Although considerable attention is being paid to medication reconciliation-ensuring that patients are continued on prescribed medications as they transition across different settings of care, little attention has been paid to developing systematic approaches to stopping medications at transitions of care, particularly for patients near the end of life. In hospice, helping patients reduce the number of medications or discontinue certain medications may help to improve patient's quality of life and reduce medication-related side effects.
Older adults use a large number of medications, often to manage multiple chronic diseases. Many of these medications, statins for example, are for long-term prevention of disease. In hospice, palliation of symptoms and improving quality of life are typically the priority, not long-term health investments. In the context of hospice, medications not directly contributing to symptom improvement are considered low-value medications. Thoughtfully working with patients to discontinue low-value medications may be an opportunity for hospice providers to improve patient care (by reducing side effects and drug interactions) while also improving use of resources.
Reducing use of low-value medications in hospice may also have physical benefits. Many medications come with a profile of side effects that also need to be treated. Some medications cause gastrointestinal distress, leading to the use of a variety of other medications, both over the counter and prescription. Drug interactions and side effects can be the cause of discomfort and even reduced quality of life. For example, hospice patients using antihypertensives and diuretics may feel dizzy and weak as they eat and drink less. These symptoms can easily be mistaken for progressive illness and subsequently treated with more interventions.
There are no evidence-based guidelines on stopping medications at the end of life (Tjia et al., 2013). A recent survey of hospice patients in the last 7 days of life concluded that many patients continue to receive therapy targeting the underlying disease in addition to palliative therapy (Dwyer et al., 2015). Now, some evidence is emerging on the clinical value of drug discontinuation. A 2015 study on discontinuation of statins in patients with limited life expectancy found small improvements in quality of life and lower medication costs, with no greater number of cardiovascular events (Kutner et al., 2015). Other studies have found reduced falls and improvements in cognitive status resulting from cessation of psychotropic drugs (van der Cammen et al., 2014).
Hospice clinicians can verify that drug discontinuation is an emotional experience for most patients. Giving up medications is often experienced as a loss of something tangible. It may evoke a sense of "giving up," along with fear of consequences: "if I stop I will have a heart attack?" Many patients do not want to disappoint loved ones or their providers, and feel that compliance is expected from "good patients." Patients may make comments such as, "But my doctor told me I could never stop this." Even patients who prefer fewer medications often do not bring it up because they have little experience in shared decision making (Linsky et al., 2015) and do not feel it is their role to raise the issue.
As other authors have discussed, it can be challenging to discuss drug discontinuation in hospice (Collier et al., 2013). Drug cessation may include risks of perpetuating hospice myths such as:
* Hospice actively helps people to die
* Hospice takes everything away
* Hospice is only for the last few hours or days
* Hospice doesn't want to pay for anything
As a result, many hospice practitioners believe the conversation is too risky to have and shy away from discussing medication discontinuation.
Yet, engaging in discussion with patients and families represents another avenue for promoting patient autonomy based on informed consent. In fact the American Nurses Association's (ANA's) Nursing Code of Ethics suggests that a nursing role is to minimize unwarranted, unwanted, or unnecessary treatments and patient suffering (ANA, 2015). Hospice clinicians who raise the topic must make it clear that they do not have an agenda other than comfort of the patient. Informed consent is only met when all information is shared about both the risks and benefits of all treatment options.
Hospice clinicians may want to develop empathetic approaches to broaching the topic of medication discontinuation and to promote shared decision making about medications. A starting point for conversations may be drugs that may have lower value at the end of life. These include statins, vitamins, eye drops (except those for comfort), antihypertensives, and antihyperglycemics. Patients may also appreciate the opportunity to discuss changing or stopping medications that are uncomfortable to take.
When considering how to start a conversation about medication discontinuation, the process of medication reconciliation provides an opportunity for nurses to explore the impact of medications on the patient. Guided discussions including questions like: "Why are you taking this? How long have you been taking it? Have you had any problems with it? How does it make you feel? What happens if you miss a dose?" Such conversations may build trust and understanding between the nurse and patient, thus ensuring that decision making is shared and centered on the patient's experience.
In spite of there being relatively little evidence on discontinuation of specific drugs, evidence outside of hospice demonstrates that adopting shared decision making with patients, in a manner that addresses decisions in the context of the individual patient's goals, often results in patients choosing fewer interventions with lower costs (Veroff et al., 2013). Thus, the conversations may have value both in improving patient engagement and experience, while also promoting appropriate clinical care.
There is now increased movement to develop approaches to talking with patients about stopping therapeutic medications at the end of life (LeBlanc et al., 2015). The mission of hospice is to reduce suffering and support quality of life. Hospice providers must seek opportunities to bring comfort while supporting the ethical standard of doing no harm. In this case, talking with patients about stopping drugs that no longer have value is an opportunity for partnership and improved quality.
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