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Rodrigues-Ribeiro JL, Castro L, Pinto-Ribeiro F, Nunes R. Impact of palliative care at end-of-life Covid-19 patients - a small-scale pioneering experience. BMC Palliat Care 2024; 23:37. [PMID: 38336652 PMCID: PMC10858566 DOI: 10.1186/s12904-024-01368-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
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.
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Affiliation(s)
- João Luís Rodrigues-Ribeiro
- Palliative Care Unit, WeCare Saúde, Rua Corregedor Gaspar Cardoso, 480, Póvoa de Varzim, Porto, 4490-492, Portugal.
- Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal.
- Intra-Hospital Team for Palliative Care Support, Hospital de Braga, ULS Braga, Braga, Portugal.
| | - Luísa Castro
- Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
| | - Filipa Pinto-Ribeiro
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, 4710-057, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, 4806-909, Portugal
| | - Rui Nunes
- Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
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Tak YW, Han JH, Park YJ, Kim DH, Oh JS, Lee Y. Examining Final-Administered Medication as a Measure of Data Quality: A Comparative Analysis of Death Data with the Central Cancer Registry in Republic of Korea. Cancers (Basel) 2023; 15:3371. [PMID: 37444480 DOI: 10.3390/cancers15133371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Death is a crucial outcome in retrospective cohort studies, serving as a criterion for analyzing mortality in a database. This study aimed to assess the quality of extracted death data and investigate the potential of the final-administered medication as a variable to quantify accuracy for the validation dataset. Electronic health records from both an in-hospital and the Korean Central Cancer Registry were used for this study. The gold standard was established by examining the differences between the dates of in-hospital deaths and cancer-registered deaths. Cosine similarity was employed to quantify the final-administered medication similarities between the gold standard and other cohorts. The gold standard was determined as patients who died in the hospital after 2006 and whose final hospital visit/discharge date and death date differed by 0 or 1 day. For all three criteria-(a) cancer stage, (b) cancer type, and (c) type of final visit-there was a positive correlation between mortality rates and the similarities of the final-administered medication. This study introduces a measure that can provide additional accurate information regarding death and differentiates the reliability of the dataset.
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Affiliation(s)
- Yae Won Tak
- Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Jeong Hyun Han
- Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Yu Jin Park
- Medical Information-Management Team, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Do-Hoon Kim
- Medical Big Data Research Center, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
| | - Ji Seon Oh
- Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Yura Lee
- Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
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3
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McCaffrey N, Cheah SL, Luckett T, Phillips JL, Agar M, Davidson PM, Boyle F, Shaw T, Currow DC, Lovell M. Treatment patterns and out-of-hospital healthcare resource utilisation by patients with advanced cancer living with pain: An analysis from the Stop Cancer PAIN trial. PLoS One 2023; 18:e0282465. [PMID: 36854021 PMCID: PMC9974128 DOI: 10.1371/journal.pone.0282465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/16/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND About 70% of patients with advanced cancer experience pain. Few studies have investigated the use of healthcare in this population and the relationship between pain intensity and costs. METHODS Adults with advanced cancer and scored worst pain ≥ 2/10 on a numeric rating scale (NRS) were recruited from 6 Australian oncology/palliative care outpatient services to the Stop Cancer PAIN trial (08/15-06/19). Out-of-hospital, publicly funded services, prescriptions and costs were estimated for the three months before pain screening. Descriptive statistics summarize the clinico-demographic variables, health services and costs, treatments and pain scores. Relationships with costs were explored using Spearman correlations, Mann-Whitney U and Kruskal-Wallis tests, and a gamma log-link generalized linear model. RESULTS Overall, 212 participants had median worst pain scores of five (inter-quartile range 4). The most frequently prescribed medications were opioids (60.1%) and peptic ulcer/gastro-oesophageal reflux disease (GORD) drugs (51.6%). The total average healthcare cost in the three months before the census date was A$6,742 (95% CI $5,637, $7,847), approximately $27,000 annually. Men had higher mean healthcare costs than women, adjusting for age, cancer type and pain levels (men $7,872, women $4,493, p<0.01) and higher expenditure on prescriptions (men $5,559, women $2,034, p<0.01). CONCLUSIONS In this population with pain and cancer, there was no clear relationship between healthcare costs and pain severity. These treatment patterns requiring further exploration including the prevalence of peptic ulcer/GORD drugs, and lipid lowering agents and the higher healthcare costs for men. TRIAL REGISTRATION ACTRN12615000064505. World Health Organisation unique trial number U1111-1164-4649. Registered 23 January 2015.
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Affiliation(s)
- Nikki McCaffrey
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood Campus, Burwood, VIC, Australia
- * E-mail:
| | - Seong Leang Cheah
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Tim Luckett
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Jane L. Phillips
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove Brisbane, Queensland
| | - Meera Agar
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Patricia M. Davidson
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Frances Boyle
- Patricia Ritchie Centre for Cancer Care and Research, Mater Hospital North Sydney, and University of Sydney, Sydney, NSW, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - David C. Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Melanie Lovell
- Department of Palliative Care, HammondCare, Greenwich Hospital, Sydney, NSW, Australia
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia
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4
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Azar I, Wang S, Dhillon V, Kenitz J, Lombardo D, Deano R, Mahmood S, Mamdani H, Shields AF, Philip PA, Stellini M, Schulman-Marcus J. Preferences and Attitudes of Cardiologists in Management of Patients with Cancer. Palliat Med Rep 2022; 3:279-286. [DOI: 10.1089/pmr.2022.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ibrahim Azar
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
- IHA Hematology Oncology, Pontiac, Michigan, USA
| | - Stephani Wang
- Division of Cardiology, Department of Medicine, University of California, Irvine, California, USA
| | - Vikram Dhillon
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Jacqueline Kenitz
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Dawn Lombardo
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Roderick Deano
- Division of Cardiology, Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Syed Mahmood
- Division of Cardiology, Department of Medicine, Weill Cornell Medical Center, New York, New York, USA
| | - Hirva Mamdani
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Anthony F. Shields
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Philip Agop Philip
- Division of Hematology-Oncology, Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Michael Stellini
- Division of Palliative Care, Department of Medicine, Wayne State University and Karmanos Cancer Institute, Detroit, Michigan, USA
| | - Joshua Schulman-Marcus
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, New York, USA
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Peralta T, Castel-Branco MM, Reis-Pina P, Figueiredo IV, Dourado M. Prescription trends at the end of life in a palliative care unit: observational study. BMC Palliat Care 2022; 21:65. [PMID: 35505394 PMCID: PMC9066954 DOI: 10.1186/s12904-022-00954-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 04/22/2022] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Tatiana Peralta
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
| | - Maria Margarida Castel-Branco
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Paulo Reis-Pina
- Palliative Care Unit "Bento Menni", Casa de Saúde da Idanha, Sintra, Portugal.,Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Isabel Vitória Figueiredo
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Marília Dourado
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Center for Studies and Development of Continuous and Palliative Care (CEDCCP), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Centre for Health Studies and Research of the University of Coimbra (CEISUC), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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6
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Ham L, Geijteman ECT, Aarts MJ, Kuiper JG, Kunst PWA, Raijmakers NJH, Visser LE, van Zuylen L, Brokaar EJ, Fransen HP. Use of potentially inappropriate medication in older patients with lung cancer at the end of life. J Geriatr Oncol 2021; 13:53-59. [PMID: 34366274 DOI: 10.1016/j.jgo.2021.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 06/10/2021] [Accepted: 07/29/2021] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Laurien Ham
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands.
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands
| | - Mieke J Aarts
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands
| | - Josephina G Kuiper
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30-40, Utrecht 3528 AE, the Netherlands
| | - Peter W A Kunst
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Onze Lieve Vrouwe Gasthuis, PO box 9243, Amsterdam 1006 AE, the Netherlands
| | - Natasja J H Raijmakers
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands
| | - Loes E Visser
- Department of Hospital Pharmacy, Haga Teaching Hospital, PO box 40551, The Hague 2504 LN, the Netherlands; Department of Epidemiology, Erasmus Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands; Department of Hospital Pharmacy, Erasmus Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam University Medical Centre, De Boelelaan 1117, Amsterdam 1081 HV, the Netherlands
| | - Edwin J Brokaar
- Department of Hospital Pharmacy, Haga Teaching Hospital, PO box 40551, The Hague 2504 LN, the Netherlands
| | - Heidi P Fransen
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands
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7
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Roux B, Morin L, Papon A, Laroche ML. Prescription and deprescription of medications for older adults receiving palliative care during the last 3 months of life: a single-center retrospective cohort study. Eur Geriatr Med 2019; 10:463-471. [PMID: 34652792 DOI: 10.1007/s41999-019-00175-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Near the end of life, drugs to ensure comfort and improve quality of life should be prioritized, and unnecessary drugs should be avoided. The aim was to assess the evolution and quality of drug therapy throughout the last 3 months of life of older adults in need of palliative care. METHODS A single-center retrospective cohort study included older adults (≥ 65 years) who died in a teaching hospital between 1 January 2014 and 30 June 2014 and had been identified as patients in need of palliative care in their last 3 months of life. Drugs were collected from electronic medical records and defined as 'unnecessary' or 'essential' based on a review of the literature. RESULTS A total of 149 patients were included [age: 82.1 (SD 8.6) years, women: 46.3%]. The mean number of medications varied from 6.7 (SD 3.3) drugs 90 days before death, to 7.5 (SD 4.1) 7 days before death, to 5.6 (SD 3.6) on the day of death. During the final week of life, one additional prescription of essential drugs was observed for 75.2% of patients and 79.3% of patients had at least one unnecessary drug deprescribed. The most prescribed and deprescribed drug classes were, respectively, analgesics (56.4%) and antithrombotic agents (38.2%) during the last week of life. CONCLUSIONS Near the end of life, medication therapy is adapted to the goals of palliative care. However, this only occurs during the last week of life. Earlier transition to palliative care is necessary to avoid exposure to unnecessary drugs.
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Affiliation(s)
- Barbara Roux
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France. .,INSERM UMR 1248, University of Limoges, Limoges, France.
| | - Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Arnaud Papon
- Department of Geriatric Medicine, University Hospital of Limoges, Limoges, France
| | - Marie-Laure Laroche
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France.,INSERM UMR 1248, University of Limoges, Limoges, France
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Al-Shahri MZ, Sroor MY, Ghareeb WA, Aboulela EN, Edesa W. The Use of Antidiabetic, Antihypertensive, and Lipid-lowering Medications in the Elderly Dying with Advanced Cancer. Indian J Palliat Care 2019; 25:124-126. [PMID: 30820114 PMCID: PMC6388588 DOI: 10.4103/ijpc.ijpc_96_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Maintenance of medications that are unconducive to the quality of life is difficult to justify in dying terminally-ill cancer patients. Objective We aimed at determining the prevalence of administering antidiabetic, antihypertensive, and lipid-lowering medications to elderly patients dying with cancer. Methods We reviewed the medical records of patients above 60 years of age with advanced cancer who died in a palliative care unit. The collected data included the use of antidiabetic, antihypertensive, and lipid-lowering medications during the last week of life. Results Of 103 patients, 51.5% were female and the median age was 69 years. The most common cancers included gastrointestinal (40.8%), gynecological (13.6%), and head and neck (12.6%). All patients had advanced cancer and 59.2% had hypertension, 52.4% had diabetes mellitus, and 19.4% had dyslipidemia. During their last week of life, 38.8% received antidiabetic, 23.3% received antihypertensive, and 3.9% received lipid-lowering agents. The data showed that 68.5% of people with diabetes received antidiabetic medications, 37.7% of hypertensive patients received antihypertensive medications, and 20% of dyslipidemics received lipid-lowering agents. Hypoglycemia was reported in 7.5% of patients receiving antidiabetic drugs, while hypotension was reported in 66.7% of patients receiving antihypertensive agents. Conclusion Many elderly patients dying with advanced cancer in a palliative care unit were maintained on medications for chronic conditions until the very late stages of their lives. For such imminently dying patients, benefits of such medications are unlikely and burdens are possible. Further research is needed to explore physicians' justifications, if any, for maintaining such patients on apparently futile medications.
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Affiliation(s)
| | - Mahmoud Yassein Sroor
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Wael Ali Ghareeb
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Enas Noshy Aboulela
- Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Wael Edesa
- Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
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9
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Gonçalves F. Deprescription in Advanced Cancer Patients. PHARMACY 2018; 6:E88. [PMID: 30134513 PMCID: PMC6164016 DOI: 10.3390/pharmacy6030088] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/15/2018] [Accepted: 08/18/2018] [Indexed: 11/16/2022] Open
Abstract
The use of multiple drugs is often referred to as polypharmacy, although this term has not been precisely defined. Frequently, drugs are used unwisely in multiple combinations increasing the risk of adverse reactions, or for the long-term prevention of diseases in patients with a short life expectancy who, therefore, will not benefit from them. The reflection on this has led to the introduction of the concept of deprescription. There are many reasons for the inappropriate drug prescription and barriers to reduce medications. Tools were developed to help prescribers to limit the number of prescribed drugs that patients are taking. Several studies have shown that deprescription of some drugs is possible and safe and can even have a positive influence on wellbeing, cognitive function, falls, and admission to a hospital. Deprescription should be individualized and carried out, as far as possible, in agreement with patients and their families. A six-step method for deprescription is proposed.
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Affiliation(s)
- Ferraz Gonçalves
- Palliative Care Service, Instituto Português de Oncologia, R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal.
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10
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Zueger PM, Holmes HM, Calip GS, Qato DM, Pickard AS, Lee TA. Medicare Part D Use of Older Medicare Beneficiaries Admitted to Hospice. J Am Geriatr Soc 2018; 66:937-944. [DOI: 10.1111/jgs.15328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Patrick M. Zueger
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
| | - Holly M. Holmes
- Division of Geriatric and Palliative MedicineUTHealth McGovern Medical SchoolHouston Texas
| | - Gregory S. Calip
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
- Division of Public Health Sciences, Epidemiology ProgramFred Hutchinson Cancer Research CenterSeattle Washington
| | - Dima M. Qato
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
| | - A. Simon Pickard
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
| | - Todd A. Lee
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
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11
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Oliveira L, Ferreira MO, Rola A, Magalhães M, Ferraz Gonçalves J. Deprescription in Advanced Cancer Patients Referred to Palliative Care. J Pain Palliat Care Pharmacother 2016; 30:201-5. [DOI: 10.1080/15360288.2016.1204411] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Cardona-Morrell M, Kim J, Turner RM, Anstey M, Mitchell IA, Hillman K. Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. Int J Qual Health Care 2016; 28:456-69. [PMID: 27353273 DOI: 10.1093/intqhc/mzw060] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2016] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care. DATA SOURCES English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015). STUDY SELECTION All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL). DATA EXTRACTION A 13-item quality score estimated independently by two authors. RESULTS OF DATA SYNTHESIS Evidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%); and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%). CONCLUSION This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.
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Affiliation(s)
- M Cardona-Morrell
- The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, PO Box 6087 UNSW, Sydney NSW 1466, Australia
| | - Jch Kim
- School of Medicine, Ground floor, 30, Western Sydney University, Narellan Road & Gilchrist Drive, Campbelltown NSW 2560, Australia
| | - R M Turner
- School of Public Health and Community Medicine, Level 2, Samuels Building, Samuels Ave, The University of New South Wales, Kensington NSW 2033, Australia
| | - M Anstey
- Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Perth WA 6009, Australia
| | - I A Mitchell
- Intensive Care Unit, Building 12, Level 3, Canberra Hospital, Yamba Drive, Garran, Canberra, ACT 2605, Australia
| | - K Hillman
- The Simpson Centre for Health Services Research, SWS Clinical School and the Ingham Institute for Applied Medical Research, The University of New South Wales, PO Box 6087 UNSW, Sydney NSW 1466, Australia Intensive Care Unit, Level 2, Liverpool Hospital, Elizabeth St & Goulburn St, Liverpool NSW 2170, Australia
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Van Den Noortgate NJ, Verhofstede R, Cohen J, Piers RD, Deliens L, Smets T. Prescription and Deprescription of Medication During the Last 48 Hours of Life: Multicenter Study in 23 Acute Geriatric Wards in Flanders, Belgium. J Pain Symptom Manage 2016; 51:1020-6. [PMID: 26921490 DOI: 10.1016/j.jpainsymman.2015.12.325] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/21/2015] [Accepted: 12/23/2015] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
| | - Rebecca Verhofstede
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Ruth D Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
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Milic M, Foster A, Rihawi K, Anthoney A, Twelves C. ‘Tablet burden’ in patients with metastatic breast cancer. Eur J Cancer 2016; 55:1-6. [DOI: 10.1016/j.ejca.2015.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/15/2015] [Accepted: 11/12/2015] [Indexed: 11/28/2022]
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Todd A, Husband A, Andrew I, Pearson SA, Lindsey L, Holmes H. Inappropriate prescribing of preventative medication in patients with life-limiting illness: a systematic review. BMJ Support Palliat Care 2016; 7:113-121. [DOI: 10.1136/bmjspcare-2015-000941] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 10/09/2015] [Accepted: 11/25/2015] [Indexed: 12/20/2022]
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Hopcroft P, Peel NM, Poudel A, Scott IA, Gray LC, Hubbard RE. Prescribing for older people discharged from the acute sector to residential aged-care facilities. Intern Med J 2015; 44:1034-7. [PMID: 25302723 DOI: 10.1111/imj.12553] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 06/28/2014] [Indexed: 11/28/2022]
Abstract
For frail older people, admission to hospital is an opportunity to review the indications for specific medications. This research investigates prescribing for 206 older people discharged into residential aged care facilities from 11 acute care hospitals in Australia. Patients had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean of 7.2 regular medications at admission to hospital and 8.1 medications on discharge, with hyper-polypharmacy (≥10 drugs) increasing from 24.3% to 32.5%. Many drugs were preventive medications whose time until benefit was likely to exceed the expected lifespan. In summary, frail patients continue to be exposed to extensive polypharmacy and medications with uncertain risk-benefit ratio.
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Affiliation(s)
- P Hopcroft
- Centre for Research in Geriatric Medicine, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Hubbard RE, Peel NM, Scott IA, Martin JH, Smith A, Pillans PI, Poudel A, Gray LC. Polypharmacy among inpatients aged 70 years or older in Australia. Med J Aust 2015; 202:373-7. [PMID: 25877120 DOI: 10.5694/mja13.00172] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 10/22/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To investigate medication changes for older patients admitted to hospital and to explore associations between patient characteristics and polypharmacy. DESIGN Prospective cohort study. PARTICIPANTS AND SETTING Patients aged 70 years or older admitted to general medical units of 11 acute care hospitals in two Australian states between July 2005 and May 2010. All patients were assessed using the interRAI assessment system for acute care. MAIN OUTCOME MEASURES Measures of physical, cognitive and psychosocial functioning; and number of regular prescribed medications categorised into three groups: non-polypharmacy (0-4 drugs), polypharmacy (5-9 drugs) and hyperpolypharmacy (≥ 10 drugs). RESULTS Of 1220 patients who were recruited for the study, medication records at admission were available for 1216. Mean age was 81.3 years (SD, 6.8 years), and 659 patients (54.2%) were women. For the 1187 patients with complete medication records on admission and discharge, there was a small but statistically significant increase in mean number of regular medications per day between admission and discharge (7.1 v 7.6), while the prevalence of medications such as statins (459 [38.7%] v 457 [38.5%] patients), opioid analgesics (155 [13.1%] v 166 [14.0%] patients), antipsychotics (59 [5.0%] v 65 [5.5%] patients) and benzodiazepines (122 [10.3%] v 135 [11.4%] patients) did not change significantly. Being in a higher polypharmacy category was significantly associated with increase in comorbidities (odds ratio [OR], 1.27; 95% CI, 1.20-1.34), presence of pain (OR, 1.31; 1.05-1.64), dyspnoea (OR, 1.64; 1.30-2.07) and dependence in terms of instrumental activities of daily living (OR, 1.70; 1.20-2.41). Hyperpolypharmacy was observed in 290/1216 patients (23.8%) at admission and 336/1187 patients (28.3%) on discharge, and the proportion of preventive medication in the hyperpolypharmacy category at both points in time remained high (1209/3371 [35.9%] at admission v 1508/4117 [36.6%] at discharge). CONCLUSIONS Polypharmacy is common among older people admitted to general medical units of Australian hospitals, with no clinically meaningful change to the number or classification (symptom control, prevention or both) of drugs made by treating physicians.
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Affiliation(s)
| | | | - Ian A Scott
- University of Queensland, Brisbane, QLD, Australia
| | | | - Alesha Smith
- University of Queensland, Brisbane, QLD, Australia
| | | | - Arjun Poudel
- University of Queensland, Brisbane, QLD, Australia
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