVES

To explore prescription trends and describe changes to drug regimens in inpatient hospice care.

DESIGN

We performed a retrospective longitudinal and descriptive analysis of prescriptions for regular and as-needed (PRN) medication at three timepoints in deceased patients of one Swiss hospice.

SETTING/SUBJECTS

Prescription records of all patients (≥ 18 years) with an inpatient stay of three days and longer (admission and time of death in 2020) were considered eligible for inclusion.

RESULTS

Prescription records of 58 inpatients (average age 71.7 ± 12.8 [37-95] years) were analyzed. The medication analysis showed that polypharmacy prevalence decreased from 74.1% at admission to 13.8% on the day of death. For regular medication, overall numbers of prescriptions decreased over the patient stay while PRN medication decreased after the first consultation by the attending physician and increased slightly towards death.

CONCLUSIONS

Prescription records at admission revealed high initial rates of polypharmacy that were reduced steadily until time of death. These findings emphasize the importance of deprescribing at end-of-life and suggest pursuing further research on the contribution of clinical guidance towards optimizing drug therapy and deprescribing in inpatient hospice care.

Prescription trends at the end of life in a palliative care unit: observational study

Background

Symptomatic control is essential in palliative care, particularly in end-of-life, in which the pathophysiological changes that characterize this last phase of life strengthen the need to carry out an early therapeutic review. Hence, we aim to evaluate the prescribing pattern at a palliative care unit at two different time points: on admission and the day of the patient’s death.

Methods

Quantitative, analytic, longitudinal, retrospective and observational study. Participants were adult patients who were admitted and died in a palliative care unit, in Portugal. Sociodemographic, clinical and pharmacological data were collected, including frequencies and routes of administration of schedule prescribed drugs and rescue drugs, from the day of admission until the day of death.

Results

115 patients were included with an average age of 70.0 ± 12.9 years old, 53.9 were male, mostly referred by the Hospital Palliative Care Support Teams. The most common pathology was cancer, mainly in advanced stage. On admission, the median scheduled prescription was seven and “as needed” was three drugs. On the day of death, a decrease of prescriptions was observed. Opioids were always the most prescribed drugs. Near death, there was a higher tendency to prescribe butylscopolamine, midazolam, diazepam and levomepromazine. The most frequent route of drug administration was oral on admission and subcutaneous on the day of death.

Conclusions

Polypharmacy is a reality in palliative care despite specialist palliative care teams. A reduction of prescribed drugs was verified, essentially due less comorbidity-oriented drugs. Further studies are required to analyse the importance of Hospital Palliative Care Support Teams.

Medication chart review at end of life of paediatric palliative patients

AIM

This study aimed to review the use of medications in a paediatric palliative care (PPC) population during the last two weeks of life.

METHODS

This is a retrospective observational cohort study that included 50 consecutive patients who were referred to KK Hospital PPC service from 2011 to 2015. Those who died after two weeks from discharge date were excluded. Medication charts were reviewed and relevant data were extracted.

RESULTS

The study population included 42 patients and consists predominantly oncological and neurological diagnoses. The median number of medications used was 11.5. Ninety-five percent (40 out of 42) of study population required analgesia where 81% (34 out of 42) were opioid. There was prevalent use of antibiotics (86% of study population, 36 out of 42). Less frequently used medications included steroids, sedatives, laxatives and antiemetics (48%, 52%, 48% and 38% of study population respectively).

CONCLUSION

Significant number of medications was used in PPC during the last two weeks of life. Apart from significant use of analgesia, there is also notable use of antibiotics. Future directions in education such as prescription of laxatives with opioid are proposed.

Is polypharmacy associated with mortality in the very old: findings from the Newcastle 85+ Study

Polypharmacy is common in the very old (≥85 years), where little is known about its association with mortality. We aimed to investigate the association between polypharmacy and all-cause mortality in the very old, over an 11-year time period. Data were drawn from the Newcastle 85+ Study (741), a cohort of people who were born in 1921 and turned 85 in 2006. Survival analysis was performed using Cox proportional hazards models with time-varying covariates, wherein polypharmacy was operationalised continuously. Each additional medication prescribed was associated with a 3% increased risk of mortality (HR: 1.03, 95% CI: 1.00-1.06). Amongst the very old, the risks and benefits of each additional medication prescribed should be carefully considered.

Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life

Purpose of Review

To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL).

Recent Findings

We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators.

Summary

EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.

Shared Medication PLanning In (SIMPLIfy) Home Hospice: An Educational Program to Enable Goal-Concordant Prescribing In Home Hospice

CONTEXT

Simplifying medication regimens by tapering and/or withdrawing unnecessary drugs is important to optimize quality of life and safety for patients with serious illness. Few resources are available to educate clinicians, patients and family caregivers about this process.

OBJECTIVE

To describe the development of an educational program called Shared Medication PLanning In (SIMPLIfy) Home Hospice.

METHODS

An environmental scan identified a state-of-the-art educational program for home hospice deprescribing that we adapted using a stakeholder panel engagement process. The stakeholder panel (two hospice administrators, three nurses, two physicians, two pharmacists, and two former family caregivers) drawn from two geographically diverse hospice agencies reviewed the educational program and recommended additional content.

RESULTS

Iterative rounds of review and feedback resulted in: 1) a three-part clinician educational program (total duration = 1.5 hour) that presents a standardized, goal-concordant, medication review approach to align medications and conversations about regimen simplification with patient and family caregiver goals of care; 2) a patient-family caregiver medication management educational notebook that presents common symptoms, hospice medications, and medication regimen simplification principles; and 3) a brief guide including helpful phrases to use as conversation starters for key steps in the program. A professional designer created thematic coherence for all materials that was well received by stakeholder panelists and hospice staff.

CONCLUSION

Educational materials can support hospice programs' and clinicians' efforts to implement goal-concordant medication simplification that optimizes end-of-life outcomes for patients and family caregivers. Evaluation of outcomes including medication appropriateness and family caregiver medication administration burden are not yet available.

Impact of deprescribing dual-purpose medications on patient-related outcomes for older adults near end-of-life: a systematic review and meta-analysis

Introduction:

The decision to deprescribe medications used for both disease prevention and symptom control (dual-purpose medications or DPMs) is often challenging for clinicians. We aim to establish the impact of deprescribing DPMs on patient-related outcomes for older adults near end-of-life (EOL).

Methods:

This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. Literature was searched on PubMed, EMBASE, CINAHL, PsycINFO and Google Scholar until December 2019 for studies on deprescribing intervention with a control group (with or without randomisation); targeting ⩾65-year olds, at EOL, with at least one life-limiting illness and at least one potentially inappropriate DPM. We were interested in any patient-related outcomes. Studies with similar outcome assessment criteria were subjected to meta-analysis and narrative synthesis otherwise. The risk of bias was assessed using Cochrane Risk of Bias and ROBINS-I tools for randomised controlled trials (RCTs) and quasi-experimental non-randomised controlled studies, respectively.

Results:

Five studies covering 689 participants with mean age 81.6–85.7 years, the majority (74.6–100%) with dementia were included. The risk of bias was moderate to low. The deprescribing of DPMs lowered the risk of mortality (risk ratio (RR) = 0.59, 95% confidence interval (CI) = 0.44–0.79) and referral to acute care facilities (RR = 0.40, 95% CI = 0.22–0.73), but did not have a significant impact on the risk of falls, non-vertebral fracture, emergency presentation, unplanned hospital admission, or general practitioner visits. No significant difference was observed in the quality of life, physical and cognitive functions between the intervention and control groups.

Conclusion:

There is some evidence that deprescribing of DPMs for older adults near the EOL can lower the risk of mortality and referral to acute care facilities, but there are insufficient good-quality studies powered to confirm a benefit in terms of quality of life, physical or cognitive function, health service utilisation and adverse events.

Plain Language Summary

What is the health impact of withdrawal or dose reduction of medication used for disease prevention and symptom control in older adults near end-of-life?

Introduction: Older adults (aged ⩾ 65 years) with advanced diseases such as cancer, dementia, and organ failure tend to have a limited life expectancy. With the progression of these diseases towards the end-of-life, the intensity for day-to-day supportive care becomes increasingly necessary. The use of medications for symptom management is a critical part of such care, but the use of medications for long-term disease prevention can become irrelevant due to the already shortened life expectancy and may become harmful due to alterations in physiology and pharmacology associated with age and frailty. This necessitates the withdrawal or dose reduction of inappropriate medications, the process called deprescribing. The decision to deprescribe medications used for both disease prevention and symptom control (DPMs) in this population is often challenging for clinicians. In this context, whether deprescribing of DPMs can improve patient-related health outcomes is unknown.

Methods: Evidence from the literature was reviewed and analysed, and the quality of studies was assessed. Five studies were identified, which had 689 participants with an average age above 80 years and mostly suffering from dementia.

Results: The analysis of these studies showed deprescribing of DPMs lowered the risk of death and referral to acute care facilities at 12 months but had no significant impact on falls, non-vertebral fractures, emergency presentations, unplanned hospital admission, general practitioner visits, quality of life, physical and mental functions.

Conclusion: In conclusion, there were insufficient numbers of high-quality studies powered to confirm whether deprescribing of DPMs reduces adverse events, health service use, or improves the quality of life or functioning in older adults near the end of life.

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.

Objective(s)

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.

Deprescribing in Hospice Patients: Discontinuing Aspirin, Multivitamins, and Statins

Objective

To facilitate deprescribing of aspirin, multivitamins, and statins in hospice patients enrolled in Mayo Clinic Hospice, Rochester, Minnesota.

Patients and Methods

During the fall of 2019, we conducted a quality improvement project to improve care of Mayo Clinic Hospice patients by decreasing the percentage of patients taking aspirin, multivitamins, or statins. Project interventions included the addition of a palliative medicine fellow to the hospice interdisciplinary team, nurse education, and implementation of an evidence-based deprescribing resource tool. The resource tool included a communication framework to guide deprescribing conversations and a literature summary supporting deprescribing. The project team recorded the number of patients taking 1 of these medications by intermittently surveying the hospice census. Process and counterbalance measures were tracked with online surveys of hospice nursing staff.

Results

At the start of the project, 22 of 69 patients (32%) were taking aspirin, a multivitamin, or a statin. After introduction of the deprescribing resource tool and the addition of a palliative medicine fellow to the interdisciplinary team, this was reduced to 20 of 83 patients (24%), a 24% decrease. Results appeared to be driven primarily by a reduction in multivitamin use (33% decrease). Self-reported comfort and knowledge about deprescribing improved among the hospice nursing staff, as did satisfaction in their workflow from 5.4 to 6.0 (maximum, 7).

Conclusion

The addition of a dedicated team member to address medication issues and provision of an evidence-based deprescribing resource tool appear to reduce the use of unnecessary and potentially harmful medications in ambulatory hospice patients.

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.

Family and health-care professionals managing medicines for patients with serious and terminal illness at home: a qualitative study

Background

More effective ways of managing symptoms of chronic and terminal illness enable patients to be cared for, and to die, at home. This requires patients and family caregivers to manage complex medicines regimens, including powerful painkillers that can have serious side effects. Little is known about how patients and family caregivers manage the physical and emotional work of managing medicines in the home or the support that they receive from health-care professionals and services.

Objective

To investigate how patients with serious and terminal illness, their family caregivers and the health-care professionals manage complex medication regimens and routines of care in the domestic setting.

Design

A qualitative study involving (1) semistructured interviews and group discussions with 40 health-care professionals and 21 bereaved family caregivers, (2) 20 patient case studies with up to 4 months’ follow-up and (3) two end-of-project stakeholder workshops.

Setting

This took place in Nottinghamshire and Leicestershire, UK.

Results

As patients’ health deteriorated, family caregivers assumed the role of a care co-ordinator, undertaking the everyday work of organising and collecting prescriptions and storing and administering medicines around other care tasks and daily routines. Participants described the difficulties of navigating a complex and fragmented system and the need to remain vigilant about medicines prescribed, especially when changes were made by different professionals. Access to support, resilience and coping capacity are mediated through the resources available to patients, through the relationships that they have with people in their personal and professional networks, and, beyond that, through the wider connections – or disconnections – that these links have with others. Health-care professionals often lacked understanding of the practical and emotional challenges involved. All participants experienced difficulties in communication and organisation within a health-care system that they felt was complicated and poorly co-ordinated. Having a key health professional to support and guide patients and family caregivers through the system was important to a good experience of care.

Limitations

The study achieved diversity in the recruitment of patients, with different characteristics relating to the type of illness and socioeconomic circumstances. However, recruitment of participants from ethnically diverse and disadvantaged or hard-to-reach populations was particularly challenging, and we were unable to include as many participants from these groups as had been originally planned.

Conclusions

The study identified two key and inter-related areas in which patient and family caregiver experience of managing medicines at home in end-of-life care could be improved: (1) reducing work and responsibility for medicines management and (2) improving co-ordination and communication in health care. It is important to be mindful of the need for transparency and open discussion about the extent to which patients and family caregivers can and should be co-opted as proto-professionals in the technically and emotionally demanding tasks of managing medicines at the end of life.

Future work

Priorities for future research include investigating how allocated key professionals could integrate and co-ordinate care and optimise medicines management; the role of domiciliary home care workers in supporting medicines management in end-of-life care; patient and family perspectives and understanding of anticipatory prescribing and their preferences for involvement in decision-making; the experience of medicines management in terminal illness among minority, disadvantaged and hard-to-reach patient groups; and barriers to and facilitators of increased involvement of community pharmacists in palliative and end-of-life care.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.

Development of criteria for identifying potentially inappropriate prescribing in older adults with cancer receiving palliative care (PIP-CPC)

OBJECTIVES

To develop criteria for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults (≥65 years) with cancer who are receiving palliative care and have an estimated life expectancy of <1 year.

MATERIALS AND METHODS

A two-round Delphi exercise was conducted using web-based questionnaires. A panel of 18 expert stakeholders with expertise in palliative care, oncology and/or geriatric medicine across Ireland and the United Kingdom rated their level of agreement with each statement using a 5-point Likert scale and had the option of adding free-text comments throughout the questionnaire. A priori decision rules were used to accept or reject criteria.

RESULTS

Twenty-eight criteria were presented in Round 1. Group consensus was achieved for 15 criteria which were included in the final set of criteria. Following a review of the panel's ratings and additional comments for the remaining 13 criteria, four criteria were removed from Round 2. Group consensus was achieved for all nine criteria included in Round 2. The final set comprised 24 criteria relating to: anorexia-cachexia (n = 1); anxiety (n = 2); constipation (n = 5); delirium (n = 1); depression (n = 3); diarrhoea (n = 1); dyspnoea/breathlessness (n = 1); fatigue (n = 2); insomnia (n = 2); nausea and vomiting (n = 2); pain (n = 3); duplicate drug classes (n = 1).

CONCLUSION

A consensus-agreed set of prescribing criteria has been developed for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults with cancer who are receiving palliative care and have an estimated life expectancy of less than one year. Future studies should examine the application and validity of these criteria.

Retrospective analysis of a pilot pharmacist-led hospice deprescribing program initiative

CONTEXT

Medication deprescribing in palliative care settings has been insufficiently studied.

OBJECTIVE

To determine the feasibility of a deprescribing program in hospice patients with limited life expectancy.

DESIGN

Pharmacist-led, single arm, single-centered, retrospective analysis of a pilot deprescribing program in an integrated healthcare delivery organization between 9/1/2018 to 1/31/2019.

OUTCOME MEASURES

The primary outcome was the proportion of patients who achieved ≥50% reduction of the recommended medications to deprescribe.

RESULTS

A total of 97 patients were included in the analysis. The average age was 77.5 ± 23.7 years, with 53.6% being women and 54.6% white. The most common primary diagnosis was cancer (58.8%), with cardiovascular disease the next most common (15.5%). The mean number of baseline comorbidities was 2.0 ± 1.6. Of 698 prescriptions at the start of hospice enrollment, 79.4% of patients achieved a ≥50% reduction in medications recommended for deprescribing. This success was seen mostly in cardiovascular and other nonspecific medications. We found that every 1-unit increase in the number of patient encounters with hospice pharmacists was associated with a 3.2-fold higher odds of achieving a ≥50% reduction in medications that were recommended for deprescribing.

CONCLUSION

The findings from this pilot study revealed that a collaborative, pharmacist-led, collaborative medication deprescribing program initiative was associated with a 79% success in ≥50% medication reduction. More frequent patient encounters had higher odds of success. Future studies, utilizing a control group, should focus on determining the effectiveness of the program and the impact on quality of life.

Therapeutic Futility in Terminal Cancer Patients: A Retrospective and Observational Study

Introduction Advanced cancer patients often need therapy for symptomatic control, in addition to cancer and other disease treatments. As the cancer disease progresses and life expectancy decreases, there should be a change in the goal of care. If this change is not accompanied by therapeutic adjustments, there is a risk of maintaining useless and ineffective treatments, as well as potential harmful drug interactions. This study analyzed the prevalence of therapeutic futility in patients with advanced cancer disease. Materials and methods This was a retrospective and observational single-center study, that included advanced cancer patients who died during the hospital stay, at a University Hospital in Lisbon, Portugal. Demographic and clinical data were collected. A Palliative Prognostic Score (PaP) was used to stratify patients according to their prognosis group. An analysis of the prescribed therapy was performed to quantify the "potentially inappropriate medications" (PIMs) and "inappropriate medications" (IMs), at admission and 24 hours prior to the patient's death. Results Over 140 patients were included. On the first day of hospitalization, 119 patients (85%) were exposed to at least one IM or PIM and 100 patients (71%) were still exposed to at least one IM or PIM in the last 24 hours of life. Regarding chemotherapy, 66 patients (47%) had treatment in the last two months of life, 38 (27%) in the last month, and 17 (12%) in the last two weeks prior to death. Therapeutic simplification (suspension of IMs and reduction of at least 50% of PIMs during hospitalization) was performed in 43% of the overall population and was higher in PaP score group C, but not statistically significant (p=0.09). The patient's inclusion in PaP score group C and inpatient consultation by the palliative care team were independent predictors of therapeutic simplification. Discussion There is an effort to achieve greater therapeutic suitability in palliative patients. However, many patients maintain futile and disproportionate therapy at the end of life (EoL). In many cases, systemic cancer treatment is performed until quite late in the course of the disease. The prescription of PIMs was significantly higher than that of IMs, which could be expected given their definition. A shorter life expectancy at admission led to a greater therapeutic simplification, as well as an intervention by the Palliative Care Team, which can be explained by the more focused approach towards quality-of-life improvement and symptomatic control. Different than expected the prescription of supportive therapies at hospital admission was not a predictor of therapeutic simplification. Although there was a reduction in IMs and PIMs in the studied population, and therapeutic simplification occurred in one fraction of the patients, the fact is that more than half of the patients evaluated did not undergo therapeutic simplification as defined in this work. Conclusion It appears that there is an effort to achieve greater therapeutic suitability in palliative patients, however, many patients maintain futile therapy at the EoL. It is of paramount importance to change the standard of care in this setting, to privilege a more patient-focused approach and tailored therapy, and to prioritize symptomatic control and quality-of-life improvement.

Effectiveness and sustainability of deprescribing for hospitalized older patients near end of life: a systematic review

Introduction: Polypharmacy is prevalent in hospitals and deprescribing strategies for older people are strongly promoted. However, evidence of their feasibility and sustainability among patients receiving end of life care is lacking. The objective of this review was to ascertain effectiveness and post-discharge sustainability of hospital-initiated deprescribing strategies in older people near the end of life. Areas covered: The authors searched for controlled trials, with low risk of bias and measures of effectiveness post-discharge. Intervention description, duration, and healthcare provider engagement were investigated for their impact on reduction of number of medications, proportions of patients prescribed inappropriate medications, returns to emergency, hospital admission and adverse events. Expert opinion: Limited evidence suggests hospital-initiated deprescribing interventions may reduce prescribing inappropriateness among older terminal patients in the short term, but evidence beyond 3 months is lacking for significant prevention of adverse events or health service utilization. Heterogeneity precluded meta-analysis, and short follow-up periods precluded quantitative assessment of sustainability. Trials of older people with terminal conditions with larger sample sizes and longer follow-up periods are needed to confirm the effectiveness and sustainability of deprescribing at the end of life. Objective tools to reliably identify near end-of-life status would be useful in selecting target groups for these interventions.

Deprescribing in the Home Palliative Setting

Background: When patients' goals of care have shifted toward comfort, treatment should focus on alleviating symptoms rather than prolonging life at the expense of comfort. Objective: To determine whether the number of noncomfort medications is associated with deprescribing in patients seen by a home-visiting palliative care physician. Design: Single-centre retrospective chart review of patients cared for in the home setting by a specialty palliative care program to determine factors associated with deprescribing. All medications on initial consult were classified as comfort, possibly for comfort, and definitely not for comfort (DNC). Patients were stratified depending on whether intentional deprescribing occurred. Data were analyzed for associations between deprescribing and other variables: number and proportion of DNC medications, diagnosis, palliative performance scale (PPS), number of encounters, code status, preferred place of death, and time to death. Setting: Study population included 80 patients followed by specialist home-visiting palliative physicians in a tertiary center. Inclusion criteria were adult patients with PPS ≤60%, initially seen by a home-visiting palliative physician between 2016 and 2018 and followed for at least 60 days or until death. Results: Deprescribing occurred in 44% of study patients within 60 days. Median number of DNC medications was 3 in the deprescribed group and 0 in the nondeprescribed group (p < 0.001). Proportion of DNC medications was 29% in the deprescribed group and 15% in the nondeprescribed group (p < 0.01). Conclusions: Deprescribing is associated with an increased number and proportion of DNC medications at the time of initial in-home palliative assessment. Deprescribing rates varied greatly between different home-visiting palliative providers.

Polypharmacy and the use of low or limited value medications in advanced cancer

BACKGROUND

Patients with advanced malignancy are often on medications for co-morbidities, including those for primary or secondary prevention. The benefit from these medications can be limited and may result in adverse effects, interact with medications used for the malignancy or associated symptoms, increase pill burden and reduce quality of life.

AIMS

To evaluate the proportion of patients with advanced malignancy that were continued on low or limited value medications and identify the factors associated with this. We also sought to determine how prevalent polypharmacy was within this group of patients and the factors associated with this.

METHODS

A retrospective chart review was conducted of patients with incurable malignancy admitted under medical oncology at Liverpool Hospital over a 90-day period. Demographic variables, co-morbidities, disease related parameters and medications were reviewed. Criteria were established to identify low or limited value medications.

RESULTS

Seventy-eight patients were identified between September and December 2018. Thirty-day mortality was 33%. Sixty-five percent of the cohort was on five or more medications and 24% on 10 or more. One low or limited value medication was reported in 36% and 20% were on two or more. Age ≤60 years was associated with a risk of being on at least one unnecessary medication. Patients with fewer co-morbidities and those in their last 3 months of life were significantly less likely to have polypharmacy. Nine percent of the cohort was on three or more antihypertensives and 6% of patients were on three or more oral hypoglycaemics.

CONCLUSION

Polypharmacy and continued prescribing of low or limited value medications was identified in a high proportion of patients. Further studies are needed to assess the impact of continuing these medications, as well as investigation of patient and physician attitudes towards de-escalation.

Polypharmacy, Medication Possession, and Deprescribing of Potentially Non-Beneficial Drugs in Hospice Patients

Patients frequently have comorbidities that when combined with their primary diagnosis qualifies the patient for hospice. Consequently, patients are at risk for polypharmacy due to the number of medications prescribed to treat both the underlying conditions and the related symptoms. Polypharmacy is associated with negative consequences, including increased risk for adverse drug events, drug-drug and drug-disease interactions, reduced functional status and falls, multiple geriatric syndromes, medication nonadherence, and increased mortality. Polypharmacy also increases the complexity of medication management for caregivers and contributes to the cost of prescription drugs for hospices and patients. Deprescribing or removing nonbeneficial or ineffective medications can reduce polypharmacy in hospice. We study medication possession ratios and rates of deprescribing of commonly prescribed but potentially nonbeneficial classes of medication using a large hospice pharmacy database. Prevalence of some classes of potentially inappropriate medications is high. We report possession ratios for 10 frequently prescribed classes, and, because death and prescription termination are competing events, we calculate prescription termination rates using Cumulative Incidence Functions. Median duration of antifungal and antiviral medications is brief (5 and 7 days, respectively), while statins and diabetes medications have slow discontinuance rates (median termination durations of 93 and 197 days). Almost all patients with a proton pump inhibitor prescription have the drug for their entire hospice stay. Data from this study identify those drug classes that are commonly deprescribed slowly, suggesting drug classes and diagnoses that hospices may wish to focus on more closely, as they act to limit polypharmacy and reduce prescription costs.

Polypharmacy in Palliative Care: Two Deprescribing Tools Compared with a Clinical Review

Background: Lack of guidance is highlighted as a barrier to deprescribing in palliative care. Two deprescribing tools exist, but with inclusion and exclusion criteria that limit utility. The tools have not previously been compared directly or used in an unselected palliative population. Objective: To compare the OncPal and STOPPFrail deprescribing tools to an expert review in an unselected palliative population. Secondary aims included a description of medicines incorrectly classified by both tools. Design: Fifty palliative inpatients were retrospectively reviewed by an expert panel, and both tools were independently applied to the patients. Positive and negative predictive values (PPV and NPV) were calculated per patient using the expert review as the gold standard. Results: The median number of medicines per patient was 11, with 19% of medicines deemed inappropriate. The PPV and NPV were 75% (interquartile range 50-100) and 91% (interquartile range 84-100), respectively, for OncPal, and 100% (interquartile range 50-100) and 90% (interquartile range 78-100), respectively, for STOPPFrail. There was no statistically significant difference between the tools (PPV p = 0.42 and NPV p = 0.07). The main medicines incorrectly ceased by OncPal were antianginals for stable coronary artery disease, and haloperidol for nausea by STOPPFrail. Conclusion: There was no significant difference between the tools. Both tools performed well in an unselected population. Some minor amendments could improve the PPV of both tools.

Medication use in aged care residents in the last year of life: A scoping review

BACKGROUND

A substantial number of older adults die in residential aged care facilities, yet little is known about the characteristics of and how best to optimise medication use in the last year of life.

AIM

The aim of this review was to map characteristics of medication use in aged care residents during the last year of life in order to examine key concepts related to medication safety and draw implications for further research and service provision.

DESIGN

A scoping review following Arskey and O'Malley's framework was conducted using a targeted keyword search, followed by assessments of eligibility based on title and content of abstracts and full papers. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the scoping review protocol was prospectively registered to the Open Science Framework on 27 November 2018.

DATA SOURCES

We searched MEDLINE, EMBASE, AMED, CINAHL and Cochrane databases to identify peer-reviewed studies published between 1937 and 2018, written in English and looking at medication use in individuals living in aged care facilities within their last year of life.

RESULTS

A total of 30 papers were reviewed. Five key overarching themes were derived from the analysis process: (1) access to medicines at the end of life, (2) categorisation and classes: medicines and populations, (3) polypharmacy and total medication numbers, (4) use of symptomatic versus preventive medications and (5) 'inappropriate' medications.

CONCLUSION

Number of prescriptions or blunt categorisations of medications to assess their appropriateness are unlikely to be sufficient to promote well-being and medication safety for older people in residential aged care in the final stages of life.

An exploration of the experiences of professionals supporting patients approaching the end of life in medicines management at home. A qualitative study

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.

What Are the Factors Identifying Caregivers Who Need Help in Managing Medications for Palliative Care Patients at Home? A Population Survey

Background: For most people, the last 12 months of life are spent living in the community, with the support of family and friends for a number of caregiving functions. Previous research has found that managing medicines is challenging for caregivers. Currently there is little information describing which caregivers may struggle with tasks associated with managing a loved one's medicines. Aim: The aim of this study was to identify factors that flag caregivers who are likely to experience problems when managing someone else's medications. Setting/Participants: The annual South Australian Health Omnibus Survey provides a face-to-face, cross-sectional, whole-of-population view of health care. Structured interviews, including questions covering palliative care and end-of-life care, were conducted with 14,625 residents in their own homes. Results: Of the 1068 respondents who had provided care for someone who died of a terminal illness in the last five years, 7.4% identified that additional support with medicine management would have been beneficial. In addition, three factors were predictive of the need for additional support in managing medicines: aged <65 years; lower household income; and living in a metropolitan region. Conclusion: The findings of this study provide insights to inform the development of palliative care service models to support informal caregivers in the management of medications for people with a life-limiting illness.

Symptomatic Events in a Community Palliative Care Population: A Prospective Pilot Study

Background: The palliative care population is prescribed a large number of drugs, increasing as patients deteriorate. The cumulative effects of these medications combined with underlying symptom burden can result in significant morbidity. There is an urgent need to describe possible symptomatic events that could be exacerbated by commonly prescribed drugs in palliative care and their impact. Objectives: To trial the feasibility and acceptability of determining baseline symptomatic event rates for community palliative care patients from which a composite measure of symptomatic events can be developed. Design: This prospective pilot study of patient-reported symptomatic events recruited a convenience cohort of 27 community palliative care patients in a metropolitan specialist palliative care service in Australia. Results: This study has demonstrated a high prevalence rate of symptomatic events (total crude event/participant day rate 0.87) in the study population. Conclusion: Data collection of patient-centered symptomatic events was acceptable and feasible to participants. This pilot supports a fully powered study.

Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy with Older Adults: A Qualitative Review of Randomized Controlled Outcome Research

Objective: Many older adults cope with various chronic physical health conditions, and in some cases, with mental health and/or cognitive difficulties. Mindfulness-based interventions offer an evidence-based, mind-body complementary treatment approach for a wide range of comorbidities, yet most investigations were conducted with young or middle-aged adults. The purpose of this review was to identify randomized controlled trials (RCTs) of two leading mindfulness-based interventions conducted with older adults. Methods: Our search of five databases identified seven RCT investigations of either Mindfulness-Based Stress Reduction (MBSR) or Mindfulness-Based Cognitive Therapy (MBCT) conducted exclusively with older adults. Results: Results generally supported the use of MBSR for chronic low back pain, chronic insomnia, improved sleep quality, enhanced positive affect, reduced symptoms of anxiety and depression, and improved memory and executive functioning. In a sample of older adults exhibiting elevated anxiety in the absence of elevated depression, MBCT effectively reduced symptoms of anxiety. Conclusions: This review highlights the feasibility and possible benefits of MBSR and MBCT for older adults. Additional large scale RCTs conducted with older adults coping with the range of physical, behavioral, and cognitive challenges older adults commonly face still are needed. Clinical Implications: MBSR may be a promising intervention for older adults experiencing a variety of health concerns and possibly even cognitive decline. MBCT may reduce geriatric anxiety, although its effects on geriatric depression were not measured.

Prescription and deprescription of medications for older adults receiving palliative care during the last 3 months of life: a single-center retrospective cohort study

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.

Clinically Significant Drug-Drug Interactions Involving Medications Used for Symptom Control in Patients With Advanced Malignant Disease: A Systematic Review

CONTEXT

Most patients with advanced malignant disease need to take several drugs to control symptoms. This treatment raises risks of serious adverse effects and drug-drug interactions (DDIs).

OBJECTIVES

To identify studies reporting clinically significant DDIs involving medications used for symptom control, other than opioids used for pain management, in adult patients with advanced malignant disease.

METHODS

Systematic review with searches in Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials, from the start of the databases (Embase from 1980) through June 21, 2018. In addition, reference lists of relevant full-text articles were hand-searched.

RESULTS

Of 9699 retrieved citations, 462 were considered potentially eligible. After full-text reading, 29 were included in the final analysis, together with 13 articles from reference lists. The 42 included publications were case reports, letters to the Editor, and one retrospective study. Drugs most often involved were antiepileptics, antidepressants, corticosteroids, and nonopioid analgesics. Clinical manifestations of identified DDIs included sedation, respiratory depression, serotonin syndrome, neuroleptic malignant syndrome, delirium, seizures, ataxia, liver and kidney failure, bleeding, cardiac arrhythmias, rhabdomyolysis, and others. The most common mechanisms eliciting DDIs were alteration of CYP450-dependent metabolism and overstimulation of serotonin receptors in the central nervous system.

CONCLUSION

Drugs used for symptom control in patients with advanced cancer may cause serious DDIs. Although there is limited evidence for the risk of clinically significant DDIs, physicians treating patients with cancer should try to limit polypharmacy, avoid drug combinations with a high risk of DDIs, and closely monitor patients for adverse drug reactions.

Clinicians' perceptions of opioid error-contributing factors in inpatient palliative care services: A qualitative study

BACKGROUND

Opioid errors are a leading cause of patient harm and adversely impact palliative care inpatients' pain and symptom management. Yet, the factors contributing to opioid errors in palliative care are poorly understood. Identifying and better understanding the individual and system factors contributing to these errors is required to inform targeted strategies.

OBJECTIVES

To explore palliative care clinicians' perceptions of the factors contributing to opioid errors in Australian inpatient palliative care services.

DESIGN

A qualitative study using focus groups or semi-structured interviews.

SETTINGS

Three specialist palliative care inpatient services in New South Wales, Australia.

PARTICIPANTS

Inpatient palliative care clinicians who are involved with, and/or have oversight of, the services' opioid delivery or quality and safety processes.

METHODS

Deductive thematic content analysis of the qualitative data. The Yorkshire Contributory Factors Framework was applied to identify error-contributing factors.

FINDINGS

A total of 58 clinicians participated in eight focus groups and 20 semi-structured interviews. Nine key error contributory factor domains were identified, including: active failures; task characteristics of opioid preparation; clinician inexperience; sub-optimal skill mix; gaps in support from central functions; the drug preparation environment; and sub-optimal clinical communication.

CONCLUSION

This study identified multiple system-level factors contributing to opioid errors in inpatient palliative care services. Any quality and safety initiatives targeting safe opioid delivery in specialist palliative care services needs to consider the full range of contributing factors, from individual to systems/latent factors, which promote error-causing conditions.

Preventive drugs in the last year of life of older adults with cancer: Is there room for deprescribing?

BACKGROUND

The continuation of preventive drugs among older patients with advanced cancer has come under scrutiny because these drugs are unlikely to achieve their clinical benefit during the patients' remaining lifespan.

METHODS

A nationwide cohort study of older adults (those aged ≥65 years) with solid tumors who died between 2007 and 2013 was performed in Sweden, using routinely collected data with record linkage. The authors calculated the monthly use and cost of preventive drugs throughout the last year before the patients' death.

RESULTS

Among 151,201 older persons who died with cancer (mean age, 81.3 years [standard deviation, 8.1 years]), the average number of drugs increased from 6.9 to 10.1 over the course of the last year before death. Preventive drugs frequently were continued until the final month of life, including antihypertensives, platelet aggregation inhibitors, anticoagulants, statins, and oral antidiabetics. Median drug costs amounted to $1482 (interquartile range [IQR], $700-$2896]) per person, including $213 (IQR, $77-$490) for preventive therapies. Compared with older adults who died with lung cancer (median drug cost, $205; IQR, $61-$523), costs for preventive drugs were higher among older adults who died with pancreatic cancer (adjusted median difference, $13; 95% confidence interval, $5-$22) or gynecological cancers (adjusted median difference, $27; 95% confidence interval, $18-$36). There was no decrease noted with regard to the cost of preventive drugs throughout the last year of life.

CONCLUSIONS

Preventive drugs commonly are prescribed during the last year of life among older adults with cancer, and often are continued until the final weeks before death. Adequate deprescribing strategies are warranted to reduce the burden of drugs with limited clinical benefit near the end of life.

Discontinuation of medications at the end of life: A population study in Belgium, based on linked administrative databases

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.

Frequency of Polypharmacy in Advanced Cancer Patients Consulted with the Palliative Service of Imam Khomeini Hospital (Tehran), Iran, 2017

Background:

Polypharmacy is defined as the concurrent use of more than four or five medications by an individual. The prevalence of this condition has increased due to the ageing population and the related illnesses. Use of multiple medications would increase the risk of side-effects, drug interactions, and medical costs. The present study aimed to determine the frequency of polypharmacy in the advanced cancer patients.

Methods:

In this cross-sectional study, 92 patients with advanced cancer were selected through convenience sampling from the inpatients and outpatients who referred to the Palliative Care Unit of Imam Khomeini Hospital (Tehran) in 2017. An examining physician completed a researcher-made checklist for all the subjects based on the patients’ biography and medical records. Statistical analysis was performed by using SPSS software (version 19.0) through descriptive and analytical tests at the significance level of p<0.05.

Results:

The participants’ mean age was 55.5±16.2 years. A minimum of one comorbid disease was seen in 81.5% of the patients (n=75), the most prevalent of which were psychiatric disorders. Eighty-eight percent of the patients (n=81) were on at least 5 or more medications. Opioids and antacids were the most common medications used by these patients.

Conclusion:

The frequency of polypharmacy and average number of consumed medications were high in patients with advanced cancer. Studying the effectiveness of these medications can highly help the physicians stop or continue prescribing such medications, and guide the focus of attention towards the drugs that can improve the patients’ quality of life in the final days.

Missed opportunities: unnecessary medicine use in patients with lung cancer at the end of life - an international cohort study

AIMS

The aims of the current study were: (i) to examine the prescribing of preventative medication in a cohort of people with advanced lung cancer on hospital admission and discharge across different healthcare systems; and (ii) to explore the factors that influence preventative medication prescribing at hospital discharge.

METHODS

A retrospective cohort study was conducted across two centres in the UK and the US. The prescribing of preventative medication was examined at hospital admission and discharge for patients who died of lung cancer. A zero-inflated negative binomial regression model was used to examine the association between preventative medications at discharge and patient- and hospital-based factors. The classes of preventative medication prescribed included were: vitamins and minerals, and antidiabetic, antihypertensive, antihyperlipidaemic and antiplatelet medications.

RESULTS

In the UK site (n = 125), the mean number of preventative medications prescribed was 1.9 [standard deviation (SD) 1.7) on admission, and 1.7 (SD 1.7) on discharge, and in the US site (n = 191) the mean was 2.6 (SD 2.2) on admission and 1.9 (SD 2.2) on discharge. The model found a significant association between the number of preventative drugs prescribed on admission and the number on discharge; it also found a significant association between the total number of drugs prescribed on discharge and the number of preventative medications on discharge. Other indicators related to patient and hospital factors were not significantly associated with the number of preventative medications supplied on discharge.

CONCLUSIONS

The use of preventative medication was common in lung cancer patients, despite undergoing discharge. Patient- and hospital-based factors did not influence the prescribing of preventative medication.