If ever there is a time for compassionate medicine, it is when a patient is nearing the end of life. Unfortunately, when hospice becomes involved in patient care and recommendations are made for the discontinuation of medications, patients and caregivers alike can feel abandoned. They may feel as though the discontinuations will hasten death, worsen symptoms, or imply the patient is not worth treating any longer.
The difficulty of appropriately communicating rationale for drug discontinuation often results in continuation of unnecessary polypharmacy in order to avoid those difficult discussions. However, if approached appropriately, these discontinuations can be made while assuring patients and caregivers of a desire to improve quality of life.
Careful consideration must be made when determining what medications to discontinue in hospice patients. Helpful questions to ask include:
–Does a medication’s risks outweigh its benefits?
–Is the therapeutic benefit diminished to the extent that the medication no longer provides benefit?
–Is there a lack of evidence to support the continuation of therapy?
–Does this medication help meet goals of care for this patient?
–If the medication was recently added, is the time to benefit longer than life expectancy?
–Is there a clear indication for the medication?
–Has the medication been effective?
–Does the medication interact with other products or disease states?
–Are there therapeutic duplications in the patient’s drug regimen?
–Could the medication be treating a side effect of another medication?
–Is the patient and/or caregiver over-burdened with current drug regimen?
When there is no time to taper medications, ensure staff and caregivers are aware to monitor patients for withdrawal symptoms, such as rebound hypertension when blood pressure medications are discontinued or agitation when antipsychotics are stopped.
Discussions regarding discontinuation of medications can be intimidating for case managers to initiate, but educating staff on the benefits of appropriate discontinuation can give them more confidence in their presentation of such recommendations. As hospice staff knowledge increases regarding issues surrounding the continuation versus discontinuation of risky medications, case managers are more likely to seize the opportunity to discuss the benefits of timely discontinuation. Are family members recognizing the patient’s decline? Consider discontinuing unnecessary medications. Is the patient experiencing troublesome side effects that decrease quality of life? Consider discontinuation of offending medications. Are medications becoming ineffective? Consider stopping those drugs that are no longer providing benefit.
Additional education regarding optimal discontinuation methods can prevent undesirable withdrawal symptoms. Tapering may be necessary, especially in discontinuation of:
Paroxetine and venlafaxine
Beta-blockers
Clonidine
Anti-seizure medications
Antipsychotics
Baclofen and tizanidine
Corticosteroids
Benzodiazepines
Ultimately, goals of care should always center around providing the most excellent care for the hospice patient. As medication decisions are made, ensure that both the patient’s and physician’s goals of care are met. Honest, open communication with the patient, family, and caregivers as well as among participants of IDG will help guide decision-making and result in the medication regimen most appropriate for the compassionate care of each patient.
